Preoperative factors predicting remission of type 2 diabetes mellitus after Roux-en-Y gastric bypass surgery for obesity.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is an effective treatment for morbid obesity. This bariatric procedure has also been noted to resolve hyperglycaemia in up to 70% of obese diabetics. We evaluated outcomes in diabetic patients undergoing RYGB in our institution, aiming to identify factors predicting diabetes remission. METHODS: One hundred ten type 2 diabetic (T2DM) patients undergoing RYGB were studied. Baseline demographics, diabetic status pre- and post-surgery and outcomes were evaluated. Outcomes were compared to a matched non-diabetic cohort. RESULTS: The mean age of the patients was 45 +/- 11. The majority (70%; n = 77) were female and the mean baseline body mass index was 47 +/- 7. Mean (+/-SD range) excess weight loss at 6, 12 and 24 months was 58.3 +/- 26.4% (30.5-167%), 63.2 +/- 17.2% (0-99.2%) and 84.1 +/- 21.3% (16.5-121%), respectively. Diabetic medication was discontinued in 68.4% patients and reduced in a further 14.3%. Mean preoperative HbA1c was 7.1 +/- 2.0 and mean postoperative HbA1c 5.48 +/- 0.2. Patients with a baseline HbA1c >10 had a 50% rate of remission compared to 77.3% with an HbA1c of 6.5-7.9. The mean duration of T2DM preoperatively was 5.5 +/- 7 years. A preoperative duration of T2DM greater than 10 years was shown to significantly reduce the chances of remission (p = 0.005). CONCLUSIONS: RYGB for morbid obesity achieves significant weight reduction in diabetic patients with remission of pre-surgical hyperglycaemia in the majority. The study supports findings that a shorter duration and better control of diabetes prior to surgery corresponds to a higher rate of remission. It supports the argument for early surgical intervention in the morbidly obese diabetic patient.

Quality improvement programme to achieve acceptable colonoscopy completion rates: prospective before and after study.

PROBLEM: A large audit of colonoscopy in the United Kingdom showed that the unadjusted completion rate was 57% when stringent criteria for identifying the caecum were applied. The caecum should be reached 90% of the time. Little information is available on what units or operators need to do to improve to acceptable levels. DESIGN: Quality improvement programme using two completed cycles of audit. SETTING: Endoscopy department in a university linked general hospital in northeast England. KEY MEASURES FOR IMPROVEMENT: Colonoscopy completion rate. STRATEGY FOR CHANGE: Two audit cycles were completed between 1999 and 2002. Changes to practice were based on results of audit and took into account the opinions of relevant staff. Lack of time for each colonoscopy, poor bowel preparation, especially in frail patients, and a mismatch between number of colonoscopies done and completion rate for individual operators were responsible for failed colonoscopies. Appropriate changes were made. EFFECTS OF CHANGE: The initial crude colonoscopy completion rate was 60%, improving to 71% after the first round of audit and 88% after the second round, which approximates to the agreed audit standard of 90%. The final adjusted completion rate was 94%. LESSONS LEARNT: Achievement of the national targets in a UK general hospital is possible by lengthening appointments, admitting frail patients for bowel preparation to one ward, and allocating colonoscopies to the most successful operators.