Risk prediction of complications of metabolic syndrome before and 6 years after gastric bypass

Long-term changes in lipid indices following Roux-en-Y gastric bypass: a meta-analysis

INTRODUCTION

Bariatric surgery yields clinically significant long-term weight loss accompanied by marked improvements in numerous weight-related comorbidities including type 2 diabetes, hypertension, dyslipidemia, obstructive sleep apnea, and fatty liver disease.

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the effect of (RYGB) surgery on lipid profile.

DATA SOURCE

We searched PubMed, Scopus, Web of Science and Scholar from inception to May 20th, 2024.

STUDIES SELECTION

Clinical studies that reported lipid profile data with a follow-up of at least 5 years after RYGB were eligible.

DATA EXTRACTION

Two independent reviewers extracted data and assessed the risk of bias.

RESULTS

Of the 4922 articles identified from our database search, 38 studies that measured lipid profile following RYGB were identified and selected for the analysis. Compared to pre-surgery, at post-surgery follow-up of ≥ 5 years, RYGB was associated with significant reductions in mean total cholesterol (TC) (WMD: - 17.95 mg/dl, 95% CI: - 22.68, - 13.22, 95% PI: - 46.18, 10.27 p < 0.001; I2:92.3), LDL-cholesterol (WMD: - 18.55 mg/dl, 95% CI: -21.85, -15.25, 95% PI: - 39.01, 1.92 p < 0.001; I2:91.8), and triglycerides (WMD: - 60.76 mg/dl, 95% CI: - 66.29, - 55.22, 95% PI: - 91.24, - 30.27 p < 0.001; I2:83.7), and increase in HDL-cholesterol (WMD: 13.75 mg/dl, 95% CI: 12.38, 15.13, 95% PI: 5.32, 22.19 p < 0.001; I2:91.4).

CONCLUSION

RYBG is associated with clinically significant large improvements in serum lipids at a post-operative follow-up of 5 years or more.

Association of prior bariatric surgery with financial and clinical outcomes of acute myocardial infarction

BACKGROUND

Superior clinical outcomes after hospitalization for cardiovascular-related disease such as acute heart failure have been linked with prior history of bariatric surgery, but similar analyses in acute myocardial infarction (MI) are currently limited.

OBJECTIVE

This work examines clinical outcomes and resource utilization in patients with acute MI hospitalizations with a prior history of bariatric surgery.

SETTING

Academic university-affiliated hospital in the United States.

METHODS

All adult patients with hospitalizations with a primary diagnosis of acute MI were queried using the 2016-2020 Nationwide Readmissions Database. The study population was comprised of patients with an International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code for obesity (body mass index ≥35 kg/m2) as well as those with a prior history of bariatric surgery regardless of their body mass index status. Comparison was made between those with a prior history of bariatric surgery and those without. Univariate analysis and multivariate regression models were used to examine the association between bariatric surgery and outcomes of interest, which included in-hospital mortality, medical complications, and resource utilization.

RESULTS

Of an estimated 2,736,606 hospitalizations for acute MI, 296,902 patients (10.8%) had a diagnosis of obesity and/or a prior history of bariatric surgery. The bariatric cohort was more frequently female and had a lower prevalence of congestive heart failure, chronic lung disease, diabetes, and electrolyte derangements than the nonbariatric cohort. After risk adjustment, prior history of bariatric surgery was associated with significantly lower odds of in-hospital mortality, cardiogenic shock, and acute kidney injury. Additionally, prior history of bariatric surgery was linked to a decreased duration of hospital stay and lower hospitalization costs as well as lower odds of nonhome discharge.

CONCLUSION

Among acute MI patients with obesity, prior history of bariatric surgery was associated with decreased odds of in-hospital mortality, improved clinical outcomes, and lower resource utilization. Expansion of bariatric surgery programs may provide improved access to a medical intervention that is intertwined with cardiovascular health.

Gastric Bypass Mortality Trends in Racial Cohorts: Are We Improving?

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) continues to be safely performed in racial cohorts. However, studies continue to report differences in complications, with non-Hispanic black (NHB) patients having a higher rate of adverse outcomes, including mortality. It is unclear how these disparate outcomes have evolved over time. Our objective was to determine RYGB procedure and mortality trends in racial cohorts.

METHODS

Using the 2015 to 2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project (MBSAQIP) database, we identified primary RYGB cases performed laparoscopically or robotically. Non-Hispanic white (NHW) and non-Hispanic black (NHB) patient cohorts were matched based on patient and surgical characteristics. Conditional logistic regression analysis was conducted on the matched pairs. Primary outcomes of interest included year-to-year all-cause and procedure-related mortality. Stata/MP 16.1 was utilized for analysis, and a p-value of < 0.05 and a 95% confidence interval that excluded 1 were considered significant.

RESULTS

A total of 148,829 RYGB cases in NHW (82.8%) and Black (17.2%) patients were analyzed. RYGB trends remain similar for NHB and NHW patients over 5 years. In matched cohorts, all-cause mortality (OR 2.23; 95% CI: 1.16-4.29), aggregate related readmission (OR 1.39; 95% CI: 1.27-1.51), related reintervention (OR 1.36; 95% CI: 1.19-1.56), and VTE (OR 1.86; 95% CI: 1.40-2.45) were more likely in NHB patients. During the study period, year-to-year mortality was higher in NHB patients compared to NHW patients.

CONCLUSION

Over a 5-year period, year-to-year mortality remains higher in NHB patients after RYGB. While bariatric outcomes continue to improve, outcome gaps between racial cohorts seem to persist.

Movement Is Life-Optimizing Patient Access to Total Joint Arthroplasty: Cardiovascular Health Disparities

Cardiovascular disease includes a collection of conditions with 6.7% of American adults having coronary artery disease and 45% having hypertension. Proper management of these conditions is low (<25%). Hypertension is highest among African Americans and is associated with lower socioeconomic status and education level. Heart disease is associated with postoperative complications, such as cardiovascular and cerebrovascular events, pulmonary and coagulopathy complications, and mortality. Underserved communities can be optimized beginning with a thorough preoperative assessment, which includes evaluating for food security, instituting dietary modifications and exercise regimens, and improving cardiovascular health with pharmacologic modalities and specialty care. Nurse navigators can be invaluable for guiding patients through a cardiovascular preoperative optimization pathway.

Metabolic Syndrome-Related Kidney Injury: A Review and Update

Metabolic syndrome (MetS) includes visceral obesity, hyperglycemia, dyslipidemia, and hypertension. The prevalence of MetS is 20-25%, which is an important risk factor for chronic kidney disease (CKD). MetS causes effects on renal pathophysiology, including glomerular hyperfiltration, RAAS, microalbuminuria, profibrotic factors and podocyte injury. This review compares several criteria of MetS and analyzes their differences. MetS and the pathogenesis of CKD includes insulin resistance, obesity, dyslipidemia, inflammation, oxidative stress, and endothelial dysfunction. The intervention of MetS-related renal damage is the focus of this article and includes controlling body weight, hypertension, hyperglycemia, and hyperlipidemia, requiring all components to meet the criteria. In addition, interventions such as endoplasmic reticulum stress, oxidative stress, gut microbiota, body metabolism, appetite inhibition, podocyte apoptosis, and mesenchymal stem cells are reviewed.

Association of Gastric Bypass Surgery With Risk of Developing Diabetic Retinopathy Among Patients With Obesity and Type 2 Diabetes in Sweden: An Observational Study

Importance

Knowledge of the incidence and progression of diabetic retinopathy (DR) after gastric bypass surgery (GBP) in patients with obesity and diabetes could guide the management of these patients.

Objective

To investigate the incidence of diabetic ocular complications in patients with type 2 diabetes after GBP compared with the incidence of diabetic ocular complications in a matched cohort of patients with obesity and diabetes who have not undergone GBP.

Design, Setting, and Participants

Data from 2 nationwide registers in Sweden, the Scandinavian Obesity Surgery Registry and the National Diabetes Register, were used for this cohort study. A total of 5321 patients with diabetes from the Scandinavian Obesity Surgery Registry who had undergone GBP from January 1, 2007, to December 31, 2013, were matched with 5321 patients with diabetes from the National Diabetes Register who had not undergone GBP, based on sex, age, body mass index (BMI), and calendar time (2007-2013). Follow-up data were obtained until December 31, 2015. Statistical analysis was performed from October 5, 2018, to September 30, 2019.

Exposure

Gastric bypass surgery.

Main Outcomes and Measures

Incidence of new DR and other diabetic ocular complications.

Results

The study population consisted of 5321 patients who had undergone GBP (3223 women [60.6%]; mean [SD] age, 49.0 [9.5] years) and 5321 matched controls (3395 women [63.8%]; mean [SD] age, 47.1 [11.5] years). Mean (SD) follow-up was 4.5 (1.6) years. The mean (SD) BMI and hemoglobin A1c concentration at baseline were 42.0 (5.7) and 7.6% (1.5%), respectively, in the GBP group and 40.9 (7.3) and 7.5% (1.5%), respectively, in the control group. The mean (SD) duration of diabetes was 6.8 (6.3) years in the GBP group and 6.4 (6.4) years in the control group. The risk for new DR was reduced in the patients who underwent GBP (hazard ratio, 0.62 [95% CI, 0.49-0.78]; P < .001). The dominant risk factors for development of DR at baseline were diabetes duration, hemoglobin A1c concentration, use of insulin, glomerular filtration rate, and BMI.

Conclusions and Relevance

This nationwide matched cohort study suggests that there is a reduced risk of developing new DR associated with GBP, and no evidence of an increased risk of developing DR that threatened sight or required treatment.

Weight Loss After Bariatric Surgery in Morbidly Obese End-Stage Kidney Disease Patients as Preparation for Kidney Transplantation. Matched Pair Analysis in a High-Volume Bariatric and Transplant Center

Background

The number of morbidly obese kidney transplant candidates is growing. They have limited access to kidney transplantation and are at a higher risk of postoperative complications. Bariatric surgery is considered as a safe weight loss method in those patients.

Objectives

Matched pair analysis was designed to analyze the preparatory and postoperative weight loss after bariatric procedures in end-stage kidney disease (ESKD) and non-ESKD morbidly obese patients.

Methods

Twenty patients with ESKD underwent bariatric surgery in our Centre of Excellence for Bariatric and Metabolic Surgery between 2015 and 2019 (nine one-anastomosis gastric bypasses, nine Roux-en-Y gastric bypasses, and two sleeve gastrectomies). They were compared with matched pairs from a dataset of 1199 morbidly obese patients without ESKD. Data on demographic factors and comorbidities was recorded. BMI was obtained at the start of the preparatory period preceding the bariatric procedure, at the time of procedure, and during the 1-year follow-up.

Results

The ESKD and non-ESKD patients did not differ significantly in preoperative weight loss (13.00 ± 11.69 kg and 15.22 ± 15.96 kg respectively, p = 0.619). During the 1-year follow-up, the weight loss was similar to the non-ESKD group. In the first 3 months, faster weight loss in ESKD was observed. Initial and follow-up BMI values did not differ significantly between groups. We demonstrated that obese patients with ESKD can lose weight as effectively as non-ESKD patients.

Conclusion

Morbidly obese ESKD patients have an equal weight loss to patients without ESKD. Bariatric surgery could improve access to kidney transplantation and may potentially improve transplantation outcomes of obese patients with ESKD.

Defining remission of type 2 diabetes in research studies: A systematic scoping review

BACKGROUND

Remission has been identified as a top priority by people with type 2 diabetes. Remission is commonly used as an outcome in research studies; however, a widely accepted definition of remission of type 2 diabetes is lacking. A report on defining remission was published (but not formally endorsed) in Diabetes Care, an American Diabetes Association (ADA) journal. This Diabetes Care report remains widely used. It was the first to suggest 3 components necessary to define the presence of remission: (1) absence of glucose-lowering therapy (GLT); (2) normoglycaemia; and (3) for duration ≥1 year. Our aim is to systematically review how remission of type 2 diabetes has been defined by observational and interventional studies since publication of the 2009 report.

METHODS AND FINDINGS

Four databases (MEDLINE, EMBASE, Cochrane Library, and CINAHL) were searched for studies published from 1 September 2009 to 18 July 2020 involving at least 100 participants with type 2 diabetes in their remission analysis, which examined an outcome of type 2 diabetes remission in adults ≥18 years and which had been published in English since 2009. Remission definitions were extracted and categorised by glucose-lowering therapy, glycaemic thresholds, and duration. A total of 8,966 titles/abstracts were screened, and 178 studies (165 observational and 13 interventional) from 33 countries were included. These contributed 266 definitions, of which 96 were unique. The 2009 report was referenced in 121 (45%) definitions. In total, 247 (93%) definitions required the absence of GLT, and 232 (87%) definitions specified numeric glycaemic thresholds. The most frequently used threshold was HbA1c<42 mmol/mol (6.0%) in 47 (20%) definitions. Time was frequently omitted. In this study, a total of 104 (39%) definitions defined time as a duration. The main limitations of this systematic review lie in the restriction to published studies written in English with sample sizes of over 100. Grey literature was not included in the search.

CONCLUSIONS

We found that there is substantial heterogeneity in the definition of type 2 diabetes remission in research studies published since 2009, at least partly reflecting ambiguity in the 2009 report. This complicates interpretation of previous research on remission of type 2 diabetes and the implications for people with type 2 diabetes. Any new consensus definition of remission should include unambiguous glycaemic thresholds and emphasise duration. Until an international consensus is reached, studies describing remission should clearly define all 3 components of remission.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019144619.

Can surgical weight loss reduce the risk of developing coronary heart disease?

BACKGROUND

Coronary heart disease (CHD) accounts for one third of all deaths in people older than 35 years in the United States.

OBJECTIVES

The aim of this study is to determine the impact of bariatric surgery, especially laparoscopic sleeve gastrectomy, on the risk of developing CHD.

SETTING

Academic, University affiliated hospital.

METHODS

We retrospectively reviewed all patients who underwent bariatric surgery from 2010-2016. All patients between 30 and 74 years of age without a previous history of CHD were included in our study. The risk score for predicting the incidence of CHD was measured preoperatively and at 12 months of follow-up.

RESULTS

Of the 1330 patients studied, 225 patients (16.9%) had all the required variables to calculate the CHD risk score. The mean age of our population was 51.4 ± 11.3 years, mostly female (67%, n = 152) and white (58.7%, n = 132). At the preoperative setting, our patient population had a systolic blood pressure in the prehypertensive ranges, with 40% (n = 90) having type 2 diabetes and 60% (n = 134) having arterial hypertension. The preoperative CHD preoperative risk was 8.9 ± 7.7% or 8-fold higher than the ideal risk. After 12 months of follow-up, the CHD absolute risk reduction was 2.7%, and the relative risk reduction was 42.0% for female patients and 5.4% and 38.8%, respectively, for male patients. All the metabolic factors used to calculate the risk of developing CHD had a significant improvement after 12 months.

CONCLUSIONS

Surgical weight loss reduces the risk of developing CHD. Further studies should assess these findings in a long-term follow-up.

Impact of weight trajectory after bariatric surgery on co-morbidity evolution and burden

Background

Bariatric surgery, such as Roux-en-Y gastric bypass [RYGB] has been shown to be an effective intervention for weight management in select patients. After surgery, different patients respond differently even to the same surgery and have differing weight-change trajectories. The present analysis explores how improving a patient’s post-surgical weight change could impact co-morbidity prevalence, treatment and associated costs in the Canadian setting.

Methods

Published data were used to derive statistical models to predict weight loss and co-morbidity evolution after RYGB. Burden in the form of patient-years of co-morbidity treatment and associated costs was estimated for a 100-patient cohort on one of 6 weight trajectories, and for real-world simulations of mixed patient cohorts where patients experience multiple weight loss outcomes over a 10-year time horizon after RYGB surgery. Costs (2018 Canadian dollars) were considered from the Canadian public payer perspective for diabetes, hypertension and dyslipidaemia. Robustness of results was assessed using probabilistic sensitivity analyses using the R language.

Results

Models fitted to patient data for total weight loss and co-morbidity evolution (resolution and new onset) demonstrated good fitting. Improvement of 100 patients from the worst to the best weight loss trajectory was associated with a 50% reduction in 10-year co-morbidity treatment costs, decreasing to a 27% reduction for an intermediate improvement. Results applied to mixed trajectory cohorts revealed that broad improvements by one trajectory group for all patients were associated with 602, 1710 and 966 patient-years of treatment of type 2 diabetes, hypertension and dyslipidaemia respectively in Ontario, the province of highest RYGB volume, corresponding to a cost difference of $3.9 million.

Conclusions

Post-surgical weight trajectory, even for patients receiving the same surgery, can have a considerable impact on subsequent co-morbidity burden. Given the potential for alleviated burden associated with improving patient trajectory after RYGB, health care systems may wish to consider investments based on local needs and available resources to ensure that more patients achieve a good long-term weight trajectory.

The Outcome of Bariatric Surgery in Patients Aged 75 years and Older

BACKGROUND

Bariatric surgery has been shown to be safe and effective in patients aged 60-75 years; however, outcomes in patients aged 75 or older are undocumented.

METHODS

Patients aged 75 years and older who underwent bariatric procedures in two academic centers between 2006 and 2015 were studied.

RESULTS

A total of 19 patients aged 75 years and above were identified. Eleven (58%) were male, the median age was 76 years old (range 75-81), and the median preoperative body mass index (BMI) was 41.4 kg/m² (range 35.8-57.5). All of the bariatric procedures were primary procedures and performed laparoscopically: sleeve gastrectomy (SG) (n = 11, 58%), adjustable gastric band (AGB) (n = 4, 21%), Roux-en-Y gastric bypass (RYGB) (n = 2, 11%), banded gastric plication (n = 1, 5%), and gastric plication (n = 1, 5%). The median operative time was 120 min (range 75-240), and the median length of stay was 2 days (range 1-7). Three patients (16%) developed postoperative atrial fibrillation which completely resolved at discharge. At 1 year, the median percentage of total weight loss (%TWL) was 18.4% (range 7.4-22.0). The 1-year %TWL varied among the bariatric procedures performed: SG (21%), RYGB (22%), AGB (7%), and gastric plication (8%). There were no 30-day readmissions, reoperations, or mortalities.

CONCLUSION

Our experience suggests that bariatric surgery in selected patients aged 75 years and older would be safe and effective despite being higher risk. Age alone should not be the limiting factor for selecting patients for bariatric surgery.

Malnutrition as a Complication of Bariatric Surgery - A Clear and Present Danger?

Obesity is a chronic life-threatening disease, and bariatric surgery is the most effective treatment in those patients. The two main operations are laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB). LSG carries a smaller risk for nutritional deficiencies, while gastric bypass procedures are associated with increased nutritional deficiencies because the procedure is more complex and changes the gastrointestinal anatomy. Recent studies comparing LSG and RYGB have proven that these types of operation may lead to a similar weight reduction effect but cause different micronutrient deficiencies. Types of malnutrition after bariatric surgery include protein-energy malnutrition and deficiencies of micronutrients, such as iron, folate, vitamin A, and vitamin B₁₂. Bariatric patients who do not adhere to the recommended diets are at a greater risk of developing relevant malnutrition. Therefore, life-long postoperative clinical and laboratory monitoring is necessary to diagnose deficiencies of vitamins, trace elements, and minerals and to correct them with supplements. Unfortunately, no standardized aftercare regimes exist for these patients, and the costs for nutritional supplements are paid by the patients themselves.

Bariatric surgery is associated with a lower rate of death after myocardial infarction and stroke: A nationwide study

AIM

To assess the potential protective effect of bariatric surgery on mortality after myocardial infarction (MI) or cerebrovascular accident (CVA).

MATERIALS AND METHODS

Using the National Inpatient Sample (2007-2014), 2218 patients with a principal discharge diagnosis of acute MI and 2168 patients with ischaemic CVA who also had history of prior bariatric surgery were identified. Utilizing propensity scores, these patients were matched 1:5 with patients who had similar principal diagnoses but no history of bariatric surgery (controls). Control group-1 included participants with obesity (BMI ≥ 35 kg/m² ) only and participants in control group-2 were matched according to post-surgery BMI with the bariatric surgery group. The primary and secondary endpoints were in-hospital all-cause mortality and length of hospital stay, respectively. Outcomes after MI and CVA were separately compared among groups in multivariate regression models.

RESULTS

A total of 48 300 (weighted) participants were included in the analysis. The distribution of covariates was well balanced after propensity matching. Mortality rates after MI were significantly lower in patients with a history of bariatric surgery compared with control group-1 (1.85% vs 3.03%; odds ratio (OR), 0.61; 95% confidence interval (CI), 0.44-0.86; P = 0.004) and with control group-2 (2.00% vs 3.26%; OR, 0.62; 95% CI, 0.44-0.88; P = 0.008). Similarly, in-hospital mortality rates after CVA were significantly lower in patients with a history of bariatric surgery compared with control group-1 (1.43% vs 2.74%; OR, 0.54; 95% CI, 0.37-0.79; P = 0.001) and with control group-2 (1.54% vs 2.59%; OR, 0.61; 95% CI, 0.41-0.91; P = 0.015). Furthermore, length of stay was significantly shorter in the bariatric surgery group for all comparisons (P < 0.001).

CONCLUSION

Prior bariatric surgery is associated with significant protective effect on survival after MI and CVA.

A novel risk prediction model for 30-day severe adverse events and readmissions following bariatric surgery based on the MBSAQIP database

BACKGROUND

Although bariatric surgery is safe, some patients fear serious complications.

OBJECTIVES

This retrospective study used the 2015 Metabolic and Bariatric Surgery Accreditation Quality Improvement Project (MBSAQIP) database to evaluate patient outcomes for gastric bypass (GB) and sleeve gastrectomy and to develop a risk prediction model for serious adverse events (SAEs) and readmission rates 30 days after surgery.

SETTING

MBSAQIP national patient database.

METHODS

We created separate exploratory multivariable logistic regression models for SAEs and readmissions. We then externally validated both models using the 2016 MBSAQIP Participant Use Data File.

RESULTS

Significant predictors of SAEs were preoperative body mass index (adjusted odds ratio [AOR] 1.07, P < .0001); GB surgery (AOR 2.08, P < .0001); cardiovascular disease (AOR 1.43, P < .0001); smoking (AOR 1.12, P = .04); diabetes (AOR 1.15, P = .0001); hypertension (AOR 1.17, P < .0001); limited ambulation (AOR 1.48, P < .0001); sleep apnea (AOR 1.12, P = .001); history of pulmonary embolism (AOR 2.81, P < .0001); and steroid use (AOR 1.40, P = .001). Significant predictors of readmissions were GB surgery (AOR 1.81, P < .0001); female sex (AOR 1.26, P < .0001); diabetes (AOR 1.08, P = .04); hypertension (AOR 1.11, P = .004); preoperative body mass index (AOR 1.05, P < .0001); sleep apnea (AOR 1.11, P = .002); history of pulmonary embolism (AOR 2.35, P < .0001); cardiovascular disease (AOR 1.61, P < .0001); smoking (AOR 1.14, P = .01); and limited ambulation (AOR 1.55, P < .0001). External validation supported these covariates, with similar model discriminative power.

CONCLUSIONS

Our exploratory regression models may be used by clinicians to counsel patients about surgical risks, although future external validation should occur in non-North American populations.

MANAGEMENT OF ENDOCRINE DISEASE: Which metabolic procedure? Comparing outcomes in sleeve gastrectomy and Roux-en Y gastric bypass

Obesity and its associated comorbidities have become one of the largest challenges for health care in the near future. Conservative therapy for obesity and related comorbidities has a very high failure rate and poor long-term results. Similarly, the conservative and medical management of the majority of metabolic diseases such as type 2 diabetes mellitus are only able to slow down disease progression but have no causal effect on the disease process. Obesity surgery has evolved as a highly effective therapy for severe obesity achieving long-lasting weight loss. Furthermore, several studies have demonstrated the beneficial effects of obesity surgery on reduction of overall mortality, reduction of cardiovascular events and superior control of obesity-related diseases such as type 2 diabetes mellitus, dyslipidemia and also the non-alcoholic steatohepatitis compared to medical therapy. Based on these findings, the term 'metabolic surgery' with the focus on treating metabolic diseases independent of body weight has been coined. Of great interest are recent studies that show that even existing complications of metabolic diseases such as diabetic nephropathy or the non-alcoholic steatohepatitis can be reversed by metabolic surgery. Although metabolic surgery has proven to be a safe and effective treatment for obesity, resolution of comorbidities and enhancing quality of life, it is still uncertain and unclear, which surgical procedure is the most effective to achieve these metabolic effects. The aim of this review is to compare the effects of the two currently most widely used metabolic operations, the Roux-en-Y gastric bypass and the sleeve gastrectomy in the treatment of obesity and its related comorbidities.

Laparoscopic Sleeve Gastrectomy for the Management of Type 1 Diabetes Mellitus

BACKGROUND

The prevalence of obesity is on a continuous rise worldwide, with major studies clearly correlating obesity with the development of chronic metabolic disorders including type 2 diabetes. Bariatric surgery has proven to be beneficial in the management of this condition; however, a limited number of studies exist on its effect on type 1 diabetes.

OBJECTIVE

The objective of this study is to evaluate the outcome of laparoscopic sleeve gastrectomy for the management of patients with type 1 diabetes (DM1).

SETTING

This is a retrospective cohort study conducted in a university hospital and private practice in Kuwait.

RESEARCH DESIGN AND METHODS

Analysis was conducted on 10 patients diagnosed with type 1 diabetes that underwent bariatric surgery from October 2008 until December 2016 at Amiri Hospital and Royale Hayat Hospital, Kuwait. Primary parameters included body mass index (BMI), % excess weight (%EWL) loss at follow-up, glycosylated hemoglobin (A1C), and basal insulin requirements. Total cholesterol readings and fasting blood glucose (FBS) levels were considered secondary outcomes. Statistical analysis of the data was carried out using Statistical Package for the Social Sciences (SPSS) software.

RESULTS

Mean BMI showed a reduction from 41.9 ± 5.4 to 31.4 ± 8.4 kg/m². Mean %EWL after the follow-up period was 74.4 ± 25.3%. A1C levels failed to show a significant difference 12 months post-op (p = 0.189). Cholesterol levels did not display a significant decrease either (p = 0.447). When it came to insulin requirements, a significant difference was perceived, with the mean number of units of insulin required dropping from 76.6 to 18.2 (p = 0.026). FBS readings also showed a drop from 15.1 ± 3.8 to 7.8 ± 2.9 mmol/L (p = 0.001).

CONCLUSIONS

Laparoscopic sleeve gastrectomy resulted in significant weight loss, comorbidity resolution as well as reduction in their insulin doses post-op. However, glycemic control does not seem to show significant improvement in these patients. Larger, more long-term studies are needed to reach a definite conclusion on this topic.

Human catalase gene promoter haplotype and cardiometabolic improvement after bariatric surgery

Although its powerful impact on most co-morbidities has been widely demonstrated, the metabolic outcomes of bariatric surgery (BS) show a great heterogeneity among patients. Haplotypes of one of the major antioxidant enzyme, catalase (CAT), are associated with hypertension, dyslipidemia, and diabetes. The haplotype referred to as CAT1 includes homozygous carriers of CATH1 [-844G,-89A,-20T], whereas CAT2 haplotype includes heterozygous carriers (CATH1/CATH2) and CATH2 homozygous [-844A,-89T,-20C]. The aim of our study was to evaluate the impact of CAT1 and CAT2 haplotypes on traditional cardiovascular and metabolic markers one year after BS in a women population. The 294 women with a body mass index (BMI) >35 kg/m2 were followed-up for one year after BS, monitoring their anthropometric, metabolic and inflammatory parameters. CAT1 patients had significantly improved diastolic blood pressure (DBP) and Creactive protein (CRP) levels compared to CAT2 one year after BS. In untreated women at baseline, the change of CRP one year after BS was higher in CAT1 patients. In the population of women receiving at least one anti-lipidic, anti-hypertensive or anti-diabetic treatment at baseline, DBP and fat mass were lower one year after BS in CAT1 patients and the greater change of fat mass was associated with a higher change of adiponectin. The results highlight the beneficial impact of the CAT1 haplotype on traditional cardiovascular and metabolic parameters after BS. Our findings suggest that the CAT1 haplotype could be implicated in the level of metabolic and cardiovascular improvement after BS.

Neurologic Manifestations of Vitamin B Deficiency after Bariatric Surgery

INTRODUCTION

The aim of this study was to assess the incidence, clinical presentation, and outcomes of neurologic disorders secondary to vitamin B deficiencies following bariatric surgery.

METHODS

Patients at a single academic institution who underwent bariatric surgery and developed neurologic complications secondary to low levels of vitamins B1, B2, B6, and B12 between the years 2004 and 2015 were studied.

RESULTS

In total, 47 (0.7%) bariatric surgical patients (Roux-en-Y gastric bypass n = 36, sleeve gastrectomy n = 9, and duodenal switch n = 2) developed neurologic manifestations secondary to vitamin B deficiencies. Eleven (23%) patients developed postoperative anatomical complications contributed to poor oral intake. Median duration to onset of neurologic manifestation following surgery was 12 months (IQR, 5-32). Vitamin deficiencies reported in the cohort included B1 (n = 30), B2 (n = 1), B6 (n = 12), and B12 (n = 12) deficiency. The most common manifestations were paresthesia (n = 31), muscle weakness (n = 15), abnormal gait (n = 11), and polyneuropathy (n = 7). Four patients were diagnosed with Wernicke-Korsakoff syndrome (WKS) which was developed after gastric bypass (n = 3) and sleeve gastrectomy (n = 1). Seven patients required readmission for management of severe vitamin B deficiencies. Overall, resolution of neurologic symptoms with nutritional interventions and pharmacotherapy was noted in 40 patients (85%). The WKS was not reversible, and all four patients had residual mild ataxia and nystagmus at the last follow-up time.

CONCLUSIONS

Nutritional neurologic disorders secondary to vitamin B deficiency are relatively uncommon after bariatric surgery. While neurologic disorders are reversible in most patients (85%) with vitamin replacements, persistent residual neurologic symptoms are common in patients with WKS.

[Relevance of bariatric surgery care]

The relevance of care in bariatric surgery must be judged in terms of the resulting benefit/risk balance. Laparoscopic approach has been proved to reduce postoperative mortality. Postoperative mortality is less than 0.1% in France. Depending on procedures, long-term percentage of weight loss is estimated around 15-30%. Long-term mortality and cardiovascular events are reduced compared to control patients. The over-risk of suicide should be known. Long-term follow-up after bariatric surgery is poor in France.

[Quality indicators for metabolic and bariatric surgery in Germany : Evidence-based development of an indicator panel for the quality of results, indications and structure]

An expert committee was appointed by the German Society for General and Visceral Surgery to develop a panel of appropriate quality indicators to collate the quality of results, indications and structure in metabolic and bariatric surgery. This entailed assimilating the available evidence (systematic literature search), results from the national registry of the society (StuDoQ|MBE) and specific socioeconomic aspects (e. g. severely limited access to metabolic and bariatric surgery in Germany). These quality parameters were to be incorporated into the national guidelines and the rules of procedure for certification in the future. The committee concluded that mortality, MTL30 and severe complications needing intervention (Clavien-Dindo ≥ 3b) are suitable indicators to measure surgical outcome quality due to their relevance, scientific soundness and practicability. As a systematic follow-up is mandatory after bariatric surgery, a minimum follow-up quota is now required using reported quality of life data as an indicator of process quality. As intestinal bypass procedures have been shown to be superior in the treatment of type 2 diabetes, these procedures should be offered to eligible patients and also be performed. The proposed threshold values based on the results of the available literature and StuDoQ registry are to be considered as preliminary and need to be validated and adjusted if necessary in the future. The StuDoQ|MBE is considered a valuable tool to gather this information and also represents the appropriate infrastructure for the collation of relevant risk adjustors.

Outcomes of Bariatric Surgery in Patients with Inflammatory Bowel Disease

BACKGROUND

Obesity has become prevalent in patients with inflammatory bowel disease (IBD). Bariatric surgery can be considered to be contraindicated in IBD patients. We aimed to evaluate feasibility, safety, and efficacy of bariatric surgery in IBD patients.

METHODS

We retrospectively identified all morbidly obese patients with a known diagnosis of IBD, who underwent bariatric surgery between January 2005 and December 2012. Postoperative outcomes and status of IBD in patients on maintenance therapy for their disease were assessed.

RESULTS

We identified 20 IBD patients including 13 ulcerative colitis (UC) and 7 Crohn's disease (CD) patients with a mean age of 54.0 ± 10.5 years, BMI of 50.1 ± 9.0 kg/m(2), and duration of IBD of 11.3 ± 5.2 years. Eleven patients were on medication for IBD at baseline. Bariatric procedures included sleeve gastrectomy (N = 9), gastric bypass (N = 7), gastric banding (N = 3), and one conversion of band to gastric bypass. There were no intraoperative complications, but two conversions to laparotomy due to adhesions. Mean BMI change and excess weight loss at 1 year was 14.3 ± 5.7 kg/m(2) and 58.9 ± 21.1 %, respectively. Seven early postoperative complications occurred including dehydration (N = 5), pulmonary embolism (N = 1), and wound infection (N = 1). During a mean follow-up of 34.6 ± 21.7 months, five patients developed complications including pancreatitis (N = 2), ventral hernia (N = 2), and marginal ulcer (N = 1). Nine out of ten eligible patients experienced improvement in their IBD status.

CONCLUSIONS

Bariatric surgery is feasible and safe in morbidly obese patients suffering from IBD. In addition to being an effective weight loss procedure, bariatric surgery may help mitigate symptoms in this patient population.

Early Postoperative Outcomes of Primary Bariatric Surgery in Patients on Chronic Steroid or Immunosuppressive Therapy

BACKGROUND

Previous research suggests that patients on chronic steroids may be at an increased risk of postoperative morbidity after major surgery. We aimed to evaluate the prognostic impact of chronic use of steroid or immunosuppression on 30-day morbidity and mortality rates after primary bariatric surgery.

METHODS

From American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified patients who underwent primary bariatric surgery between 2005 and 2013. Logistic regression was used to determine the prognostic impact of chronic use of steroid or immunosuppression on the 30-day postoperative outcomes.

RESULTS

One thousand two hundred seventy seven steroid/immunosuppressant-dependent (SD) and 112,892 non-dependent (ND) patients were analyzed. SD patients had a higher baseline risk profile compared to ND patients. Thirty-day mortality rates for SD and ND patients were 0.55 and 0.11 %, respectively (P < 0.001) which corresponds to an adjusted odds ration (OR) of 6.85 (95 % confidence interval (CI) 1.95-24.12). SD patients had a higher 30-day major morbidity compared to ND patients (5.01 versus 2.54 %; P < 0.001, respectively). After adjustment, this translated into an OR of 2.21 (95 % CI 1.29-3.79). Among SD patients, there was no significant difference in 30-day major morbidity after gastric bypass compared to sleeve gastrectomy (OR = 0.36; 95 % CI 0.08-1.66).

CONCLUSIONS

Chronic and active use of steroid or immunosuppressant medications is a strong predictor of 30-day postoperative morbidity and mortality following primary bariatric surgery. Among the steroid/immunosuppressant users, complication rates were similar for gastric bypass and sleeve gastrectomy patients. Further studies are needed to help guide the management or discontinuation of such medications in the perioperative period.

Changes in adiposity and other cardiometabolic risk factors following Roux-en-Y gastric bypass: A 12-month prospective cohort study in Chinese patients

AIM

We aimed to investigate the changes in adiposity and other cardiometabolic risk factors in the year following Roux-en-Y gastric bypass (RYGB) in patients of Chinese ethnicity.

METHODS

The study recruited 209 patients who met the indications for bariatric surgery. Adiposity and cardiometabolic risk factors were assessed at baseline and over the 12 months following surgery in all participants. SPSS® software was used for statistical analysis.

RESULTS

The mean body mass index (BMI) was 29.98 kg/m² at baseline and steadily decreased to 25.32 kg/m² at 12 months, giving a relative change of -15.5% (p < 0.001). All of the lipid profile fractions except high-density lipoprotein (HDL) declined during the first 12 months of follow up; serum HDL increased during this time (all ANOVA p < 0.001). The mean fasting plasma glucose was 9.49 mmol/L at baseline and gradually decreased to 5.69 mmol/L at 12 months, giving a relative change of -40.0% (p < 0.001).

CONCLUSION

Following the RYGB procedure, changes in measures of adiposity were paralleled by a significant improvement in cardiometabolic factors for 12 months after surgery.

Can Sleeve Gastrectomy "Cure" Diabetes? Long-term Metabolic Effects of Sleeve Gastrectomy in Patients With Type 2 Diabetes

OBJECTIVE

The aim of the study was to assess long-term metabolic effects of laparoscopic sleeve gastrectomy (LSG) in patients with type 2 diabetes (T2DM) and to identify predictive factors for long-term diabetes remission and relapse.

BACKGROUND

LSG has become the most common bariatric operation worldwide. Its long-term metabolic effects in patients with T2DM are, however, unknown.

METHODS

Outcomes of 134 patients with obesity with T2DM who underwent LSG at an academic center during 2005 to 2010 and had at least 5 years of follow-up were assessed.

RESULTS

At a median postsurgical follow-up of 6 years (range: 5-9), a mean body mass index loss of -7.8 ± 5.1 kg/m (total weight loss: 16.8% ± 9.7%) was associated with a reduction in mean glycated hemoglobin (HbA1c, -1.3 ± 1.8%, P < 0.001), fasting blood glucose (-37.8 ± 70.4 mg/dL, P < 0.001) and median number of diabetes medications (-1, P < 0.001). Long-term glycemic control (HbA1c <7%) was seen in 63% of patients (vs 31% at baseline, P < 0.001), diabetes remission (HbA1c <6.5% off medications) in 26%, complete remission (HbA1c <6% off medications) in 11%, and "cure" (continuous complete remission for ≥5 years) was achieved in 3%. Long-term relapse of T2DM after initial remission occurred in 44%. Among patients with relapse, 67% maintained glycemic control (HbA1c <7%). On adjusted analysis, taking 2 or more diabetes medications at baseline predicted less long-term remission (odds ratio 0.19, 95% confidence interval 0.07-0.55, P = 0.002) and more relapse of T2DM (odds ratio 8.50, 95% confidence interval: 1.40-49.20, P = 0.02). Significant improvement in triglycerides (-53.7 ± 116.4 mg/dL, P < 0.001), high-density lipoprotein (8.2 ± 12.9 mg/dL, P < 0.001), systolic (-8.9 ± 18.7 mmHg, P < 0.001) and diastolic blood pressure (-2.6 ± 14.5 mmHg, P = 0.04), and cardiovascular risk (13% relative reduction, P < 0.001) was observed.

CONCLUSIONS

LSG can significantly improve cardiometabolic risk factors including glycemic status in T2DM. Long-term complete remission and "cure" of T2DM, however, occur infrequently.

Bariatric surgery may reduce the risk of Alzheimer's diseases through GLP-1 mediated neuroprotective effects

Obesity and diabetes are associated with deficits in multiple neurocognitive domains and increased risk for dementia. Over the last two decades, there has been a significant increase in bariatric and metabolic surgery worldwide, driven by rising intertwined pandemics of obesity and diabetes, along with improvement in surgical techniques. Patients undergoing bariatric surgery achieve a significant decrease in their excess weight and a multitude of sequela associated with obesity, diabetes, and metabolic syndrome. Glucagon-like peptide 1 (GLP-1) is an intestinal peptide that has been implicated as one of the weight loss-independent mechanisms in how bariatric surgery affects type 2 diabetes. GLP-1 improves insulin secretion, inhibits apoptosis and induce pancreatic islet neogenesis, promotes satiety, and can regulate heart rate and blood pressure. Moreover, numerous studies have demonstrated potential neuroprotective and neurotrophic effects of GLP-1. Increased GLP-1 activity has been shown to increase cortical activity, promote neuronal growth, and inhibit neuronal degeneration. Specifically, in experimental studies on Alzheimer's disease, GLP-1 decreases amyloid deposition and neurofibrillary tangles. Furthermore, recent studies have also suggested that GLP-1 based therapies, new class of antidiabetic drugs, have favorable effects on neurodegenerative disorders such as Alzheimer's disease. We present a hypothesis that bariatric surgery can help delay or even prevent the onset of Alzheimer's disease in long-term by increasing the levels of GLP-1. This hypothesis has a potential for many studies from basic science projects to large population studies to fully understand the neurological and cognitive consequences of bariatric surgery and associated rise in GLP-1.

IMPACT OF ROUX-EN-Y GASTRIC BYPASS SURGERY (RYGB) ON METABOLIC SYNDROME COMPONENTS AND ON THE USE OF ASSOCIATED DRUGS IN OBESE PATIENTS

BACKGROUND

The prevalence of obesity and metabolic syndrome is increasing worldwide and both behavior modification and drug therapy have low adherence. Gastric bypass has shown effective results in both reducing weight and improving comorbidities.

OBJECTIVE

To evaluate the impact of Roux-en-Y Gastric Bypass Surgery (RYGB) on both metabolic syndrome components and the use of associated drugs in obese patients.

METHODS

Historical cohort of patients subjected to Roux-en-Y Gastric Bypass Surgery (RYGB) between January 2007 and March 2014 in a private clinic. The sample consisted of 273 obese class II and III individuals, 86.4% of whom were female, with age ≥20 years, followed up for 2 months after surgery. Sociodemographic, anthropometric, biochemical, clinical, and drug-use data were collected from patients' medical records.

RESULTS

Significant differences were found in weight, body mass index and waist circumference, after 60 postoperative days. Components for metabolic syndrome diagnosis (hypertension P=0.001; hyperglycemia P<0.001; hypertriglyceridemia P=0.006) were reduced after 60 days of postoperative, with the exception HDL-c (P=0.083). There was a significant reduction in the use of antihypertensive (P<0.001), hypoglycemic (P=0.013), lipid lowering (P<0.001), and antiobesity (P=0.010) drugs and increased use of gastroprotective drugs, vitamins, and minerals (P<0.001) after 60 postoperative days.

CONCLUSION

Patients subjected to Roux-en-Y Gastric Bypass Surgery exhibited both weight loss and significant improvement not only in metabolic syndrome components (except for HDL-c) but in the use of drugs associated with obesity and metabolic syndrome.

Bariatric surgery and diabetic retinopathy: a systematic review and meta-analysis of controlled clinical studies

BACKGROUND

Uncontrolled studies have indicated appearance or progression of diabetic retinopathy in obese diabetic patients after bariatric surgery. The aim of this systematic review and meta-analysis was to compare the rate of appearance, as well as progression or regression of diabetic retinopathy in studies comparing medical and surgical treatment of obese type 2 diabetes.

METHODS AND FINDINGS

Intervention effect (new cases of retinopathy, and cases with any change of diabetic retinopathy score) was expressed as odds ratio (OR), with 95% confidence intervals (CIs); change of diabetic retinopathy score was expressed as standardized mean difference (SMD), with 95% CIs. Meta-analyses were performed by a random-effects model according to DerSimonian and Laird. Heterogeneity was assessed through Q and I2 statistics for each comparison, and potential sources of heterogeneity were discussed where appropriate. Appropriate methodology [preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement] was used. Seven studies were analyzed, and incident cases of retinopathy were fewer with bariatric surgery than with medical treatment; change of retinopathy score (three studies) was not different, while only two studies were available on numbers of patients showing progression or regression of retinopathy. Heterogeneity was not significant, and publication bias was not present.

CONCLUSIONS

Bariatric surgery seems to prevent new cases of diabetic retinopathy, but available studies are not sufficient to support progression or regression of retinopathy. Further studies are needed to draw firm conclusions on the effect of bariatric surgery on diabetic retinopathy.

Temporal Effect of Bariatric Surgery on Predicted 10-Year and Lifetime Cardiovascular Risk at 1 Month, 6 Months, and 5 Years Following Surgery: A Pilot Study

BACKGROUND AND AIMS

Cardiovascular (CV) risk equations are routinely used to predict risk in nonbariatric populations, but have not been studied in depth in patients undergoing bariatric surgery and specifically those with impaired glucose regulation. The aim of this pilot study was to investigate changes in the 10-year and lifetime predicted CV risk in subjects with impaired glucose regulation before, 1 month, 6 months, and 5 years after bariatric surgery.

METHOD AND RESULTS

A nonrandomized prospective study was conducted of 45 participants with impaired glucose regulation undergoing temporal assessments during follow-up. Body weight, body mass index (BMI), blood pressure, lipid profile, and HbA1c were recorded preoperatively, 1 month, 6 months, and 5 years postoperatively. Preoperative and postoperative predicted CV risk was calculated using the QRISK2, QRISK lifetime, and JBS3 calculators. Follow-up rates were 93%, 91%, and 71% at 1 month, 6 months, and 5 years, respectively. The sample had a mean age of 48.8 ± 7.0 years, a mean BMI of 53.9 ± 11.1 kg/m², and a mean HbA1c of 7.5% ± 1.7%. The predicted 10-year QRISK2 score decreased by 35%, 54%, and 24% at 1 month, 6 months, and 5 years, respectively (P < 0.001). The predicted lifetime risk also decreased with the greatest reduction (24.5% with QRISK lifetime and 26.7% with JBS3 lifetime score) observed at 5 years even though the subjects were 5 years older.

CONCLUSION

Bariatric surgery in patients with impaired glucose regulation is associated with a significant reduction in predicted 10-year and lifetime CV risk in a population that was 5 years older compared to baseline.

A Challenge between Trainee Education and Patient Safety: Does Fellow Participation Impact Postoperative Outcomes Following Bariatric Surgery?

BACKGROUND

Surgical training may potentially influence patient care. A safe, high-quality bariatric and metabolic surgery practice requires dedicated and specialized training commonly acquired during a fellowship. This study evaluates the impact of fellow participation on early postoperative outcomes in bariatric surgery.

METHODS

From the American College of Surgeons (ACS-NSQIP) database, we identified all obese patients who had undergone primary laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG) between 2010 and 2012. Logistic regression was used to prognosticate the surgical fellow (PGY-6, 7, or 8) participation in bariatric surgeries on perioperative outcomes, as compared to surgeries with no trainee participation.

RESULTS

The study cohort consisted of 10,838 patients (8819 LRYGB, 2019 LSG, 32 % fellow participation). Fellows participated in higher-risk surgeries. Fellow involvement was associated with increased operative time in LRYGB (difference 42.4 ± 1.2 min, p < 0.001) and in LSG (difference 38.8 ± 2.5 min, p < 0.001). Multivariate regression revealed that fellow involvement in LSG did not significantly alter postoperative adverse events. Conversely, in the LRYGB group, fellow participation was independently associated with higher rates of overall complications (OR = 1.37, 95 % CI 1.16-1.63), serious complications (OR = 1.23, 95 % CI 1.00-1.52), surgical complications (OR = 1.42; 95 % CI 1.17-1.73), and reoperation (OR = 1.43, 95 % CI 1.10-1.87). On adjusted analysis, while readmission was higher with fellow involvement in both procedures, mortality rates were comparable.

CONCLUSIONS

Fellow involvement resulted in a clinically appreciable increase in operative times. Fellow participation in the operating room was also independently associated with worse early postoperative outcomes following LRYGB, but was not the case for LSG. Promoting proficiency in surgical simulation laboratories and a gradual participation of fellows from LSG to LRYGB during fellowship may be associated with a reduction in postoperative complications.

The future of the Roux-en-Y gastric bypass

Archaic surgical procedures such as the jejunoileal bypass, vertical banded gastroplasty and duodenal switch have contributed to the current best practice of Roux-en-Y gastric bypass (RYGB) procedure for the treatment of obesity and its consequences. Despite this, RYGB has been blighted with late occurring adverse events such as severe malnutrition, marginal ulcer and reactive hypoglycemia. Despite this, RYGB has given us an opportunity to examine the effect of surgery on gut hormones and the impact on metabolic syndrome which in turn has allowed us to carry out a lower impact but equally, if not more effective, procedure - the vertical sleeve gastrectomy (VSG). We examine the benefits of sleeve gastrectomy from the less challenging technical aspect to the effect on obesity and its metabolic syndrome long-term and have concluded that sleeve gastrectomy is possibly the next current best practice.

Longer-Term Physiological and Metabolic Effects of Gastric Bypass Surgery

Obesity is closely associated with the development of type 2 diabetes. Many strategies have been used in the past to combat these two conditions, but very few provide for stable and durable glycemic control. Bariatric surgery has emerged as a powerful tool for treating obesity and in over 70 % of cases provides a short-term cure for diabetes. While the acute metabolic effects of surgery are striking, it remains important for us to also consider the long-term effects. This review aims to summarize the chronic or long-term metabolic and physiological effects of Roux-en-Y gastric bypass (RYGB) surgery on pancreatic function, skeletal muscle and hepatic insulin sensitivity, and gastrointestinal remodeling. An increased understanding of the current state of research in these areas can provide the basis for stimulating further research that would contribute to new treatment and management strategies for obesity and diabetes.

Bariatric Surgery in Obese Patients With Type 1 Diabetes

OBJECTIVE

There is a paucity of data on the impact of bariatric surgery in type 1 diabetes (T1D). The aim of this review was to quantify the overall effects of bariatric surgery in obese patients with T1D.

METHODS

We searched PubMed, Scopus, ISI Web of Knowledge, and Google Scholar from their inception to December 2015 to identify all relevant studies of bariatric surgery in adult obese patients with T1D.

RESULTS

The review included 17 studies with 107 individuals, including 10 case series and 7 case reports. Overall, the dominant procedure was gastric bypass (n = 70; 65%). All studies reported a significant reduction in excess weight. A significant reduction in weight-adjusted daily insulin requirements was shown in all case series except one. Pooled mean ± SD of pre- and postoperative glycated hemoglobin (HbA1c) for the entire cohort with available data (n = 96) was 8.4 ± 1.3% and 7.9 ± 1.1%, respectively (P = 0.01). In addition to common postoperative complications, profound glycemic changes (diabetic ketoacidosis and hypoglycemia) and gastrointestinal dysmotility symptoms (prolonged ileus and acute gastric remnant dilation) have been reported. No surgical mortality was reported.

CONCLUSIONS

Bariatric surgery leads to significant weight loss in severely obese patients with T1D and results in a significant improvement in insulin requirements and glycemic status. The favorable metabolic effects of bariatric surgery may facilitate medical management of and cardiovascular risk reduction in T1D in the setting of severe obesity. Diabetic ketoacidosis and hypoglycemia are potentially serious complications. Short-term results of bariatric surgery in patients with T1D are encouraging, but larger and longer-term studies are needed.

The Impact of Bariatric Surgery on Diabetic Retinopathy: A Systematic Review and Meta-Analysis

BACKGROUND

Significant reductions in glucose control immediately post bariatric surgery in patients with longstanding poor glycemic control can lead to the paradoxical progression of diabetic retinopathy (DR) in susceptible individuals. Bariatric surgery results in dramatic and immediate diabetic control postoperatively. We aimed to systematically review the literature to assess the effect of bariatric surgery on DR.

METHODS

A comprehensive search of electronic databases (e.g., MEDLINE, EMBASE, SCOPUS, Web of Science, and the Cochrane Library) was completed. All randomized controlled trials, non-randomized comparison study, and case series were included. Inclusion criteria included English-speaking studies, enrolling ≥ 5 patients, and contained ophthalmological data on outcome of DR pre- and post bariatric surgery. Two independently reviewers screened abstracts, reviewed full text versions of all studies classified, and extracted data. All comparison studies included in the meta-analysis were assessed independently by two reviewers for methodological quality using the Cochrane Risk of Bias (RoB) tools. Disagreements were resolved by re-extraction, or third-party adjudication. Where possible and appropriate, a meta-analysis was conducted.

RESULTS

A total of 277 studies were identified using our search criteria for screening. Four primary studies (n = 148 patients) met our inclusion criteria and were included in the systematic review. These included no randomized controlled trials and four non-randomized case series. Patients with no preoperative DR (n = 80), following bariatric surgery, an average of 92.5 ± 7.4 % remained disease free, while 7.5 ± 7.4 % of patients progressed to DR. Patients with diabetic retinopathy preoperatively (n = 68), following bariatric surgery, an average of 57.4 ± 18.5 % of patients had no change, 23.5 ± 18.7 % of patients had progression, and 19.2 ± 2.9 % of patients had improvement in their disease.

CONCLUSIONS

Progression of diabetic retinopathy is a significant issue postoperatively following bariatric surgery. Patients with a diagnosis of DR prior to surgery are at increased risk of further progression in their disease and should receive adequate counseling and evaluation prior to undergoing a surgical procedure. However, the few primary studies in this systematic review limit any conclusion. Further studies are needed to further evaluate these results.

Effect of Roux-en-Y gastric bypass on the remission of type 2 diabetes: a 3-year study in Chinese patients with a BMI <30 kg/m2

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is an effective treatment for patients with type 2 diabetes (T2D) and morbid obesity. However, T2D remission after surgery has not been adequately studied in Chinese patients with a body mass index (BMI)<30 kg/m².

OBJECTIVES

The objective of this study was to evaluate the 3-year effect of RYGB among patients with T2D with a BMI<30 kg/m² and elucidate the predictors of T2D remission.

SETTING

Department of General Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.

METHODS

Sixty-six Chinese patients with T2D and a BMI 25-30 kg/m² were retrospectively examined for metabolic outcomes 3 years after RYGB. Remission was defined as glycated hemoglobin (HbA1C)<6.5% and no medications. Binary logistic regression analysis was used to identify preoperative parameters independently predictive of diabetes remission at 1 and 3 years postoperatively [variables: sex, age, BMI, T2D duration, plasma glucose 2 hours after meal, HbA1C, fasting C-peptide, visceral fat area, free triiodothyronine, and thyroid-stimulating hormone. There was no significant difference in fasting insulin or glucose between the remission and no remission groups.

RESULTS

Patients were a mean 50.4±11.4 years of age at baseline, and 57.6% were female. Mean T2D duration was 8.9±5.2 years, baseline HbA1C level was 8.3±1.9%, and baseline BMI was 28.2±1.2 kg/m² (range: 25.5-30.0). BMI was 22.5±1.8 kg/m² (range: 19.1-28.0) at 1 year and 23.0±1.76 kg/m² (range: 19.7-28.0) at 3 years. Remission was achieved in 49 patients (74.2%) at 1 year and 38 patients (57.6%) at 3 years. There was a significant reduction in medication for diabetes, hypertension, and hyperlipidemia (P<.01). Compared with patients in the no remission group, patients in the remission group had higher fasting C-peptide levels (P<.01) and free triiodothyronine levels (P = .01) at 1 year. Multiple logistic regression analysis confirmed that fasting C-peptide (odds ratio = 3.795, P = .007) and free triiodothyronine (odds ratio = 4.661, P = .019) levels were predictors of T2D remission at 1 year. No significant difference was found between the 2 groups at 3 years.

CONCLUSIONS

RYGB resulted in significant clinical and biochemical improvements in Chinese patients with BMI 25-30 kg/m² and T2D. Appropriate patient selection (better β-cell function) may produce better outcomes.

Factors associated with length of stay in intensive care after bariatric surgery

BACKGROUND

Although uncommon, admission to the intensive care unit (ICU) after bariatric surgery may be necessary. This study evaluates characteristics of bariatric surgery patients that are admitted to the ICU, and identifies possible risk factors for increased ICU length of stay (LOS).

SETTING

Academic hospital, United States.

METHODS

A retrospective review of all ICU admissions after bariatric surgery from 2006 to 2013 was performed. Demographic characteristics and perioperative data were extracted, and risk factors for the LOS and mortality in the ICU were analyzed.

RESULTS

In total, 124 out of 4398 (2.8%) patients were admitted to the ICU after bariatric surgery. The mean age of these patients was 52.7±11.8 years and included 79 female patients (64%). There were 19 nonemergent or planned admissions (15.3%) and 105 unplanned admissions (84.7%). Mean body mass index was 47.8±12.2 kg/m², and mean American Society of Anesthesiology (ASA) score was 3.1±0.6. Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding were performed in 80 (65%), 18 (15%), and 6 (5%) patients, respectively. Revisional procedures were performed in 15 (12%) patients. Respiratory failure was the most common cause for admission, occurring in 35 (28.2%) patients. The most common surgical complications requiring ICU admission were bleeding (n = 27) and anastomotic leak (n = 21). Mean ICU LOS was 6.0±9.6 (1-65) days. Mortality occurred in 5 (4.0%) patients. Based on univariate analysis, risk factors associated with ICU LOS were conversion from laparoscopic to open approach, anastomotic leak, time from operation to ICU admission, and reoperation. Higher ASA score was a significant risk factor for mortality.

CONCLUSION

ICU admission after bariatric surgery is uncommon but is associated with a significantly increased mortality. Anastomotic leak, conversions, time from operation to ICU admission, and reoperation have the greatest impact in determining the LOS in the ICU after bariatric surgery.

The Role of the Multidisciplinary Conference in the Evaluation of Bariatric Surgery Candidates with a High-Risk Psychiatric Profile

Background: Implementation of a multidisciplinary conference (MC) attended by medical, surgical, nutrition, bioethics, and psychology specialists may help identify treatment plans for bariatric surgery candidates with a high-risk psychiatric profile. Methods: Data were assessed for all bariatric candidates evaluated by the MC in an academic center between January 2009 and December 2010. Results: A total of 134 patients of 2798 patients assessed by four different psychologists were subsequently evaluated by the MC. The most frequent psychiatric diagnoses were mood disorders (n = 37, 27.6%), anxiety disorders (n = 24, 17.9%), and binge eating disorder (n = 19, 14.1%). More than one psychiatric diagnosis was observed in 95.6% of the cohort. Substance abuse issues were present in 25% patients. Fifteen patients (11.2%) were eventually cleared and underwent surgery, 35 (26.1%) left the program before completing their requirements, and 84 patients (62.7%) were still working toward their individualized goals in the program. For those who underwent surgery, mean preoperative management duration was 221 days (range, 111-366) with an average of 11 preoperative psychiatric visits (range, 9-15). Conclusions: Patients with a high-risk psychosocial profile seeking bariatric surgery require multiple visits and resources to determine their candidacy. The majority of these patients are either deemed ineligible for surgery or require prolonged preoperative evaluation.

Is Bariatric Surgery an Effective Treatment for Type II Diabetic Kidney Disease?

Type II diabetic kidney disease is devastating to patients and society alike. This review will evaluate bariatric surgery as a treatment for diabetic kidney disease primarily through its ability to induce and maintain regression of type II diabetes. The review begins by outlining the global challenge of diabetic kidney disease, its link to obesity, and the comparative benefits of bariatric surgery on weight and type II diabetes. It then surveys comprehensively the relevant literature, which reports that although bariatric surgery is associated with reductions in albuminuria, its effect on harder clinical end points like progression of diabetic kidney disease is not known. The review also includes a critical assessment of the risks and costs of bariatric surgery and concludes by acknowledging the major knowledge gaps in the field and providing research strategies to overcome them. Until these knowledge gaps are filled, clinicians will be forced to rely on their own subjective judgment in determining the benefit-risk ratio of bariatric surgery for patients with diabetic kidney disease.