Adjustable gastric band surgery or medical management in patients with type 2 diabetes and obesity: three-year results of a randomized trial

The dual challenge of diabesity: pathophysiology, management, and future directions

Diabesity, the concurrent occurrence of obesity and type-2 diabetes mellitus (T2DM), represents a pressing global health challenge characterized by intricate pathophysiological mechanisms and a wide range of associated comorbidities. Central to its development are insulin resistance, metabolic syndrome, and chronic low-grade inflammation mediated by dysregulated adipokine secretion and systemic metabolic dysfunction. These mechanisms underpin the progression of diabesity and its complications, including cardiovascular disease and hypertension. Management strategies encompass lifestyle interventions focusing on tailored dietary modifications and structured physical activity, pharmacological treatments targeting both glycemic control and weight loss, and surgical interventions such as bariatric surgery, which have demonstrated efficacy in achieving durable outcomes. Clinical trials and meta-analyses underscore the comparative advantages of different treatment modalities in terms of efficacy, safety, and sustainability. Moreover, long-term follow-up studies emphasize the critical need for sustained multidisciplinary interventions to prevent relapse and enhance patient outcomes. Future advancements in management include exploring precision medicine approaches that integrate individual metabolic profiles, lifestyle factors, and emerging therapeutic innovations. A multidisciplinary approach combining advanced therapeutic strategies and patient-centered care remains pivotal for optimizing management and improving prognoses for individuals with diabesity. This review highlights the complex interplay between obesity and T2DM, offering comprehensive insights into their pathophysiology, clinical presentation, and management paradigms.

Effects of different Metabolic Bariatric Surgeries in Testosterone Levels: A Systematic Review and Meta-Analysis

Obesity, a globally prevalent condition associated with various comorbidities, has significant impacts on male endocrine health, including alterations in testosterone levels. Metabolic Bariatric Surgery stands out as an effective approach to promoting weight loss and improving hormonal outcomes. This study aims to evaluate and compare the effects of Roux-en-Y gastric bypass (RYGB) and Laparoscopic Sleeve Gastrectomy (LSG) or Laparoscopic adjustable gastric banding (LAGB) on testosterone levels in men. This systematic review and meta-analysis followed the Cochrane Handbook and PRISMA guidelines, registered under Id no. CRD42025633946, approved on Jan 29, 2025, in the Prospective International Registry of Systematic Reviews (PROSPERO). The search was conducted in Medline, Embase, and Web of Science platforms (up to July 2024) focused on studies comparing RYGB and LSG or LAGB and reporting pre- and post-surgery testosterone levels. Data on patients, interventions, and outcomes were extracted, and statistical analyses employed random-effects models and heterogeneity assessment. The combined analysis showed a mean difference of 113.07 ng/dL (95% CI: 1.47 to 224.67) favoring RYGB, with high heterogeneity (I2 = 65%). Individual studies suggest a greater increase in testosterone levels in the RYGB group. This review suggests that RYGB may lead to a significant increase in testosterone levels, but the results should be interpreted cautiously due to study limitations and variability, and future studies with larger samples and standardized protocols are needed.

Health-Related Quality of Life and Health Utility After Metabolic/Bariatric Surgery Versus Medical/Lifestyle Intervention in Individuals With Type 2 Diabetes and Obesity: The ARMMS-T2D Study

OBJECTIVE

Type 2 diabetes and obesity are associated with reduced health-related quality of life (HRQoL) and health utility (HU), but long-term effects of metabolic/bariatric surgery (MBS) compared with those of medical/lifestyle intervention (MLI) on these outcomes are unclear.

RESEARCH DESIGN AND METHODS

We studied 228 individuals with type 2 diabetes and obesity randomly assigned to MBS (Roux-en-Y gastric bypass, sleeve gastrectomy, or gastric band; n = 152) or MLI (n = 76) in the ARMMS-T2D study. HRQoL (36-Item Short-Form Health Survey [SF-36], including Physical Component Score [PCS] and Mental Component Score [MCS]) and HU (Short Form 6 Dimensions [SF-6D]) were measured annually up to 12 years.

RESULTS

At baseline, participants' mean ± SD age was 49.2 ± 8.0 years, 68.4% were female, BMI was 36.3 ± 3.4 kg/m2, and HbA1c was 8.7 ± 1.6%. PCS improved significantly more in the MBS versus MLI group over 12 years (+2.37 ± 0.53 vs. -0.95 ± 0.73; difference 3.32 ± 0.85; P < 0.001). MBS was associated with better general health (P < 0.001), physical functioning (P = 0.001), and vitality (P = 0.003). Reduction in BMI was greater after MBS versus MLI (P < 0.001) and correlated with improved PCS (r = -0.43; P < 0.001). Change in PCS was not associated with change in HbA1c. MCS changed minimally from baseline and was similar between MBS and MLI groups during follow-up (-0.21 ± 0.61 vs. -0.89 ± 0.84; difference 0.68 ± 0.97; P = 0.48). Improvements in HU were greater in the MBS versus MLI group over 12 years (+0.02 ± 0.01 vs. -0.01 ± 0.01; difference 0.03 ± 0.01; P = 0.003).

CONCLUSIONS

Metabolic surgery produces sustained weight loss and improves PCS, general health, physical functioning, vitality, and HU in individuals with type 2 diabetes and obesity compared with medical therapy up to 12 years after intervention.

Comparative effectiveness of metabolic and bariatric surgeries: a network meta-analysis

Bariatric surgery is recommended for patients with unhealthy weight. Our study aim to compare and rank different bariatric surgical approaches in reducing weight parameters. We searched MEDLINE, Cochrane CENTRAL, Scopus, and Web of Science databases from inception to September 2023. We extracted all outcomes as mean change from the baseline. The mean difference and 95% confidence interval were used as a summary measure. All analysis was conducted with R version 4.2.2 (2022-10-31) and R Studio version 2022.07.2 (2009-2022) (RStudio, Inc.). Included surgeries were: Biliopancreatic diversion (BPD-RYGB), Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Gastric Plication (LGP), Duodenal-Jejunal Bypass Sleeve (DJBS), Single-anastomosis gastric bypass (SAGB), Laparoscopic vertical banded gastroplasty (LVBG), Sleeve Gastrectomy (SG), Laparoscopic adjustable gastric banding (LAGB), Gastric plication, Biliopancreatic diversion (BPD), and Intra-gastric balloon (IGB). Only clinical trials were included, with outcomes focused on weight parameters such as reductions in BMI (kg/m²), weight (kg), waist circumference (cm), fat mass (kg), and excess weight loss (EWL) (%). Our analysis of 67 studies showed that SADI-S was the best surgical technique in decreasing BMI (kg/m2) (MD = -18.06; 95% CI [-25.31; -10.81]) and DS follows in efficacy with a P-score (MD = -18.88; 95% CI [-31.15; -6.62]) however the pooled analysis was heterogeneous (I2 = 98.5%). For weight (kg), waist circumference (cm), and fat mass (kg), BPD-RYGB was the best surgical technique to reduce these parameters (MD = -41.48; 95% CI [-47.80, -35.51], MD = -29.08; 95% CI [-37.16, -21.00], and MD = -31.11; 95% CI [-38.77, -23.46]; respectively). The pooled analysis was heterogeneous except in fat mass (I2 = 0%, p-value = 0.8). Our network meta-analysis showed that the best surgical technique in increasing EWL (%) was RY-DS (MD = -61.27; % CI [-91.72; -30.82]) the next one in efficacy according to P-score was LVBG (MD = -59.03; % CI [-84.47; -33.59]). SADI-S is most effective in reducing BMI followed by RYGB. DS was associated with most estimated weight loss %.

SICOB Italian clinical practice guidelines for the surgical treatment of obesity and associated diseases using GRADE methodology on bariatric and metabolic surgery

Obesity is a chronic disease associated with increased morbidity and mortality and reduced quality of life. Pharmacotherapy can be associated with life style changes in increasing and maintaining weight loss and ameliorating obesity-related complications and comorbidities. In patients affected by obesity and uncontrolled obesity-associated complications or high degrees of BMI (> 40 Kg/m2), metabolic bariatric surgery can be a valid therapeutic option. Many different types of surgical procedures have been developed in last decades, mainly performed via laparoscopic approaches. However, clinical indications for metabolic and bariatric surgery (MBS) and the choice of the most appropriate type of procedure have not been clarified so far.The Italian Society of Bariatric and Metabolic Surgery for Obesity (Società Italiana di Chirurgia dell'Obesità e delle Malattie Metaboliche-SICOB) decided to design and develop the updated version of the Italian guidelines aimed at assisting healthcare professionals in the choice of the surgical option for the treatment of obesity and related conditions. Between June and October 2022, a panel of 24 experts and an evidence review team (ERT, 10 members), participated in the definition of clinical questions, outcomes, and recommendations and collected and analyzed all the available evidence on the basis of pre-specified search strategies. GRADE methodology and PICO (Patient, Intervention, Comparison, Outcome) conceptual framework have been adopted for the development of the present guidelines. Aim of the present guideline is to verify indications to surgery with respect to the presence of comorbid conditions, evaluate the different types of surgical approaches and endoscopic bariatric procedure and revise indication to revision surgery and postoperative procedures.

Comparative Analysis of Bariatric Surgery and Non-surgical Therapies: Impact on Obesity-Related Comorbidities

Obesity is associated with a broad spectrum of comorbidities, including metabolic dysregulation, cardiovascular complications, and socioeconomic impacts. Traditional lifestyle interventions often yield transient results in weight management, while bariatric surgery offers a promising alternative. This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and focused on randomized controlled trials comparing bariatric surgery (e.g., Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB), and sleeve gastrectomy (SG)) with non-surgical therapies (drug therapy and lifestyle modifications) in the management of obesity-related comorbidities, particularly hypertension and type 2 diabetes mellitus (T2DM). We comprehensively searched databases like PubMed, PMC, and EBSCO using Medical Subject Headings (MeSH) terms related to obesity, bariatric surgery, and non-surgical treatments. We included seven studies involving participants aged 18-64 published within the last six years. We rigorously assessed these studies for quality and extracted data to evaluate outcomes such as weight loss, diabetes remission rates, hypertension management, and renal function. The review found that bariatric surgery consistently resulted in substantial and sustained weight loss compared to non-surgical therapies. Surgical interventions significantly improved hypertension control, reduced cardiovascular risks, and enhanced glycemic control in diabetic patients. The effectiveness of bariatric surgery in promoting diabetes remission was attributed not only to weight loss but also to physiological changes in gastrointestinal anatomy, gut hormones, and energy balance regulation. Limitations identified in the literature included variations in study methodologies, follow-up durations, and patient characteristics, which limited direct comparisons and generalizations. Future research should incorporate more extended follow-up periods and standardized methods to further validate these findings' durability and broad applicability across diverse patient populations. In conclusion, bariatric surgery emerges as an effective treatment option for managing obesity-related comorbidities, particularly hypertension and T2DM. While acknowledging the inherent risks and complexities associated with surgical interventions, ongoing research and clinical innovations are crucial to optimizing patient outcomes and reducing the global burden of obesity-related diseases.

Oxidative Stress Responses in Obese Individuals Undergoing Bariatric Surgery: Impact on Carcinogenesis

Obesity is a big public health problem that claims several thousand lives every year. Bariatric surgery has arisen as a suitable procedure for treating obesity, particularly morbid obesity. Oxidative stress, genotoxicity, apoptosis, and inflammatory responses are recognized as the most important occurrences in carcinogenesis, as they actively contribute to the multistep process. This study aimed to briefly review the connection between oxidative stress, genotoxicity, apoptosis, and inflammation in obese patients undergoing bariatric surgery, focusing on its impact on carcinogenesis. Regarding oxidative stress, bariatric surgery may inhibit the synthesis of reactive oxygen species. Moreover, a significant reduction in the inflammatory status after weight loss surgery was not observed. Bariatric surgery prevents apoptosis in several tissues, but the maintenance of low body weight for long periods is mandatory for mitigating DNA damage. In conclusion, the association between bariatric surgery and cancer risk is still premature. However, further studies are yet needed to elucidate the real association between bariatric surgery and a reduced risk of cancer.

Long-Term Outcomes of Medical Management vs Bariatric Surgery in Type 2 Diabetes

Importance

Randomized clinical trials of bariatric surgery have been limited in size, type of surgical procedure, and follow-up duration.

Objective

To determine long-term glycemic control and safety of bariatric surgery compared with medical/lifestyle management of type 2 diabetes.

Design, Setting, and Participants

ARMMS-T2D (Alliance of Randomized Trials of Medicine vs Metabolic Surgery in Type 2 Diabetes) is a pooled analysis from 4 US single-center randomized trials conducted between May 2007 and August 2013, with observational follow-up through July 2022.

Intervention

Participants were originally randomized to undergo either medical/lifestyle management or 1 of the following 3 bariatric surgical procedures: Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable gastric banding.

Main Outcome and Measures

The primary outcome was change in hemoglobin A1c (HbA1c) from baseline to 7 years for all participants. Data are reported for up to 12 years.

Results

A total of 262 of 305 eligible participants (86%) enrolled in long-term follow-up for this pooled analysis. The mean (SD) age of participants was 49.9 (8.3) years, mean (SD) body mass index was 36.4 (3.5), 68.3% were women, 31% were Black, and 67.2% were White. During follow-up, 25% of participants randomized to undergo medical/lifestyle management underwent bariatric surgery. The median follow-up was 11 years. At 7 years, HbA1c decreased by 0.2% (95% CI, -0.5% to 0.2%), from a baseline of 8.2%, in the medical/lifestyle group and by 1.6% (95% CI, -1.8% to -1.3%), from a baseline of 8.7%, in the bariatric surgery group. The between-group difference was -1.4% (95% CI, -1.8% to -1.0%; P < .001) at 7 years and -1.1% (95% CI, -1.7% to -0.5%; P = .002) at 12 years. Fewer antidiabetes medications were used in the bariatric surgery group. Diabetes remission was greater after bariatric surgery (6.2% in the medical/lifestyle group vs 18.2% in the bariatric surgery group; P = .02) at 7 years and at 12 years (0.0% in the medical/lifestyle group vs 12.7% in the bariatric surgery group; P < .001). There were 4 deaths (2.2%), 2 in each group, and no differences in major cardiovascular adverse events. Anemia, fractures, and gastrointestinal adverse events were more common after bariatric surgery.

Conclusion and Relevance

After 7 to 12 years of follow-up, individuals originally randomized to undergo bariatric surgery compared with medical/lifestyle intervention had superior glycemic control with less diabetes medication use and higher rates of diabetes remission.

Trial Registration

ClinicalTrials.gov Identifier: NCT02328599.

French National Authority for Health assessment of metabolic surgery for type 2 diabetes remission-A meta-analysis in patients with class I to III obesity

OBJECTIVE

Randomized controlled trials (RCTs) have demonstrated the superiority of metabolic surgery (MS) over medical therapy (MT) in patients with obesity and type 2 diabetes, leading, to a joint statement in 2016 proposing MS to patients with class I obesity and uncontrolled glycemia. Yet, these RCTs included few patients with class I obesity (body mass index 30-35 kg/m2) and even fewer patients with overweight. Our aim was to provide an updated systematic review (SR) with meta-analysis (MA) of RCTs reporting diabetes remission (DR) after MS in these patients.

RESEARCH DESIGN AND METHODS

We included in the SR with MA only RCTs with at least 24-month follow-up found in Medline, Cochrane Library, Embase, and LiSSA between January 2008 and September 2022 comparing DR post-MT versus post-MS. We calculated relative risk (RR) and 95 % confidence intervals (CIs) using the Mantel-Haenszel random-effects approach to examine differences in DR between patients allocated to MS versus MT.

RESULTS

DR was significantly higher in MS versus MT after 36 months' follow-up in patients with obesity (RR = 6.65 [95 %CI 2.24;19.79]; I² = 27 %; 5 trials, 404 patients), but also specifically in patients with class I obesity (RR = 5.27 [1.31;21.23]; I² = 0 %; 4 trials, 80 patients). Furthermore, and in line with previous results, all additional MAs performed in patients with obesity in this work favor MS (specifically Roux-en-Y gastric bypass) over MT at 24, 36 (only) and 60 months of follow-up.

CONCLUSIONS

Although the data available in patients with class I obesity and type 2 diabetes remains limited, MA shows higher rates of DR after MS compared with MT after 36 months' follow-up in these patients. Consequently, the French National Authority for Health French (HAS) recommends MS for these patients.

Long term outcomes of metabolic/bariatric surgery in adults

The prevalence of obesity continues to rise around the world, driving up the need for effective and durable treatments. The field of metabolic/bariatric surgery has grown rapidly in the past 25 years, with observational studies and randomized controlled trials investigating a broad range of long term outcomes. Metabolic/bariatric surgery results in durable and significant weight loss and improvements in comorbid conditions, including type 2 diabetes. Observational studies show that metabolic/bariatric surgery is associated with a lower incidence of cardiovascular events, cancer, and death. Weight regain is a risk in a fraction of patients, and an association exists between metabolic/bariatric surgery and an increased risk of developing substance and alcohol use disorders, suicidal ideation/attempts, and accidental death. Patients need lifelong follow-up to help to reduce the risk of these complications and other nutritional deficiencies. Different surgical procedures have important differences in risks and benefits, and a clear need exists for more long term research about less invasive and emerging procedures. Recent guidelines for the treatment of obesity and metabolic conditions have been updated to reflect this growth in knowledge, with an expansion of eligibility criteria, particularly people with type 2 diabetes and a body mass index between 30.0 and 34.9.

Outcomes and Adverse Events After Bariatric Surgery: An Updated Systematic Review and Meta-analysis, 2013-2023

Purpose

Bariatric surgery is an increasingly common treatment for obesity and related comorbidities. This meta-analysis aimed to compare the outcomes of bariatric surgery and medical treatment (MT).

Materials and Methods

A systematic search of articles published from January 2013 to May 2023 identified 20 studies. The treatment arms included Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), gastric banding, and MT. The assessed outcomes included body weight loss, diabetes mellitus (DM) remission, changes in dyslipidemia and hypertension markers, and adverse events.

Results

Bariatric surgery resulted in significantly better short- and long-term weight loss than MT, with RYGB and SG showing the most substantial reduction. The DM remission rates were notably higher in the surgery group, with marked improvements in hemoglobin A1c and fasting glucose levels. Improvements in dyslipidemia were inconclusive, whereas hypertension showed modest improvements, particularly with RYGB. Complication rates varied, with RYGB reporting higher rates of early complications, and SG reporting increased rates of late complications. The perioperative reoperation rates were low across all surgical treatments. Specific adverse events, such as intestinal obstruction and anastomosis site problems, were more common in the RYGB group, whereas reflux symptoms were more common in the SG group.

Conclusion

Bariatric surgery, especially RYGB and SG, provided superior weight loss and DM remission outcomes compared to MT, although with varied complication profiles. These findings underscore the need for careful patient selection and postoperative management in bariatric surgery. Future studies should aim to refine these processes to improve patient outcomes.

The Rapid Changes in Bodyweight and Glycemic Control Are Determined by Pre-status After Bariatric Surgery in Both Genders in Young Chinese Individuals

PURPOSES

The primary aim of this clinical study is to identify the factors associated with rapid glycemic, bodyweight, and lipid profile remission in young obese patients following bariatric surgery.

MATERIALS AND METHODS

In a total of 131 Chinese in-patients at Shanghai Pudong Hospital, China, we retrospectively analyzed in-patient data of metabolic parameters, including BMI, waist circumference, blood pressure (BP), and blood laboratory tests, such as plasma lipids and lipoprotein, hemoglobulin A1c (HbA1c), and oral glucose tolerance tests (OGTT) before bariatric surgery. We followed up these indices at the first month, third months, half-year, and one year later.

RESULTS

The results showed that bodyweight, BP, fasting plasma glucose (FPG), HbA1c, and triglyceride (TG) levels decreased significantly in one to three months following surgery in both male and female patients (p<0.05). We demonstrated that age (male: β=-0.181; female: β=-0.292) and the pre-operation HbA1c levels (male: β=0.935; female: β=0.919) were independent predictors of HbA1c reduction in both young obese male and female patients in three months after surgery. For body weight loss, age (β=-0.229) and pre-operation bodyweight (β=0.735) are the predictors in females, but only pre-operation body weight (β=0.798) is the independent predictor in obese young male patients.

CONCLUSION

 This study discovered that changes in bodyweight were determined by age, pre-operation status of bodyweight, and HbA1C in obese young Chinese.

Effects of Metabolic Medicine and Metabolic Surgery on Patient-Reported Outcomes Among Patients with Type 2 Diabetes

The assessment and management of patient-reported outcomes (PROs) is considered secondary to that of cardiometabolic outcomes. When assessed, health-related quality of life (HRQOL), a PRO, can yield pertinent information that cannot be obtained from cardiometabolic assessments. For instance, physical and mental distress can be quantified and treated. Moreover, treatment convenience and satisfaction can be gaged. Behavioral modification, bariatric surgery, and pharmacotherapy can improve PROs. Typically, HRQOL is responsive to changes in weight. Specifically, weight loss and weight gain are associated with positive and negative changes in quality of life, respectively. In addition, patient satisfaction can be influenced by glycemic control. Therefore, hypoglycemia and hyperglycemic episodes can negatively affect patient satisfaction. When managing type 2 diabetes (T2D), it is important to consider how therapies impact PROs. Generally, changes in clinical outcomes mirror changes in PROs. To best manage T2D, integrating the assessment of PROs with clinical outcomes is needed.

Alliance of Randomized Trials of Medicine vs Metabolic Surgery in Type 2 Diabetes (ARMMS-T2D): Study rationale, design, and methods

AIMS

Long-term data from randomized clinical trials comparing metabolic (bariatric) surgery versus a medical/lifestyle intervention for treatment of patients with obesity/overweight and type 2 diabetes (T2D) are lacking. The Alliance of Randomized Trials of Medicine vs Metabolic Surgery in Type 2 Diabetes (ARMMS-T2D) is a consortium of four randomized trials designed to compare long-term efficacy and safety of surgery versus medical/lifestyle therapy on diabetes control and clinical outcomes.

MATERIALS AND METHODS

Patients with T2D and body mass index (BMI) of 27-45 kg/m² who were previously randomized to metabolic surgery (Roux-en-Y gastric bypass, adjustable gastric band, or sleeve gastrectomy) versus medical/lifestyle intervention in the STAMPEDE, SLIMM-T2D, TRIABETES, or CROSSROADS trials have been enrolled in ARMMS-T2D for observational follow-up. The primary outcome is change in glycated haemoglobin after a minimum 7 years of follow-up, with additional analyses to determine rates of diabetes remission and relapse, as well as cardiovascular and renal endpoints.

RESULTS

In total, 302 patients (192 surgical, 110 medical/lifestyle) previously randomized in the four parent studies were eligible for participation in the ARMMS-T2D observational study. Participant demographics were 71% white, 27% African-American and 68% female. At baseline: age, 50 ± 8 years; BMI, 36.5 ± 3.5 kg/m² ; duration of diabetes, 8.8 ± 5.6 years; glycated haemoglobin, 8.6% ± 1.6%; and fasting glucose, 168 ± 64 mg/dl. More than 35% of patients had a BMI <35 kg/m² .

CONCLUSIONS

ARMMS-T2D will provide the largest body of long-term, level 1 evidence to inform clinical decision-making regarding the comparative durability, efficacy and safety of metabolic surgery relative to a medical/lifestyle intervention among patients with T2D, including those with milder class I obesity or mere overweight.

Body composition changes at 12 months following different surgical weight loss interventions in adults with obesity: A systematic review and meta-analysis of randomized control trials

To determine relative lean mass and fat mass changes in adults with obesity following surgical weight loss interventions, a systematic review and meta-analysis was conducted. The Cochrane Central Register of Controlled Trials, PubMed, Web of Science, EMBASE, and Scopus were screened for eligible studies. Inclusion criteria included randomized controlled trials (RCTs) performed in populations with obesity (body mass index ≥30 kg/m² ) aged over 18 years, who underwent any type of bariatric surgery and reported body composition measures via dual-energy X-ray absorptiometry or bio-electrical impedance analysis. Authors conducted full text screening and determined that there were six RCTs eligible for inclusion, with data extracted at 12 months post-surgery. Meta-analysis revealed that, relative to gastric banding, Roux-en-Y gastric bypass (RYGB) led to greater total body mass loss (mean difference [MD]: -9.33 kg [95% CI: -12.10, -6.56]) and greater fat mass loss (MD: -8.86 kg [95% CI: -11.80, -5.93], but similar lean mass loss (MD: -0.55 kg [95% CI: -3.82, 2.71]. RYGB also led to similar changes in total body mass, fat mass, and lean mass compared with sleeve gastrectomy. RYGB results in greater 12-month weight and fat loss, but similar changes in lean mass, compared with gastric banding. Further RCTs comparing body composition changes following different bariatric surgery procedures are required.

Time impact on the antidiabetic effects of key bariatric surgeries: a network meta-analysis of randomized controlled trials with meta-regression

BACKGROUND

Few studies compare the efficacy of the key bariatric procedures in type 2 diabetes management over the long term. None offer a reliable comparison of their respective efficacy loss over time.

OBJECTIVES

To analyze and compare the time evolution of the antidiabetic effects of the key bariatric procedures.

SETTING

Obesity surgery departments in America, Europe, and Asia.

METHODS

All the randomized clinical trials assessing the efficacy of bariatric surgery in type 2 diabetes management with 1-5 years of follow-up were reviewed. A network meta-analysis with meta-regression was performed to compare the effectiveness of each technique and its respective efficacy loss temporal dynamics.

RESULTS

Thirty-one trials involving 1906 patients were included. In comparison to Roux-en-Y gastric bypass, the 5-year complete or partial diabetes remission rates were inferior with medical treatment (odds ratio [OR] = .05; 95% credible interval [CrI]: .02-.13) and gastric banding (OR = .38; 95% CrI: .16-.87), equivalent with sleeve gastrectomy (OR = 1.08; 95% CrI: .59-1.97), and superior with 1 anastomosis gastric bypass (OR = 3.00; 95% CrI: 1.12-8.33) and biliopancreatic diversion and its affiliated techniques (OR = 3.71; 95% CrI: 1.16-12.55). However, remission rates and glycemic control progressively decreased whatever the treatment option evaluated. Moreover, this loss of efficacy followed a statistically comparable temporal dynamic to those of Roux-en-Y gastric bypass regardless of the therapeutic strategy implemented.

CONCLUSIONS

No therapeutic modality offered stable antidiabetic effects. The gap observed between the techniques after a 5-year follow up concerning remission rates and glycemic control could depend essentially on the magnitude of the effects initially obtained. However, these results need to be confirmed over longer follow-up periods.

Postbariatric hypoglycemia: symptom patterns and associated risk factors in the Longitudinal Assessment of Bariatric Surgery study

BACKGROUND

Postbariatric hypoglycemia (PBH) can be a devastating complication for which current therapies are often incompletely effective. More information is needed regarding frequency, incidence, and risk factors for PBH.

OBJECTIVES

To examine hypoglycemia symptoms following Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) and baseline and in-study risk factors.

SETTING

Multicenter, at 10 US hospitals in 6 geographically diverse clinical centers.

METHODS

A prospective, longitudinal cohort study of adults undergoing RYGB or LAGB as part of clinical care between 2006 and 2009 were recruited and followed until January 31, 2015, with baseline and annual postoperative research assessments. We analyzed baseline prevalence and post-operative incidence and frequency of self-reported hypoglycemia symptoms as well as potential preoperative risk factors.

RESULTS

In all groups, postoperative prevalence of hypoglycemia symptoms was 38.5%. Symptom prevalence increased postoperatively from 2.8%-36.4% after RYGB in patients without preoperative diabetes (T2D), with similar patterns in prediabetes (4.9%-29.1%). Individuals with T2D had higher baseline hypoglycemia symptoms (28.9%), increasing after RYGB (57.9%). Hypoglycemia symptoms were lower after LAGB, with 39.1% reported hypoglycemia symptoms at only 1 postoperative visit with few (4.0%) having persistent symptoms at 6 or more annual visits. Timing of symptoms was not restricted to the postprandial state. Symptoms of severe hypoglycemia were reported in 2.6-3.6% after RYGB. The dominant risk factor for postoperative symptoms was preoperative symptoms; additionally, baseline selective serotonin (SSRI) and serotonin-norepinephrine (SNRI) reuptake inhibitor use was also associated with increased risk in multivariable analysis. Weight loss and regain were not related to hypoglycemia symptom reporting.

CONCLUSION

Hypoglycemia symptoms increase over time after RYGB, particularly in patients without diabetes. In a small percentage, symptoms can be persistent or severe and require hospitalization. Preoperative hypoglycemia symptoms and SSRI/SNRI use in RYGB patients without diabetes is associated with increased risk of symptoms.

The Impact of Bariatric Surgery Versus Non-Surgical Treatment on Blood Pressure: Systematic Review and Meta-Analysis

The purpose of this study was to compare bariatric surgery versus non-surgical treatment on blood pressure for patients with obesity. Nineteen RCTs (1353 total patients) were included. In the pooled analyses, bariatric surgery reduces more systolic blood pressure (WMD: - 3.937 mmHg, CI95%: - 6.000 to - 1.875, p < 0.001, I² = 0%), diastolic blood pressure (WMD: - 2.690 mmHg, CI95%: - 3.994 to - 1.385, P < 0.001, I² = 0%) and more antihypertensives. In subgroup analyses, patients after Roux-en-Y gastric bypass, with poor control of hypertension (BP > 130/80 mmHg) and diabetes mellitus (HbA1C > 7.0%, FPG > 7.0 mmol/L), elder patients (> 45 years), non-severe obesity (BMI < 40 kg/cm², body weight < 120 kg), less waist circumference (< 115 cm) tend to decrease more blood pressure. Besides, patients after surgery also lost more weight (p < 0.001), decreased more waist circumference (p < 0.001), fasting plasma glucose (p < 0.001), glycosylated hemoglobin (p < 0.001), triglycerides (p < 0.001), hsCRP (p = 0.001), increased more high-density lipoprotein cholesterol (p < 0.001), and had better remission of metabolic syndrome (p < 0.001). Changes in total cholesterol, low-density lipoprotein cholesterol, renal function, resting heart rate, and 6-min walking test were not significantly different. Therefore, bariatric surgery is more effective than non-surgical treatment in controlling patients' blood pressure.

Progress in treatment of type 2 diabetes by bariatric surgery

The incidence of type 2 diabetes (T2D) is increasing at an alarming rate worldwide. Bariatric surgical procedures, such as the vertical sleeve gastrectomy and Roux-en-Y gastric bypass, are the most efficient approaches to obtain substantial and durable remission of T2D. The benefits of bariatric surgery are realized through the consequent increased satiety and alterations in gastrointestinal hormones, bile acids, and the intestinal microbiota. A comprehensive understanding of the mechanisms by which various bariatric surgical procedures exert their benefits on T2D could contribute to the design of better non-surgical treatments for T2D. In this review, we describe the classification and evolution of bariatric surgery and explore the multiple mechanisms underlying the effect of bariatric surgery on insulin resistance. Based upon our summarization of the current knowledge on the underlying mechanisms, we speculate that the gut might act as a new target for improving T2D. Our ultimate goal with this review is to provide a better understanding of T2D pathophysiology in order to support development of T2D treatments that are less invasive and more scalable.

A Review of the Current Evidence: Impact of Metabolic Surgery on Diabetes Outcomes and Obesity-Associated Macrovascular Complications

PURPOSE OF REVIEW

Type 2 diabetes (T2D) and obesity are comorbidities that generally progress with time even when non-invasive therapies are prescribed. Indeed, weight loss that is achieved with behavioral modification alone is generally inconsistent and often short-lived. In contrast, although patients do experience weight regain with metabolic surgery, they still benefit from a significant net decrease in weight. As a result, T2D remission can be achieved in up to 60% of patients within 2 years after surgery. However, it is unknown if the positive effects of metabolic surgery extend to macrovascular disease risk reduction.

RECENT FINDINGS

As noted in four randomized controlled trials (RCTs), Roux-en-Y gastric bypass (RYGB) facilitates partial remission of T2D in about 30% of volunteers 5 years after surgery. Of the four RCTs, only one investigated the effects of sleeve gastrectomy (SG) at 5 years; that study found that the rate of partial relapse was slightly lower with SG (23%). However, observational studies indicate that the gap between RYGB and SG may be larger than that observed in RCTs. In contrast, the rate of full remission is noted infrequently 5 years after SG or RYGB. Metabolic surgery also mitigates macrovascular disease risk as indicated by multiple observational studies. The effects of metabolic surgery on cardiometabolic parameters are clinically meaningful. The weight loss that is facilitated by metabolic surgery reduces the metabolic and inflammatory stress caused by T2D and obesity. In turn, metabolic surgery likely mitigates macrovascular disease risk. Additional evidence from RCTs is needed to substantiate the effects of metabolic surgery on macrovascular disease risk.