Bariatric versus diabetes surgery after five years of follow up.

BACKGROUND: Bariatric surgery (BS) is totally different from diabetes surgery (DS) in the patient characters, goals of surgery, and management although similar in surgical procedure. Comparison of BS and DS with long-term data is lacking. MATERIALS AND METHODS: A retrospective review of patients who received BS and patients who received DS at Min-Sheng General Hospital from 2007 to 2013 was designed. All inpatient and outpatient follow-up data were analyzed. Patients undergoing BS for the treatment of morbid obesity were compared with patients undergoing metabolic surgery for the treatment of type 2 diabetes mellitus (T2DM). Patients who received revision surgeries were excluded. The main outcome measures were: (1) operation risk; (2) weight loss; and (3) diabetes remission. RESULTS: Between 2007 and 2013, 2073 patients who received BS and 741 patients who received DS were recruited from both centers. DS patients were older (41.1 ± 10.9 years vs. 33.1 ± 9.3 years, p < 0.05) and were more likely to be male (40.2% vs. 28.2%, p < 0.05) and to have diabetes (100% vs. 6.0%, p < 0.05), however, they had similar body mass index (BMI) (37.9 ± 8.0 vs. 38.5 ± 9.7, p = 0.78) compared to the BS patients. Surgical procedures are significantly different between the two groups (73.3% of the DS surgeries were gastric bypass procedure, whereas this procedure made up only 47.1% of BS surgeries). Although the major complication rates were similar (2.0% vs. 2.4%), the DS program had a significant higher mortality rate than the BS program (0.54% vs. 0.1%; p < 0.05). At the 5-year follow-up time point, 58.0% of the BS patients had achieved successful results (weight loss > 30%) and 80% of the DS patients had complete remission of their diabetes [hemoglobin A1c (HbA1c) < 6.0%]. Both the DS and the BS group had good results in up to 85% of the patients at the 5-year follow-up time point. CONCLUSION: The clinical profiles were very different between the BS and the DS programs. Both programs achieved the desired outcomes equally well, however, the DS program had a higher risk than the BS program.

Effect of Bariatric Surgery vs Medical Treatment on Type 2 Diabetes in Patients With Body Mass Index Lower Than 35: Five-Year Outcomes.

IMPORTANCE: It has been well recognized that metabolic surgery has short-term benefits for mildly obese patients with type 2 diabetes mellitus (T2DM), but how long these effects can be sustained is uncertain. OBJECTIVE: To compare the 5-year efficacy between gastrointestinal metabolic surgery and medical treatment on glycemic control and diabetes remission in patients with T2DM and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) lower than 35. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study compares long-term outcomes for mildly obese patients with T2DM receiving metabolic surgery (n = 52) vs medical treatment (n = 299). The surgical group, enrolled from August 20, 2007, to June 25, 2008, and followed up through December 31, 2013, received standard sleeve gastrectomy (n = 19) or bypass (n = 33) procedures in a regional hospital. The medical group, selected from a nationwide community cohort that was recruited from August 27, 2003, to December 31, 2005, and followed up through December 31, 2012, was matched with the surgical group by age, BMI, and diabetes duration. MAIN OUTCOMES AND MEASURES: Glycated hemoglobin (HbA1c) reduction and prolonged complete and partial diabetes remission (defined as HbA1c <6.0% and 6.0%-6.5% of total hemoglobin [Hb; to convert to proportion of total Hb, multiply by 0.01], respectively, for those who were exempted from any antidiabetic drugs for 5 years). RESULTS: At the end of the fifth year, the surgical group had a mean weight loss of 21.0% (from a mean [SD] BMI of 31.0 [2.4] to 24.5 [2.7]), their mean (SD) HbA1c decreased from 9.1% (2.1%) to 6.3% (1.1%) of total Hb, 18 participants (36.0%) had complete remission, 14 (28.0%) had partial remission, 1 (1.9%) died, and 1 (1.9%) had end-stage renal disease. In the same follow-up period in the medical group, 3 (1.2%) had complete remission, 4 (1.6%) had partial remission, 9 (3.0%) died, and 2 (0.7%) had end-stage renal disease; their mean HbA1c remained around 8% of total Hb (mean [SD], 8.1% [1.8%] of total Hb at baseline and 8.0% [1.6%] of total Hb at 5 years), and BMI also stayed similar (mean [SD], 29.1 [2.4] at baseline and 28.8 [2.6] at 5 years). The HbA1c reduction and complete and partial remission rates were all significantly larger in the surgical group as compared with the medical group (all P < .001). However, the mortality rate and end-stage renal disease incidence were not significantly different in these 2 comparison groups (P = .66 and .37, respectively). CONCLUSIONS AND RELEVANCE: For mildly obese patients with T2DM, the improvement in glycemic control from metabolic surgery lasts at least 5 years. However, the survival benefit and lifelong adverse outcomes require more than 5 years to be established.

Laparoscopic sleeve gastrectomy for type 2 diabetes mellitus: predicting the success by ABCD score.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is becoming a primary bariatric surgery for obesity and related diseases. This study presents the outcome of LSG with regard to the remission of type 2 diabetes mellitus (T2 DM) and the usefulness of a grading system to categorize and predict outcome of T2 DM remission. METHODS: A total of 157 patients with T2 DM (82 women and 75 men) with morbid obesity (mean body mass index 39.0±7.4 kg/m(2)) who underwent LSG from 2006 to 2013 were selected for the present study. The ABCD score is composed of the patient's age, body mass index, C-peptide level, and duration of T2 DM (yr). The remission of T2 DM after LSG was evaluated using the ABCD score. RESULTS: At 12 months after surgery, 85 of the patients had complete follow-up data. The weight loss was 26.5% and the mean HbA1c decreased from 8.1% to 6.1%. A significant number of patients had improvement in their glycemic control, including 45 (52.9%) patients who had complete remission (HbA1c<6.0%), another 18 (21.2%) who had partial remission (HbA1c<6.5%), and 9 (10.6%) who improved (HbA1c<7%). Patients who had T2 DM remission after surgery had a higher ABCD score than those who did not (7.3±1.7 versus 5.2±2.1, P<.05). Patients with a higher ABCD score were also at a higher rate of success in T2 DM remission (from 0% in score 0 to 100% in score 10). CONCLUSION: LSG is an effective and well-tolerated procedure for achieving weight loss and T2 DM remission. The ABCD score, a simple multidimensional grading system, can predict the success of T2 DM treatment by LSG.

Recent advances in bariatric/metabolic surgery: appraisal of clinical evidence.

Obesity and associated type 2 diabetes mellitus (T2DM) are becoming a serious medical issue worldwide. Bariatric surgery has been shown to be the most effective and durable therapy for the treatment of morbid obese patients. Increasing data indicates bariatric surgery as metabolic surgery is an effective and novel therapy for not well controlled obese T2DM patients. The review of recent developments in bariatric/metabolic surgery covers 4 major fields. 1) Improvement of safety: recent advances in laparoscopic/metabolic surgery has made this minimal invasive surgery more than ten times safer than a decade ago. The safety profile of laparoscopic/metabolic surgery is compatible with that of laparoscopic cholecystectomy now. 2) New bariatric/metabolic surgery: laparoscopic sleeve gastrectomy (LSG) is becoming the leading bariatric surgery because of its simplicity and efficacy. Other new procedures, such as gastric plication, banded plication, single anastomosis (mini) gastric bypass and Duodeno-jejunal bypass with sleeve gastrectomy have all been accepted as treatment modalities for bariatric/metabolic surgery. 3) Mechanism of bariatric/metabolic surgery: Restriction is the most important mechanism for bariatric surgery. Weight regain after bariatric surgery is usually associated with loss of restriction. Recent studies demonstrated that gut hormone, microbiota and bile acid changes after bariatric surgery may play an important role in durable weight loss as well as in T2DM remission. However, weight loss is still the cornerstone of T2DM remission after metabolic surgery. 4) PATIENT SELECTION: patients who may benefit most from bariatric surgery was found to be patients with insulin resistance. For Asian T2DM patients, the indication of metabolic surgery has been set to those with not well controlled (HbA1c > 7.5%) disease and with their BMI > 27.5 Kg/m(2). A novel diabetes surgical score, ABCD score, is a simple system for predicting the success of surgical therapy for T2DM.

Duodenal-jejunal bypass with sleeve gastrectomy versus the sleeve gastrectomy procedure alone: the role of duodenal exclusion.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) has become accepted as a stand-alone procedure as a less complex operation than laparoscopic duodenojejunal bypass with sleeve gastrectomy (DJB-SG). OBJECTIVES: The aim of this study was to compare one-year results between DJB-SG and SG. SETTING: University hospital. METHODS: A total of 89 patients who received a DJB-SG surgery were matched with a group of SG that were equal in age, sex, and body mass index (BMI). Complication rates, weight loss, and remission of co-morbidities were evaluated after 12 months. RESULTS: The mean preoperative patient BMI in the DJB-SG and SG groups was similar. There were more patients with type 2 diabetes mellitus (T2DM) in the DJB-SG group than in the SG group. The mean operative time and length of hospital stay (LOS) were significantly longer in the DJB-SG group than in the SG group. At 12 months after surgery, the BMI was lower and excess weight loss higher in DJB-SG than SG. Remission of T2DM was greater in the DJB-SG group. Low-density lipoprotein, total cholesterol, and metabolic syndrome (MS) improved after operation in both groups. CONCLUSIONS: In this study DJB-SG was superior to SG in T2DM remission, triglyceride improvement, excess weight loss, and lower BMI at 1 year after surgery. Adding duodenal switch to sleeve gastrectomy increases the effect of diabetic control and MS resolution.

Gastro-intestinal Quality of Life After Metabolic Surgery for the Treatment of Type 2 Diabetes Mellitus.

BACKGROUND: Emerging evidence has shown that bariatric/metabolic surgery ameliorates type 2 diabetes (T2DM) in mildly obese patients (BMI < 35 kg/m(2)) but long-term data is inadequate. We investigated the change of the quality of life after metabolic surgery in not well-controlled T2DM patients with BMI < 35 kg/m(2). METHODS: The quality of life was measured by the gastrointestinal quality of life index (GIQLI), a 36-item questionnaire divided into three domains of general health and one domain of specific gastro-intestinal symptoms, administered before operation, at 3, 6, and 12 months after surgery. A control group matched in age, gender, and BMI was recruited for comparison. RESULTS: A total of 86 patients were enrolled, and the preoperative BMI and HbA1C (mean ± SD) were 30.7 ± 2.8 kg/m(2) and 9.3 ± 2.1 %, respectively. At 1 year after surgery, the BMI and HbA1C were 24.3 ± 2.3 kg/m(2) and 6.2 ± 1.1 %, respectively. There was a significantly improvement in all of the measures of glucose metabolism. Complete remission (HbA1C < 6.0 %) was achieved in 56 subjects (65 %) at 12 months. The GIQLI score was significantly impaired in T2DM patients before surgery compared with the control group. The GIQLI score significantly increased from 109.2 ± 20.0 to 116.1 ± 14.2 points 1 year after surgery. The patients had improvement in the three domains of general health (social, physical, and emotional function) without a difference with the normal control but deteriorated in the domain of specific symptoms. Most of the patients experienced symptoms including abdominal pain, bloating, flatulence, belching, abdominal noise, regurgitation, dysphagia, slow eating speed, nausea, bowel urgency, and incontinence after metabolic syndrome. CONCLUSIONS: Health-related QOL improved dramatically after metabolic surgery for not well-controlled T2DM patients with BMI < 35 kg/m(2), but patients might develop specific gastro-intestinal symptoms after surgery.

Medium-Term Results of Laparoscopic Sleeve Gastrectomy: a Matched Comparison with Gastric Bypass.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is considered a primary bariatric surgery and is increasingly being performed worldwide; however, long-term data regarding the durability of this procedure are inadequate. Here, we report the long-term results of LSGs in comparison to those of gastric bypass surgeries. METHODS: A prospectively collected bariatric database from Ming-Shen General Hospital was retrospectively studied. Five hundred nineteen morbidly obese patients (mean age 36.0 ± 9.1 years old (14-71), 74.6 % female, mean body mass index (BMI) 37.5 ± 6.1 kg/m(2)) underwent LSG as a primary bariatric procedure from 2006 to 2012 at our institute. The operative parameters, weight loss, laboratory data, and quality of life were followed. Another two matched groups of laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic single anastomosis (mini-) gastric bypass (SAGB) patients who were matched in terms of age, sex, and BMI were recruited for comparisons. RESULTS: The mean surgical time for LSG was 113.5 ± 31.3 min, and the mean blood loss was 49.1 + 100.9 ml. The rate of major complications was 1.6 %, and the average length of the postoperative stay was 3.0 ± 1.7 days. The operation times of the RYGB patients were longer than those of both the LSG and SAGB patients. The RYGB and SAGB patients experienced higher major complication rate than the LSG patients. The weight loss of the LSG patient at 5 years was 28.3 + 8.9 %, and the mean BMI was 27.1 + 4.3. The RYGB patients exhibited a 5-year weight loss similar to the LSG patients, and the SAGB patients exhibited greater weight loss than both of the other groups. Both the RYGB and SAGB patients exhibited significantly better glycemic control and lower blood lipids than the LSG patients, but the LSG patients exhibited a lesser micronutrient deficiency than the RYGB and SAGB groups. All three of the groups exhibited improved quality of life at 5 years after surgery, and there was no significant between-group difference in this measure. CONCLUSIONS: LSG appears to be an ideal bariatric surgery, and the efficacy of this surgery is not inferior to that of gastric bypass.

The Effect and Predictive Score of Gastric Bypass and Sleeve Gastrectomy on Type 2 Diabetes Mellitus Patients with BMI < 30 kg/m(2).

BACKGROUND: Metabolic surgery is a novel therapy for mild obesity (BMI 30-35 Kg/m(2)) in type 2 diabetes mellitus (T2DM) patients. The ABCD score, which comprise age, BMI, C-peptide level, and duration of T2DM (years), was reported as useful in predicting the success of T2DM treatment using metabolic surgery. This study examines gastric bypass and sleeve gastrectomy as a salvage treatment for non-obese (BMI < 30 kg/m(2)) T2DM patients and evaluates the role of ABCD scores. METHODS: From January 2007 to July 2013, 512 (71.2%) of 711 T2DM patients enrolled in a metabolic surgical program had at least 1-year follow-up were recruited. Clinical data and outcomes of 80 (15.6%) patients with BMI < 30 Kg/m(2) were compared with those of the other 432 (84.4%) patients with BMI ≥ 30 Kg/m(2). Complete remission was defined as HbA1c ≤ 6%, and partial remission was defined as HbA1c < 6.5%. A binary logistic regression was used to identify predictors of T2DM remission. RESULTS: Mean age of the 80 non-obese T2DM patients was 47.7 ± 9.1 years, and mean HbA1c and disease duration were 9.1 ± 1.8% and 6.5 ± 5.1 years, respectively. Mean total body weight loss was 17.1 ± 7.4% at 1 year, and mean BMI decreased from 26.9 ± 2.2 to 22.7 ± 2.5 kg/m(2) at 1 year. Complete remission of T2DM was achieved in 25.0% of patients, and partial remission was achieved in 23.8%. The complete remission rate was significantly lower than the 49.5% found in patients with BMI 30-35 and 79.0% of patients with BMI > 35 Kg/m(2). In univariate analysis, non-obese patients who had T2DM remission after surgery were heavier and had a wider waist, higher C-peptide levels, shorter disease duration, more weight loss, and higher ABCD score than those without remission. The ABCD score remained the only independent predictor of success after multivariate logistical regression analyses (P = 0.003). CONCLUSIONS: Metabolic surgery may be useful in achieving glycemic control of selected non-obese T2DM patients. The ABCD score is a simple multidimensional grading system that can predict the success of T2DM treatment.

Acute gastric remnant dilatation, a rare early complication of laparoscopic mini-gastric bypass.

Several thousands of laparoscopic mini-gastric bypass have been performed globally by a number of surgeons. There is growing evidence that mini-gastric bypass is a safe and effective procedure. We report a rare case of massive gastric remnant dilation in a 45-year-old man after laparoscopic mini-gastric bypass. Acute gastric dilatation is a surgical emergency. In our case, a triad of clinical suspicion, laboratory profile, and emergency radiologic investigation were essential for early diagnosis and management. Image-guided gastrostomy tube placement provides an effective decompression of the gastric remnant. A literature review revealed no previous reports of similar complications in mini-gastric bypass.

Obstructive jaundice: a rare complication of laparoscopic greater curvature plication.

Laparoscopic greater curvature plication (LGCP) is relatively a new procedure. We report a novel complication of obstructive jaundice in a 24-year-old patient post LGCP. This was secondary to gastric mucosa prolapse with obstruction of the ampulla of Vater. A literature review revealed no previous reports of similar complication.