Prediabetes remission after bariatric surgery: a 4-years follow-up study

BACKGROUND

Bariatric surgery leads to weight loss and to cardiometabolic risk improvement. Although prediabetes remission after bariatric surgery is biologically plausible, data on this topic is scarce. We aimed to assess prediabetes remission rate and clinical predictors of remission in a 4 year follow up period.

METHODS

Observational longitudinal study including patients with obesity and prediabetes who had undergone bariatric surgery in our centre. Prediabetes was defined as having a baseline glycated haemoglobin (A1c) between 5.7% and 6.4% and absence of anti-diabetic drug treatment. We used logistic regression models to evaluate the association between the predictors and prediabetes remission rate.

RESULTS

A total of 669 patients were included, 84% being female. The population had a mean age of 45.4 ± 10.1 years-old, body mass index of 43.8 ± 5.7 kg/m2, and median A1c of 5.9 [5.8, 6.1]%. After bariatric surgery, prediabetes remission rate was 82%, 73%, 66%, and 58%, respectively in the 1st, 2nd, 3rd, and 4th years of follow-up. Gastric sleeve (GS) surgery was associated with higher prediabetes remission rate than Roux-en-Y gastric bypass surgery in the 3rd year of follow-up. Men had a higher remission rate than women, in the 1st and 3nd years of follow-up in the unadjusted analysis. Younger patients presented a higher remission rate comparing to older patients in the 3rd year of follow-up.

CONCLUSION

We showed a high prediabetes remission rate after bariatric surgery. The remission rate decreases over the follow-up period, although most of the patients maintain the normoglycemia. Prediabetes remission seems to be more significant in patients who had undergone GS, in male and in younger patients.

New Endoscopic Solutions in Managing Phlegmonous Esophagitis

A 48-year-old woman was admitted in the emergency department due to epigastric pain, nausea, vomiting, and cough. She presented with fever and increased inflammatory parameters. A thoracoabdominal computed tomography (CT) was performed and revealed thickening of the gastric fundus and esophagus, with an apparent laceration in esophageal mucosa and associated dissection of esophageal wall. In upper endoscopy (UE), a bulging of esophageal and gastric walls was observed, with an ulceration in proximal esophagus, suggestive of a perforation. After multidisciplinary discussion, a minimally invasive endoscopic approach was decided. Internal esophageal drainage (IED) was assured with performance of some incisions with Dual-knife® (Olympus, Tokyo) along the mucosal and submucosal layers in the esophagus. During the incision, extravasation of pus was evident. One week later, due to clinical worsening and evidence of esophageal perforation in CT scan, UE was repeated. We confirmed esophageal perforation with visualization of two millimetric defects in the proximal esophagus. Significant bulging of the gastric fundus and body was also observed. IED was repeated with mucosal incision of the gastric bulging using Needle-Cut 3V® (Olympus, Tokyo), with extravasation of a significant quantity of pus. We decided to proceed to endoscopic vacuum therapy that was performed with sponge placement in the esophageal lumen (Endosponge®, B. Braun, Melsungen, Germany). UE was repeated 1 week later with sponge removal and confirmation of resolution of esophageal perforation. An improvement of the thickening of gastric fundus and body was also seen. One month later after admission, the patient was discharged home, eating normally, and remains well in the follow-up.

How Far Can Our Expectations Go on Revisional Bariatric Surgery After Failed Adjustable Gastric Banding?

PURPOSE

Bariatric surgery has proven its effectiveness in the treatment of obesity and related comorbidities. However, several procedures may be required to treat this chronic disease and/or complications after bariatric surgery. The most frequent revisional surgeries performed after failed laparoscopic adjustable gastric banding (AGB) have been Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). The aim of this study is to compare medium-term outcomes of primary and revisional bariatric procedures.

MATERIAL AND METHODS

Single institution, matched case-control study of obese patients submitted to bariatric surgery, divided into four groups of 50 patients: (A) primary RYGB; (B) primary SG; (C) revisional Roux-en-Y gastric bypass (rRYGB) after failed laparoscopic AGB; (D) revisional sleeve gastrectomy (rSG) after failed laparoscopic AGB. Demographic variables, surgical procedures characteristics and complications, weight loss outcomes and resolution of comorbidities were compared.

RESULTS

Mortality and morbidity were comparable between primary and revisional procedures. Weight loss outcomes were inferior in patients submitted to rRYGB when compared to those submitted to RYGB, with no significant differences found when comparing the other groups. Regarding comorbidities' outcomes, only patients submitted to rSG had lower odds of comorbidities' improvement. Patients submitted to rRYGB had an odd 7 times higher of comorbidities' improvement than those submitted to rSG, independent of weight loss outcomes.

CONCLUSION

Revisional surgeries are safe procedures with adequate weight loss outcomes in this difficult set of patients. The choice of revisional procedure may not influence weight loss outcomes, but rRYGB seems to be a better option regarding comorbidities' resolution.

Acute improvement in insulin resistance after laparoscopic Roux-en-Y gastric bypass: is 3 days enough to correct insulin metabolism?

BACKGROUND

Although medium- to long-term improvement in insulin resistance and T2DM after Roux-en-Y gastric bypass (RYGB) is well documented, few studies have analyzed the acute effects after surgery. Understanding these effects might help explain the physiologic adjustments after surgery and help in managing insulin resistance and controlling the hypoglycemic treatment for bariatric patients.

METHODS

We recruited a prospective cohort of 55 consecutive female patients that underwent primary laparoscopic RYGB between January and June/2011. Blood samples were collected preoperatively and at the first, third, and fifth post-operative days after an overnight fast.

RESULTS

There was a significant increase in homeostasis model assessment for insulin resistance (HOMA-IR) on day 1 (2.36 vs 3.12; p = 0.032), followed by a rapid decrease from day 3 onward (3.12 vs 1.70; <0.001). We found a statistically significant difference (p < 0.05) at all time points compared with baseline. HOMA-IR levels at POD5 were 47 % lower than baseline values and were not significantly different from values at 6 months (1.24 vs 0.93; p = 0.09). The blood levels of glucose and insulin closely matched those of HOMA-IR.

CONCLUSIONS

RYGB results in a rapid improvement in insulin resistance and a clinically significant decrease in fasting glucose and insulin levels. This improvement is significant at the 3rd post-operative day, and by the 5th day, patients express insulin resistance levels that are similar to those expressed at 6 months after surgery. This work highlights the acute metabolic impact of surgery. Understanding the behavior of insulin and glucose after surgery might improve our knowledge of the pathophysiology of diabetes and lead to novel therapies and tailored surgical approaches.