Laparoscopic Roux-en-Y gastric bypass for BMI <35 kg/m2: a tailored approach

Assessing academic impact through a bibliometrics analysis: Gastroesophageal reflux disease in the context of obesity treatment and bariatric surgery

Aims

The global rise in obesity rates has led to increased use of bariatric surgery, which can potentially exacerbate or induce gastroesophageal reflux disease. This study aimed to assess the academic impact and trends in research on gastroesophageal reflux disease in the context of obesity treatment and bariatric surgery through a comprehensive bibliometric analysis.

Materials and methods

A bibliometric analysis was conducted using data from Web of Science and Scopus databases, covering publications from 1993 to 2024. The study utilized the Bibliometrix R package to analyze publication trends, collaborative networks, and research topics.

Results

The analysis encompassed 257 documents from 82 sources, with 6192 total citations and an 8.2% annual growth rate in publications. The United States emerged as the leading contributor with 90 publications. Key research topics included bariatric surgery, sleeve gastrectomy, and gastroesophageal reflux disease, with increasing focus on complications and revisional bariatric surgery in recent years. Two main research clusters were identified: one focusing on general health aspects and demographics, and another on specialized bariatric procedures and outcomes. However, the analysis is constrained by its reliance on data from only two bibliographic databases, which may not encompass all pertinent studies, and by a geographic bias toward high-income countries. Moreover, our deep literature reviews highlighted that obesity is a known risk factor for gastroesophageal reflux disease, and while Roux-en-Y gastric bypass often reduces gastroesophageal reflux disease symptoms, sleeve gastrectomy may exacerbate or cause de novo gastroesophageal reflux disease postoperatively.

Conclusions

This bibliometric study reveals a significant increase in research activity on gastroesophageal reflux disease in relation to obesity treatment and bariatric surgery, particularly since 2017. The findings highlight the growing importance of this field and the need for continued international research efforts to optimize surgical protocols and improve patient outcomes.

"Dysfunctions" induced by Roux-en-Y gastric bypass surgery are concomitant with metabolic improvement independent of weight loss

Metabolic surgery has been increasingly recommended for obese diabetic patients, but questions remain as to its molecular mechanism that leads to improved metabolic parameters independently of weight loss from a network viewpoint. We evaluated the role of the Roux limb (RL) in Roux-en-Y gastric bypass (RYGB) surgery in nonobese diabetic rat models. Improvements in metabolic parameters were greater in the long-RL RYGB group. Transcriptome profiles reveal that amelioration of diabetes state following RYGB differs remarkably from both normal and diabetic states. According to functional analysis, RYGB surgery significantly affected a major gene group, i.e., the newly changed group, which represented diabetes-irrelevant genes abnormally expressed after RYGB. We hypothesize that novel "dysfunctions" carried by this newly changed gene group induced by RYGB rebalance diabetic states and contribute to amelioration of metabolic parameters. An unusual increase in cholesterol (CHOL) biosynthesis in RL enriched by the newly changed group was concomitant with ameliorated metabolic parameters, as demonstrated by measurements of physiological parameters and biodistribution analysis using [14C]-labeled glucose. Our findings demonstrate RYGB-induced "dysfunctions" in the newly changed group as a compensatory role contributes to amelioration of diabetes. Rather than attempting to normalize "abnormal" molecules, we suggest a new disease treatment strategy of turning "normal" molecules "abnormal" in order to achieve a new "normal" physiological balance. It further implies a novel strategy for drug discovery, i.e. targeting also on "normal" molecules, which are traditionally ignored in pharmaceutical development.

One Anastomosis Gastric Bypass/Minigastric Bypass in Patients with BMI < 35 kg/m2 and Type 2 Diabetes Mellitus: Preliminary Report

INTRODUCTION

Obesity in the world has been increasing, and the number of diabetic patients will increase by 114%, and the best treatment results are achieved through surgery. Several techniques have been described; the gastric bypass of an anastomosis (MGB/OAGB) has been gaining popularity for its simplicity and good results. We present a prospective study with this technique in 16 mild obesity patients with type 2 diabetes mellitus or peripheral insulin resistance.

OBJECTIVE

To evaluate weight loss as well as metabolic changes by measuring fasting glycemia and Hb A1c after 1 year of follow-up.

MATERIAL AND METHODS

Sixteen patients were operated on with the OAGB/MGB technique from September 2014 to January 2016, with some form of metabolic syndrome, whether DM2, RPI, HBP, or dyslipidemia, including patients in the study with a follow-up of at least 12 months.

RESULTS

There were 13 cases of female sex and 3 of male, average age of 42.9 years, with an average weight of 87.7 kg and BMI of 32.2 kg/m². Metabolic values were fasting glycemia of 193.6 ± 52.9 mg/dl and HbA1c of 8.4% ± 1 (preop) and glycemia posop, 78.8 ± 7.6 mg/dl; HbA1c posop, 6.1 ± 0.2; preop weight, 87.7 ± 14 kg (69-116); weight posop, 66.8 ± 10.5 kg (49-90); BMI preop, 32.2 ± 1.8 (30-34.9); BMI posop, 25.4 ± 1.7 (21.7-27.6); percentage of excess weight lost, 87.6 ± 11.8 (70.9-100) % with 100% remission of diabetes.

CONCLUSION

The results show the benefits of MGB/OAGB in mild obese diabetic patients.

Metabolic surgery for the treatment of type 2 diabetes in patients with BMI lower than 35 kg/m2 : Why caution is still needed

Bariatric surgery has shifted from being a risky procedure to an evidence-based one, with proven benefits on all-cause mortality, cardiovascular disease, cancer, and diabetes control. The procedure has an overall positive result on type 2 diabetes mellitus (T2DM), with a substantial number of patients achieving disease remission. This has resulted in several studies assessing possible weight-independent effects of bariatric surgery on glycemic improvement, in addition to recommendation of the procedure to patients with class 1 obesity and T2DM, for whom the procedure was classically not indicated, and adoption of a new term, "metabolic surgery," to highlight the overall metabolic benefit of the procedure beyond weight loss. Recently, the Diabetes Surgery Summit (DSS) has included metabolic surgery in its T2DM treatment algorithm. Although the discussion brought by this consensus is highly relevant, the recommendation of metabolic surgery for patients with uncontrolled T2DM and a body mass index of 30 to 35 kg/m² still lacks enough evidence. This article provides an overall view of the metabolic benefits of bariatric/metabolic surgery in patients with class 1 obesity, compares the procedure against clinical treatment, and presents our rationale for defending caution on recommending the procedure to less obese individuals.

Role of Bile Acids and GLP-1 in Mediating the Metabolic Improvements of Bariatric Surgery

BACKGROUND & AIMS

Bile diversion to the ileum (GB-IL) has strikingly similar metabolic and satiating effects to Roux-en-Y gastric bypass (RYGB) in rodent obesity models. The metabolic benefits of these procedures are thought to be mediated by increased bile acids, although parallel changes in body weight and other confounding variables limit this interpretation.

METHODS

Global G protein-coupled bile acid receptor-1 null (Tgr5^-/-) and intestinal-specific farnesoid X receptor null (Fxr^Δ/E) mice on high-fat diet as well as wild-type C57BL/6 and glucagon-like polypeptide 1 receptor deficient (Glp-1r^-/-) mice on chow diet were characterized following GB-IL.

RESULTS

GB-IL induced weight loss and improved oral glucose tolerance in Tgr5^-/-, but not Fxr^Δ/E mice fed a high-fat diet, suggesting a role for intestinal Fxr. GB-IL in wild-type, chow-fed mice prompted weight-independent improvements in glycemia and glucose tolerance secondary to augmented insulin responsiveness. Improvements were concomitant with increased levels of lymphatic GLP-1 in the fasted state and increased levels of intestinal Akkermansia muciniphila. Improvements in fasting glycemia after GB-IL were mitigated with exendin-9, a GLP-1 receptor antagonist, or cholestyramine, a bile acid sequestrant. The glucoregulatory effects of GB-IL were lost in whole-body Glp-1r^-/- mice.

CONCLUSIONS

Bile diversion to the ileum improves glucose homeostasis via an intestinal Fxr-Glp-1 axis. Altered intestinal bile acid availability, independent of weight loss, and intestinal Akkermansia muciniphila appear to mediate the metabolic changes observed after bariatric surgery and might be manipulated for treatment of obesity and diabetes.

A Modified Tripeptide Motif of RS1 (RSC1A1) Down-Regulates Exocytotic Pathways of Human Na+-d-glucose Cotransporters SGLT1, SGLT2, and Glucose Sensor SGLT3 in the Presence of Glucose

A domain of protein RS1 (RSC1A1) called RS1-Reg down-regulates the plasma membrane abundance of Na+-d-glucose cotransporter SGLT1 by blocking the exocytotic pathway at the trans-Golgi. This effect is blunted by intracellular glucose but prevails when serine in a QSP (Gln-Ser-Pro) motif is replaced by glutamate [RS1-Reg(S20E)]. RS1-Reg binds to ornithine decarboxylase (ODC) and inhibits ODC in a glucose-dependent manner. Because the ODC inhibitor difluoromethylornithine (DFMO) acts like RS1-Reg(S20E), and DFMO and RS1-Reg(S20E) are not cumulative, we raised the hypothesis that RS1-Reg(S20E) down-regulates the exocytotic pathway of SGLT1 at the trans-Golgi by inhibiting ODC. We investigated whether QEP down-regulates human SGLT1 (hSGLT1) like hRS1-Reg(S20E) and whether human Na+-d-glucose cotransporter hSGLT2 and the human glucose sensor hSGLT3 are also addressed. We expressed hSGLT1, hSGLT1 linked to yellow fluorescent protein (hSGLT1-YFP), hSGLT2-YFP and hSGLT3-YFP in oocytes of Xenopus laevis, injected hRS1-Reg(S20E), QEP, DFMO, and/or α-methyl-d-glucopyranoside (AMG), and measured AMG uptake, glucose-induced currents, and plasma membrane-associated fluorescence after 1 hour. We also performed in vitro AMG uptake measurements into small intestinal mucosa of mice and human. The data indicate that QEP down-regulates the exocytotic pathway of SGLT1 similar to hRS1-Reg(S20E). Our results suggests that both peptides also down-regulate hSGLT2 and hSGLT3 via the same pathway. Thirty minutes after application of 5 mM QEP in the presence of 5 mM d-glucose, hSGLT1-mediated AMG uptake into small intestinal mucosa was decreased by 40% to 50%. Thus oral application of QEP in a formulation that optimizes uptake into enterocytes but prevents entry into the blood is proposed as novel antidiabetic therapy.

Surgical treatment of obesity

Obesity prevalence continues to increase worldwide, as do the numerous chronic diseases associated with obesity, including diabetes, non-alcoholic fatty liver disease, dyslipidemia, and hypertension. The prevalence of bariatric surgery also continues to increase and remains the most effective and sustainable treatment for obesity. Over the last several years, numerous prospective and longitudinal studies have demonstrated the benefits of bariatric surgery on weight loss, mortality, and other chronic diseases. Even though the mechanisms underlying many of these beneficial effects remain poorly understood, surgical management of obesity continues to increase given its unmatched efficacy. In this commentary, we discuss recent clinical advancements as well as several areas needed for future research, including indications for bariatric and metabolic surgery, determination of responders and non-responders, metabolic surgery in non-obese individuals, and the evolving role of bariatric surgery in adolescents.

Role of the family doctor in the management of adults with obesity: a scoping review

OBJECTIVES

Obesity management is an important issue for the international primary care community. This scoping review examines the literature describing the role of the family doctor in managing adults with obesity. The methods were prospectively published and followed Joanna Briggs Institute methodology.

SETTING

Primary care. Adult patients.

INCLUDED PAPERS

Peer-reviewed and grey literature with the keywords obesity, primary care and family doctors. All literature published up to September 2015. 3294 non-duplicate papers were identified and 225 articles included after full-text review.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data were extracted on the family doctors' involvement in different aspects of management, and whether whole person and person-centred care were explicitly mentioned.

RESULTS

110 papers described interventions in primary care and family doctors were always involved in diagnosing obesity and often in recruitment of participants. A clear description of the provider involved in an intervention was often lacking. It was difficult to determine if interventions took account of whole person and person-centredness. Most opinion papers and clinical overviews described an extensive role for the family doctor in management; in contrast, research on current practices depicted obesity as undermanaged by family doctors. International guidelines varied in their description of the role of the family doctor with a more extensive role suggested by guidelines from family medicine organisations.

CONCLUSIONS

There is a disconnect between how family doctors are involved in primary care interventions, the message in clinical overviews and opinion papers, and observed current practice of family doctors. The role of family doctors in international guidelines for obesity may reflect the strength of primary care in the originating health system. Reporting of primary care interventions could be improved by enhanced descriptions of the providers involved and explanation of how the pillars of primary care are used in intervention development.

Effects of Laparoscopic Roux-en-Y Gastric Bypass for Type 2 Diabetes Mellitus: Comparison of BMI > 30 and < 30 kg/m2

BACKGROUND

Recently, many studies focused on type 2 diabetes mellitus (T2DM) patients with body mass index (BMI) < 30 kg/m2 and suggested that those patients might benefit from Roux-en-Y gastric bypass (RYGB). However, evidence on its effectiveness to improve T2DM patients with BMI < 30 kg/m2 is still lacking. The aim of this study is to explore whether T2DM patients with BMI < 30 kg/m2 get similar surgical effect from RYGB compared with those patients with BMI > 30 kg/m2.

METHODOLOGY

Seventy patients with uncontrolled T2DM underwent laparoscopic RYGB from May 2010 to December 2015 in the GI Department of Daping Hospital. Weight, BMI, waist circumference, glucose, and lipid metabolic parameters were collected and evaluated at baseline and 1, 3, 6, 12, and 24 months postsurgery. Patients with BMI < 30 kg/m2 were compared with those with BMI > 30 kg/m2.

RESULTS

Among the 70 patients, 47 (67.1%) BMI < 30 kg/m2, and 23 (32.9%) BMI > 30 kg/m2. Patients with BMI < 30 kg/m2 are significantly older; they are female predominant and have longer duration of diabetes. The complete remission of T2DM was 28.2% of the BMI < 30 kg/m2 group and 57.9% of the BMI > 30 kg/m2 group (p = 0.029). There was no significant difference in the change of glucose and lipid metabolic parameters of both groups. FPG, 2hPG, and HbA1c% levels were significantly improved after 1 month (p < 0.05), and then remained essentially stable from the sixth month in both groups.

CONCLUSIONS

The 2-year study has shown that RYGB is a safe and effective procedure in treating T2DM with BMI < 30 kg/m2, although the complete remission of T2DM in the BMI < 30 kg/m2 group is lower than the BMI > 30 kg/m2 group.

The Diabetes Surgery Summit II Guidelines: a Disease-Based Clinical Recommendation

There is mounting evidence, derived from mechanistic studies, RCTs, and other high-quality studies that there are weight loss independent antidiabetic effects of gastrointestinal surgery. Additionally, there appears to be no relation between the positive metabolic outcomes to baseline BMI. The outdated US National Health Institutes guidelines from 1991 were centered on BMI only criterion and often misleading. The Second Diabetes Surgery Summit held in collaboration with leading diabetes organizations and endorsed by a large group of international Professional Societies developed guidelines that defined eligibility based on the severity and degree of T2D medical control while referring to obesity as a qualifier and not the sole criterion. That is the first time that guidelines are provided to put metabolic surgery into the T2D treatment algorithms.

Seven Years of Mini-Gastric Bypass in Type II Diabetes Patients with a Body Mass Index <35 kg/m(2)

BACKGROUND

Mini-gastric bypass (MGB) is a safe, effective, and reversible procedure for patients with type II diabetes mellitus (T2DM) and morbid obesity. Less is known, however, about its long-term effects in patients with a body mass index (BMI) <35 kg/m(2).

METHODS

From February 2007 to February 2014, 1468 patients underwent MGB at our institution, including 983 with T2DM. Of these, 128 (82 women), of mean age 41.6 ± 10.2 years, had a BMI of 30-35 kg/m(2). Prospectively collected data were analyzed retrospectively. Factors assessed included disease duration, family history, medication use, remission, and biochemical indicators, including fasting plasma glucose, glycosylated hemoglobin (HbA1c), serum insulin, and C-peptide concentrations. Remission of T2DM was defined as HbA1c <6.0 % without medication.

RESULTS

Prior to surgery, patients had a mean BMI of 33.4 ± 3.3 kg/m(2), mean waist circumference of 104.5 ± 8.2 cm, mean C-peptide concentration of 3.4 ± 1.2 ng/ml, and mean T2DM duration of 6.5 ± 3.1 years. Within 6 months of MGB, 95 % of these patients had attained HbA1c <7 %. Complete remission rates at 1, 2, and 7 years were 64, 66, and 53 %, respectively. Mean HbA1c decreased from 10.7 ± 1.5 % at baseline to 6.2 ± 0.5% at 1 year, 5.4 ± 1.2 % at 3 years, and 5.7 ± 1.8 % at 7 years. No deaths occurred, but two (1.6 %) patients experienced major complications.

CONCLUSIONS

MGB provides good, long-term control of T2DM in patients with class I obesity. Early intervention results in higher remission rates.

PRELIMINARY ANALYSIS OF INTERLEUKIN-6 CHANGES IN PRE- AND POSTOPERATIVE IN DIABETIC PATIENTS WITH BMI<35 SUBMITTED TO PARTIAL DUODENAL SWITCH

Background:

Studies related to obesity have shown association with metabolic syndrome. Data showing that obesity is capable to cause low grade chronic inflammation, without its classic signs and symptoms, call attention to researches to study different cells types and the mechanism of the inflammatory process.

Aim:

To evaluate the variation of glycated hemoglobin (HbA1c) and the pro-inflammatory cytokine interleukin-6 (IL6) in diabetic patients with BMI <35 kg/m² in the pre and postoperative of partial duodenal switch.

Method:

Nine patients were studied before and one year after the operation and the variation of the serum IL6 was measured by Elisa. The changes of HbA1c were also registered.

Results:

The pre-operative IL6 levels reached 65,50436±2,911993 pg/ml and one year after de operation 39,47739±3,410057 and the HbA1c average of 10,67 and 5.8 in the same period.

Conclusion:

The partial duodenal switch was efficient to control one year after the procedure the chronic inflammatory process caused by the diabetes mellitus type 2 with BMI <35 by dropping the IL6 levels and bringing the HbA1c to normal.

How Durable Are the Effects After Metabolic Surgery?

Bariatric surgery was initially developed as a tool for weight reduction only, but it is gaining popularity because of its remarkable effect on glucose metabolism in morbidly obese and less obese patients. Recent publications have shown the superiority of metabolic surgery over medical treatment for diabetes, creating a new field of clinical research that is currently overflowing in the medical community with outstanding high-quality data. Metabolic surgery is effective in treating diabetes, even in non-morbidly obese patients.

A meta-analysis of short-term outcomes of patients with type 2 diabetes mellitus and BMI ≤ 35 kg/m2 undergoing Roux-en-Y gastric bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is effective for type 2 diabetes mellitus (T2DM) patients with a body mass index (BMI) >35 kg/m(2). It is unknown whether it benefits those with a BMI ≤ 35 kg/m(2). In the last decade, the effect of bariatric procedures on metabolic outcomes in individuals who underwent surgery outside National Institutes of Health (NIH) guidelines (BMI ≤ 35 kg/m(2)) was both interesting and controversial.

OBJECTIVE

We performed a systematic analysis evaluating the effect of RYGB for T2DM patients with a BMI ≤ 35 kg/m(2).

METHODS

We searched databases (Embase, Ovid, PubMed, China National Knowledge Infrastructure [CNKI], and Cochrane Library) and relevant journals between January 1980 and October 2013. Keywords used in electronic searching included 'diabetes', 'gastric bypass', 'BMI', and 'body mass index'. Inclusion criteria were as follows: (1) patients who underwent RYGB; (2) sample size ≥ 15; (3) patients with a BMI ≤ 35 kg/m(2); and (4) follow-up ≥ 12 months. Exclusion criteria were as follows: (1) data extracted from a database; (2) trials for sleeve gastrectomy; (3) trials for laparoscopic banding; (4) trials for bilio-pancreatic diversion; and (5) trials for duodenojejunal bypass. Participants and intervention type 2 diabetes patients with BMI ≤ 35 kg/m(2) who underwent RYGB. Two investigators reviewed all reported studies independently. Data were extracted according to previously defined endpoints. A meta-analysis was performed for these parameters, with homogeneity among different trials.

RESULTS

Nine articles fulfilled inclusion criteria. After 12 months, patients with T2DM had a significant decrease in their BMI postoperatively (p < 0.00001, weighted mean difference [WMD] -7.42, 95 % confidence interval [CI] -8.87 to -5.97), and remission of diabetes (glucose: p < 0.00001, WMD -59.87, 95 % CI -67.74 to -52.01; hemoglobin A1c p < 0.00001, WMD -2.76, 95 % CI -3.41 to -2.11). There were no deaths in all trials, and the complication rate was between 6.7 and 25.9 %. Mean length of hospital stay was 2.00 to 3.20 days, and mean operative time was from 72.8 to 112.0 min. In terms of study limitations, publication and selection bias were unavoidable. Trials with small sample sizes were excluded, which may lead to a selection bias.

CONCLUSION

RYGB was effective for T2DM patients with BMI ≤ 35 kg/m(2). Further clinical studies with long-term follow-up data are necessary to clarify this issue.

Metabolic surgery: roux-en-Y gastric bypass and variables associated with diabetes remission in patients with BMI <35

Metabolic results of bariatric surgery have determined an expansion of its traditional indications, being increasingly performed in non-severely obese patients, especially in type 2 diabetes mellitus (T2DM). Our aim is to determine the effectiveness of laparoscopic Roux-en-Y gastric bypass (LRYGB) in T2DM remission in patients with body mass index (BMI) below 35 kg/m(2) and the variables associated with T2DM remission after surgery. Retrospective analysis of diabetic patients with BMI <35 kg/m(2) who underwent LRYGB in our center between 2002 and 2010 was done. We analyzed patient's demographics, comorbidities, BMI, excess weight loss percentage (EWLp), complications, and metabolic results at 3 years. Univariate and multivariate analyses were performed to determine variables associated with T2DM remission. One hundred patients were included. Sixty patients (60 %) were women; median age was 48 years old (interquartile range (IQR) 42-54), and median preoperative BMI was 32.7 kg/m(2) (IQR 31.6-34.1). Median preoperative duration of T2DM was 4 years (IQR 2-7), with 49, 30, 2, and 18 % on treatment with one, two, and three hypoglycemic agents and insulin, respectively. Ninety-four percent achieved 36-month follow-up, and at this time, median EWLp was 93 % (IQR 67-121). A total of 53.2, 9.6, 25.5, and 11.7 % achieved a T2DM complete remission, partial remission, improvement, and no improvement, respectively. T2DM remission only was associated with non-insulin use in multivariate analysis, with an OR = 15.1 (2.8-81.2) and p = 0.002. LRYGB is a reliable and effective treatment in diabetic patients with a BMI <35 kg/m(2) at 3 years. T2DM remission's best results are observed in non-insulin diabetic patients.

Effects of gastric bypass on type 2 diabetes in patients with BMI 30 to 35

BACKGROUND

This study aims to investigate if the benefits on glycemic control following Roux-en-Y gastric bypass (RYGB) in morbidly obese type 2 diabetes (T2DM) patients are maintained in the 30-35 kg/m(2) BMI (body mass index) range, comparing results with those in literature.

METHODS

The study participants were twenty T2DM patients aging 35-70 years, BMI 30.0-34.9 kg/m(2), minimum diabetes duration 3 years, glycosylated haemoglobin (HbA1c) ≥7.5% despite good clinical practice medical therapy, submitted to laparoscopic RYGB, and monitored during 36 months. Twenty-seven matched diabetic patients as controls.

RESULTS

Five females, mean age 57 (42-69) years, weight 96.0 (70-111) kg, BMI 32.9 (30.3-34.9) kg/m(2), waist circumference 112 (100-128) cm, diabetes duration 14 (3-28) years, HbA1c 9.5 (7.5-14.2) %, and C-peptide 3.2 (1,6-9.1) mcg/l. Ten patients were on insulin. There was no mortality, and there were two major late complications. BMI and waist decreased stabilizing around 25 kg/m(2) and 92 cm. Fasting serum glucose and HbA1c reached values around 150 mg/dl and 7%, which subsequently maintained. There was remission in 25% of cases, control 45%, and all the others improved. HOMA-IR and insulin sensitivity index normalized at 1 month, then maintained. AIR and insulinogenic index showed no postoperative changes. Diabetes remission correlated negatively with duration (p < 0.05; r (2) = 0.61), while control positively with C-peptide (p < 0.05; r (2) = 0.19). In the control group, FSG, HbA1c, serum triglyceride, and cholesterol significantly decreased with considerable progressive increase of antidiabetic/antihyperlipemic therapy. All patients had HbA1c >7% at 2-3 years.

CONCLUSIONS

Glycemic control obtained by RYGB in this study was less good than that reported by others, apparently due to different patient selection criteria. Our results do not support RYGB weight loss-independent effect on beta-cell function in the T2DM patients with BMI 30-35 kg/m(2).

Ileal Interposition in Rats with Experimental Type 2 Like Diabetes Improves Glycemic Control Independently of Glucose Absorption

Bariatric operations in obese patients with type 2 diabetes often improve diabetes before weight loss is observed. In patients mainly Roux-en-Y-gastric bypass with partial stomach resection is performed. Duodenojejunal bypass (DJB) and ileal interposition (IIP) are employed in animal experiments. Due to increased glucose exposition of L-cells located in distal ileum, all bariatric surgery procedures lead to higher secretion of antidiabetic glucagon like peptide-1 (GLP-1) after glucose gavage. After DJB also downregulation of Na(+)-d-glucose cotransporter SGLT1 was observed. This suggested a direct contribution of decreased glucose absorption to the antidiabetic effect of bariatric surgery. To investigate whether glucose absorption is also decreased after IIP, we induced diabetes with decreased glucose tolerance and insulin sensitivity in male rats and investigated effects of IIP on diabetes and SGLT1. After IIP, we observed weight-independent improvement of glucose tolerance, increased insulin sensitivity, and increased plasma GLP-1 after glucose gavage. The interposed ileum was increased in diameter and showed increased length of villi, hyperplasia of the epithelial layer, and increased number of L-cells. The amount of SGLT1-mediated glucose uptake in interposed ileum was increased 2-fold reaching the same level as in jejunum. Thus, improvement of glycemic control by bariatric surgery does not require decreased glucose absorption.

Visceral fat area as a new predictor of short-term diabetes remission after Roux-en-Y gastric bypass surgery in Chinese patients with a body mass index less than 35 kg/m2

BACKGROUND

Metabolic surgery has been proposed for inadequately controlled type 2 diabetes mellitus (T2DM) in association with obesity. However, prediction of successful T2DM remission after surgery has not been clearly studied in Chinese patients. The objective of this study was to predict the outcome in those with T2DM after metabolic surgery to help in patient selection.

METHODS

A retrospective review of prospectively collected data of 68 ethnic Chinese with mean body mass index (BMI) of 31.5 and T2DM were examined for the metabolic outcomes at 1 year after Roux-en-Y gastric bypass (RYGB). Visceral and abdominal subcutaneous fat areas were assessed using magnetic resonance imaging before and 1 year after RYGB. Remission was defined as a glycated hemoglobin (HbA1 c)<6.5% and no medications at 1 year. Binary logistic regression analysis was used to identify predictors.

RESULTS

At 1 year after surgery, the BMI in the study group decreased from 31.5±3.6 to 24.5±2.5 kg/m2. Remission was achieved in 50 patients (73.5%) at 1 year. Compared with patients in the nonremission group, patients in the remission group had a shorter duration of diabetes, lower preoperative HbA1 c level, higher fasting C-peptide level, and more visceral fat area (VFA). Preoperative BMI and waist circumference did not differ between the 2 groups.

CONCLUSION

The metabolic improvement in T2DM after RYGB in the mildly obese is greater with a shorter duration of diabetes, higher fasting C-peptide. Those who have more visceral adiposity may obtain greater benefit from RYGB.

Efficacy of metabolic surgery on HbA1c decrease in type 2 diabetes mellitus patients with BMI <35 kg/m2--a review

High glycated hemoglobin A1c (HbA1c) is strongly correlated with developing type 2 diabetes mellitus (T2DM) complications; this study reviews the efficacy of various types of metabolic surgeries in reducing HbA1c levels in type 2 diabetics with BMI <35 kg/m(2). An electronic search of MEDLINE databases using terms 'metabolic surgery', type 2 diabetes mellitus, BMI <35 kg/m(2), and related keywords for studies published between 1987 and 2013. Data from 53 articles with 2,258 patients were selected for this review. The weighted mean change in HbA1c was -2.8 % (95 % CI -2.8 to -2.7, p < 0.01) and weighted mean BMI change was -5.5 kg/m(2) (95 % CI -5.6 to -5.4, p < 0.01). There was a strong correlation between weighted percentage mean change in HbA1c and BMI. Adjustable gastric banding and duodenal jejunal bypass were inferior to other surgeries in reducing BMI and HbA1c in BMI <35 kg/m(2). Metabolic surgery significantly decreases HbA1c in T2DM patients with BMI <35 kg/m(2) and that the magnitude of HbA1c change may be a useful surrogate of DM control.

Metabolic Surgery for Type 2 Diabetes in Patients with a BMI of <35 kg/m(2): A Surgeon's Perspective

Bariatric surgery was developed with the aim of weight reduction. Success was defined only by excess weight loss. Other indices of resolution of metabolic comorbidities were reported, but were mostly secondary. Several communications have reported that regardless of body mass index (BMI), complete or partial remission of type 2 diabetes mellitus (T2DM) is possible. These results mostly occur before weight loss, positioning metabolic surgery as a good tool for controlling the current T2DM epidemic. Medical treatment is evolving, but is expensive and not risk-free. Surgery aimed mainly at diseases such as diabetes and not weight loss are referred to as "metabolic surgery." Metabolic surgery has been proven to be safe and effective, and although more data are needed, it is unquestionable that a new discipline has been founded. Metabolic surgery can effectively treat T2DM in individuals with any BMI, including that below 35 kg/m(2).

Bariatric surgery in moderately obese patients: a prospective study

Introduction. Moderate obesity (BMI 30-35 kg/m(2)) affects 25% of the western population. The role of bariatric surgery in this context is currently debated, reserved for patients with comorbidity, as an alternative to conservative medical treatment. We describe our experience in moderately obese patients treated with bariatric surgery. Materials and Methods. Between September 2011 and September 2012, 25 patients with grade I obesity and comorbidities underwent bariatric surgery: preoperative mean BMI 33.2 kg/m(2), 10 males, mean age 42 years. In presence of type 2 diabetes mellitus (T2DM) (56%), gastric bypass was performed; in cases with hypertension (64%) and obstructive sleep apnea (OSA) (12%), sleeve gastrectomy was performed. All operations were performed laparoscopically. Results. Mean follow-up was 12.4 months. A postoperative complication occurred: bleeding from the trocar site was resolved with surgery in local anesthesia. Reduction in average BMI was 6 points, with a value of 27.2 kg/m(2). Of the 14 patients with T2DM, 12 (86%) discontinued medical therapy because of a normalization of glycemia. Of the 16 patients with arterial hypertension, 14 (87%) showed remission and 2 (13%) improvement. Complete remission was observed in patients with OSAS. Conclusions. The results of our study support the validity of bariatric surgery in patients with BMI 30-35 kg/m(2). Our opinion is that, in the future, bariatric surgery could be successful in selected cases of moderately obese patients.

The effect of duodenojejunal bypass for type 2 diabetes mellitus patients below body mass index 25 kg/m(2): one year follow-up

Purpose

The goals of this study are to evaluate the effect of duodenojejunal bypass (DJB) for type 2 diabetes mellitus (T2DM) patients below body mass index (BMI) 25 kg/m² in one year follow-up, and to compare the results of 1 week which we have reported in 2011.

Methods

In this prospective observational study, there were 31 type 2 diabetic patients who underwent DJB at Inha University Hospital from July 2009 to January 2011. We did laboratories such as 75-g oral glucose tolerance test (OGTT), insulin level and hemoglobin A1c (HbA1c), etc. and compared their changes of preoperative, a week, 3 months, and 12 months.

Results

Mean BMI was 23.1 ± 1.3 kg/m², mean duration of T2DM was 8.3 ± 4.7 and mean age was 46.6 ± 7.7 years. There were a significant decrease of 75-g OGTT levels and increase of insulin secretion after 3 months. 13.3% showed diabetic remission (HbA1c < 6.0, medication cessation) and 26.7% showed diabetic improvement. The rates of remission and improvement much declined comparing with that of postoperative 1 week although those were determined by fasting and postprandial 2 hour level of glucose.

Conclusion

This is the first study of metabolic surgery in Korean diabetes patients in the healthy weight range. DJB exerted positive influences on insulin resistance as well as beta cell function. Early effects on T2DM after DJB could be estimated as one of good modalities, although the effectiveness seems to be unacceptable. Further studies are mandatory for evaluation of the effectiveness of metabolic surgery and finding prognostic factors.

Resolution of type 2 diabetes after gastrectomy for gastric cancer with long limb Roux-en Y reconstruction: a prospective pilot study

PURPOSE

It is unclear whether metabolic surgery is effective in non obese type 2 diabetes mellitus (T2DM) and the result after gastrectomy and conventional reconstruction for gastric cancer with non obese T2DM are not satisfactory for improvement of T2DM. Prospective single-arm pilot study with long limb Roux-en Y reconstruction after gastrectomy was evaluated on its safety and efficacy as a potential cure for T2DM in patients with non obese gastric cancer.

METHODS

Fifteen patients with non obese T2DM and gastric cancer were enrolled. After gastrectomy, the gastrointestinal tract was reconstructed by Roux-en Y gastrojejunostomy or esophagojejunostomy. The biliopancreatic and Roux limb were 100 to 120 cm long each.

RESULTS

There was no surgery-related mortality, but four cases experienced complications (26.7%). Before surgery, the mean body mass index was 25.2 ± 3.4 kg/m(2) and mean glycated hemoglobin (HbA1c) was 7.7 ± 1.4% with antidiabetic medications. The mean BMI decreased to 21.7 ± 3.1 kg/m(2) (P < 0.05) and the mean HbA1c decreased to 6.3 ± 0.8% (P < 0.05) 6 months after surgery. At the end of the study (follow-up duration, 12.5 ± 5.5 months), HbA1c decreased to <6% in 11 patients (78.6%) without any antidiabetic medications. There were no patients who had anemia, and/or malnutrition after surgery except one patient who died due to recurrence four months after surgery.

CONCLUSION

Long limb Roux-en Y reconstruction after gastrectomy is feasible and has the potential to cure T2DM in non obese gastric cancer patients. A randomized controlled trial is needed to confirm this result.

Weight loss surgery for mild to moderate obesity: a systematic review and economic evaluation

BACKGROUND

A systematic review and economic evaluation was commissioned to determine the effectiveness and cost-effectiveness of bariatric surgery for mild [class I, body mass index (BMI) 30 to 34.99] or moderate (class II, BMI 35 to 39.99) obesity.

METHODS

We searched 17 electronic resources (to February 2010) and other sources. Studies meeting predefined criteria were identified, data-extracted and assessed for risk of bias using standard methodology. A model was developed to estimate cost-effectiveness.

RESULTS

Two RCTs were included. Evidence from both indicated a statistically significant benefit from laparoscopic adjustable banding (LAGB) compared to a non-surgical comparator for weight loss and in obesity-related comorbidity. Both interventions were associated with adverse events. LAGB costs more than non-surgical management. For people with class I or II obesity and type 2 diabetes (T2D), the incremental cost-effectiveness ratio (ICER) at 2 years is £20,159, reducing to £4,969 at 5 years and £1,634 at 20 years. Resolution of T2D makes the greatest contribution to this reduction. In people with class I obesity, the ICER is £63,156 at 2 years, £17,158 at 5 years, and £13,701 at 20 years. Cost-effectiveness results are particularly sensitive to utility gain from reduction in BMI, factors associated with poorer surgical performance and diabetes health state costs.

CONCLUSIONS

Bariatric surgery appears to be a clinically effective and cost-effective intervention for people with class I or II obesity who also have T2D but is less likely to be cost-effective for people with class I obesity.

Lifestyle modifications and surgical options in the treatment of patients with obesity and type 2 diabetes mellitus

This article reviews recent developments in the behavioral and surgical treatment of obesity and type 2 diabetes mellitus (T2DM). Randomized controlled trials of comprehensive lifestyle-modification programs, which include dietary interventions, physical activity, and behavioral therapy, have shown weight losses of 7% to 10% of initial body weight within 4 to 6 months after treatment. These programs also reduce the likelihood of developing T2DM by 58% for individuals with impaired glucose tolerance. Long-term maintenance of these improvements requires continued implementation of the program diet, physical activity, and self-regulatory behaviors. This can be successfully facilitated by continued patient-provider contact, which is frequently delivered by phone, mail, email, or online. However, these benefits may have less impact on those with extreme obesity or more significant health problems. For these individuals, bariatric surgery may be a more appropriate treatment. Bariatric surgical procedures induce mean weight losses of 15% to 30% of initial body weight (depending on the procedure) within 2 years after surgery, as well as a 45% to 95% rate of diabetes remission. Familiarity with these developments can help physicians and patients to determine which combinations of behavioral, medical, and surgical interventions are appropriate for the treatment of obesity and T2DM.

Comparison of Bariatric Surgical Procedures for Diabetes Remission: Efficacy and Mechanisms

Bariatric surgery induces a mean weight loss of 15-30% of initial body weight (depending on the procedure), as well as a 45-95% rate of diabetes remission. Procedures that induce greater weight loss are associated with higher rates of diabetes remission. Improvements in glucose homeostasis after bariatric surgery are likely mediated by a combination of caloric restriction (followed by weight loss) and the effects of altered gut anatomy on the secretion of glucoregulatory gut hormones.

Jejunal nutrient sensing is required for duodenal-jejunal bypass surgery to rapidly lower glucose concentrations in uncontrolled diabetes

Gastrointestinal bypass surgeries restore metabolic homeostasis in patients with type 2 diabetes and obesity(1), but the underlying mechanisms remain elusive. Duodenal-jejunal bypass surgery (DJB), an experimental surgical technique that excludes the duodenum and proximal jejunum from nutrient transit(1,2), lowers glucose concentrations in nonobese type 2 diabetic rats(2–5). Given that DJB redirects and enhances nutrient flow into the jejunum and that jejunal nutrient sensing affects feeding(6,7), the repositioned jejunum after DJB represents a junction at which nutrients could regulate glucose homeostasis. Here we found that intrajejunal nutrient administration lowered endogenous glucose production in normal rats through a gut-brain-liver network in the presence of basal plasma insulin concentrations. Inhibition of jejunal glucose uptake or formation of long chain fatty acyl-coA negated the metabolic effects of glucose or lipid, respectively, in normal rats, and altered the rapid (2 d) glucose-lowering effect induced by DJB in streptozotocin (STZ)-induced uncontrolled diabetic rats during refeeding. Lastly, in insulin-deficient autoimmune type 1 diabetic rats and STZ-induced diabetic rats, DJB lowered glucose concentrations in 2 d independently of changes in plasma insulin concentrations, food intake and body weight. These data unveil a glucoregulatory role of jejunal nutrient sensing and its relevance in the early improvement of glycemic control after DJB in rat models of uncontrolled diabetes.

Roux-en-Y gastric bypass stands the test of time: 5-year results in low body mass index (30-35 kg/m(2)) Indian patients with type 2 diabetes mellitus

BACKGROUND

Our objective was to evaluate the long-term results of laparoscopic Roux-en-Y gastric bypass on excess weight loss, remission of the metabolic syndrome, and complications in Indian patients with uncontrolled type 2 diabetes mellitus (T2DM) with a body mass index of 30-35 kg/m(2). The setting was a corporate hospital in Mumbai, India.

METHODS

The present prospective observational study was begun in January 2006. A total of 52 patients with uncontrolled T2DM and a body mass index of 30-35 kg/m(2) elected to undergo laparoscopic Roux-en-Y gastric bypass. The duration of T2DM was 3.5-14.5 years (median 8.4). Of the 52 patients, 61.5% had hypertension and 59.6% had dyslipidemia. Remission of T2DM and other components of the metabolic syndrome were assessed. All patients were followed up for 5 years.

RESULTS

The median percentage of excess weight loss was 72.2% at 1 year and 67.8% at 5 years. Of the 52 patients, 84.6% had achieved euglycemia and 73.1% had achieved complete remission, 23.1% partial remission, and 3.84% no remission at 1 year. Weight regain occurred in 8 patients. They required antihypertensive drugs and statins, decreasing the complete remission rate to 57.7% and partial remission rate to 38.5% at 5 years. However, 96.2% improvement in metabolic status was found at the end of 5 years.

CONCLUSION

Laparoscopic Roux-en-Y gastric bypass is a safe, efficacious, and cost-effective treatment for uncontrolled T2DM in patients with a body mass index of 30-35 kg/m(2). Early-onset T2DM, better weight loss, and greater C-peptide levels were predictors of success after surgery. The improvement after surgery in hyperglycemia, hypertension, and dyslipidemia could help in controlling the occurrence of micro- and macrovascular complications and decrease the morbidity and mortality associated with T2DM.

Effects of gastric bypass surgery in patients with type 2 diabetes and only mild obesity

OBJECTIVE

Roux-en-Y gastric bypass (RYGB) ameliorates type 2 diabetes in severely obese patients through mechanisms beyond just weight loss, and it may benefit less obese diabetic patients. We determined the long-term impact of RYGB on patients with diabetes and only class I obesity.

RESEARCH DESIGN AND METHODS

Sixty-six consecutively selected diabetic patients with BMI 30-35 kg/m(2) underwent RYGB in a tertiary-care hospital and were prospectively studied for up to 6 years (median 5 years [range 1-6]), with 100% follow-up. Main outcome measures were safety and the percentage of patients experiencing diabetes remission (HbA(1c) <6.5% without diabetes medication).

RESULTS

Participants had severe, longstanding diabetes, with disease duration 12.5 ± 7.4 years and HbA(1c) 9.7 ± 1.5%, despite insulin and/or oral diabetes medication usage in everyone. For up to 6 years following RYGB, durable diabetes remission occurred in 88% of cases, with glycemic improvement in 11%. Mean HbA(1c) fell from 9.7 ± 1.5 to 5.9 ± 0.1% (P < 0.001), despite diabetes medication cessation in the majority. Weight loss failed to correlate with several measures of improved glucose homeostasis, consistent with weight-independent antidiabetes mechanisms of RYGB. C-peptide responses to glucose increased substantially, suggesting improved β-cell function. There was no mortality, major surgical morbidity, or excessive weight loss. Hypertension and dyslipidemia also improved, yielding 50-84% reductions in predicted 10-year cardiovascular disease risks of fatal and nonfatal coronary heart disease and stroke.

CONCLUSIONS

This is the largest, longest-term study examining RYGB for diabetic patients without severe obesity. RYGB safely and effectively ameliorated diabetes and associated comorbidities, reducing cardiovascular risk, in patients with a BMI of only 30-35 kg/m(2).

Alterações dos parâmetros clínicos e laboratoriais em pacientes obesos com diabetes melito tipo 2 submetidos à derivação gastrojejunal em y de Roux sem anel

OBJETIVOS: Verificar as alterações do peso e índice de massa corporal em pacientes obesos grau II e III com diabete melito tipo 2 nos períodos pré e pós-operatório e as alterações dos parâmetros laboratoriais de glicemia de jejum, glicemia pós-prandial, hemoglobina glicada, insulina nos períodos pré e pós-operatório. MÉTODOS: Realizou-se estudo prospectivo selecionando 40 pacientes com obesidade grau II e III, submetidos à derivação gastrojejunal em Y-de-Roux sem anel. Analisou-se no pré e pós-operatório de 60 dias o peso, índice de massa corporal, glicemia de jejum, glicemia pós-prandial, hemoglobina glicada e insulina. RESULTADOS: O peso médio pré-operatório foi de 107,3Kg diminuindo para 89,5Kg no pós-operatório. O índice de massa corporal médio inicial foi de 39,5Kg/m2 e 32,9Kg/m2 com 60 dias de pós-operatório. A glicemia de jejum no pré-operatório foi de 132 mg/dl e no pós-operatório diminuiu 40,4 mg/dl em média. A glicemia pós-prandial foi de 172 mg/dl no pré-operatório e 111,6 mg/dl no controle pós-operatório. A hemoglobina glicada inicial foi de 7% declinando para 5,7% no pós-operatório. A insulina pré-operatória foi 29,6 uIU/ml e a pós-operatória 13,9 uIU/ml. Todas as variáveis apresentaram significância estatística com p<0,001. CONCLUSÃO: Houve significante diminuição de peso e no índice de massa corporal entre os períodos pré e pós-operatórios e diminuição também significante dos parâmetros laboratoriais de glicemia de jejum, glicemia pós-prandial, hemoglobina glicada, insulina entre os mesmos períodos.

Influence of gastrectomy for stomach cancer on type 2 diabetes mellitus for patients with a body mass index less than 30 kg/m(2)

Purpose

The impressive effect of LRYGBP on mildly obese patients (30 kg/m² < BMI < 35 kg/m²) with T2DM raises the argument for lowering the threshold for surgical intervention to non-obesity (BMI < 30 kg/m²). The goal of this study was to evaluate the effect of gastrectomy on non-obese patients with T2DM and what preoperative clinical factors are associated with postoperative long term improvement.

Methods

In this retrospective review, we analyzed the change in diabetic status in 75 patients with gastric cancer undergoing three different gastrectomies in a single institution from June 1996 to September 2009. Pre- and postoperative fasting blood glucose, serum hemoglobin A1c and diabetic medication requirements were compared. The demographic data and other biochemical markers were also collected.

Results

At an average follow-up of 35.0 ± 25.9 months, we collected the data of 75 patients and evaluated the change of diabetes status. There was no resolution of diabetes in Billroth-I (B-I) group, and 45.2% of patients improved whereas the resolution rate of Billroth-II (B-II) and RY group was 22.2% and 23.5% and 85.2% and 88.2%, respectively. The improvement rate of diabetes mellitus (DM) status was 7.46 times higher in B-II than in B-I patients. The method of reconstruction is the most powerful factor and severity and duration of diabetes showed significant clinical factors for the improvement of the disease after surgery.

Conclusion

According to these results, foregut-bypass procedure may improve the type 2 DM better than can be explained by the effect of weight loss only. Diabetes remission is significantly higher in those with duration of diabetes less than 5 years.

Predictors of diabetes remission after bariatric surgery in Asia

BACKGROUND

Obesity and type II diabetes mellitus (T2DM) are closely related and difficult to control by current medical treatment. Bariatric surgery has been proposed for inadequately controlled T2DM in association with obesity. However, prediction of successful T2DM remission after surgery has not been clearly studied in Asian patients. This information might be helpful for applying gastrointestinal surgery as metabolic surgery for T2DM.

METHODS

This was a retrospective clinical study. From January 2002 to December 2008, 88 consecutive patients with morbid obesity, who were enrolled into a surgically supervised weight loss program, and who had T2DM before surgery with at least 1 year complete follow-up data were included. Sixty-eight (77.2%) patients received gastric bypass procedures, and the remaining 20 (22.8%) received restrictive procedures. We analyzed the available information during the initial evaluation of patients who were referred for bariatric surgery, by logistic regression analysis and data mining methods for predictors of successful diabetes remission after surgery.

RESULTS

Overall, 68 (77.2%) of the 88 patients had remission of their T2DM 1 year after surgery. Patients in the bypass group had a higher remission rate than those in the restrictive group [59/68 (86.7%) vs. 9/20 (45.0%), p=0.000]. In univariate analysis, patients who had T2DM remission after surgery were younger, heavier, had a wider waist, less severe disease, shorter duration, and higher C-peptide levels than those without remission. Type of operation and T2DM duration remained independent predictors of success after multivariate logistical regression analysis (p<0.000). Data mining analysis confirmed that T2DM duration was the most important predictor.

CONCLUSIONS

Bariatric surgery is a treatment option for T2DM. Duration of diabetes is the most predictor of success after surgery.

Current evidence for a role of GLP-1 in Roux-en-Y gastric bypass-induced remission of type 2 diabetes

Weight-reducing surgical procedures such as Roux-en-Y gastric bypass (RYGB) have proven efficient as means of decreasing excess body weight. Furthermore, some studies report that up to 80% of patients with type 2 diabetes mellitus (T2DM) undergoing RYGB experience complete remission of their T2DM. Interestingly, the majority of remissions occur almost immediately following the operation and long before significant weight loss has taken place. Following RYGB, dramatic increases in postprandial plasma concentrations of the incretin hormone glucagon-like peptide-1 (GLP-1) have been recorded, and the known antidiabetic effects of GLP-1 are thought to be key mediators in RYGB-induced remission of T2DM. However, the published studies on the impact of RYGB on GLP-1 secretion are few, small and often not controlled properly. Furthermore, mechanistic studies delineating the role of endogenous GLP-1 secretion in RYGB-induced remission of T2DM are lacking. This article critically evaluates the current evidence for a role of GLP-1 in RYGB-induced remission of T2DM.

Role of bariatric-metabolic surgery in the treatment of obese type 2 diabetes with body mass index <35 kg/m2: a literature review

Bariatric surgery has been used to treat type 2 diabetes mellitus (T2DM); however, its efficacy is still debatable. This literature review analyzed articles that evaluated the effects of bariatric surgery in treatment of T2DM in obese patients with a body mass index (BMI) of <35 kg/m(2). A paired t test was applied for the analysis of pre- and postintervention mean BMI, fasting plasma glucose (FPG), and glycosylated hemoglobin (A1c) values. A significant (P<0.001) reduction in BMI (from 29.95±0.51 kg/m(2) to 24.83±0.44 kg/m(2)), FPG (from 207.86±8.51 mg/dL to 113.54±4.93 mg/dL), and A1c (from 8.89±0.15% to 6.35±0.18%) was observed in 29 articles (n=675). T2DM resolution (A1c <7% without antidiabetes medication) was achieved in 84.0% (n=567) of the subjects. T2DM remission, control, and improvement were observed in 55.41%, 28.59%, and 14.37%, respectively. Only 1.63% (n=11) of the subjects presented similar or worse glycemic control after the surgery. T2DM remission (A1c <6% without antidiabetes medication) was higher after mini-gastric bypass (72.22%) and laparoscopic/Roux-en-Y gastric bypass (70.43%). According to the Foregut and Hindgut Hypotheses, T2DM results from the imbalance between the incretins and diabetogenic signals. The procedures that remove the proximal intestine and do ileal transposition contribute to the increase of glucagon-like peptide-1 levels and improvement of insulin sensitivity. These findings provide preliminary evidence of the benefits of bariatric-metabolic surgery on glycemic control of T2DM obese subjects with a BMI of <35 kg/m(2). However, more clinical trials are needed to investigate the metabolic effects of bariatric surgery in T2DM remission on pre-obese and obese class I patients.

Medical versus surgical treatment of type 2 diabetes: the search for level 1 evidence

Data from observational and nonrandomized comparative studies have shown a dramatic effect of bariatric surgery on type 2 diabetes mellitus (T2DM), including in nonobese patients. However, a relative paucity of level 1 evidence is available to define the exact role of surgery as a treatment modality for T2DM, especially in less obese subjects. Performing randomized clinical trials in this field, however, poses significant and specific challenges for the study design. We have addressed such challenges in a carefully designed randomized controlled trial comparing glycemic control with optimal medical management versus Roux-en-Y gastric bypass in overweight to mildly obese patients with T2DM mellitus (body mass index 26-35 kg/m(2)). The present report describes the rationale and design of the Weill Cornell Medical College study. In addition to glycemic endpoints, however, clinical trials should also investigate the effect of surgery on cardiovascular risk or T2DM-specific morbidity. Addressing these endpoints would entail large, randomized clinical trials with prolonged period of observation and ideally a multicenter study design. Such a multisite trial poses substantial logistical and financial challenges, which would predictably delay rather than accelerate progress of research in this field. A consortium of centers performing independent small and medium size randomized clinical trials may provide a more realistic and feasible approach. In this paper, we present an overview of on-going randomized clinical trials in this field and propose a worldwide consortium of randomized controlled trials (WORLDCoRDS) using the Weill Cornell Medical College protocol. The aim of this consortium is to standardize research in T2DM surgery and timely accumulate homogeneous data that can help assess the effects of GI surgery on cardiovascular risk and T2DM-related mortality and morbidity.

Metabolic laparoscopic gastric bypass for obese patients with type 2 diabetes

BACKGROUND

Bariatric surgery has been proposed as the most effective treatment for patients with type 2 diabetes mellitus (T2DM) and body mass index (BMI) above 35 kg/m(2). The purpose of our study was to access remission rate and improvement of metabolic control of T2DM after gastric bypass.

METHODS

A prospective study was carried out on 94 diabetic patients, who underwent gastric bypass with a 200-cm biliopancreatic limb. Characteristics evaluated included weight, BMI, percentage of excess BMI lost (% EBMIL), fasting glucose, HbA1c, and lipid profile up to 36 months after surgery, as well as anti-diabetic treatment before and after surgery.

RESULTS

At the time of surgery, patients had a mean BMI of 44.3 ± 0.65 kg/m(2) and length of T2DM diagnosis of 6.2 ± 0.98 years and HbA1c of 6.6 ± 0.21%. After a mean time of follow-up of 2.6 ± 0.13 years, the weight loss was significant from 3 months onwards after surgery, reaching its peak at 24 months with a BMI of 32.1 ± 0.9 kg/m(2) and corresponding % EBMIL of 69.0 ± 2.84%. Remission rates of diabetes were 87.91% at 6 months, 92.68% at 12 months, 92.85% at 24 months, and 100% at 36 months of follow-up.

CONCLUSIONS

Gastric bypass in obese patients is associated with a high remission rate of diabetes and improvement of the metabolic control. Although confirmation with randomized controlled studies is needed, these results suggest that this type of surgery might be particularly indicated for obese diabetic patients with good pancreatic reserve.

Safety and efficacy of Roux-en-Y gastric bypass to treat type 2 diabetes mellitus in non-severely obese patients

The efficacy of Roux-en-Y gastric bypass (RYGB) to control type 2 diabetes mellitus (T2DM) has been demonstrated in morbidly obese patients. Surgical procedures primarily focused on T2DM control in patients with body mass index (BMI) < 35 kg/m(2) have shown to effectively induce remission of T2DM. However, only few reports have evaluated the safety and efficacy of RYGB in this group of patients. The aim of this study is to assess the safety and efficacy of RYGB in TD2M patients with BMI < 35 kg/m(2). All T2DM patients with BMI < 35 kg/m(2) and at least 12 months of follow-up who underwent laparoscopic RYGB were included. Safety of the procedure was evaluated according to mortality, need of reoperation/conversion, and complication rates. Metabolic parameters were evaluated at baseline and 6, 12, and 24 months after surgery. Thirty patients were included. Seventeen (56.6%) were women. Age, BMI, and duration of diabetes were 48 ± 9 years, 33.7 ± 1.2 kg/m(2), 4 ± 2.9 years, respectively. No mortality was observed. No conversion/reoperation was needed. Average length of stay was 3.2 ± 0.9 days. Early and late postoperative complications were observed in five (16.6%) and five (16.6%) patients, respectively. Twelve months after surgery, remission was observed in 25 of 30 patients (83.3%). After 2 years, remission was achieved in 13 of 20 patients (65%), and hemoglobin A1c decreased from 8.1 ± 1.8% to 5.9 ± 1.1% and homeostasis model assessment of insulin resistance from 5.7 ± 3.2 to 1.9 ± 0.8 after 12 months. RYGB is a safe and effective procedure to induce T2DM remission in otherwise not eligible patients for bariatric surgery. Evidence from prospective studies is needed to validate this approach.

Metabolic effects of bariatric surgery in type 2 diabetic patients with body mass index < 35 kg/m2

AIM

The aim of this meta-analysis is to assess the metabolic effects of bariatric surgery in type 2 diabetes mellitus (T2DM) patients with body mass index (BMI) < 35 kg/m(2) .

METHODS

We performed an electronic literature search of published articles to identify relevant evidence since inception to June 2011. Primary outcome measures were metabolic improvement and resolution diabetes after bariatric surgery. The weighted mean difference (WMD) and its 95% confidence interval (CI) were calculated from the raw data extracted from the original literature. The software Review Manager (version 4.3.1) was applied for meta-analysis.

RESULTS

Thirteen trials involving 357 patients were included in the meta-analysis. The follow-up interval ranged from 6 months to 18 years. According to WMD calculation, bariatric surgery led to 5.18 kg/m(2) of BMI lowering (95% CI, 3.79-6.57, p < 0.00001), 4.8 mmol/l of fasting plasma glucose (FPG) decrement (95% CI, 3.88-5.71 mmol/l, p < 0.00001), 2.59% of HbA1c decreasing (95% CI, 2.12-3.07%, p < 0.00001), 56.67 mg/dl of triglyceride decrement (95% CI 11.53-101.82, p = 0.01) and 48.38 mg/dl of total cholesterol reduction (95% CI 21.08-75.68, p = 0.0005). Moreover, the procedures produced an increased high-density lipoprotein cholesterol by 5.37 mg/dl (95% CI -11.37-0.63, p = 0.08). However, this effect was not statistically significant. Overall, 80.0% of the patients achieved adequate glycaemic control (HbA1c < 7%) without antidiabetic medication. The surgeries produced a low incidence of major complications (3.2%) with no mortality.

CONCLUSIONS

Bariatric surgery is effectual and safe in the treatment of non-severely obese (BMI < 35 kg/m(2) ) T2DM patients. Moreover, the metabolic benefits acquired from the procedures can be long sustained after the surgery.

Glycemic control after stomach-sparing duodenal-jejunal bypass surgery in diabetic patients with low body mass index

BACKGROUND

Bariatric surgery frequently results in the resolution of type 2 diabetes mellitus (T2DM). One of the many factors that could explain such findings is the duodenal exclusion of the alimentary tract. To test this hypothesis, a surgical model that induces glycemic control without significant weight loss would be ideal. In the present study, we evaluated the early metabolic changes that occur in overweight diabetic patients after laparoscopic duodenal-jejunal bypass (DJB) and determined the factors associated with success in T2DM resolution. The setting was a private practice.

METHODS

A total of 35 patients (20 men and 15 women) were included in the present study. The mean preoperative body mass index was 28.4 ± 2.9 kg/m(2). DJB was performed in all patients, and the anthropometric data and blood samples were collected at baseline (preoperatively) and 3, 6, 9, and 12 months after surgery. Success was defined when patients reached a glycated hemoglobin level of <7% without diabetic medication.

RESULTS

T2DM remission was observed in 14 (40%) of 35 patients. No differences in the homeostasis model assessment insulin resistance index levels and patient weight were observed before and 12 months after DJB surgery. Gender, duration of T2DM, previous use of insulin, preoperative homeostasis model assessment insulin resistance index, and C-peptide levels were not significant predictive factors of success or nonsuccess. The only factor that significantly predicted postoperative positive outcomes was a waist circumference reduction of ≥ 7% compared with baseline within the first 6 months after surgery.

CONCLUSION

DJB improves glycemic control; however, it does not increase insulin sensitivity in overweight diabetic patients. These changes were observed without significant weight loss.

A model for predicting the resolution of type 2 diabetes in severely obese subjects following Roux-en Y gastric bypass surgery

BACKGROUND

Severely obese type 2 diabetics who undergo Roux-en Y gastric bypass surgery have significant improvements in glycaemic control. Little work has been undertaken to establish the independent predictors of such resolution or to develop a predictive model. The aim of this study was to develop a mathematical model and establish independent predictors for the resolution of diabetes.

METHODS

A consecutive sample of 130 severely obese type 2 diabetics who underwent gastric bypass surgery for weight loss from November 1997 to May 2007 with prospective pre-operative documentation of biochemical and clinical measurements was followed up over 12 months. Logistic discrimination analysis was undertaken to identify those variables with independent predictive value and to develop a predictive model for resolution of type 2 diabetes. Consecutive samples of 130 patients with body mass index (BMI) ≥ 35 with type 2 diabetes were selected. One hundred and twenty-seven patients completed the study with a sufficient data set. Patients were deemed unresolved if (1) diabetic medication was still required after surgery; (2) if fasting plasma glucose (FPG) remained >7 mmol/L; or (3) HbA1c remained >7%.

RESULTS

Resolution of diabetes was seen in 84%, while diabetes remained but was improved in 16% of patients. Resolution was rapid and sustained with 74% of those on medication before surgery being able to discontinue this by the time of discharge 6 days following surgery. Five pre-operative variables were found to have independent predictive value for resolution of diabetes, including BMI, HbA1c, FPG, hypertension and requirement for insulin. Two models have been proposed for prediction of diabetes resolution, each with 86% correct classification in this cohort of patients.

CONCLUSIONS

Type 2 diabetes resolves in a very high percentage of patients undergoing gastric bypass surgery for severe obesity. The key predictive variables include pre-operative BMI, HbA1c, FPG, the presence of hypertension and diabetic status.

Diabetes remission and insulin secretion after gastric bypass in patients with body mass index <35 kg/m2

BACKGROUND

Most morbidly obese patients who undergo gastric bypass experience rapid remission of type 2 diabetes mellitus (T2DM) but the response in non-morbidly obese patients is not clear. This trial prospectively assessed the effect of diabetes remission, glucose metabolism, and the serial changes of insulin secretion after gastric bypass in inadequately controlled T2DM patients with a BMI of 23-35 kg/m(2).

METHODS

A total of 62 consecutive patients with T2DM and a BMI of 23-35 kg/m(2) underwent gastric bypass. Data were prospectively collected before surgery and 1, 4, 12, 26, and 52 weeks and 2 years after surgery. Insulin secretion was measured by insulinogenic index and area under the curve (AUC) during a standard oral glucose tolerance test (OGTT). Remission of type 2 diabetes was defined as fasting glucose level <110 mg/dl and HbA1c <6.0% without any glycemic therapy.

RESULTS

Of the 62 patients, 24 were men and 38 were women (age 43.1 ± 10.8 years). Their preoperative characteristics were as follows: BMI 30.1 ± 3.3 kg/m(2), waist circumference 99.6 ± 9.6 cm, C-peptide 3.1 ± 1.4 ng/ml, and duration of T2DM 5.4 ± 5.1 years. The mean BMI decreased postoperatively to 22.6 ± 2.3 kg/m(2) in 1 year and 23.0 ± 2.7 kg/m(2) in 2 years. The mean HbA1c decreased from 9.7 ± 1.9% to 5.8 ± 0.5% in 1 year and 5.9 ± 0.5% in 2 years. Complete remission of T2DM was achieved in 57% in 1 year and 55% in 2 years after surgery. Before surgery, the OGTT test showed a blunted insulin secretion pattern with an insulinogenic index of 0.1 ± 0.2 and AUC of 2,324 ± 1,015 μIU min/ml. In 1 week after surgery, the insulinogenic index increased to 0.16 and AUC decreased to 1,366 μIU min/ml along with a rapid drop of insulin resistance. The insulinogenic index and AUC gradually increased to 0.27 and 3,220, respectively, 1 year after surgery and remained stable up to 2 years with a very low insulin resistance.

CONCLUSIONS

Laparoscopic gastric bypass facilitates immediate improvement in the glucose metabolism of inadequately controlled non-severe obese T2DM patients, and the benefit is sustained up to 2 years after surgery. The benefit is regulated by the decrease in insulin resistance, increase in early insulin response, and total insulin secretion to glucose load.

Body mass trajectories through midlife among adults with class I obesity

BACKGROUND

Little is known about the body mass trajectories for adults with class I obesity. Our objective was to map the body mass trajectories through midlife for young adults with class I obesity in the United States.

METHODS

Data from the National Longitudinal Study of Youth 1979 was used to generate a cohort of 1058 men and women, aged 25-33 years with class I obesity in 1990. Group-based trajectory modeling was used to identify the number and shape of the body mass index trajectories from 1990 to 2008 for this cohort.

RESULTS

By 2008, about 15% of men and women with class I obesity in 1990 experienced a body mass index increase to >40 kg/m(2). The trajectory analyses showed that roughly one third of the sample were on 1 of 2 body mass index trajectory groups that culminated with an average BMI well above 35 kg/m(2).

CONCLUSION

The large majority of young adults with class I obesity are likely to gain weight over time. For many, the weight gain will be significant and greatly increase their risk of obesity-related co-morbidities and reduced life expectancy. As a result, bariatric surgery or other intensive weight management options might be warranted.