Biliopancreatic diversion for severe obesity: long-term weight maintenance and occurrence of nutritional complications are two facets of the same coin.

BACKGROUND: Despite the widespread clinical use of hypoabsorptive metabolic bariatric surgery, very long-term outcomes are still lacking. The aim of the study was to assess the long-term safety and efficacy of biliopancreatic diversion at 30 years in patients with class 3 obesity (BMI over 40 kg/m2). METHODS: This retrospective single-centre study used data from a prospectively collected database on a sample of consecutive patients submitted to biliopancreatic diversion with a minimum follow-up of 30 years. Outcomes assessed included overall survival, long-term weight loss and weight maintenance, remission of obesity-related co-morbidities, and short- and long-term surgical and/or nutritional or metabolic complications. RESULTS: Among 199 consecutive patients (136 female, 63 male) who had surgery between November 1992 and April 1994, the mean age at operation was 38 (range 14-69) years and mean preoperative BMI was 48.7 (32.0-74.3) kg/m2. At baseline, 91 of 199 patients (45.7%) had type 2 diabetes. At 20 and 30 years, 122 (61%) and 38 (19%) of the 199 patients respectively were available for follow-up. At 30 years, the overall mortality rate was 12% (23 of 199). Surgical complications were concentrated in the short-term follow-up, whereas nutritional or metabolic complications increased progressively over time. A nutritional complication was diagnosed in 73 of 122 patients (60%) at 20 years and 28 of 38 (74%) at 30 years. Weight loss and glycaemic control were maintained throughout the follow-up; mean % total weight loss was 32.8 (range 14.1-50.0) at 1 year and 37.7 (range 16.7-64.8) at 30 years. One patient presented with recurrence of type 2 diabetes at 20 and 30 years; there were no patients with new-onset type 2 diabetes. CONCLUSION: Biliopancreatic diversion leads to good and sustained weight maintenance up to 30 years with low perioperative risk, but at the cost of a high long-term prevalence of nutritional complications.

Management of malabsorptive bariatric surgery after cancer surgery for malignancies of the digestive apparatus.

BACKGROUND: Data regarding management of former bariatric operations after onset of a malignancy are still lacking and there is no consensus whether bariatric surgery negatively influences the oncologic management of patients. OBJECTIVES: To investigate the strategy by which patients previously submitted to bariatric surgery were managed after diagnosis of malignancy of the digestive apparatus, whether a revision was performed or not, to assess the incidence of nutritional complications, and the effect of revision versus no revision of bariatric surgery on the outcome of cancer treatment. SETTING: University Hospital, Italy. METHODS: Occurrence of a malignancy of the digestive apparatus in patients submitted to biliopancreatic diversion was investigated retrospectively. Patients' data were collected preoperatively, at 2 and 3 years after the operation, at oncologic diagnosis, and at the longest available postoncologic follow-up. RESULTS: From May 1976 to January 2017, 3341 morbidly obese patients were submitted to biliopancreatic diversion. Sixteen patients were diagnosed with a malignancy involving the digestive apparatus 5 to 28 years after bariatric surgery. Of 10 patients diagnosed with colorectal cancer, 6 were revised. At 2 years after biliopancreatic diversion, body mass index, hemoglobin, and iron levels were significantly lower than preoperatively. Serum transferrin and total protein were unchanged. There was no difference between body mass index, hemoglobin, transferrin, and total protein levels at 2 years and at oncologic diagnosis, or between revised and unrevised patients. CONCLUSION: Revision of a preexisting bariatric operation after digestive cancer surgery is common, although selected, unrevised cases do not seem to be associated with worse outcome.

Long-Term Follow-Up Study of Liver-Related Outcome After Bilio-Pancreatic Diversion in Patients with Initial, Significant Liver Damage.

BACKGROUND: Obesity is associated with NAFLD, and bariatric surgery has significant impact on this liver disease, with reported improvement in hepatic fibrosis. AIMS: To investigate the effects of bariatric surgery on long-term liver disease-related outcome in obese patients with nonalcoholic fatty liver disease (NAFLD) and significant liver damage. METHODS: This study included 56 NAFLD patients who underwent bilio-pancreatic diversion for morbid obesity and who had significant fibrosis at intraoperative liver biopsy. Data were analyzed at 1, 3, and 5 years of follow-up, and at the latest available visit in patients who had longer follow-up. We assessed the incidence of clinically relevant liver events (ascites, hepatic encephalopathy, portal hypertension-related bleeding, and jaundice) as well as modifications of a validated biochemical index such as the NAFLD score. RESULTS: During a median follow-up of 78 months, median weight decreased from 119 to 78 kg (P < 0.0001), and median body mass index decreased from 45.2 to 29.0 kg/m2 (P < 0.0001). None of the patients developed clinical complications of liver disease, and none died due to liver-related causes. Median NAFLD score significantly decreased (P = 0.0005) during follow-up from - 0.929 (- 1.543 to - 0.561) to - 1.609 (- 2.056 to - 1.102). The NAFLD score category was unchanged in 32 patients (57%), improved in 18 (32%), and worsened in 6 (11%). CONCLUSIONS: Patients with NAFLD and proven histological liver damage at surgery do not develop complications of liver disease in long term after bilio-pancreatic diversion. Moreover, noninvasive parameters of liver damage improve. Thus, preexisting liver damage does not seem to be a contraindication to bilio-pancreatic diversion.

The long-term impact of biliopancreatic diversion on glycemic control in the severely obese with type 2 diabetes mellitus in relation to preoperative duration of diabetes.

BACKGROUND: Bariatric surgery has been shown to be effective in severely obese patients with type 2 diabetes mellitus (T2DM). OBJECTIVE: Evaluate the long-term efficacy of biliopancreatic diversion (BPD) for the treatment of T2DM depending on the preoperative duration of T2DM. SETTING: University Hospital. METHODS: Retrospective analysis investigating 2 subsets of severely obese patients who had undergone BPD from 1984 to 1995. The first included 52 patients with a preoperative T2DM duration of ~1 year (SD group - 49 on oral agents and 3 on insulin), and the second included 68 patients who had been diabetic for>5 years before BPD (LD group - 52 on oral agents and 16 on insulin). Postoperatively, T2DM was regarded as in remission when fasting serum glucose (FSG) was lower than 100 mg/dL on regular diet and without antidiabetic therapy. RESULTS: In the SD patients, the number of individuals without T2DM remission were lower both at 5-10 (0/31, 0% of patients, versus 8/54, 15% of patients, p<.04) and at>15 years (1/28, 3% of patients, versus 10/41, 24% of patients, p<.0012). Furthermore, after BPD, the number of patients with dyslipidemia strongly reduced (p<.001) in both groups, values at 5-10 years remaining very similar to those observed at>15 years. CONCLUSION: These results indicate that severely obese patients with longer T2DM duration have a worse metabolic outcome maintained at long and very long term following BPD.

Effects of gastric bypass on type 2 diabetes in patients with BMI 30 to 35.

BACKGROUND: This study aims to investigate if the benefits on glycemic control following Roux-en-Y gastric bypass (RYGB) in morbidly obese type 2 diabetes (T2DM) patients are maintained in the 30-35 kg/m(2) BMI (body mass index) range, comparing results with those in literature. METHODS: The study participants were twenty T2DM patients aging 35-70 years, BMI 30.0-34.9 kg/m(2), minimum diabetes duration 3 years, glycosylated haemoglobin (HbA1c) ≥7.5% despite good clinical practice medical therapy, submitted to laparoscopic RYGB, and monitored during 36 months. Twenty-seven matched diabetic patients as controls. RESULTS: Five females, mean age 57 (42-69) years, weight 96.0 (70-111) kg, BMI 32.9 (30.3-34.9) kg/m(2), waist circumference 112 (100-128) cm, diabetes duration 14 (3-28) years, HbA1c 9.5 (7.5-14.2) %, and C-peptide 3.2 (1,6-9.1) mcg/l. Ten patients were on insulin. There was no mortality, and there were two major late complications. BMI and waist decreased stabilizing around 25 kg/m(2) and 92 cm. Fasting serum glucose and HbA1c reached values around 150 mg/dl and 7%, which subsequently maintained. There was remission in 25% of cases, control 45%, and all the others improved. HOMA-IR and insulin sensitivity index normalized at 1 month, then maintained. AIR and insulinogenic index showed no postoperative changes. Diabetes remission correlated negatively with duration (p < 0.05; r (2) = 0.61), while control positively with C-peptide (p < 0.05; r (2) = 0.19). In the control group, FSG, HbA1c, serum triglyceride, and cholesterol significantly decreased with considerable progressive increase of antidiabetic/antihyperlipemic therapy. All patients had HbA1c >7% at 2-3 years. CONCLUSIONS: Glycemic control obtained by RYGB in this study was less good than that reported by others, apparently due to different patient selection criteria. Our results do not support RYGB weight loss-independent effect on beta-cell function in the T2DM patients with BMI 30-35 kg/m(2).

The effects of biliopancreatic diversion on type 2 diabetes mellitus in patients with mild obesity (BMI 30-35 kg/m2) and simple overweight (BMI 25-30 kg/m2): a prospective controlled study.

BACKGROUND: Beneficial effects of BPD on T2DM in BMI >35 kg/m(2) patients are far better than those in patients with BMI 25-35. This study was aimed at investigating if a similar difference exists between patients with mild obesity (OB, BMI 30-35) or simple overweight (OW, BMI 25-30). METHODS: Fifteen OB (six M) and 15 OW (13 M), diabetic for ≥ 3 years, with HbA1c ≥ 7.5% despite medical therapy, underwent BPD. OB/OW: age 55.1 ± 8.0/57.8 ± 6.7 years, BMI 33.1 ± 1.5/28.0 ± 1.3 kg/m(2), diabetes duration 11.6 ± 8.0/11.1 ± 6.1 years, insulin therapy 4/8 p. FSG and HbA1c were determined preoperatively and up to 2 years. Insulin resistance and beta-cell function were explored by means of HOMA-IR and IVGTT (AIR). Thirty-eight diabetic patients on medical therapy served as controls. RESULTS: Mean BMI stabilized around 27 since the 4th month in OB, and 24 since 1st month in OW. FSG in OB/OW preop, 1, 12, 24 months: 234 ± 76/206 ± 62 mg/dL, 154 ± 49/176 ± 75, 131 ± 32/167 ± 48, 134 ± 41/154 ± 41 (cross-sectional n.s. at all times); HbA1c: 9.5 ± 1.6/9.1 ± 1.3, 7.3 ± 1.1/7.3 ± 1.2, 5.9 ± 0.6/7.1 ± 1.1 (p < 0.01), 5.9 ± 0.9/6.9 ± 1.1 (p < 0.01). HOMA-IR, preoperatively 10.7 ± 5.8/7.5 ± 5.4, went below 3.0 at 1 month and remained such until 2 years in both groups. AIR, preoperatively 1.11 ± 3.17/1.27 ± 2.68 µIU/mL, in OB significantly increased at 4 months to 7.63 ± 5.79, maintained up to 2 years with 6.95 ± 3.19, whereas in OW, statistical significance was reached only at 2 years with 5.02 ± 4.87. CONCLUSIONS: Significantly different BPD effect, thus biological severity of T2DM, also exists between mildly obese and simply overweight patients. The rise of AIR allows hoping that an increase of beta-cell mass may occur in the long run.

Effects of biliopanceratic diversion on type 2 diabetes in patients with BMI 25 to 35.

OBJECTIVE: Biliopancreatic diversion (BPD) resolves type 2 diabetes in near totality of morbidly obeses [BMI (body mass index) ≥35 kg/m]. However, studies of BPD effect in BMI range 25.0 to 34.9 kg/m, including about 90% of diabetic patients, are lacking. MATERIALS AND METHODS: If BPD effects are independent of weight changes, they should be maintained in patients who, being mildly obese or overweight, will lose little or no weight after operation. Thirty type 2 diabetic patients with BMI 25 to 34.9 were submitted to BPD and monitored 12 months. Thirty-eight diabetic patients selected from a large database, kept 1 year on medical therapy, served as controls. RESULTS: Nineteen male and 11 female. Mean age 56.4 ± 7.4 years, weight 84.8 ± 11.1 kg, BMI 30.6 ± 2.9 kg/m, waist circumference 104 ± 9.4 cm, diabetes duration 11.2 ± 6.9 years, HbA1c 9.3±1.5. Twelve patients on insulin. Fifteen (2 F) with BMI < 30 (mean: 28.1). No mortality or major adverse events occurred. BMI progressively decreased, stabilizing around 25 since the fourth month, without excessive weight loss. One year after BPD, mean HbA1c was 6.3%±0.8, with 25 patients (83%) controlled (HbA1c≤7%) on free diet, without antidiabetics, and the remaining improved. Acute insulin response to intravenous glucose had increased from 1.2 ± 2.9 to 4.2 ± 4.4 µIU/mL. Diabetes resolution correlated positively with BMI. HbA1c decreased at 1 year in the control group, along with an overall increased amount of antidiabetic therapy. CONCLUSIONS: BPD improves or resolves diabetes in BMI 25 to 35 without causing excessive weight loss, its action being on insulin sensitivity and beta-cell function. The strikingly different response between morbidly obese and low BMI patients might depend on different beta-cell defect. ClinicalTrials.gov Identifier: NCT00996294.

Does biliopancreatic diversion carry increased risk for colorectal cancer? A cohort study.

BACKGROUND: Because of the rearrangement of the gastrointestinal tract, biliopancreatic diversion (BPD) could lead to an increased risk of colorectal cancer caused by possible carcinogenetic action of the unabsorbed food and bile acid on colonic mucosa. METHODS: The incidence of colorectal cancer in 1,898 obese subjects submitted to BPD from May 76 to July 2002 with a minimum follow-up of 5 years was retrospectively evaluated. RESULTS: Among 28,811 person-years, seven cases of colorectal cancer were detected, for an overall incidence of 29.4 per 100,000, which is not different from that observed in the general Italian population, and lower than that reported for obese and type 2 diabetes patients. Logistic regression model suggests that occurrence of colorectal cancer is positively related to the time elapsed from BPD. CONCLUSION: This study indicates that BPD does not carry any increased risk for colorectal cancer. The complete postoperative restoration of insulin sensibility could exert a valuable protective action.

Bariatric surgery in adolescents: a long-term follow-up study.

BACKGROUND: The benefits of bariatric surgery in adult obese patients are well known, but data are lacking regarding the outcome of the surgery in adolescents. The aim of this study was to retrospectively assess the operative morbidity and mortality, percentage of loss of initial excess weight, and the incidence of long-term complications and reoperations in a cohort of obese patients who underwent biliopancreatic diversion (BPD) before their 18th birthday. METHODS: A total of 76 adolescent subjects underwent BPD between 1976 and 2005. Of these 78 patients, 7 had Prader-Willi syndrome and 1 had Turner syndrome and were excluded from the study. RESULTS: The patient population comprised 52 girls and 16 boys. Their mean age was 16.8 years, mean body weight at operation was 125 kg (mean body mass index 46 kg/m2). Operative mortality was nil. The mean follow-up was 11 years (range 2-23). The mean percentage of loss of initial excess weight at each patient's longest follow-up was 78%. Before surgery, 33 patients were hypertensive (49%), 11 were dyslipidemic (16%), 3 were hyperglycemic, and 2 had type 2 diabetes. At the longest follow-up period after surgery, only 6 patients were hypertensive, and none were dyslipidemic or diabetic. A total of 19 reoperations were performed in 14 patients (20%), including 7 revisions. Eleven patients developed protein malnutrition 1-10 years after BPD. The long-term mortality rate was 4%. At 4 to 23 years after BPD, 18 of the women had given birth to 28 healthy babies. Three women had had a complicated pregnancy. CONCLUSION: Adolescents can undergo malabsorptive bariatric surgery with excellent long-term weight loss results and an incidence of long-term complications similar to that observed during the 30-year evolution of BPD in our experience.

Type 2 diabetes and weight loss following biliopancreatic diversion for obesity.

BACKGROUND: The authors investigated the weight loss and maintenance in type 2 diabetic obese patients undergoing biliopancreatic diversion (BPD). METHODS: Two series of diabetic and non-diabetic obese patients matched for gender, age and baseline body mass index (BMI) were evaluated prior to BPD, on the occasion of the regular follow-up visit at 1, 2 and 3 years following the operation, and at the fifth postoperative year. At each follow-up point, body weight (BW), BMI, and serum glucose concentration were measured. RESULTS: In all type 2 diabetic patients, the serum glucose level fell to within the normal range at the first postoperative year and remained within normal limits without any medication throughout all the follow-up period. In preoperatively diabetic subjects, mean values of BW and BMI were closely similar to those of non-diabetic subjects at all follow-up points, and the stabilization weight was independently related to age and to initial BW values. CONCLUSIONS: In obese patients with type 2 diabetes, the glucose level steadily normalized in every case following BPD, and values remained unchanged throughout the follow-up period. After the operation, the type 2 diabetic obese patients experienced the same stable weight reduction as their non-diabetic counterparts.