Preoperative prediction of type 2 diabetes remission after Roux-en-Y gastric bypass surgery: a retrospective cohort study

Validation of the Swiss-Finnish Bariatric Metabolic Outcome Score within a large prospective registry cohort

BACKGROUND

The Swiss-Finnish Bariatric Metabolic Outcome Score (SF-BARI Score), based on merged data of two RCTs, is a composite endpoint designed to evaluate and categorize outcomes after metabolic bariatric surgery (MBS). The aim of this study was to externally validate the score using registry data.

METHODS

Individual patient data were included from the Dutch Audit for Treatment of Obesity, the Scandinavian Obesity Surgery Registries (SOReg-Sweden and SOReg-Norway), and the merged RCT data used for establishing the SF-BARI Score. All patients undergoing primary MBS from January 2010 to June 2018, with complete baseline characteristics, as well as complete 1- and 5-year follow-up data, were included. The mean total score and distribution were compared between the combined registry and merged RCT data.

RESULTS

There was no statistically significant difference in the mean SF-BARI Score between the registries (21 603 patients) and merged RCTs (457 patients) at 5 years (90.9 versus 89.1 points; difference = 1.8 (95% c.i. -1.0 to 4.7); P = 0.212), and the score distribution was similar. Statistically significant differences in baseline characteristics existed regarding sex (male 20.9% versus 29.3%), type 2 diabetes (16.7% versus 33.9%), hypertension (30.4% versus 66.1%), dyslipidaemia (13.7% versus 46.5%), obstructive sleep apnoea syndrome (12.0% versus 17.4%), and sleeve gastrectomy (SG) rate (21.0% versus 49.9%) (P < 0.001). The mean score estimate at 5 years in Roux-en-Y gastric bypass was 11.2 (95% c.i. 10.2 to 12.2) points higher compared with SG (P < 0.001).

CONCLUSION

This study verified the feasibility of the SF-BARI Score, enabling standardized reporting and allowing for comparison of different treatment modalities.

Impact of bodyweight loss on type 2 diabetes remission: a systematic review and meta-regression analysis of randomised controlled trials

BACKGROUND

Bodyweight loss is associated with type 2 diabetes remission; however, the quantitative relationship between the degree of bodyweight loss and the likelihood of remission, after controlling for confounding factors, remains unknown. We aimed to analyse the relationship between the degree of bodyweight loss and diabetes remission after controlling for various confounding factors, and to provide estimates for the effect sizes of these factors on diabetes remission.

METHODS

This systematic review and meta-regression analysis followed Cochrane and PRISMA guidelines to systematically review, synthesise, and report global evidence from randomised controlled trials done in individuals with type 2 diabetes and overweight or obesity. The outcome was the proportion of participants with complete diabetes remission (HbA1c <6·0% [42 mmol/mol] or fasting plasma glucose [FPG] <100 mg/dL [5·6 mmol/L], or both, with no use of glucose-lowering drugs) or partial diabetes remission (HbA1c <6·5% [48 mmol/mol] or FPG <126 mg/dL [7·0 mmol/L], or both, with no use of glucose-lowering drugs) at least 1 year after a bodyweight loss intervention. We searched PubMed, Embase, and trial registries from database inception up to July 30, 2024. Data were extracted from published reports. Meta-analyses and meta-regressions were performed to analyse the data. The study protocol is registered with PROSPERO (CRD42024497878).

FINDINGS

We identified 22 relevant publications, encompassing 29 outcome measures of complete diabetes remission and 33 outcome measures of partial remission. The pooled mean proportion of participants with complete remission 1 year after the intervention was 0·7% (95% CI 0·1-4·6) in those with bodyweight loss less than 10%, 49·6% (40·4-58·9) in those with bodyweight loss of 20-29%, and 79·1% (68·6-88·1) in those with bodyweight loss of 30% or greater; no studies reported on complete remission with 10-19% bodyweight loss. The pooled mean proportion of participants with partial remission 1 year after the intervention was 5·4% (95% CI 2·9-8·4) in those with bodyweight loss less than 10%, 48·4% (36·1-60·8) in those with 10-19% bodyweight loss, 69·3% (55·8-81·3) in those with bodyweight loss of 20-29%, and 89·5% (80·0-96·6) in those with bodyweight loss of 30% or greater. There was a strong positive association between bodyweight loss and remission. For every 1 percentage point decrease in bodyweight, the probability of reaching complete remission increased by 2·17 percentage points (95% CI 1·94-2·40) and the probability of reaching partial remission increased by 2·74 percentage points (2·48-3·00). No significant or appreciable associations were observed between age, sex, race, diabetes duration, baseline BMI, HbA1c, insulin use, or type of bodyweight loss intervention and remission. Overall, data were derived from randomised controlled trials with a low risk of bias in all quality domains.

INTERPRETATION

A robust dose-response relationship between bodyweight loss and diabetes remission was observed, independent of age, diabetes duration, HbA1c, BMI, and type of intervention. These findings highlight the crucial role of bodyweight loss in managing type 2 diabetes and reducing the risk of diabetes-related complications.

FUNDING

Biomedical Research Program at Weill Cornell Medicine-Qatar and the Qatar National Research Fund (a member of Qatar Foundation).

Noninvasive identification of metabolic dysfunction-associated steatohepatitis (INFORM MASH): a retrospective cohort and disease modeling study

BACKGROUND

Using common clinical parameters, we aimed to noninvasively identify and predict metabolic dysfunction-associated steatohepatitis (MASH)/MASH with clinically significant fibrosis.

RESEARCH DESIGN AND METHODS

Patients aged ≥18 with electronic health record (EHR) documented liver function tests and liver biopsies between 2016 and 2021 were retrospectively identified from the Geisinger Health System Research Liver Registry. MASH cases were confirmed using the nonalcoholic fatty liver disease (NAFLD) activity score. Training and validation datasets were used to create an algorithm/predictive model assessing EHR-derived predictors of MASH/MASH with clinically significant fibrosis (fibrosis stage F2-F4). Predictive accuracy was evaluated using the area under the curve.

RESULTS

The analysis included 2698 patients. We created a composite likelihood score using variables significant for MASH and/or MASH with clinically significant fibrosis: liver enzymes (alanine aminotransferase [ALT], aspartate aminotransferase [AST]), prior year AST, metabolic disease, pulse (heart rate), and body mass index. The score had higher sensitivity and specificity for predicting MASH than Fibrosis-4 (FIB-4) Index, AST to platelet ratio index (APRI), and NAFLD fibrosis score (NFS); sensitivity and specificity were comparable to FIB-4 and APRI for predicting MASH with clinically significant fibrosis but superior to NFS.

CONCLUSION

The composite likelihood score could potentially be a tool for early MASH screening.

Reduced Risk of Cardiovascular Diseases After Bariatric Surgery Based on the New Predicting Risk of Cardiovascular Disease EVENTs Equations

BACKGROUND

We applied the novel Predicting Risk of Cardiovascular Disease EVENTs equations to evaluate cardiovascular-kidney-metabolic (CKM) health and estimated cardiovascular disease (CVD) risk after bariatric surgery.

METHODS

Among 7804 patients (aged 20-79 years) undergoing bariatric surgery at Vanderbilt University Medical Center during 1999 to 2022, CVD risk factors from before surgery to 2 years after surgery were extracted from electronic health records. The 10- and 30-year risks of total CVD, atherosclerotic CVD, coronary heart disease, stroke, and heart failure (HF) were estimated for patients without CVD history at each time point (n=124-2910), using the social deprivation index-enhanced Predicting Risk of Cardiovascular Disease EVENTs equations. Paired t tests or McNemar tests were used to compare pre- with postsurgery CKM health and CVD risk. Two-sample t tests were used to compare CVD risk reduction between patient subgroups.

RESULTS

CKM health was significantly improved after surgery with lower systolic blood pressure, non-high-density lipoprotein cholesterol, and diabetes prevalence, and higher high-density lipoprotein and estimated glomerular filtration rate. The 10-year risks of total CVD and its subtypes decreased by 21.7% to 56.3% at 1 year after surgery and by 14.6% to 46.5% at 2 years after surgery, with the largest reduction observed for HF. Younger age, White race, >30% weight loss, and diabetes history were associated with greater HF risk reductions. Similar results were found for the 30-year CVD risk estimates.

CONCLUSIONS

Bariatric surgery significantly improves CKM health and reduces estimated CVD risk, particularly HF, by 47% to 56% within 1 to 2 years after surgery. HF risk reduction may vary by patient's demographics, weight loss, and disease history, which warrants further research.

Advances in Metabolic Bariatric Surgeries and Endoscopic Therapies: A Comprehensive Narrative Review of Diabetes Remission Outcomes

Background and Objectives: Type 2 diabetes (T2D), closely associated with obesity, contributes to increased morbidity and mortality due to complications such as cardiometabolic disease. This review aims to evaluate the effectiveness of metabolic and bariatric surgeries (MBS) and endoscopic bariatric therapies (EBTs) in achieving diabetes remission and to examine key predictors influencing remission outcomes. Materials and Methods: This review synthesizes data from studies on MBS and EBT outcomes, focusing on predictors for diabetes remission such as preoperative insulin use, diabetes duration, HbA1c, and C-peptide levels. Additionally, predictive scoring systems, including the Individualized Metabolic Surgery (IMS), DiaRem, Advanced-DiaRem, ABCD, and Robert et al. scores, were analyzed for their utility in forecasting remission likelihood. Results: Key predictors of T2D remission include shorter diabetes duration, lower HbA1c, and higher C-peptide levels, while prolonged insulin use, and higher insulin doses are associated with lower remission rates. Scoring models like IMS and DiaRem demonstrate that lower scores correlate with a higher likelihood of remission, especially for procedures such as Roux-En-Y gastric bypass (RYGB). RYGB generally shows higher remission rates compared to sleeve gastrectomy (SG), particularly among patients with mild disease severity, while EBTs like ESG and IGBs contribute 5-20% total weight loss (TWL) and moderate glycemic control improvements. Conclusions: Both MBS and EBTs are effective for T2D management, with predictive scoring models aiding in individualized patient selection to optimize remission outcomes. Further research to validate these predictive tools across diverse populations could enhance treatment planning for both surgical and endoscopic interventions.

Prediction Model of Diabetes Remission at 1-Year after Sleeve Gastrectomy and Comparison with other Models

BACKGROUND

Although numerous prediction models are available for diabetes remission following metabolic bariatric surgery, few are based on sleeve gastrectomy (SG). This study aimed to establish a predictive model for type 2 diabetes mellitus (T2DM) remission following SG and evaluate the efficacy of existing predictive models.

METHODS

Patient data were gathered from a cohort study titled "Longitudinal Study of Bariatric Surgery in Western China." The synthetic minority oversampling technique was implemented, with 70% randomly selected as the training set and the remaining 30% as the testing set. Univariate logistic regression was used to identify factors associated with T2DM remission. These were included in subsequent stepwise multivariate analyses. A nomogram was then constructed. It was evaluated using a receiver operating characteristic (ROC) curve, calibration plot, and decision curve analysis. Finally, eight pre-existing predictive models were validated.

RESULTS

Initially, 166 patients were enrolled with a T2DM remission rate of 89.2%. Univariate logistic regression indicated that male patients, T2DM duration exceeding 1 year, elevated fasting blood glucose levels, and higher HbA1c levels were less likely to achieve remission 1 year following SG. A nomogram was constructed using variables, including sex, T2DM duration, and HbA1c levels. The ROC curve indicated that the nomogram had higher accuracy (AUC = 0.826, 95%CI: 0.768-0.884). Moreover, the AUCs were 0.790 (95%CI: 0.692-0.887), 0.865 (95%CI: 0.774-0.956) and 0.813 (95%CI: 0.733-0.893) for the testing, externally validated, and raw datasets, respectively.

CONCLUSIONS

The nomogram exhibited high efficacy in predicting T2DM remission in Chinese patients who underwent SG.

Metabolic disease remission after Roux-en-Y gastric bypass depends on preoperative disease severity: use of a new objective metabolic scoring system

BACKGROUND

Severity stratification and longitudinal evaluation of metabolic conditions in response to Roux-en-Y gastric bypass (RYGB) are not standardized. Our Assessment of Obesity-related Metabolic Comorbidities (AOMC) scoring tool combines pharmacotherapy and biochemical data to objectively define type 2 diabetes (T2D), hypertension (HTN), and dyslipidemia (DYS) severity. We previously showed that AOMC more accurately describes disease severity than clinical history alone.

OBJECTIVES

We aimed to show that AOMC more precisely and reproducibly measures metabolic disease response to RYGB and preoperative disease severity influences remission rates.

SETTING

University hospital, United States.

METHODS

AOMC scores for T2D, DYS, and HTN were calculated preoperatively and postoperatively (1-, 2-, and 5-years) for patients who underwent RYGB over 14 years. Generalized linear mixed-effect models were used to evaluate AOMC score trends and remission over time.

RESULTS

Of 351 patients, 214, 188, and 303, presented with any T2D, DYS, or HTN respectively. One-year remission rates were: T2D 57.1%, DYS 59.7%, and HTN 29.3%. Over 5 years post-RYGB, remission rates declined for T2D (P < .05) and DYS (P < .05) but remained steady for HTN (P > .05). Remission was associated with preoperative disease severity: those with premetabolic disease had the highest remission rates (i.e., 1-year: pre-T2D 81.4%, pre-DYS 91.4%, pre-HTN 53.5%, all P < .05), while those with most severe scores preoperatively (untreated/uncontrolled) had the lowest remission rates.

CONCLUSIONS

AOMC allows precise assessment of comorbidity severity and disease-specific postoperative quantification of comorbidity responses and remission rates. These findings can guide preoperative metabolic disease optimization and postoperative metabolic recovery expectations and standardize communication regarding comorbidity severity.

Prioritising patients for publicly funded bariatric surgery in Queensland, Australia

OBJECTIVES

This study reports the development and pilot application of the Bariatric Surgery Assessment and Prioritisation Tool (BAPT) for use in a public health system. The BAPT was designed as a patient prioritisation instrument to assess patients with excessive weight and type 2 diabetes suitable for bariatric surgery. We assessed whether the instrument successfully identified those who gained the greatest benefits including weight loss, diabetes remission, reduction in comorbidities, and health-related quality of life (HR-QoL).

METHODS

The BAPT instrument was applied to score 292 patients referred for bariatric surgery in Queensland between 2017 and 2020 based on their, body mass index, diabetes status, surgical risk (e.g. pulmonary embolism) and comorbidities (e.g. non-alcoholic steatohepatitis). These data were collected at referral and at 12-months post-surgery for 130 patients and stratified by BAPT scores. Outcomes included clinical and HR-QoL.

RESULTS

Patients' BAPT scores ranged from 12 to 78 (possible range 2-98). Those with higher scores tended to be younger (p < 0.001), have higher BMI (p < 0.001) or require insulin to manage diabetes (p < 0.01). All patients lost similar percentages of body weight (20-25%, p = 0.73) but higher-scoring patients were more likely to discontinue oral diabetes medications (p < 0.001) and the improvement in glycated haemoglobin was four times greater in patients scoring 70-79 points compared to those scoring 20-29 (p < 0.05). Those who scored ≥ 50 on the BAPT were substantially more likely to obtain diabetes remission (57% vs 31%). BAPT scores of 40 and above tended to have greater improvement in HR-QoL.

CONCLUSIONS

The BAPT prioritised younger patients with higher BMIs who realised greater improvements in their diabetes after bariatric surgery. Higher-scoring BAPT patients should be prioritised for bariatric surgery as they have a greater likelihood of attaining diabetes remission.

Precision Medicine in Bariatric Procedures

Obesity is a multi-factorial disease that is influenced by genetic, epigenetic, and environmental factors. Precision medicine is a practice wherein prevention and treatment strategies take individual variability into account. It involves using a variety of factors including deep phenotyping using clinical, physiologic, and behavioral characteristics, 'omics assays (eg, genomics, epigenomics, transcriptomics, and microbiomics among others), and environmental factors to devise practices that are individualized to subsets of patients. Personalizing the therapeutic modality to the individual can lead to enhanced effectiveness and tolerability. The authors review advances in precision medicine made in the field of bariatrics and discuss future avenues and challenges.

Epidemiology and Trends of Obesity and Bariatric Surgery in Korea

The prevalence of obesity in Korea has steadily increased over the past decade, reaching 38.4% in 2021. Notably, the rate of class II- III obesity, defined as a body mass index (BMI) of 30 kg/m2 or higher, exceeded 7% in the same year. Since January 2019, the National Health Insurance Service (NHIS) has provided coverage for bariatric surgery (BS) for eligible patients. Coverage is available for individuals with a BMI of 35 kg/m2 or higher, or those with a BMI of 30 kg/m2 or higher who also have obesity-related comorbidities. Additionally, partial reimbursement is offered for BS in patients with type 2 diabetes mellitus who have BMI values between 27.5 and 30 kg/m2. From 2019 to 2022, the NHIS recorded 9,080 BS procedures, with sleeve gastrectomy being the most commonly performed. The average percentage of weight loss 198±99.7 days post-surgery was 17.9%, with 80.0% of patients losing more than 10% of their body weight. This article presents the trends in obesity and BS in Korea.

Comparison of scoring systems for predicting short- and long-term type 2 diabetes remission after bariatric surgery

INTRODUCTION

Our study aimed to compare the short- and particularly long-term type 2 diabetes mellitus (T2DM) remission prediction abilities of ABCD, individualised metabolic surgery (IMS), DiaRem2, Ad-DiaRem and DiaBetter scoring systems in Turkish adult type 2 diabetic morbidly obese patients who underwent bariatric surgery.

PATIENTS AND METHODS

Our study was planned as a retrospective cohort study. A total of 137 patients with T2DM, including 78 sleeve gastrectomy (SG) and 59 Roux-en-Y gastric bypass (RYGB) patients, were included in the 1 st -year evaluation after bariatric surgery, and a total of 115 patients with T2DM, including 64 SG and 51 RYGB patients, were included in the evaluation at the end of the 5 th year.

RESULTS

In the 1 st year after bariatric surgery, area under the ROC curve (AUC) values for diabetes remission scores were 0.863 for Ad-DiaRem, 0.896 for DiaBetter, 0.840 for DiaRem2, 0.727 for ABCD and 0.836 for IMS. At 5 years after bariatric surgery, the AUC values for diabetes remission were 0.834 for Ad-DiaRem, 0.888 for DiaBetter, 0.794 for DiaRem2, 0.730 for ABCD and 0.878 for IMS.

CONCLUSIONS

According to our study, the DiaBetter score provided a better AUC value than the other scores both in the short and long term but showed similar predictive performance to Ad-DiaRem in the short term and IMS in the long term. We believe that DiaBetter and Ad-DiaRem scores might be more appropriate for short-term assessment and DiaBetter and IMS scores for long-term remission assessment.

Sex-differential testosterone response to long-term weight loss

OBJECTIVES

Obesity-associated gonadal dysfunction is a common comorbidity in patients seeking weight loss interventions. We examined the incremental effect of weight loss on gonadal axes in men and women over 3 years. Changes in sex hormones were compared between dietary intervention (Diet) and bariatric procedures: Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG) and laparoscopic adjustable gastric banding (LAGB). Additional analysis assessed changes in corticotropic, somatotropic and thyroid axes after weight loss interventions.

METHODS

This prospective, observational study included 61 adults with Body Mass Index >30 kg/m2, mean age 51 (SD = 11) years. Endocrine parameters were measured at baseline and at 6 timepoints over 36-months.

RESULTS

For each 1 kg of weight lost, between baseline and 36 months, total testosterone increased by 0.6% (95% CI: 0.2%, 1.0%, p = 0.002) in males and decreased by 0.8% (95% CI: -1.4%, -0.3%, p = 0.003) in females. These changes remained statistically significant when controlled for age and for menopausal status in females. At 36 months, in comparison with Diet, RYGB women had lower total testosterone by 54% (95% CI: -90%, -17%, p = 0.004), reduced free androgen index (FAI) by 65% (95% CI; -114%, -17%, p = 0.009) while SG had reduced FAI by 39% (95% CI; -77%, 0%, p = 0.05). No such differences between groups were noted for male subjects. Adrenocorticotropic hormone declined by 0.3% (95% CI: 0.0, -0.5%, p = 0.05), insulin-like growth factor-1 increased by 0.4% (95% CI; 0.2%, 0.7%, p = 0.005), without such thyrotrophin change for each 1 kg of weight loss, for entire cohort, over 36 months.

CONCLUSIONS

The testosterone changes observed in this study were proportional to the amount of weight loss. In females, reduction in androgens was independent of age and menopausal status and more pronounced after bariatric procedures. This study finding warrants further clinical research to explore an impact of androgen reduction on functional and cognitive status in postmenopausal women. The observed changes in pituitary hormones may contribute to the metabolic benefits of bariatric surgery.

Preoperative duration of type 2 diabetes mellitus and remission after Roux-en-Y gastric bypass: a single center long-term cohort study

BACKGROUND

Roux-en-Y gastric bypass (RYGB) has demonstrated excellent glycemic control and type 2 diabetes mellitus (T2DM) remission for patients with obesity and T2DM. Duration of T2DM is a consistent negative predictor of remission after RYGB. However, the exact timing to offer surgical intervention during the course of the disease is not well elucidated.

MATERIAL AND METHODS

The authors performed a retrospective cohort study between 2008 and 2020 to establish the exact association between duration of T2DM and remission after RYGB. The authors divided our cohort into quartiles of preoperative disease duration to quantify the change in remission rates for each year of delay between T2DM diagnosis and RYGB. The authors also compared the average time to remission and changes in glycemic control parameters.

RESULTS

A total of 519 patients (67.2% female; age 53.4±10.7 year; BMI 46.6±8.4 kg/m 2 ) with a follow-up period of 6.6±3.8 years were included. Remission was demonstrated in 51% of patients. Longer duration of T2DM was a significant negative predictor of remission with an estimated decrease in remission rates of 7% for each year of delay [(OR=0.931 (95% CI: 0.892-0.971); P< 0.001)]. Compared to patients with <3 years of T2DM, remission decreased by 37% for patients with 3-6 years, 64% for those with 7-12 years, and 81% for patients with more than 12 years ( P <0.001). Half of the patients reached T2DM remission after 0.5 and 1.1 years, respectively, for the first and second quartiles, while patients in the other quartiles never reached 50% remission. Lastly, The authors noted an overall improvement in all glycemic control parameters for all quartiles at last follow-up.

CONCLUSION

Patients with a recent history of T2DM who undergo early RYGB experience significantly higher and earlier T2DM remission compared to patients with a prolonged history of preoperative T2DM, suggesting potential benefit of early surgical intervention to manage patients with obesity and T2DM.

Navigating the Predictive Landscape: DiaRem's Role in Unveiling Outcomes for Diabetes Remission following ESG

PURPOSE

Rising obesity and type 2 diabetes mellitus (T2DM) rates can be mitigated by various strategies, with a 10% total body weight loss (TBWL) threshold often required for T2DM remission. T2DM remission rates after bariatric surgery like Roux-en-Y gastric bypass (RYGB) are well established; endoscopic sleeve gastroplasty (ESG) is a less invasive option that averages 15% TBWL and allows for T2DM remission. This study explores the DiaRem (Diabetes Remission post-RYGB) score's ability to predict T2DM remission 1-year post-ESG.

MATERIALS AND METHODS

We conducted a retrospective cohort study on 39 individuals with T2DM who underwent ESG. Age, utilization of diabetes medications, insulin administration, and hemoglobin A1c levels were used to calculate the DiaRem score. The area under the receiver operating characteristic curve (AUC) was employed to evaluate the discriminative ability of DiaRem in distinguishing diabetes remission.

RESULTS

Among the 39 patients with a median hemoglobin A1c of 6.7, 12.8% required insulin, and 43.6% used diabetes medication. At 1-year post-ESG, 69.2% of patients experienced diabetes remission with a median %TWBL of 12.7. The DiaRem score's ability to detect diabetes resolution for ESG patients had a sensitivity of 100% and a specificity of 58.3%, at the optimal cutoff value of 10. The AUC was 0.779 (95% CI 0.546-0.959).

CONCLUSION

Our study demonstrated the DiaRem score's predictive value for T2DM remission post-ESG, highlighting its utility in clinical decision-making for ESG-related outcomes. Further investigation is needed to identify alternative indicators that may enhance predictive accuracy, thus refining personalized decision-making for this patient group.

Reduced Risk of Cardiovascular Diseases after Bariatric Surgery Based on the New PREVENT Equations

Background

We applied the novel Predicting Risk of Cardiovascular Disease EVENTs (PREVENT) equations to evaluate cardiovascular-kidney-metabolic (CKM) health and estimated CVD risk, including heart failure (HF), after bariatric surgery.

Methods

Among 7804 patients (20-79 years) undergoing bariatric surgery at Vanderbilt University Medical Center during 1999-2022, CVD risk factors at pre-surgery, 1-year, and 2-year post-surgery were extracted from electronic health records. The 10- and 30-year risks of total CVD, atherosclerotic CVD (ASCVD), coronary heart disease (CHD), stroke, and HF were estimated for patients without a history of CVD or its subtypes at each time point, using the social deprivation index-enhanced PREVENT equations. Paired t-tests or McNemar tests were used to compare pre- with post-surgery CKM health and CVD risk. Two-sample t-tests were used to compare CVD risk reduction between patient subgroups defined by age, sex, race, operation type, weight loss, and history of diabetes, hypertension, and dyslipidemia.

Results

CKM health was significantly improved after surgery with lower systolic blood pressure, non-high-density-lipoprotein cholesterol (non-HDL), and diabetes prevalence, but higher HDL and estimated glomerular filtration rate (eGFR). The 10-year total CVD risk decreased from 6.51% at pre-surgery to 4.81% and 5.08% at 1- and 2-year post-surgery (relative reduction: 25.9% and 16.8%), respectively. Significant risk reductions were seen for all CVD subtypes (i.e., ASCVD, CHD, stroke, and HF), with the largest reduction for HF (relative reduction: 55.7% and 44.8% at 1- and 2-year post-surgery, respectively). Younger age, White race, >30% weight loss, diabetes history, and no dyslipidemia history were associated with greater HF risk reductions. Similar results were found for the 30-year risk estimates.

Conclusions

Bariatric surgery significantly improves CKM health and reduces estimated CVD risk, particularly HF, by 45-56% within 1-2 years post-surgery. HF risk reduction may vary by patient's demographics, weight loss, and disease history, which warrants further research.

Preoperative predictors of type 2 diabetes remission after bilio-pancreatic diversion with duodenal switch

BACKGROUND

Many patients achieve short-term type 2 diabetes (T2D) remission after bariatric surgery, but relapses are common. Diabetes outcomes after bariatric surgery vary across procedures and populations. T2D remission scores are simple clinical tools developed to predict remission after bariatric surgery. However, they have never been tested after Biliopancreatic diversion with duodenal switch (BPD-DS).

OBJECTIVES

The aim of this study was to compare the predictive value of T2D remission scores and preoperative diabetes characteristics in predicting T2D remission after BPD-DS.

SETTING

Quebec Heart and Lung Institute - Laval University.

METHODS

We retrospectively identified 918 patients with preoperative T2D who had undergone BPD-DS. Retrospective chart review was performed and variables used to calculate predictive scores were captured. T2D status was assessed annually for up to 10 years postop. Predictive values for each score (DiarRem, Ad Diarem, and Diabetter) and single preoperative diabetes characteristics used to construct these algorithms were evaluated by area under receiver operating characteristic curves (AUC).

RESULTS

Diabetter showed greater performance for prediction of durable diabetes remission than other algorithms with acceptable discriminative ability (AUC between .69 and .79), but was not superior to T2D duration as a single predictor (P = .24 and P = .18). At 10 years, T2D duration had a better discriminative ability for the prediction of T2D remission than all 3 predictive models (AUC = .85, P < .05).

CONCLUSIONS

Better chances for T2D remission following BPD-DS are associated with a shorter duration or T2D before surgery. Duration of T2D alone offers an excellent predictive ability and is a convenient alternative to diabetes remission scores to estimate chances of long-term diabetes remission after BPD-DS.

Mid-Term Diabetes Remission Outcome in Patients with BMI ≤ 30 kg/m2 Following Sleeve Gastrectomy

BACKGROUND

Bariatric and metabolic surgery is recommended for Asian patients with type 2 diabetes mellitus (T2DM) and BMI ≥ 27.5 kg/m2. However, mid to long-term ·evidence is still lacking.

METHODS

Patients' data that underwent laparoscopic sleeve gastrectomy (SG) as the primary surgery at the Affiliated Hospital of Xuzhou Medical University were analyzed. Patients with T2DM diagnosed with either fasting blood glucose (FBG) ≥ 7.0 mmol/L or glycosylated hemoglobin (HbA1c) level ≥ 7.0% and 27.5 ≤ BMI ≤ 30 kg/m2 were included.

RESULTS

24 patients (7 male and 17 female) were included in this study. With a mean follow-up duration of 4.5 ± 1.1 years, the mean percentage of total weight loss (%TWL) was 14.4 ± 6.7%. Postoperatively, nine patients (37%) still required oral anti-diabetic medications, while no patients used insulin. FBG and HbA1c levels declined to 6.3 ± 1.5 mmol/L and 6.0 ± 1.0%, respectively. Fifteen patients (63%) were with HbA1c levels < 7% and without medication requirements, five patients (21%) were with HbA1c levels < 7% with the help of oral anti-diabetic medication, and four patients (16%) were with HbA1c levels > 7% with the help of oral anti-diabetic medication.

CONCLUSIONS

Our study provides further evidence that SG could result in both T2DM improvement and remission in patients with BMI ≤ 30 kg/m2. Longer follow-up duration and larger sample will be needed in the future.

The association between microvascular and macrovascular diseases and diabetes remission after bariatric surgery

BACKGROUND

Type-2 diabetes mellitus (T2DM) results in detrimental vascular complications including both microvascular and macrovascular diseases. Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are effective weight-loss therapies that enhance T2DM remission. However, limited data are present regarding the association between diabetes-associated diseases before RYGB and SG with T2DM remission.

METHODS

This is a retrospective cohort study in patients with T2DM who underwent RYGB or SG. We collected data on preoperative microvascular (i.e., retinopathy, nephropathy, and neuropathy) and macrovascular (coronary artery disease, cerebrovascular accidents, and peripheral artery disease) diabetes-associated diseases. Our end points included assessment of association and cumulative effect of diabetes-associated diseases and disease remission. We also performed a multivariate logistic regression to evaluate the parameters associated with T2DM remission.

RESULTS

A total of 536 patients (67% female, 94% White) were included in this study. Patients without diabetes-associated diseases had an OR of 2.72 (95% CI 1.92 to 3.88) to achieve T2DM remission compared to patients with diabetes-associated diseases (27.9% vs 59.4%; p < 0.001). Importantly, there was an additive effect of the number of diabetes-associated diseases on the T2DM remission (p < 0.001). We demonstrate a significant association between HbA1c (p < 0.001), number of diabetes medications (p < 0.001), T2DM duration (p < 0.001), surgery type (p = 0.009), and insulin use (p = 0.04) with T2DM remission.

CONCLUSION

Patients with presurgical diabetes-associated diseases had a lower remission rate after RYGB and SG. Not only do these complications represent a more practical and consistent variable to predict T2DM remission, but also help planning a multidisciplinary management of patients with more severe T2DM.

Cardiometabolic Improvements After Metabolic Surgery and Related Presurgery Factors

Context

Metabolic surgery remains the most effective and durable treatment for severe obesity and related metabolic diseases.

Objective

We examined cardiometabolic improvements after metabolic surgery and associated presurgery demographic and clinical factors in a large multiracial cohort.

Methods

Included were 7804 patients (20-79 years) undergoing first-time metabolic surgery at Vanderbilt University Medical Center from 1999 to 2022. Pre- and 1-year postsurgery cardiometabolic profiles were extracted from medical records, including body mass index (BMI), blood pressure, blood lipids, glucose, and hemoglobin A1c. The 10-year atherosclerotic cardiovascular disease (ASCVD) risk was estimated per American College of Cardiology/American Heart Association equations. Pre- to postsurgery cardiometabolic profiles were compared by paired t-test, and associated factors were identified by multivariable linear and logistic regression.

Results

Among 7804 patients, most were women and White, while 1618 were men and 1271 were Black; median age and BMI were 45 years [interquartile range (IQR): 37-53] and 46.4 kg/m2 (IQR: 42.1-52.4). At 1-year postsurgery, patients showed significant decreases in systolic blood pressure (10.5 [95% confidence interval: 10.1, 10.9] mmHg), total cholesterol (13.5 [10.3, 16.7] mg/dL), glucose (13.6 [12.9, 14.4] mg/dL), hemoglobin A1c (1.13% [1.06, 1.20]), and 10-year ASCVD risk (absolute reduction: 1.58% [1.22, 1.94]; relative reduction: 34.4% [29.4, 39.3]); all P < .0001. Older, male, or Black patients showed less reduction in 10-year ASCVD risk and lower odds of diabetes/hypertension/dyslipidemia remission than younger, female, or White patients. Patients with a history of diabetes, hypertension, dyslipidemia, or cardiovascular disease showed less cardiometabolic improvements than those without. Results were similar with or without further adjusting for weight loss and largely sustained at 2-year postsurgery.

Conclusion

Metabolic surgery results in significant cardiometabolic improvements, particularly among younger, female, or White patients and those without comorbidities.

Type-2 diabetes mellitus remission prediction models after Roux-En-Y gastric bypass and sleeve gastrectomy based on disease severity scores

AIM

Metabolic and bariatric surgery (MBS) is considered one of the most effective interventions for weight loss and associated type-2 diabetes mellitus (T2DM) remission. Multiple scores including the Individualized Metabolic Surgery (IMS), DiaRem, advanced DiaRem, and Robert et al. scores, have been developed predict T2DM remission after MBS. We aim to validate each of these scores in our cohort of patients undergoing MBS with long-term follow-up and assess their efficacy based on procedure type and preoperative BMI.

METHODS

We conducted a multicenter cohort study including patients with T2DM undergoing either Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Areas under the receiver operating characteristics (ROC) curve (AUC) were calculated to assess the discriminatory ability of the four models to detect T2DM remission.

RESULTS

A total of 503 patients (67 % females, mean age 53.5 [11] years, BMI 46.2 [8.8] kg/m2) with T2DM were included. The majority (78 %) underwent RYGB, while the rest (28 %) had SG. All four scores predicted T2DM remission in our cohort with an ROC AUC of 0.79 for IMS, 0.78 for both DiaRem and advanced-DiaRem, and 0.75 for Robert et al. score. Specific subgroups for each of these scores demonstrated higher T2DM remission rates after RYGB compared to SG.

CONCLUSION

We demonstrate the ability of the IMS, DiaRem, advanced-DiaRem and Robert et al. scores to predict T2DM remission in patients undergoing MBS. T2DM remission rates was demonstrated to decrease with more severe IMS, DiaRem and advanced-DiaRem scores and lower Robert et al. scores.

Metabolic surgery in patients with diabesity: A review of the historical backgrounds and scoring systems

Diabesity is a modern term that describes the coexistence of adverse health effects of diabetes mellitus and obesity and indicates a causal pathophysiological relationship between the two phenomena. The progression of diabesity leads to a deterioration of multiple organs and systems. Effective intervention for patients with diabesity must include optimal obesity therapy to prevent secondary complications. Metabolic surgery is the most effective and sustainable therapy for severe obesity and the elimination or prevention of many associated diseases, including type 2 diabetes mellitus, hypertension, sleep apnea, heart disease, and certain cancers. This review provides an up-to-date overview of surgical interventions for obesity, particularly the development of metabolic surgery. It evaluates different scoring systems for evidence-based selection of metabolic surgery based on disease severity. We reviewed different predictive scoring systems for better evidence-based selection of the best metabolic surgery for patients with diabesity. We found that medication type, fasting insulin level, and C-peptide influence the outcomes of different types of metabolic surgery and heterogeneous remission rates. There are different predictive scoring systems for evidence-based selection of the best metabolic surgery, either sleeve or mini-bypass, that will ensure the highest chance of diabetes remission. Using the metabolic score calculator is a useful tool to help medical specialists determine the optimal treatment strategy for a particular patient. More research is needed before we can agree on the ideal bariatric procedure that offers the highest chance of remission with the lowest incidence of hypoglycemia.

Clinical Perspectives, Eligibility, and Success Criteria for Bariatric/Metabolic Surgery

Obesity is a worldwide chronic, complex, and progressive disease that poses a challenge for physicians to pursue optimal therapeutic decision making. This chapter focuses on the definition of obesity, based on excessive fat accumulation, and thus underscores the importance of body composition, and the clinical tools used to diagnose it in the context of excess weight, metabolic alteration, and obesity-associated comorbidity development. Additionally, it addresses the indications for surgery that are currently applicable and the description of the different types of patients who could benefit the most from the surgical management of excessive body fat and its associated metabolic derangements and quality of life improvement. Furthermore, it also highlights plausible underlying mechanisms of action for the beneficial effects following bariatric/metabolic surgery.

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.

Construction and validation of a nomogram for predicting diabetes remission at 3 months after bariatric surgery in patients with obesity combined with type 2 diabetes mellitus

AIM

Bariatric metabolic surgery (BMS) is a proven treatment option for patients with both obesity and type 2 diabetes mellitus (T2DM). However, there is a lack of comprehensive reporting on the short-term remission rates of diabetes, and the existing data are inadequate. Hence, this study aimed to investigate the factors that may contribute to diabetes remission (DR) in patients with obesity and T2DM, 3 months after undergoing BMS. Furthermore, our objective was to develop a risk-predicting model using a nomogram.

METHODS

In total, 389 patients with obesity and T2DM, who had complete preoperative information and underwent either laparoscopic sleeve gastrectomy or laparoscopic gastric bypass surgery between January 2014 and May 2023, were screened in the Chinese Obesity and Metabolic Surgery Database. The patients were randomly divided into a training set (n = 272) and a validation set (n = 117) in a 7:3 ratio. Potential factors for DR were analysed through univariate and multivariate logistic regression analyses and then modelled using a nomogram. The model's performance was evaluated using receiver operating characteristic curves and the area under the curve (AUC). Calibration plots were used to assess prediction accuracy and decision curve analyses were conducted to evaluate the clinical usefulness of the model.

RESULTS

Glycated haemoglobin, triglycerides, duration of diabetes, insulin requirement and hypercholesterolaemia were identified as independent factors influencing DR. We have incorporated these five indicators into a nomogram, which has shown good efficacy in both the training cohort (AUC = 0.930) and validation cohort (AUC = 0.838). The calibration plots indicated that the model fits well in both the training and the validation cohorts, and decision curve analyses showed that the model had good clinical applicability.

CONCLUSION

The prediction model developed in this study holds predictive value for short-term DR following BMS in patients with obesity and T2DM.

Transcriptome Changes and Metabolic Outcomes After Bariatric Surgery in Adults With Obesity and Type 2 Diabetes

Context

Bariatric surgery has been shown to be effective in inducing complete remission of type 2 diabetes in adults with obesity. However, its efficacy in achieving complete diabetes remission remains variable and difficult to predict before surgery.

Objective

We aimed to characterize bariatric surgery-induced transcriptome changes associated with diabetes remission and the predictive role of the baseline transcriptome.

Methods

We performed a whole-genome microarray in peripheral mononuclear cells at baseline (before surgery) and 2 and 12 months after bariatric surgery in a prospective cohort of 26 adults with obesity and type 2 diabetes. We applied machine learning to the baseline transcriptome to identify genes that predict metabolic outcomes. We validated the microarray expression profile using a real-time polymerase chain reaction.

Results

Sixteen patients entered diabetes remission at 12 months and 10 did not. The gene-expression analysis showed similarities and differences between responders and nonresponders. The difference included the expression of critical genes (SKT4, SIRT1, and TNF superfamily), metabolic and signaling pathways (Hippo, Sirtuin, ARE-mediated messenger RNA degradation, MSP-RON, and Huntington), and predicted biological functions (β-cell growth and proliferation, insulin and glucose metabolism, energy balance, inflammation, and neurodegeneration). Modeling the baseline transcriptome identified 10 genes that could hypothetically predict the metabolic outcome before bariatric surgery.

Conclusion

The changes in the transcriptome after bariatric surgery distinguish patients in whom diabetes enters complete remission from those who do not. The baseline transcriptome can contribute to the prediction of bariatric surgery-induced diabetes remission preoperatively.

Remission of Type II Diabetes Mellitus after Duodenal Switch: the Contribution of Common Channel Length

INTRODUCTION

The role of the common channel length in duodenal switch (DS) on remission of type II diabetes mellitus (DM), when stratifying patients based on diabetes severity, is not well understood.

METHODS

We retrospectively reviewed 341 consecutive patients with DM undergoing DS with one of three different common channel (CC) lengths (100 cm, 150 cm, and 200 cm), each with a fixed 300 cm alimentary limb (AL). Patients were stratified by insulin dependence (IDDM) versus non-insulin dependent diabetes (NIDDM). Data was collected at one year and at the last available follow-up.

RESULTS

The NIDDM group had a similar average HbA1c at last follow-up for each of the CC lengths. However, the IDDM group had lower average HbA1c with shorter CC lengths (100 cm = 5.4%, 150 cm = 6%, 200 cm = 6.4%, p < 0.05). Shorter CC lengths resulted in a greater proportion of patients achieving remission in the IDDM group (66%, 50%, 32% in the 100 cm, 150 cm, and 200 cm CC, respectively, p < 0.01). Improvements in HbA1c were independent of weight loss and average DiaRem scores were similar between CC lengths. Rates of nutritional deficiencies were higher in shorter common channel lengths. Revision for malnutrition was similar between common channel lengths (100 cm group: 3.7%; 150 cm group: 1.8%; 200 cm group: 0%, p = NS).

CONCLUSIONS

When the AL is fixed, shortening CC lengths results in improved glycemic control and remission of DM in patients with the need for insulin preoperatively. Milder forms of DM are treated well with any of the CC lengths.

Postoperative Remission of Diabetes Mellitus After Gastrectomy in Patients With Diabetes Mellitus and Gastric Cancer

BACKGROUND/AIM

We investigated the postoperative treatment status for diabetes mellitus and perioperative HbA1c levels in patients with diabetes mellitus and examined the effects of clinical factors on the remission of diabetes mellitus.

PATIENTS AND METHODS

In this study, 126 patients with gastric cancer were considered to have diabetes mellitus preoperatively, of whom 79 were treated with oral antidiabetic drugs and/or insulin treatment. We compared diabetic treatment status and HbA1c values between the preoperative and postoperative periods in patients who underwent gastrectomy and examined the effects of clinical factors on improving diabetes mellitus.

RESULTS

Of the 79 patients treated preoperatively for diabetes mellitus, 34 (43%) discontinued all medications for diabetes mellitus and for 37 (47%) the therapeutic dose was reduced or switched from insulin to oral antidiabetic drugs. Total gastrectomy was an independent factor for remission of antidiabetic treatments after gastrectomy. Concerning HbA1c levels, only the absence of preoperative insulin use was an independent factor for improvement. However, reconstruction was not a significantly correlated factor for the improvement of postoperative HbA1c levels and reduction of antidiabetic medications after distal gastrectomy.

CONCLUSION

Almost all patients discontinued or had their dose of antidiabetic medications reduced after gastrectomy in clinical practice, and special attention should be paid in the management methods for diabetes mellitus in patients who underwent total gastrectomy for gastric cancer.

Diabetic Markers, Five Years after Bariatric Surgery

Background: Bariatric surgery delivers substantial weight loss for obese patients with comorbidities like diabetes mellitus. We aimed to investigate the impacts of bariatric surgery on diabetic markers after 5 years of follow-up. Methods: This is a retrospective study on patients with diabetes and a history of bariatric surgery between 2016-2017. The diabetic markers before and 5 years following surgery, including a lipid profile, glucose level, and the required antidiabetic medications, were evaluated. Results: 34 consecutive patients were included, 30 (88.2%) women, with a mean age of 52.71±8.53 years. The majority (65%) of surgeries were Roux-en-Y gastric bypass (RYGB), and the remaining were one anastomosis gastric bypass (OAGB) and sleeve gastrectomy (SG). The serum levels of diabetic markers reduced during follow-up (P=0.001), except for high-density lipoprotein levels and serum total cholesterol, which increased (P=0.011, P=0.838). Low-density lipoprotein levels reduced, but it was insignificant (P=0.194). Surgery types had affected the changes of diabetic markers (P>0.05). Demand for oral medication was reduced significantly, but insulin injection reduction was not significant (P=0.006 and P=0.099, respectively). Conclusion: Our study showed favorable bariatric surgery results on patients with diabetes in long-term follow-up. However, dyslipidemia is still a concern.

Towards precision medicine in bariatric surgery prescription

Obesity is a complex, multifactorial and chronic disease. Bariatric surgery is a safe and effective treatment intervention for obesity and obesity-related diseases. However, weight loss after surgery can be highly heterogeneous and is not entirely predictable, particularly in the long-term after intervention. In this review, we present and discuss the available data on patient-related and procedure-related factors that were previously appointed as putative predictors of bariatric surgery outcomes. In addition, we present a critical appraisal of the available evidence on which factors could be taken into account when recommending and deciding which bariatric procedure to perform. Several patient-related features were identified as having a potential impact on weight loss after bariatric surgery, including age, gender, anthropometrics, obesity co-morbidities, eating behavior, genetic background, circulating biomarkers (microRNAs, metabolites and hormones), psychological and socioeconomic factors. However, none of these factors are sufficiently robust to be used as predictive factors. Overall, there is no doubt that before we long for precision medicine, there is the unmet need for a better understanding of the socio-biological drivers of weight gain, weight loss failure and weight-regain after bariatric interventions. Machine learning models targeting preoperative factors and effectiveness measurements of specific bariatric surgery interventions, would enable a more precise identification of the causal links between determinants of weight gain and weight loss. Artificial intelligence algorithms to be used in clinical practice to predict the response to bariatric surgery interventions could then be created, which would ultimately allow to move forward into precision medicine in bariatric surgery prescription.

Predictors of T2DM Remission after Bariatric Surgery in Patients with a BMI < 35 kg/m2: a Meta-Analysis

PURPOSE

Although a few studies have reported the predictors of postoperative diabetes remission in patients with body mass index (BMI) < 35 kg/m2, the conclusions are still inconsistent. This meta-analysis aimed to evaluate the preoperative clinical factors of type 2 diabetes mellitus (T2DM) remission after bariatric surgery.

MATERIALS AND METHODS

The PubMed, Embase, and Cochrane Library databases were systematically searched until April 2022. The Newcastle-Ottawa Scale was used for quality assessment. Statistical heterogeneity was assessed with the I2 statistic, followed by subgroup and sensitivity analyses.

RESULTS

16 studies involving 932 patients were selected. T2DM remission was negatively correlated with age, duration, insulin use, fasting plasma glucose, fasting insulin, and glycosylated hemoglobin levels. While BMI, body weight, waist circumference, and C-peptide levels were positive predictors of T2DM remission in patients with a BMI < 35 kg/m2. However, there was no significant association between gender, oral hypoglycemic agent, homeostasis model assessment, high-density lipoprotein, low-density lipoprotein, total cholesterol, triglycerides, systolic blood pressure, diastolic blood pressure, and remission rate.

CONCLUSION

Patients with younger age, short diabetes duration, more obesity, better glucose control, and better β cell function were more likely to achieve T2DM remission in patients with a BMI < 35 kg/m2 after bariatric surgery.

Remission of Type 2 Diabetes Mellitus (T2DM) after Sleeve Gastrectomy (SG), One-Anastomosis Gastric Bypass (OAGB), and Roux-en-Y Gastric Bypass (RYGB): A Systematic Review

Background and Objectives: The three most widely performed bariatric surgeries are Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and one-anastomosis gastric bypass (OAGB). Aside from the benefits of weight loss, current findings suggest that these procedures can also induce remission of T2DM (type 2 diabetes mellitus). There are limited data that directly compare these three procedures. This study aims to compare the short-term and long-term remission of T2DM after RYGB, SG, and OAGB. Materials and Methods: Three databases (Embase, PubMed, and Cochrane) were searched for randomised controlled trials, prospective studies, and retrospective studies that compared the effects of RYGB, SG, and OAGB on T2DM remission. Studies published between 2001 and 2022 were analysed. Only patients with T2DM and who had primary bariatric surgery were included. Results: After applying the inclusion and exclusion criteria, seven articles were included in the review. It was found that all three procedures had comparable T2DM remission. RYGB was noted to have the highest complication rate when compared to SG and OAGB. Importantly, it was noted that other predictive factors such as age, duration of diabetes, baseline HbA1c, BMI, and use of antidiabetic medication play a crucial role in T2DM remission. Conclusions: This systematic literature review confirms the existing data that all three bariatric surgeries induce remission of T2DM. Increasing in popularity, OAGB had comparable outcomes to RYGB and SG in inducing T2DM remission. In addition to the choice of bariatric surgery, there are other independent predictive factors that have an impact on T2DM remission. Further studies with larger sample sizes, longer follow-up periods, and studies that control confounding factors are required in this field.

The role of weight control in the management of type 2 diabetes mellitus: Bariatric surgery

Diabetes mellitus is one of the major epidemics in the United States. It is heavily associated with obesity and multiple metabolic derangements that lead to long term morbidity, mortality as well as financial burden. Although medical therapy has been the mainstay in the management of diabetes mellitus, there remains a large portion of this patient population which struggles to obtain adequate glycemic control and long-term weight control with medical management alone. Bariatric surgery is a powerful tool in combating diabetes mellitus and affects glucose homeostasis through a variety of pathways. While it does provide a durable pathway for weight loss, improvement in glucose homeostasis is not only affected by the weight loss seen after bariatric surgery. Changes in gut hormone secretion, insulin regulation, and gut microbial composition also affect how these operations improve glucose homeostasis. Through improvement in the management of diabetes mellitus, comorbidities including cardiovascular disease, in turn demonstrate improvement. In this article, we will discuss the role of bariatric (metabolic) surgery as it relates to long term weight loss and the impact that weight loss has on improvement in diabetes mellitus.

Liver-Expressed Antimicrobial Peptide 2 Is a Hepatokine That Predicts Weight Loss and Complete Remission of Type 2 Diabetes Mellitus after Vertical Sleeve Gastrectomy in Japanese Individuals

INTRODUCTION

Vertical sleeve gastrectomy (VSG) is considered one of the most effective treatments for sustained weight loss and complete remission of type 2 diabetes mellitus (CR-T2DM). Liver-expressed antimicrobial peptide 2 (LEAP2), a ghrelin receptor antagonist peptide, is a metabolic hormone regulated by VSG. However, it is unknown whether LEAP2 can be used to predict the outcomes of VSG. This study aimed to evaluate LEAP2 as a predictive factor for weight loss and CR-T2DM after VSG.

METHODS

This retrospective study included 39 Japanese participants with obesity who underwent VSG. Serum LEAP2, des-acyl ghrelin (DAG), and other metabolic and anthropometric parameters were studied before and at 12 months after VSG. Receiver operating characteristics (ROC) curve was generated to evaluate predictive score for weight loss with cut-off value of >50 percent excess weight loss. ROC curve was also generated to assess CR-T2DM.

RESULTS

Serum LEAP2 levels were significantly higher in participants with body mass index (BMI) 32-50 kg/m2 than in those with normal weight. Participants with BMI >50 kg/m2 had lower serum LEAP2 concentrations than those with BMI 32-50 kg/m2. VSG caused a significant reduction in serum DAG concentrations, but it did not affect serum LEAP2 concentrations in either male or female participants. Preoperative serum LEAP2 concentration of 2.88 pmol/mL was the optimal cutoff value for predicting weight loss after VSG, with sensitivity of 80.0% and specificity of 75.9%. Preoperative serum LEAP2 level higher than 4.67 pmol/mL predicted CR-T2DM after VSG with sensitivity of 100% and specificity of 58.8%.

CONCLUSION

Preoperative serum LEAP2 could predict weight loss and CR-T2DM as outcomes of VSG.

Accuracy of prediction models for long-term type 2 diabetes remission after gastric bypass

AIM

To evaluate the accuracy of DiaBetter, DiaRem, Ad-DiaRem and 5y-Ad-DiaRem scores' at predicting T2D remission 10 or more years after surgery.

METHODS

Patients with obesity and T2D (n = 126) submitted to RYGB with 10 or more years of follow-up. It was a unicentric trial. Pre-operative anthropometric and clinical data was retrieved to calculate DiaRem, DiaBetter, Ad-DiaRem and 5y-Ad-DiaRem scores, while a hospital visit was conducted to assess current diabetes status. The area under the receiver operating characteristic (AUROC) curve was calculated as estimate of the scores' accuracy to predict long-term T2D remission.

RESULTS

Among the entire cohort (n = 126), 70 subjects (55.6%) achieved and maintained T2D remission 10 or more years after RYGB. The 5y-Ad-DiaRem score was the one that depicted the highest discriminative power (AUROC = 0.838) to predict long-term T2D remission when compared to DiaBetter (AUROC = 0.735), DiaRem (AUROC = 0.721) and Ad-DiaRem (AUROC = 0.720).

CONCLUSION

The score with highest accuracy to predict long-term T2D remission after RYGB surgery was the 5y-Ad-DiaRem. Yet, the available scores accuracy to predict T2D remission in the long term is still suboptimal, highlighting the unmet need for a better scoring system.

Effects of bariatric surgery and dietary intervention on insulin resistance and appetite hormones over a 3 year period

To examine an impact of three types of bariatric surgery compared with dietary intervention (DIET), on concurrent changes in Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) and appetite hormones over 3 years. Fifty-five adults were studied during phase of weight loss (0-12 months) and during weight stability (12-36 months) post intervention. Measurements of HOMA-IR, fasting and postprandial PYY and GLP1, adiponectin, CRP, RBP4, FGF21 hormones and dual-Xray absorptiometry were performed throughout the study. All surgical groups achieved significant reductions in HOMA-IR with greatest difference between Roux-en-Y gastric bypass and DIET (- 3.7; 95% CI - 5.4, - 2.1; p = 0.001) at 12-36 months. Initial (0-12 months) HOMA-IR values were no different to DIET after adjustment for the lost weight. During 12-36 months, after controlling for treatment procedure and weight, for every twofold increase in postprandial PYY and adiponectin, HOMA-IR decreased by 0.91 (95% CI - 1.71, - 0.11; p = 0.030) and by 0.59 (95% CI - 1.10, - 0.10; p = 0.023) respectively. Initial, non-sustained changes in RBP4 and FGF21 were not associated with HOMA-IR values. While initial rapid weight loss reduces insulin resistance, the enhanced secretions of PYY and adiponectin may contribute to weight-independent improvements in HOMA-IR during weight stability.Clinical trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613000188730.

Hypertension and hypercholesterolemia are predictive factors associated with type 2 diabetes persistence after metabolic surgery: A prospective study

BACKGROUND

Metabolic surgery is the most effective therapeutic strategy for the management of type 2 diabetes (T2DM). Several preoperative clinical factors have been associated with T2DM remission after metabolic surgery. However, other potential predictors remain unexplored.

AIM

To assess the role of basal (pre-surgery) clinical and biochemical parameters in T2DM remission after metabolic surgery.

METHODS

A prospective study including 98 patients with T2DM undergoing metabolic surgery was performed. Clinical, anthropometric, and biochemical data were collected at baseline and 1 year following metabolic surgery.

RESULTS

Patients without T2DM remission 1 year after metabolic surgery presented a longer duration of diabetes and higher glycated hemoglobin (HbA1c) levels; a higher percentage of these subjects were using insulin therapy, antihypertensive drugs, and lipid-lowering therapies before metabolic surgery, compared to those patients with T2DM remission. A lower percentage of T2DM remission after metabolic surgery was observed among patients with hypertension/hypercholesterolemia before surgery, compared to those patients without hypertension/hypercholesterolemia (51.7 % vs 86.8 %, p < 0.001, and 38.5 % vs 75 %, p < 0.001, respectively), and among patients with longer duration of diabetes (≥5 years vs <5 years; 44.4 % vs 83 %, respectively; p < 0.001). In the logistic regression model, diabetes duration, basal HbA1c, and the presence of hypertension and hypercholesterolemia before surgery were inversely related to T2DM remission following metabolic surgery, after adjusting for sex, age, waist circumference, and type of surgery.

CONCLUSIONS

In a cohort of patients with obesity and T2DM, preoperative hypertension and hypercholesterolemia, together with a longer diabetes duration and higher HbA1c concentrations, were independent predictors of T2DM persistence after metabolic surgery.

Remission with an Intervention: Is Metabolic Surgery the Ultimate Solution?

Long-term remission of type 2 diabetes following lifestyle intervention or pharmacotherapy, even in patients with mild disease, is rare. Long-term remission following metabolic surgery however, is common and occurs in 23% to 98% depending on disease severity and type of surgery. Remission after surgery is associated with excellent glycemic control without reliance on pharmacotherapy, improvements in quality of life, and major reductions in microvascular and macrovascular complications. For patients with type 2 diabetes, early intervention with metabolic surgery, when beta cell function still remains intact, provides the greatest probability of long-term remission as high as 90% or more.

Scores for Predicting Diabetes Remission in Bariatric Surgery: a Systematic Review and Meta-analysis

This systematic review aims to compare the accuracy of pre-existent scores predicting diabetes remission after bariatric and metabolic surgery. Among the scores, DiaBetter presented the largest area under the curve (AUC) (0.87; 95% CI, 0.84-0.9). Ad-DiaRem had the lowest AUC (0.79; 95% CI, 0.76-0.83). Ad-DiaRem showed the highest sensitivity (91%; 95% CI, 86-96%), with a specificity of 71.23% (95% CI 50.43 to 92.06%). IMS showed a sensitivity of 59% (95% CI, 20-90%), with the highest specificity (86%; 95% CI, 69-94%). Clinicians should associate the findings of the present review with patients' individual characteristics to help predict diabetes remission and evaluate the probability of the patient benefit from surgery.

Effect of Weight Regain on Body Composition and Metabolic Biomarkers After Sleeve Gastrectomy: a Cross-Sectional Study from a Hospital Database

INTRODUCTION

Weight regain (WR) is described in approximately 30% of patient's post-bariatric surgery. It is related to the progression or recurrence of associated medical problems and decline in health-related quality of life. This study aimed to test the return of body composition and metabolic biomarkers to pre-operative levels when WR occurs.

METHODS

In this cross-sectional study conducted in 2021, patients were randomly selected from the hospital's electronic databases between 2001 and 2020. Patient demographic data, comorbidities, body compositions, and metabolic biomarkers were collected. Three groups were defined: groups A (WR), B (weight loss), and C (control group; patients with obesity who had not yet undergone bariatric surgery).

RESULTS

A total of 88 patients were enrolled in this study and matched with the control group. The body mass index in group A was 43.8 ± 6.9 kg/m²; group B was 28.6 ± 4.2; group C was 43.9 ± 7.1. Body muscle mass, body fat mass, and visceral fat significantly differed between groups A and B (p < 0.001) but not between groups A and C (p = 0.8). There was a significant difference in leptin, ghrelin, postprandial glucagon-like peptide-1, insulin, and fibroblast growth factor-21 (but not retinol-binding protein-4) between groups A and B. Most metabolic biomarkers in group A returned to the pre-operative values as in group C.

CONCLUSION

WR had a direct negative effect on body composition and metabolic biomarkers, whereby the values returned to pre-operative levels. Early detection of WR and possible additional therapy are necessary to prevent associated medical problems.

The effect of aging on glucose metabolism improvement after Roux-en-Y gastric bypass in type 2 diabetes rats

BACKGROUND

This study aimed to investigate the effect of aging on glucose metabolism improvement after Roux-en-Y gastric bypass (RYGB) in rat models with type 2 diabetes mellitus (T2DM).

METHODS

Twenty aged Goto-Kakizaki rats were randomly assigned into RYGB-A group and sham RYGB (SR-A) group, and 10 adult Goto-Kakizaki rats also accept RYGB procedures (RYGB-Y). Glucose metabolism, resting energy expenditure (REE), glucagon-like peptide-1 (GLP-1) and total bile acid level were measured.

RESULTS

RYGB could significantly improve glucose metabolism in aged diabetic rats. The fasting blood glucose level in the RYGB-A group decreased from 15.8 ± 1.1 mmol/l before surgery to 12.3 ± 1.5 mmol/l 16 weeks after surgery (P < 0.01), and the AUC_OGTT value decreased from 2603.9 ± 155.4 (mmol/l) min to 2299.9 ± 252.8 (mmol/l) min (P = 0.08). The decrease range of fasting blood glucose in the RYGB-A group was less than that in the RYGB-Y group (20.5% ± 6.5% vs. 40.6% ± 10.6%, P < 0.01), so is the decrease range of AUC_OGTT value (11.6% ± 14.8% vs. 38.5% ± 8.3%, P < 0.01). Moreover, at the 16th postoperative week, the increase range of REE of the RYGB-A group was lower than that of the RYGB-Y group (15.3% ± 11.1% vs. 29.1% ± 12.1%, P = 0.04). The increased range of bile acid of the RYGB-A group was less than that of the RYGB-Y group (80.2 ± 59.3 % vs.212.3 ± 139.0 %, P < 0.01). The GLP-1 level of the RYGB-A group was less than that of the RYGB-Y group (12.8 ± 3.9 pmol/L vs. 18.7 ± 5.6 pmol/L, P = 0.02). There was no significant difference between the RYGB-A group and the RYGB-Y group in the level of the triiodothyronine level.

CONCLUSIONS

RYGB could induce a glucose metabolism improvement in aged diabetic rats, and aging might moderate the effect of RYGB.

Time-in-range: a promising glycemic control metric for bariatric surgery

As a complication of obesity, type 2 diabetes (T2D) is a chronic disease that is difficult to manage. However, bariatric surgery makes it possible to alleviate T2D. While the existing generic index glycosylated hemoglobin (HbA1c) is a powerful tool for examining overall blood glucose levels, it still has some limitations as a daily measure of blood glucose levels and as a judge of the effectiveness of bariatric surgery. Using the time-in-range (TIR) measurement and its derivatives is a better way to evaluate short-term blood glucose fluctuations and can be used as a supplement to HbA1c. In this article, we discuss the utility and limitations of HbA1c and other indicators used during surgery. In addition, we mentioned TIR as a novel metric that can act as an accurate predictor of the risk of T2D complications and an index of preoperative risk assessment in bariatric surgery. In contrast to previous indicators, TIR has the advantage that it cannot be affected by caloric restriction to better reflect the patient's glucose level and the level of pancreatic islet function. On this basis, TIR is a promising indicator for both the diagnosis of diabetes and the preoperative and postoperative prediction and evaluation.

Predictors of type-2 diabetes remission following bariatric surgery after a two-year follow-up

PURPOSE

Bariatric surgery is evolving as a successful tool for managing morbid obesity and T2DM. This study aimed to identify predictors of diabetes remission after two types of bariatric procedures.

METHODS

This prospective study enrolled 172 patients with morbid obesity associated with T2DM scheduled for bariatric surgery. Two laparoscopic bariatric procedures were done; single anastomosis gastric bypass (SAGB, n = 83) and sleeve gastrectomy (LSG, n = 68). Lipid accumulation product index (LAP) and quantitative insulin sensitivity check index (QUICKI) were used to evaluate lipid profile and insulin sensitivity. Two years after surgery condition of DM was evaluated as complete remission (CR), partial remission (PR), or improvement. The primary outcome measure was predictors of diabetes remission.

RESULTS

Two years after surgery, 151 patients were available for evaluation, where 75 patients (49.7%) achieved CR, while PR was found in 36 (23.8%). CR was significantly associated with younger age, shorter duration of DM (p < 0.001, for both), higher C-peptide and GLP-1 levels (p < 0.001 and p = 0.002, respectively), and bypass surgery (p = 0.027). On multivariate analysis, shorter duration of DM, lower BMI, and higher C-peptide levels were the independent factors predicting CR.

CONCLUSION

Complete remission of T2DM can be achieved in nearly half of the patients two years after SG or SAGB. The duration of diabetes and preoperative BMI and C-peptide levels are the independent factors predicting complete remissions.

Validation of the Individual Metabolic Surgery Score for Bariatric Procedure Selection in the Merged Data of Two Randomized Clinical Trials (SLEEVEPASS and SM-BOSS)

BACKGROUND

LSG and LRYGB are globally the most common bariatric procedures. IMS score categorizes T2D severity (mild, moderate, and severe) based on 4 independent preoperative predictors of long-term remission as follows: T2D duration, number of diabetes medications, insulin use, and glycemic control. IMS score has not been validated in a randomized patient cohort.

OBJECTIVES

To assess the feasibility of individualized metabolic surgery (IMS) score in facilitating procedure selection between laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) for patients with severe obesity and type 2 diabetes (T2D).

SETTING

Merged individual patient-level 5-year data of 2 large randomized clinical trials (SLEEVEPASS and SM-BOSS [Swiss Multicenter Bypass or Sleeve Study]).

METHODS

IMS score was calculated for study patients and its performance was analyzed.

RESULTS

One hundred thirty-nine out of 155 patients with T2D had available preoperative data to calculate IMS score as follows: mild stage (n = 41/139), moderate stage (n = 77/139), severe stage (n = 21/139). At 5 years, 135 (87.1%, 67 LSG/68 LRYGB) were available for follow-up and 121 patients had both pre- and postoperative data. Diabetes remission rates according to preoperative IMS score were as follows: mild stage 87.5% (n = 14/16) after LSG and 85.7% (n = 18/21) after LRYGB (P = .999), moderate stage 42.9% (n = 15/35) and 45.2% (n = 14/31) (P = .999), and severe stage 18.2% (n = 2/11) and 0% (n = 0/7) (P = .497), respectively. The T2D remission rate varied significantly between the stages as follows: mild versus moderate odds ratio (OR) 8.3 (95% CI, 2.8-24.0; P < .001), mild versus severe OR 52.2 (95% CI 9.0-302.3; P < .001), and moderate versus severe OR 6.3 (95% CI, 1.3-29.8; P = .020).

CONCLUSIONS

In our study, remission rates of T2D were not statistically different after LSG and LRYGB among all patients and among patients with mild, moderate, and severe diabetes stratified by the IMS score. However, the study may be underpowered to detect differences due to small number of patients in each subgroup. IMS score seemed to be useful in predicting long-term T2D remission after bariatric surgery.

Metabolomics analysis of type 2 diabetes remission identifies 12 metabolites with predictive capacity: a CORDIOPREV clinical trial study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is one of the most widely spread diseases, affecting around 90% of the patients with diabetes. Metabolomics has proven useful in diabetes research discovering new biomarkers to assist in therapeutical studies and elucidating pathways of interest. However, this technique has not yet been applied to a cohort of patients that have remitted from T2DM.

METHODS

All patients with a newly diagnosed T2DM at baseline (n = 190) were included. An untargeted metabolomics approach was employed to identify metabolic differences between individuals who remitted (RE), and those who did not (non-RE) from T2DM, during a 5-year study of dietary intervention. The biostatistical pipeline consisted of an orthogonal projection on the latent structure discriminant analysis (O-PLS DA), a generalized linear model (GLM), a receiver operating characteristic (ROC), a DeLong test, a Cox regression, and pathway analyses.

RESULTS

The model identified a significant increase in 12 metabolites in the non-RE group compared to the RE group. Cox proportional hazard models, calculated using these 12 metabolites, showed that patients in the high-score tercile had significantly (p-value < 0.001) higher remission probabilities (Hazard Ratio, HR, high versus low = 2.70) than those in the lowest tercile. The predictive power of these metabolites was further studied using GLMs and ROCs. The area under the curve (AUC) of the clinical variables alone is 0.61, but this increases up to 0.72 if the 12 metabolites are considered. A DeLong test shows that this difference is statistically significant (p-value = 0.01).

CONCLUSIONS

Our study identified 12 endogenous metabolites with the potential to predict T2DM remission following a dietary intervention. These metabolites, combined with clinical variables, can be used to provide, in clinical practice, a more precise therapy.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00924937.

Two-year outcomes of Roux-en-Y gastric bypass vs medical treatment in type 2 diabetes with a body mass index lower than 32.5 kg/m2: a multicenter propensity score-matched analysis

BACKGROUND

Roux-en-Y gastric bypass (RYGB) has been widely reported to be safe and feasible, and has a powerful effect on improving metabolism and weight loss in patients with a high body mass index (BMI). A few studies have focused on the comparison of RYGB with medical treatment in type 2 diabetes (T2D) patients with a lower BMI.

OBJECTIVES

To compare the metabolic effects and safety of RYGB versus medical treatment during a 2 years follow-up in T2D patients with a BMI of 25 to 32.5 kg/m².

METHODS

This retrospective and multicenter cohort study participants were extracted from the T2D patients with a lower BMI (25-32.5 kg/m²) from three bariatric centers between 2009 and 2018. Propensity score matching (PSM) was used to minimize bias, and each patient in the surgical group was matched 1:2 to the patients in the medical group with the closest propensity score. Finally, 71 patients who received RYGB and 142 patients who underwent medical treatment with a 2 years follow-up were enrolled to compare the effects of RYGB and medical treatment. The primary endpoint was achievement of the triple endpoint (the simultaneous achievement of hemoglobin A1c (HbA1c) < 7.0%, fasting low-density lipoprotein cholesterol (LDL-C) < 100 mg/dL (2.6 mmol/L), and systolic blood pressure (SBP) < 130 mmHg at the year-1 visit). Changes in weight, BMI, medication usage, complications, and adverse events were assessed.

RESULTS

In total, 213 patients (mean age of 47.4 ± 9.5 years, 70.4% male, mean BMI of 28.6 ± 2.2 kg/m²) were included in this study. At the end of the first year, 17 patients (23.9%) in the surgical group and 10 (7.0%) in the medical group had achieved the composite triple endpoint (OR 4.64; 95% CI 1.82-11.81; p = 0.001). Additionally, 43 patients (60.6%) in the surgical group and 11 patients (19.7%) in the medical group experienced remission of T2D. However, more complications were observed in the surgical group (36 vs. 22, p < 0.01).

CONCLUSIONS

Among T2D patients with a BMI between 25.0 and 32.5 kg/m², RYGB was more effective than medical treatment in resolving metabolic disorders and also resulted in more complications. The risk for complications should be considered in the clinical decision-making process for T2D patients with a low BMI.

Glucose Profiles Assessed by Intermittently Scanned Continuous Glucose Monitoring System during the Perioperative Period of Metabolic Surgery

BACKGROUND

Continuous glucose monitoring (CGM) has been widely used in the management of diabetes. However, the usefulness and detailed data during perioperative status were not well studied. In this study, we described the immediate changes of glucose profiles after metabolic surgery using intermittently scanned CGM (isCGM) in individuals with type 2 diabetes mellitus (T2DM).

METHODS

This was a prospective, single-center, single-arm study including 20 participants with T2DM. The isCGM (FreeStyle Libre CGM) implantation was performed within 2 weeks before surgery. We compared CGM metrics of 3 days before surgery and 3 days after surgery, and performed the correlation analyses with clinical variables.

RESULTS

The mean glucose significantly decreased after surgery (147.0±40.4 to 95.5±17.1 mg/dL, P<0.001). Time in range (TIR; 70 to 180 mg/dL) did not significantly change after surgery in total. However, it was significantly increased in a subgroup of individuals with glycosylated hemoglobin (HbA1c) ≥8.0%. Time above range (>250 or 180 mg/dL) was significantly decreased in total. In contrast, time below range (<70 or 54 mg/dL) was significantly increased in total and especially in a subgroup of individuals with HbA1c <8.0% after surgery. The coefficient of variation significantly decreased after surgery. Higher baseline HbA1c was correlated with greater improvement in TIR (rho=0.607, P=0.005).

CONCLUSION

The isCGM identified improvement of mean glucose and glycemic variability, and increase of hypoglycemia after metabolic surgery, but TIR was not significantly changed after surgery. We detected an increase of TIR only in individuals with HbA1c ≥8.0%.

Effect of Laparoscopic Sleeve Gastrectomy on HbA1C Level in Children with Type 2 Diabetes Mellitus

Background and Objectives: A third of the American adult population is currently pre-diabetic/morbidly obese and is, therefore, at an elevated risk for developing type 2 diabetes. Unfortunately, such a condition does not spare children from also developing morbid obesity, where incidence rates of childhood obesity—coupled with type 2 diabetes—are markedly elevated. Laparoscopic sleeve gastrectomy (LSG) is gradually becoming the novel benchmark in bariatric surgery for the treatment of morbid obesity and associated co-morbidities, also within pediatric cases. However, no comprehensive study has been conducted in children that emphasizes the effect of LSG on HbA1C levels within such a patient population suffering from type 2 diabetes. Aim: Since HbA1C is a major biomarker for type 2 diabetes progression, this study aimed to identify any dysregulated serum levels for this key molecular player (together with other parameters), for post-surgical monitoring of the beneficial metabolic effects of LSG surgery on type 2 diabetes amelioration/remission within pediatric patients. Materials and Methods: A total of 64 pediatric patients, ranging in age from 5 to 14 years old, were enrolled in this retrospective study. Multiple laboratory-based analyses datasets were also collected from individual study participants, including HbA1C and random blood sugar (RBS). All participating patients were designated for undergoing laparoscopic sleeve gastrectomy, as per standardized surgical protocols and each participant was followed-up for two years post-surgery. Laboratory investigations were re-performed in order to identify any major variations in clinical parameters. Results: HbA1c was significantly reduced among children, from 6.0 ± 0.8 (pre-LSG) to 5.4 ± 0.4 post-surgery, with a reduction rate of 10.9% (p = 0.001). Furthermore, RBS significantly decreased from 102.9 ± 34.0 (pre-LSG) to 87.1 ± 17.3 post- surgery, with a reduction rate of 15.4% (p = 0.036). Conclusions: This study provides further concrete evidence for the beneficial metabolic influence provided by LSG surgery on morbidly obese, childhood-aged patient populations, with effectiveness in reducing co-morbidity progress, in the form of type 2 diabetes, through the reduction in HbA1c levels within such patients post-surgery.

Oncometabolic surgery in gastric cancer patients with type 2 diabetes

The rates of early gastric cancer and type 2 diabetes mellitus(T2DM) are sharply increasing in Korea. Oncometabolic surgery in which metabolic surgery is conducted along with cancer surgery is a method used to treat gastric cancer and T2DM in one-stage operation. From 2011 to 2019, a total of 48 patients underwent long-limb Roux-en-Y gastrectomy (LRYG) in Inha University Hospital, and all data were reviewed retrospectively. A 75 g oral glucose tolerance test and serum insulin level test were performed before and 1 week and 1 year after surgery. One year after LRYG operation, 25 of 48 patients showed complete or partial remission and 23 patients showed non-remission of T2DM. The preoperative HbA1c level was significantly lower and the change in HbA1c was significantly greater in the T2DM remission group. Insulin secretion indices(insulinogenic index and disposition index) were increased significantly in the T2DM remission group. In contrast, the insulin resistance indices (homeostatic model assessment of insulin resistance (HOMA-IR) and Matsuda index) changed minimal. In the case of LRYG in T2DM patients, remnant β cell function is an important predictor of favorable glycemic control.