Roux-en-Y gastric bypass for Chinese type 2 diabetes mellitus patients with a BMI < 28 kg/m(2): a multi-institutional study

"Metabolic surgery in Asian patients with type 2 diabetes mellitus and body mass index less than 30kg/m2: A systematic review"

Background

The effect of metabolic surgery on long-term diabetes remission in Asian patients with a body mass index (BMI) < 30 kg/m2 has not been widely reported.

Methods

We conducted a systematic review of the PubMed and Cochrane Library databases from inception to June 2024. All clinical trials and observational studies involving the effect of metabolic surgery in Asian patients with type 2 diabetes mellitus and BMI <30 kg/m2 were considered. The quality of the studies was assessed using the Newcastle-Ottawa scale.

Results

Of the 1175 studies screened, 21 studies (11 prospective and 10 retrospective), including 1005 patients, were selected. Only one study had a control group. The longest follow-up was 60 months. The results showed significant improvement in glycated hemoglobin (HbA1c), fasting blood glucose (FBG), 2-h plasma glucose (2hPG), homeostasis model assessment for insulin resistance index (HOMA-IR), fasting C-peptide, triglycerides, total cholesterol, and a reduction in the use of oral hypoglycemic agents/insulin at 12, 24, 36, and 60 months after metabolic surgery. The most common surgical complications observed were anemia (2.1 %-33 %), marginal ulcer (4.2 %-17.3 %), gastrointestinal bleeding (1.9 %-12 %), anastomotic leak (2.1 %-3.5 %), anastomotic stenosis (2.1 %-3.5 %), reoperation (1.18 %), and a mortality rate of zero.

Conclusions

Long-term diabetes remission, along with improvements in HbA1c, 2hPG, FBG, and HOMA-IR, with an acceptable rate of complications, was observed in Asian patients with BMI <30 kg/m2 after metabolic surgery. Future research with controlled studies should focus on preoperative patient selection criteria beyond just the BMI cutoff.

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.

Is Bariatric Surgery Effective for Chinese Patients with Type 2 Diabetes Mellitus and Body Mass Index < 35 kg/m2? A Systematic Review and Meta-analysis

BACKGROUND

Bariatric surgery has been applied for weight loss and comorbidity control in China since 2000. Recent studies have shown positive results for bariatric surgery in patients with a body mass index (BMI) of less than 35 kg/m². However, the effect of surgery on Chinese patients with type II diabetes mellitus (T2DM) has not yet been systematically investigated.

METHODS

A comprehensive literature search was performed in the Cochrane Library, Embase, PubMed, and Web of Science from January 2014 to March 2020. All studies examined bariatric surgery outcomes on Chinese patients at 12-, 36-, and 60-month follow-up. The research followed the guidance of Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) recommendations.

RESULTS

Eleven studies containing 611 patients were included in this meta-analysis. Clinical indices at 12-, 36-, and 60-month follow-up were analyzed. Significant decreases were identified in body weight, BMI, waist circumference (WC), blood pressure (BP), fasting plasma glucose (FPG), glycosylated hemoglobin A1c (hemoglobin A1c, or HbA1c), triglyceride (TG), low-density lipoprotein (LDL), and high-density lipoprotein (HDL) postoperatively. An increasing trend in the T2DM remission rate was discovered. The remission group was observed to have significantly lower HbA1c and C-peptide level, a shorter duration of T2DM, and a higher BMI than the nonremission group at 12 months.

CONCLUSIONS

Bariatric surgery successfully provided significant BMI control as well as a reduction and normalization of glucose- and lipid-related metabolism at 12, 36, and 60 months postoperatively in Chinese patients with T2DM with a preoperative BMI of less than 35 kg/m². An increasing trend in the T2DM remission rate suggested promising future applications in this population.

Predictors of Type 2 Diabetes Mellitus Remission After Metabolic Surgery in Asian Patients with a BMI < 32.5 kg/m2

BACKGROUND

Metabolic surgery is an effective treatment for type 2 diabetes mellitus (T2DM) in patients with obesity. However, the efficacy in patients with body mass index (BMI) < 32.5 kg/m², especially in Asian populations, has not been widely reported, and there are few studies on the prediction of diabetes remission.

METHODS

We evaluated 112 patients with T2DM who underwent metabolic surgery between October 2008 and November 2019. The basic data of the patients were collected, and clinical variables were measured at 6 months, 1 year, and 2 years after metabolic surgery. Four independent predictors of surgical outcomes were identified to construct the prediction score.

RESULTS

Diabetes remission occurred for 38 of the 112 patients. Ninety patients underwent Roux-en-Y gastric bypass, while the remaining 22 patients underwent sleeve gastrectomy. Weight, glucose, and lipid metabolism parameters were improved significantly after metabolic surgery. Age, BMI, insulin use, and duration were independent predictors of T2DM remission. The above four factors were defined with scores and developed ABID (age, BMI, insulin use, duration) scoring system. Patients with greater ABID scores had a greater probability of diabetes remission (from 0% at score 0 to 100% at score 4).

CONCLUSIONS

The ABID score is a simple and easy-to-implement prediction score system of diabetes remission after metabolic surgery for T2DM patients with a BMI < 32.5 kg/m².

[Therapeutic effect of laparoscopic Roux-en-Y gastric bypass in non-obese patients with type 2 diabetes]

OBJECTIVE

To evaluate the effectiveness of laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery for treatment of type 2 diabetes (T₂D) in patients with a body mass index (BMI) &lt; 27.5 kg/m².

METHODS

We retrospectively analyzed the data of patients who underwent LRYGB surgery from March, 2012 to June, 2018 in the General Hospital of Guangzhou Military Command and Jinshazhou Hospital of Guangzhou University of Chinese Medicine. The changes in the parameters of glucose metabolism and physical indicators of the patients in the first, second and third years after the surgery were analyzed in patients in low BMI group and high BMI group.

RESULTS

All the 74 patients underwent LRYGB successfully without conversion to open surgery. One year after the surgery, fasting blood glucose (FBG), HbA1c, postprandial blood glucose, fasting insulin, HOMA-IR, fasting C-peptide, BMI, body weight and waistline were significantly improved compared with their preoperative values in low BMI group (P &lt; 0.05). At 2 years after the operation, FBG, HbA1c, postprandial blood glucose, HOMA-IR, BMI, body weight and waistline were significantly improved compared with the preoperative values in low BMI group (P &lt; 0.05). In the third year, FBG, HOMA-IR, fasting C-peptide, body weight and waistline were significantly improved compared with the preoperative values in low BMI group (P &lt; 0.05). There was no significant difference in the parameters of glucose metabolism and islet function between low BMI group and high BMI group at different stages. No serious complications occurred in these patients after the surgery.

CONCLUSIONS

LRYGB is effective for treatment of T2D in Chinese patients with a BMI &lt; 27.5. After the surgery, the patient show reduced waistline without significant weight loss. The long-term results of the surgery still require further investigations with a larger samples and longer follow-up.

Analysis of Predictors of Type 2 Diabetes Mellitus Remission After Roux-en-Y Gastric Bypass in 101 Chinese Patients

BACKGROUND

To investigate prognostic factors for complete remission in type 2 diabetes mellitus (T2DM) patients who underwent gastric bypass (GBP) and to establish a prognostic model for risk stratification.

METHODS

We evaluated the baseline clinical features of patients with T2DM who received at Beijing Tian Tan Hospital from April 2012 to December 2015. Complete remission of T2DM was defined as meeting the following criteria: HbA1c < 6.5%, fasting plasma glucose (FPG) < 100 mg/dL, and absence of hypoglycemic drugs for 1 year following GBP.

RESULTS

A total of 101 patients were enrolled in our study, and the complete remission rate of T2DM was 70.3% (71/101). Compared with patients with incomplete remission, patients with complete remission of T2DM had higher C-peptide levels, lower HbA1c, shorter disease duration, better β cell function, and an absence of insulin therapy. HbA1c level, fasting C-peptide, duration of T2DM, and history of medical therapy were important prognostic factors for complete remission of T2DM (P = 0.001, 0.002, 0.01, 0.028, respectively). Patients with HbA1c lower than 7.5%, a history of T2DM shorter than 9.5 years, fasting C-peptide higher than 1.2 ng/mL, and absence of insulin therapy before GBP achieved a higher complete remission rate of T2DM after GBP (AUC of the model was 0.825, 95% CI, 0.741-0.910; P = 0.001).

CONCLUSIONS

The duration of T2DM, history of medical therapy, and levels of HbA1c and fasting C-peptide are independent predictors for the prognosis of T2DM patients undergoing GBP. Patients with HbA1c lower than 7.5%, a history of T2DM shorter than 9.5 years, a fasting C-peptide higher than 1.2 ng/mL, and an absence of insulin therapy may have a higher complete remission rate of T2DM after GBP.

Does Metabolic Surgery Lead to Diabetes Remission in Patients with BMI < 30 kg/m2?: a Meta-analysis

BACKGROUND

Bariatric surgery has demonstrated to be effective in remission of type 2 diabetes in obese patients, but it is unclear in non-obese patients. The aim of this study is to investigate if metabolic surgery is effective in diabetes resolution in patients with BMI < 30 kg/m².

MATERIALS AND METHODS

A systematic review was performed and the content of the PubMed, Ovid, and the Cochrane Library databases covering the period January 2008 to April 2018 was searched. Studies with metabolic surgery performed in patients with type 2 diabetes, BMI < 30 kg/m² and a follow-up ≥ 6 months were included. Type 2 diabetes remission rate and metabolic parameters changes were measured. A meta-analysis was conducted with the selected studies.

RESULTS

Twenty-six studies were included in the meta-analysis (1105 patients). The mixed-effects meta-analysis model for overall diabetes remission rate produced an estimate of 43% (95% IC 34-53%, p < 0.001). Moderator effects of the variables race, preoperative HbA1c, BMI, months of follow-up, duration of diabetes, and age on diabetes remission were also assessed, with no significant effects being found in any of them. A reduction in BMI (- 3.57 kg/m²), fasting blood glucose (- 55.93 mg/dL) and HbA1c (- 2.08%) was observed after surgery.

CONCLUSIONS

Metabolic surgery could be effective in remission of type 2 diabetes in BMI < 30 kg/m² patients but randomized and long-term studies are necessary. The scientific community should agree in a single definition of type 2 diabetes remission, in order to know the real effect of metabolic surgery in this group of patients.

Comparison of Diabetes Remission and Micronutrient Deficiency in a Mildly Obese Diabetic Rat Model Undergoing SADI-S Versus RYGB

BACKGROUND

Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) has launched a huge challenge to classic Roux-en-Y gastric bypass (RYGB). Our objective was to compare diabetes remission and micronutrient deficiency in a mildly obese diabetic rat model undergoing SADI-S versus RYGB.

METHODS

Thirty adult male mildly obese diabetic rats were randomly assigned to sham (S), SADI-S, and RYGB groups. Body weight, food intake, fasting plasma glucose (FPG), oral glucose tolerance test (OGTT), plasma insulin, GLP-1, and ghrelin levels were measured at indicated time points. Meanwhile, insulin sensitivity and pancreatic β cell function were assessed during OGTT. Finally, plasma micronutrient evaluation and islet β cell mass analysis were performed after all animals were sacrificed.

RESULTS

As compared to sham, the SADI-S and RYGB groups achieved almost equivalent efficacy in caloric restriction and FPG control without excessive weight loss. During OGTT, the SADI-S and RYGB groups also provided comparable effects on glycemic excursion, insulin sensitivity, and β cell function; however, only rats in the RYGB group showed significant changes in gut hormones, whereas the three groups were found to exhibit no significant difference in β cell mass. In addition, only vitamin E in the RYGB group was deficient as compared with the SADI-S and S groups.

CONCLUSION

In mildly obese diabetic rat, SADI-S and RYGB procedures have comparable efficacy in diabetes remission and risk of micronutrient deficiency. These data show that each of the surgery accomplishes diabetes improvements through both overlapping and distinct mechanisms requiring further investigation.

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

BACKGROUND

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

METHODOLOGY

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

RESULTS

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

CONCLUSIONS

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

Metabolic Surgery for Type 2 Diabetes Mellitus: Experience from Asia

Type 2 diabetes mellitus (T2DM) is a current global health priority and Asia is the epicenter of this epidemic disease. Unlike in the west, where older population is most affected, the burden of diabetes in Asian countries is disproportionately high in young to middle-age adults. The incidence of diabetic nephropathy is alarmingly high in patients with early onset T2DM, especially in those with poor glycemic control. How to control this chronic and debilitating disease is currently a very important health issue in Asia. Bariatric surgery has proven successful in treating not just obesity but also T2DM in morbid obese patients (body mass index [BMI] >35 kg/m²). Gastrointestinal metabolic surgery recently has been proposed as a new treatment modality for obesity related T2DM for patients with BMI <35 kg/m². Many studies from Asia reported promising results of metabolic surgery to treat obese patients with T2DM which is not well controlled. It has been demonstrated that changes in gastrointestinal hormone secretion after gastrointestinal surgery would favor an early improvement of T2DM in Asians. New procedures have also been designed and proposed specifically for the treatment of diabetes in Asia. This article examines clinical trial data and accepted algorithms with a view toward elucidating the application of metabolic surgery for the treatment of T2DM in the Asia. We propose a systematic approach to surgical treatment, addressing current evidences, patient selection, procedure of choice, and timing and guideline for new procedures.