Type 2 diabetes remission after Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and one anastomosis gastric bypass (OAGB): results of the longitudinal assessment of bariatric surgery study

Jejunoileal side-to-side anastomosis: New hope for patients with type 2 diabetes?

In this article, we comment on an article by Wang et al published in the World Journal of Diabetes. Existing treatments with oral medications can partially mitigate the toxicity of elevated blood glucose levels in patients with type 2 diabetes mellitus. However, these patients often require lifelong, costly medications, and many struggle with poor compliance. To address the limitations of pharmacological treatments, laparoscopic jejunal-ileal lateral anastomosis has become increasingly common in clinical practice and generally yields favorable outcomes. This procedure stimulates the secretion of larger amounts of glucagon-like peptide-1 by intestinal L cells, which in turn promotes pancreatic islet cell proliferation, reduces insulin resistance, and effectively controls glucose and lipid metabolism disorders. Nonetheless, further research is needed to fully explore its indications, contraindications, the enhancement of patients' quality of life and patients’ satisfaction with the subjective experience of treatment and long-term effects.

Which Procedure Yields Better Outcomes: Sleeve Gastrectomy, Roux-en-Y Gastric Bypass or Mini Gastric Bypass? Seven Years Outcome Analysis

Background and Objectives: Bariatric surgery is the most effective method for achieving sustainable weight loss, improving quality of life, and resolving obesity-related comorbidities over the long term. However, data from long-term studies remain scarce and contradictory. Materials and Methods: This study is a retrospective analysis of prospectively collected data over a 7-year follow-up period involving 211 patients diagnosed with morbid obesity who underwent sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), or mini gastric bypass (MGB) at Samsun University Training and Research Hospital, Department of General Surgery, between 1 January 2014 and 1 January 2018. Changes in weight, remission of associated comorbidities, postoperative complications, re-admission rates, and revision requirements were compared among the patients. Results: Of the 211 patients, 20.4% were male, and 79.6% were female. During the study period, 61.1% of patients underwent SG, 29.4% underwent MGB, and 9.5% underwent RYGB. There was no statistically significant difference among the three surgical techniques in terms of weight change parameters, comorbidity remission, postoperative complications, and readmission rates. However, revision rates were significantly higher among patients who underwent SG (p < 0.05). Conclusions: SG, MGB, and RYGB techniques are comparable and reliable methods in terms of long-term weight loss, surgical outcomes, and complications. After a 7-year follow-up period, all three techniques were found to be similar in terms of HT, T2DM, and GERD remission; however, SG was observed to have a higher revision requirement compared to the other surgical techniques.

Diabetes Remission After Bariatric Surgery: A 10-Year Follow-Up Study

INTRODUCTION

Treatment of type 2 diabetes (T2DM) in patients with obesity can be challenging. Metabolic and bariatric surgery (MBS) has shown promising results in improving glycemic control and even achieving remission in T2DM patients with obesity. However, the durability of glycemic improvements in T2DM patients following MBS remains insufficiently studied.

AIM

Determine the incidence of durable remission and relapse of T2DM rates 10 years after MBS, characterize the glycemic profile after surgery, and identify factors predicting persistent remission of T2DM.

METHODS

Retrospective observational study of T2DM patients undergoing MBS between 2010 and 2013. Clinical and analytical assessments were performed preoperatively, at 2- and at 10-years postoperatively. Paired t-tests, Wilcoxon-signed-rank and McNemar tests were used to assess the differences in the metabolic status during the follow-up. Logistic regression models were used to identify predictors of T2DM remission.

RESULTS

Ninety-five patients were included (mean age 48.8 ± 9.1 years, mean HbA1c 7.0 ± 1.5%). Ten years after surgery, the rate of complete T2DM remission was 31%, partial remission was 15%, and late recurrence after initial remission was 24%. Patients with lower HbA1c (OR = 0.50; p = 0.05) and taking fewer antidiabetic drugs (OR = 0.31; p = 0.01) preoperatively were more likely to maintain long-term remission. Ten years post-MBS, patients maintained lower fasting plasma glucose (p < 0.001), HbA1c (p < 0.001), number of antidiabetic drugs (p < 0.001), and insulin use (p < 0.001).

CONCLUSION

MBS can induce a significant improvement and sustainable remission of T2DM. Early intervention, while patients still have a good glycemic control with a lower number of anti-diabetic drugs, is crucial to achieve long-lasting benefits and a potential "surgical cure" for T2DM.

The long-term impact of bariatric surgery on psoriasis symptoms and severity: a prospective observational study

BACKGROUND

Psoriasis is a common immune-mediated inflammatory skin disease associated with various comorbidities, including obesity.

OBJECTIVE

This study aimed to investigate changes to psoriasis symptoms, severity, and treatment agents in patients undergoing Metabolic and Bariatric Surgery (MBS).

SETTING

Rasool-E Akram University Hospital.

METHODS

This prospective observational study consisted of 32 adult patients with obesity and psoriasis who underwent MBS (e.g., Roux-en-Y gastric bypass, One anastomosis gastric bypass, sleeve gastrectomy) between January 2010 and December 2020. Patients with a history of prior MBS were excluded. All patients were examined by a board-certified dermatologist. Psoriasis severity was assessed with the Psoriasis Area and Severity Index (PASI).

RESULTS

The majority of patients were females (n = 29). The mean age of the study population was 46.6 ± 10.8 years, and participants were followed-up for 70.6 ± 29.1 months. A significant decrease in BMI was observed postoperatively from 41.5 ± 4.7 to 30 ± 5.5 kg/m2 (P < .001). PASI score significantly decreased from a median (interquartile range [IQR]) of 3.6 (5.90) to 1.20 (3.45) after MBS (P = .006). The number of patients who reported nail involvement significantly decreased following surgery (P = .039), although no significant difference in joint involvement was noted (P = 1.000).

CONCLUSION

This study shows that MBS can reduce psoriasis severity and lower the number of needed treatments. Given psoriasis's complexity and varied individual responses, personalized treatment is essential. Further research is necessary to validate these findings in a larger population.

Remission and relapse of diabetes after sleeve gastrectomy and one-anastomosis gastric bypass: The Tehran Obesity Treatment Study

AIMS

To evaluate the rates and predictors of remission and relapse of type 2 diabetes mellitus (T2DM) in individuals with T2DM undergoing sleeve gastrectomy (SG) or one-anastomosis gastric bypass (OAGB).

METHODS

An observational prospective study with 5 years of follow-up was conducted in a total of 891 patients (82.5% female) with concomitant T2DM and obesity (body mass index ≥ 30.0 kg/m2) undergoing SG or OAGB between March 2013 and March 2021. T2DM remission was defined as achieving a glycated haemoglobin (HbA1c) level < 48 mmol/mol and a fasting plasma glucose (FPG) level <7 mmol/L, and being off glucose-lowering agents/insulin. T2DM relapse was defined as when FPG or HbA1c reverted to the diabetic range (≥7 mmol/L and ≥48 mmol/mol, respectively), or there was a need for pharmacotherapy.

RESULTS

After bariatric surgery, the overall T2DM remission and relapse rates were 61.4 per 1000 person-months (95% confidence interval [CI] 56.8-66.4) and 5.7 per 1000 person-months (95% CI 4.1-7.9), respectively. These rates were similar in the SG and OAGB groups. Multivariate hazard ratio analysis identified history of insulin therapy and T2DM duration prior to surgery as predictors of remission, while treatment with ≥2 glucose-lowering agents was the only relapse predictor. Additionally, patients undergoing SG experienced either remission or relapse within a significantly shorter time frame compared to those undergoing OAGB.

CONCLUSION

After 5 years of follow-up, there were no significant differences between the SG and OAGB groups with regard to T2DM remission and relapse. Bariatric surgery was less likely to result in remission in patients with a history of insulin therapy and longer durations of T2DM prior to surgery. Furthermore, patients who received ≥2 glucose-lowering agents, despite possible remission, were at a higher risk of experiencing late relapse.

The Impact of Bariatric Surgery on Type 2 Diabetes Mellitus Remission: A Systematic Review

Bariatric surgery has been shown to significantly affect type 2 diabetes mellitus (T2DM) remission, particularly in obese individuals. This systematic review aims to evaluate the effectiveness of bariatric surgical interventions in inducing remission of T2DM as well as to identify factors influencing surgical outcomes. The systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive literature search was performed across multiple databases, including PubMed, Embase, and Cochrane Library, utilizing text words and controlled vocabulary in various combinations with Boolean operators "AND" and "OR." The search was limited to open-access, full-text articles in English published from 2005 to 2024, including studies involving human subjects. The quality of the included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist. In the study selection process for the systematic review, records were initially identified from three databases: Cochrane (31 records), Embase (62 records), and PubMed (52 records). This yielded 145 records. After removing 107 records, 38 records remained for screening. Of these, five records were excluded based on irrelevant problems and irrelevant outcomes. Subsequently, 33 reports were sought for full-text retrieval, with all reports being retrievable. The 33 reports were assessed for eligibility. Out of these, six were excluded due to an inaccessible full-text record. Finally, 33 studies met the inclusion criteria and were included in the review. Bariatric surgery is a highly effective intervention for individuals with T2DM, particularly those with obesity. It leads to significant weight loss and improved glycemic control through mechanisms that reduce stomach size and alter hormonal responses. This surgery not only helps many patients achieve remission from diabetes but also decreases the risk of obesity-related health issues. Beyond physical health, patients often report enhanced psychological well-being and quality of life. Overall, bariatric surgery can transform the health trajectory of select individuals, offering them a renewed sense of control and improved overall health.

Using Pre-operative Insulin Dose to Predict Diabetes Remission After Roux-En-Y Gastric Bypass and Sleeve Gastrectomy

BACKGROUND

Obesity is intricately associated with type-2 diabetes (T2D) and other cardiovascular conditions, increasing morbidity, mortality, and health care costs. Metabolic and bariatric surgeries (MBS) have shown promising results in significant weight loss and T2D remission, but existing predictive scores for post-MBS diabetes remission do not consider insulin dosage, potentially overlooking a critical factor.

METHODS

A retrospective analysis of patients with T2D who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). The study focused on insulin dosage impact, divided into quartiles, on remission rates post-MBS. The effectiveness of RYGB vs SG was compared within insulin dose quartiles with up to 5 years of follow up.

RESULTS

A total of 508 patients (64% female, 94.9% White, mean age 53.5 ± 10.5 years, BMI (46.0 ± 8.3 kg/m2) were included in the analysis. This study demonstrates a profound association between insulin dosage quartiles and T2D remission after MBS. Patients with lower insulin requirements showed superior remission rates; those in the lowest quartile had remission rates of 73%, 70%, and 62% at 1, 3, and 5 years, respectively, compared to 34%, 37%, and 36% in the highest quartile (P < 0.001 across all intervals). RYGB surgery showed a significantly better remission in the second and third insulin quartiles, suggesting its effectiveness over SG for patients with mid-range insulin requirements.

CONCLUSION

This study underscores the importance of considering insulin dosage when predicting T2D remission post-MBS. The findings advocate for a more nuanced selection of MBS procedures based on individual insulin profiles, potentially enhancing diabetes remission outcomes.

Discontinuation of blood pressure-lowering, glucose-lowering, and lipid-lowering medications after bariatric surgery in patients with morbid obesity: a nationwide cohort study in South Korea

BACKGROUND

Limited evidence exists on the patterns of medication use for hypertension, diabetes mellitus (DM), and dyslipidemia after bariatric surgery among Asian patients.

OBJECTIVES

To investigate the patterns in the use of blood pressure-lowering, glucose-lowering, and lipid-lowering medications following BS in Korean patients with morbid obesity.

SETTING

This study is a retrospective cohort study using the Health Insurance Review and Assignment claims database of South Korea (from 2019 to 2021).

METHODS

We included patients who underwent BS between 2019 and 2020 in South Korea. We evaluated the treatment patterns of blood pressure-lowering, glucose-lowering, and lipid-lowering medications at 3-month intervals for 1-year following BS, including medication use, individual medication classes, and the number of medications prescribed. Furthermore, we estimated remission rates for each disorder based on patient characteristics by defining patients who discontinued their medications for at least 2 consecutive quarters as remission.

RESULTS

A total of 3810 patients were included in this study. For 1-year following BS, a marked decrease in the number of patients using blood pressure-lowering, glucose-lowering, and lipid-lowering medications was observed. The most remarkable decrease occurred in glucose-lowering medications, which decreased by approximately -75.1% compared with that at baseline. This tendency was consistently observed when analyzing both the number of medications prescribed and the specific medication classes. Regarding remission rates, patients who were female, younger, and received the biliopancreatic diversion-duodenal switch as their BS showed a relatively higher incidence of remission than other groups.

CONCLUSIONS

BS was associated with a decrease in the use of medications for hypertension, diabetes mellitus (DM), and dyslipidemia.

Bariatric surgery and diabetes: Current challenges and perspectives

Diabetes mellitus (DM) and obesity have become public issues of global concern. Bariatric surgery for the treatment of obesity combined with type 2 DM has been shown to be a safe and effective approach; however, there are limited studies that have systematically addressed the challenges of surgical treatment of obesity combined with DM. In this review, we summarize and answer the most pressing questions in the field of surgical treatment of obesity-associated DM. I believe that our insights will be of great help to clinicians in their daily practice.

The Potential Mechanism of Remission in Type 2 Diabetes Mellitus After Vertical Sleeve Gastrectomy

In recent years, there has been a gradual increase in the prevalence of obesity and type 2 diabetes mellitus (T2DM), with bariatric surgery remaining the most effective treatment strategy for these conditions. Vertical sleeve gastrectomy (VSG) has emerged as the most popular surgical procedure for bariatric/metabolic surgeries, effectively promoting weight loss and improving or curing T2DM. The alterations in the gastrointestinal tract following VSG may improve insulin secretion and resistance by increasing incretin secretion (especially GLP-1), modifying the gut microbiota composition, and through mechanisms dependent on weight loss. This review focuses on the potential mechanisms through which the enhanced action of incretin and metabolic changes in the digestive system after VSG may contribute to the remission of T2DM.

Beyond Weight Loss: A Comprehensive Review of Pregnancy Management following Bariatric Procedures

The increasing prevalence of bariatric surgery among women of childbearing age raises critical questions about the correct management of pregnancy following these procedures. This literature review delves into the multifaceted considerations surrounding pregnancy after bariatric surgery, with a particular focus on the importance of preconception counselling, appropriate nutrition assessment, and the necessity of correct folic acid supplementation. Key areas of investigation include nutrient absorption challenges, weight gain during pregnancy, and potential micronutrient deficiencies. Examining the relationship between bariatric surgery and birth defects, particularly heart and musculoskeletal issues, uncovers a twofold increase in risk for women who underwent surgery before pregnancy, with the risk emphasized before folic acid fortification. In contrast, a nationwide study suggests that infants born to mothers with bariatric surgery exhibit a reduced risk of major birth defects, potentially associated with improved glucose metabolism. In addition, this review outlines strategies for managing gestational diabetes and other pregnancy-related complications in individuals with a history of bariatric surgery. By synthesizing existing literature, this paper aims to provide healthcare providers with a comprehensive framework for the correct management of pregnancy in this unique patient population, promoting the health and well-being of both mother and child.

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 complete remission of type 2 diabetes in patients over 65 years of age - a multicenter study

INTRODUCTION

The type 2 diabetes (T2D) improvement rate in the elderly is high after bariatric and metabolic surgery, but not all patients achieve complete remission of disease. There are some predictors for T2D remission after bariatric surgery in patients of different ages, but there are few studies describing these factors in elderly patients. The study aimed to determine predictors for diabetes remission after bariatric surgery among patients over 65 years of age.

MATERIAL AND METHODS

A retrospective study analyzed patients over 65 years with T2D who underwent laparoscopic bariatric procedures in European country from 2008 to 2022. Multivariate logistic regression analysis was performed to obtain significant, independent risk factors.

RESULTS

The group consisted of 146 patients divided into two groups: responders (R) and nonresponders (NR). The complete remission of T2D was achieved in 51 (34.9%) patients. There were 95 (65.1%) patients in the NR group with partial remission, improvement, or no changes in T2D. The mean follow-up was 50.0 months. In a multivariate logistic regression analysis, a T2D duration of less than 5 years was found to be a predictor to T2D remission (OR = 5.5, p = 0.002), %EWL significantly corresponded to T2D remission (OR = 1.090, p = 0009).

CONCLUSION

Bariatric and metabolic surgery appears to be a good option for T2D treatment in elderly patients. A shorter duration of T2D before surgery and higher %EWL after surgery were independent predictors of T2D remission in patients over 65 years of age.

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.

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.

One Anastomosis Gastric Bypass (OAGB) vs Roux en Y Gastric Bypass (RYGB) for Remission of T2DM in Patients with Morbid Obesity: a Randomized Controlled Trial

INTRODUCTION

Majority of the studies comparing Roux en Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB) are non-randomized. Moreover, few randomized studies have focussed on weight loss as the primary outcome rather than the impact on type 2 diabetes mellitus (T2DM). This randomized trial compared OABG over RYGB with the hypothesis that OAGB is not inferior to RYGB in terms of remission of T2DM.

METHODS

This was an open-labelled, randomized trial in which patients having a BMI greater than 30 kg/m² with T2DM were included. The primary outcome was the remission of T2DM.

RESULTS

In the study, 25 and 24 patients were recruited in OAGB and RYGB groups respectively. The remission rates of T2DM were similar at all timelines. The highest rate was achieved at 1 year (86.36% vs 85.71%) for both the groups and a 4-year remission rate of (72.22% vs 71.43%), for OAGB vs RYGB respectively. The % EWL was also comparable with the highest rate achieved again at 1 year (69.23% vs 66.67%) and a 4-year rate of (58.33% vs 53.33%), for OAGB vs RYGB respectively. Remission of other co-morbidities, major and minor complication rate, re-admission rate, and nutritional issues were similar in both groups.

CONCLUSION

OAGB is non-inferior to RYGB in terms of remission of type 2 diabetes mellitus, weight loss, and early and late complications with a shorter operating time.