Resolution of Diabetes After Bariatric Surgery Among Predominantly African-American Patients

Background

The aim of this study was to assess the relative efficacy in diabetes remission among predominantly African-American patients who have undergone one of the three different types of bariatric surgical procedures.

Methods

A total of 597 morbidly obese patients underwent one of the three bariatric surgical procedures at Harper University Hospital, Detroit, Michigan from 2008 to 2011. Of the three procedures, 203 (34 %) patients had laparoscopic sleeve gastrectomy, 264 (44.2 %) patients had laparoscopic gastric bypass, and 130 (21.8 %) had laparoscopic adjustable gastric banding. The prevalence of diabetes prior to surgery was 20.7, 17.4, and 24 %, respectively. There was no statistical difference in the prevalence of diabetes among the three surgical groups.

Results

Of the 119 patients with diabetes, 46 (38.7 %) were males and 73 (61.3 %) were females. The majority of patients were African-Americans (65 %). The average age of patients was 42.2?±?8.3 years for sleeve gastrectomy, 44.8?±?7.9 years for gastric banding, and 41.5?±?7.7 years for gastric bypass surgery. Of all the study patients with a preoperative diagnosis of type 2 diabetes, 86 patients (72.3 %) had resolution of diabetes 1 year after surgery. The resolution of diabetes was reported in 89.1, 66.7, and 54.8 % of patients who underwent laparoscopic gastric bypass, sleeve gastrectomy, and gastric banding, respectively.

Conclusions

This study, which was conducted among predominantly African-Americans, showed consistent results with other studies. Patients who underwent laparoscopic gastric bypass appeared to benefit the most in terms of achieving better remission of diabetes.     

Short-Term Outcomes of Laparoscopic Single Anastomosis Gastric Bypass (LSAGB) for the Treatment of Type 2 Diabetes in Lower BMI (<30 kg/m2) Patients

Background

Bariatric surgery is an efficient procedure for remission of type 2 diabetes (T2DM) in morbid obesity. However, in Asian countries, mean body mass index (BMI) of T2DM patients is about 25 kg/m². Various data on patients undergoing gastric bypass surgery showed that control of T2DM after surgery occurs rapidly and somewhat independent to weight loss. We hypothesized that in non-obese patients with T2DM, the glycemic control would be achieved as a consequence of gastric bypass surgery.

Methods

From September 2009, the 172 patients have had laparoscopic single anastomosis gastric bypass (LSAGB) surgery. Among them, 107 patients have been followed up more than 1 year. We analyzed the dataset of these patients. Values related to diabetes were measured before and 1, 2, and 3 years after the surgery.

Results

The mean BMI decreased during the first year after the surgery but plateaued after that. The mean glycosylated hemoglobin level decreased continuously. The mean fasting and postglucose loading plasma glucose level also decreased.

Conclusion

After LSAGB surgery in non-obese T2DM patients, the control of T2DM was possible safely and effectively. However, longer follow-up with matched control group is essential.     

Preoperative Prediction of Type 2 Diabetes Remission After Gastric Bypass Surgery: a Comparison of DiaRem Scores and ABCD Scores

Background

Gastric bypass surgery has been well accepted as a novel treatment modality for type 2 diabetes mellitus (T2DM) in obese patients. Some scoring systems have been proposed for the selection of T2DM patients who are eligible for gastric bypass surgery. This study compares two scoring systems with regard to remission of T2DM after gastric bypass surgery.

Methods

This retrospective cohort study included 245 patients (150 females and 95 males) who had undergone gastric bypass surgery for the treatment of T2DM with 1 year follow-up. We examined the predictive power of complete remission of two scoring systems, the DiaRem score, and the ABCD score. The DiaRem score includes the factors of age, HbA1c, medication, and insulin usage. The ABCD score includes the factors of age, BMI, C-peptide level, and duration of T2DM. The rate of remission of T2DM after gastric bypass surgery was evaluated using both scoring systems.

Results

At 1 year after surgery, the percent weight loss was 26.5 % and the mean BMI decreased from 35.7 to 26.2 kg/m². The mean HbA1c decreased from 8.8 to 6.2 %. A significant number of patients showed improvement in glycemic control, including 130 (53.1 %) patients with complete remission (HbA1c?<?6.0 %), 36 (14.7 %) patients with partial remission (HbA1c?<?6.5 %), and 26 (10.6 %) patients with improvement (HbA1c?<?7 %). Both the DiaRem score and the ABCD score predicted the success of the gastric bypass surgery, but the ABCD score was better at differentiating patients with poorer score (27.9 vs. 9.1 %, p?<?0.001).

Conclusions

Gastric bypass surgery is a treatment option for obese T2DM patients. The ABCD score is better at predicting T2DM remission at 1 year after gastric bypass surgery than the DiaRem score.

     

Preserving Duodenal-Jejunal (Foregut) Transit Does Not Impair Glucose Tolerance and Diabetes Remission Following Gastric Bypass in Type 2 Diabetes Sprague-Dawley Rat Model

Background

Possible mechanisms underlying diabetes remission following Roux-en-Y gastric bypass (RYGB) include eradication of putative factor(s) with duodenal-jejunal bypass.

Objective

The objective of this study is to observe the effects of duodenal-jejunal transit on glucose tolerance and diabetes remission in gastric bypass rat model.

Method

In order to verify the effect of duodenal-jejunal transit on glucose tolerance and diabetes remission in gastric bypass, 22 type 2 diabetes Sprague-Dawley rat models established through high-fat diet and low-dose streptozotocin (STZ) administered intraperitoneally were assigned to one of three groups: gastric bypass with duodenal-jejunal transit (GB-DJT n = 8), gastric bypass without duodenal-jejunal transit (RYGB n = 8), and sham (n = 6). Body weight, food intake, blood glucose, as well as meal-stimulated insulin, and incretin hormone responses were assessed to ascertain the effect of surgery in all groups. Oral glucose tolerance test (OGTT) and insulin tolerance test (ITT) were conducted three and 7 weeks after surgery.

Results

Comparing our GB-DJT to the RYGB group, we saw no differences in the mean decline in body weight, food intake, and blood glucose 8 weeks after surgery. GB-DJT group exhibited immediate and sustained glucose control throughout the study. Glucagon-like peptide 1 (GLP-1) and gastric inhibitory polypeptide (GIP) levels were also significantly increased from preoperative level in the GB-DJT group (p < 0.05). Insulin and GLP-1 area under curve (AUC) as well as improved glycemic excursion on OGTT did not differ between GB-DJT and RYGB groups. Outcomes with sham operation did not differ from preoperative level.

Conclusion

Preserving duodenal-jejunal transit does not impede glucose tolerance and diabetes remission after gastric bypass in type-2 diabetes Sprague-Dawley rat model.

     

Bariatric Surgery in Obese Patients with Type 1 Diabetes: Effects on Weight Loss and Metabolic Control

Background

Type 1 diabetes patients, although typically lean, experience an increased prevalence of obesity, and bariatric surgery is considered in severe cases. Bariatric surgery in such patients leads to significant weight loss and decreased insulin requirements; however, effects on glycemic control remain discussed. We assessed, in obese patients with type 1 diabetes, the effects of bariatric surgery upon body weight, body composition, and glycemic control, including the occurrence of hypoglycemic events.

Methods

Thirteen obese patients with type 1 diabetes who underwent bariatric surgery (Roux-en-Y gastric bypass n?=?6, sleeve gastrectomy n?=?7) were matched with obese patients without diabetes and with type 2 diabetes patients during 12 months of follow-up. Outcomes included body weight, DXA-assessed body composition, HbA1c, and incidence of hypoglycemia.

Results

At 12 months, median surgery-induced weight loss was 27.9 % (21.1–33.3), 26.1 % (24.8–29.7), and 27.5 % (21.8–32.1) in patients with type 1 diabetes, type 2 diabetes, and without diabetes, respectively, with no significant differences across the groups. Similar findings were observed for body fat changes. At 12 months, median HbA1c decreased from 8.3 to 7.6 % in type 1 diabetes patients versus 8.0 to 5.9 % in type 2 diabetes patients (P?=?0.04 between the groups). In type 1 diabetes patients, the number of reported minor hypoglycemia increased transiently only at 6 months. Two patients reported severe hypoglycemia (one episode each).

Conclusions

Type 1 diabetes patients benefit from bariatric surgery in terms of weight loss and glycemic control. Close monitoring of insulin therapy appears warranted to prevent minor hypoglycemia in the first months post-surgery.

     

Effect of Contemporary Bariatric Surgical Procedures on Type 2 Diabetes Remission. A Population-Based Matched Cohort Study

Objective

The objective of the study is to evaluate the effect of gastric banding, gastric bypass and sleeve gastrectomy on medium to long-term diabetes control in obese participants with type 2 diabetes mellitus.

Research Design and Methods

Matched cohort study using primary care electronic health records from the UK Clinical Practice Research Datalink. Obese participants with type 2 diabetes who received bariatric surgery from 2002 to 2014 were compared with matched control participants who did not receive BS. Remission was defined for each year of follow-up as HbA1c <6.5 % and no antidiabetic drugs prescribed.

Results

There were 826 obese participants with T2DM who received bariatric surgery including adjustable gastric banding (LAGB) 220; gastric bypass (GBP) 449; or sleeve gastrectomy (SG) 153; with four procedures undefined. Mean HbA1c declined from 8.0 % before BS to 6.5 % in the second postoperative year; proportion with HbA1c <6.5 % (<48 mmol/mol) increased from 17 to 47 %. The proportion of patients in remission was 30 % in the second year, being 20 % for LAGB, 34 % for GBP and 38 % for SG. The adjusted relative rate of remission over the first six postoperative years was 5.97 (4.86 to 7.33, P?<?0.001) overall; for LAGB 3.32 (2.27 to 4.86); GBP 7.16 (5.64 to 9.08); and SG 6.82 (5.05 to 9.19). Rates of remission were maintained into the sixth year of follow-up.

Conclusions

Remission of diabetes may continue for up to 6 years after bariatric surgical procedures. Diabetes outcomes are generally more favourable after gastric bypass or sleeve gastrectomy than LAGB.

     

Long-term follow-up evaluation of revisional gastric bypass after failed adjustable gastric banding

Background

Disappointing long-term results, frequent band failure, and high rates of band-related complications increasingly necessitate revisional surgery after adjustable gastric banding. Laparoscopic conversion to gastric bypass has been recommended as the procedure of choice. This single-center retrospective study aimed to evaluate the long-term results of revisional gastric bypass after failed adjustable gastric banding.

Methods

The study included 108 consecutive patients who underwent laparoscopic conversion of gastric banding to gastric bypass from 2002 to 2012. Indications for surgery, operative data, weight development, morbidity, and mortality were analyzed. The median follow-up period was 3.4 years (maximum, 10 years).

Results

The most common indications for band removal were band migration, insufficient weight loss, and pouch dilation. The median interval between gastric banding and gastric bypass was 6.6 years. In 52 % of the cases, band removal and gastric bypass surgery were performed simultaneously as a single-stage laparoscopic procedure. The early postoperative morbidity rate was 10.2 %. The body mass index before gastric banding (43.3 kg/m²) decreased significantly to 37.9 kg/m² before gastric bypass and to 28.8 kg/m² 5 years after gastric bypass.

Conclusions

This is the first report on the long-term outcome after conversion of failed adjustable gastric banding to gastric bypass. Findings have shown revisional gastric bypass to be a feasible bariatric procedure particularly for patients with insufficient weight loss that guarantees a constant and long-lasting weight loss.     

Prediction of Diabetes Remission in Morbidly Obese Patients After Roux-en-Y Gastric Bypass

Background

Morbidly obese patients with type 2 diabetes have shown significant improvement in glycemic control after Roux-en-Y gastric bypass (RYGB). This study aimed to elucidate the predictors of diabetes remission.

Methods

A retrospective review of a prospectively established database identified 134 type 2 diabetes patients who underwent laparoscopic RYGB between January 2011 and February 2014. Partial and complete remission of diabetes was defined as glycated hemoglobin (HbA1c) level <6.5 and <6.0 %, respectively, without the use of antidiabetic medication. Pre- and postoperative clinical outcomes were compared between the remission and non-remission groups to identify the predictors of partial or complete remission of diabetes.

Results

The mean duration of diabetes and preoperative HbA1c level were 4.6 years and 8.0 %, respectively. The body mass index (BMI) of the enrolled patients decreased from 37.9 to 28.8 kg/m² during the mean follow-up of 12.3 months; 61.8 % of the patients achieved partial or complete remission of diabetes. Multivariate analysis revealed that age at operation (odds ratio [OR]?=?0.880; 95 % confidence interval [CI] 0.807–0.960), HbA1c level (OR?=?0.527; 95 % CI 0.325–0.854), and C-peptide level (OR?=?1.463; 95 % CI 1.054–2.029) in the preoperative laboratory study, and the percentage of total weight loss (%TWL) (OR?=?1.186; 95 % CI 1.072–1.313) after RYGB were the independent predictors of partial or complete diabetes remission.

Conclusion

The predictive factors for diabetes remission after RYGB include age at operation, HbA1c and C-peptide levels, and the %TWL after surgery.

     

Ethnicity Does Not Influence Glycemic Outcomes or Diabetes Remission After Sleeve Gastrectomy or Gastric Bypass in a Multiethnic Asian Cohort

Background

In Asia, metabolic-bariatric surgery (MBS) rates have grown rapidly in parallel with rising prevalence of obesity and type 2 diabetes (T2D).

Objective

The objective of this study was to identify factors that influence glycemic outcomes and diabetes remission 12 months after sleeve gastrectomy (SG) or gastric bypass (GB) in a multiethnic Asian cohort.

Setting

The study’s setting was in a tertiary hospital in Singapore.

Methods

Data from 145 T2D patients who had SG (37%) or GB (63%) and at least 1-year follow-up were analyzed. Diabetes remission was defined as hemoglobin A1c ≤?6.0% without diabetes medications. Analysis involved binary logistic regression to identify predictors and general linear regression for variables associated with glycemic improvement after surgery.

Results

Baseline parameters are as follows: BMI 40.0?±?7.6 kg/m², A1c 8.4?±?1.6%, diabetes duration 9.3 years, ethnic composition: Chinese (51.7%), Malay (23.4%), Indian (20.7%), Others (4.1%). 55.9% achieved diabetes remission at 1 year. Baseline A1c, baseline BMI, and diabetes duration were significant pre-operative factors for remission (cumulative R ²?=?0.334). At 12 months, percentage weight loss was similar after SG (24.1?±?7.4%) and GB (25.4?±?7.4%, p?=?0.31). Greater A1c decrease was seen with GB compared to SG (2.7?±?1.6 vs 2.0?±?1.5%, p?=?0.006), significant even after adjustment for weight loss, age, BMI, baseline A1c, and diabetes duration (p?=?0.033). Weight loss at 12 months also correlated independently with A1c reduction. Ethnicity did not influence weight loss, diabetes remission, or glycemic control after MBS.

Conclusion

Baseline A1c, baseline BMI, and diabetes duration independently predict diabetes remission after MBS. GB is more effective in controlling T2D compared to SG despite similar weight loss, whereas ethnicity does not play a significant role in the multiethnic Asian cohort.

     

Remission of Type 2 Diabetes Mellitus Should Not Be the Foremost Goal after Bariatric Surgery

Background

Remission of type 2 diabetes (T2D) is a desired outcome after bariatric surgery (BS). Even if this goal is not achieved, individuals who do not strictly fulfill remission criteria experience an overall improvement. The aim of this study was to evaluate the metabolic control status in patients considered as diabetes “non-remitters.”

Methods

A retrospective study of 125 patients (59.2 % women) with preoperative diagnosis of T2D who underwent BS in a single center (2006–2011) was conducted. We collected anthropometric and metabolic parameters before surgery and at 1-year follow-up. T2D remission was defined according to the 2009 consensus statement: glycosylated hemoglobin (HbA1c) <6 %, fasting glucose (FG) <100 mg/dLs, and absence of pharmacologic treatment. We evaluated metabolic status of non-remitters, according to the American Diabetes Association's (ADA) target recommendations: HbA1c <7 %, LDL-c <100 mg/dL, triglycerides <150 mg/dL, and HDL-c >40 (male) or >50 mg/dL (female). Statistics: analysis of variance.

Results

Baseline characteristics (mean ± SD): age 53.5?±?9.7 years, BMI 43.5?±?5.6 kg/m², time since diagnosis of T2D 7.7?±?7.9 years, FG 162.0?±?56.3 mg/dL, HbA1c 7.7?±?1.6 %. ADA's target recommendations were present in 12 patients (9.6 %) preoperatively, and in 45 (36.0 %) at 1-year follow-up (p <0.001). Sixty-two (49.6 %) patients did not achieve diabetes remission; 26 (41.9 %) had now diet treatment, 30 (48.4 %) oral medications, and 6 (9.7 %) required insulin. Of the non-remitters, 57 (91.9 %) had HbA1c <7 % and 18 (40.0 %) achieved ADA's target recommendations. There were no differences between remitters and non-remitters in the number of individuals reaching ADA's combined metabolic control.

Conclusions

Although almost 50 % of the patients may not be classified as diabetes remitters, their significant improvement in metabolic control should be regarded as a success, according to most scientific societies' target recommendations.     

Patient Preferences and Bariatric Surgery Procedure Selection; the Need for Shared Decision-Making

Background

Bariatric surgery is the most effective treatment for patients suffering from obesity-related comorbidities. There is little data regarding how patients choose one particular bariatric procedure over another. This study aimed to better define the relationship between preferences of patients considering bariatric surgery and the procedure patients undergo.

Methods

A bilingual questionnaire was administered to all prospective patients seen between March 1 and August 31, 2012. The questionnaire assessed basic knowledge of bariatric surgery (based on the information seminar) as well as patient preferences of the various outcomes and complications for sleeve gastrectomy, gastric bypass, and gastric banding.

Results

One hundred seventy-two patients completed the questionnaire. Fifty-eight percent of patients chose “maximum weight loss” as the most important outcome, and 65 % chose “leak” as the most concerning complication. Subgroup analysis of patients with diabetes revealed that 58 % chose “curing diabetes” as the most important outcome. Nineteen percent of patients were either not sure which procedure they wanted or changed their decision after consultation with the surgeon.

Conclusions

The decision to choose one bariatric procedure over another is complex and is based on factors beyond absolute patient preferences. Although maximum weight loss is a commonly reported preference for patients seeking bariatric surgery, patients with diabetes are more focused on diabetes remission. Most patients have already decided which procedure to undergo prior to surgeon consultation. Patients may benefit from shared decision making, which integrates patient values and preferences along with current medical evidence to assist in the complex bariatric surgery selection process.     

The Results of a Surgical Complication Protection Program (BLIS, Inc.) for Private Pay Bariatric Patients in the U.S.: 2006–2011

Background

Bariatric surgery is the most effective treatment for morbid obesity and associated medical co morbidities. There is currently minimal surgical treatment penetration of this widespread disease. BLIS has been able to improve the access to bariatric surgery for cash-pay patients by alleviating concern about the costs of post-surgical complications. Recently, there has become an ability to attract payor groups by offering a “bundled” payment which includes BLIS complication protection.

Methods

A total of 5,364 self-pay patients underwent laparoscopic adjustable gastric banding, laparoscopic vertical sleeve gastrectomy, or laparoscopic Roux-en-Y gastric bypass with BLIS complication insurance.

Results

Of the overall 5,364 patients, the 30-day mortality rate was 0.04 % and 1-year mortality rate was 0.06 %. The frequency of complications was 5.4 % in the gastric banding group, 6.5 % in the sleeve gastrectomy group, and 9.7 % in the gastric bypass group.

Conclusions

The results for mortality and complications in the BLIS data set compares very well with other large data sets in bariatric surgery. BLIS complication insurance improves the access to bariatric surgery in patients who self-pay.     

The Safety of Laparoscopic Hand-Sutured Gastrojejunostomy in Gastric Bypass for the Treatment of Morbid Obesity

Background

Laparoscopic Roux-en-Y gastric bypass is the most commonly adopted bariatric procedure. The predominant majority of surgeons construct the anastomoses using stapled techniques. We describe our technique of complete laparoscopically sutured gastrojejunal anastomosis (GJA) and its outcomes.

Methods

Electronic database was used to collect data retrospectively for patients undergoing laparoscopic gastric bypass at the senior author's bariatric institutions. The results shown represent median (interquartile range).

Results

Between April 2002 and April 2012, 1,754 consecutive patients (78 % female) aged 43 (35–50)?years with BMI 51 (44.5–56.7)?kg/m² underwent laparoscopic gastric bypass (1,679 primary bypasses, 75 revision procedures). All the GJA were hand-sutured. The operative mortality was 0.17 %. Four patients (0.22 %) developed GJA/gastric pouch leak of whom two died, while a further three patients (0.17 %) needed endoscopic dilatation of GJA stricture during the initial 2 years after surgery.

Conclusions

In the hands of an experienced laparoscopic surgeon, laparoscopic hand-sutured GJA in patients undergoing gastric bypass is safe and effective with very low anastomotic leak and stricture rates.     

Laparoscopic Sleeve Gastrectomy Versus Single Anastomosis (Mini-) Gastric Bypass for the Treatment of Type 2 Diabetes Mellitus: 5-Year Results of a Randomized Trial and Study of Incretin Effect

Background

Bariatric surgery may be beneficial in mildly obese patients with poorly controlled diabetes. The optimal procedure to achieve diabetes remission is unknown. In 2011, we published the short-term results of a pilot study designed to evaluate the efficacy of diabetic control and the role of duodenal exclusion in mildly obese diabetic patients undergoing laparoscopic sleeve gastrectomy (SG) vs. a laparoscopic single anastomosis (mini-) gastric bypass (SAGB). This study analyzes the 5-year results and evaluates the incretin effect.

Methods

A double-blind randomized trial included 60 participants with a hemoglobin A1c (HbA1c) level higher than 7.5 %, a body mass index (BMI) between 25 and 35 Kg/m², a C-peptide level ≥1.0 ng/mL, and a diagnosis of type 2 diabetes mellitus (T2DM) for at least 6 months. A SAGB with duodenal exclusion or a SG without duodenal exclusion was performed.

Results

The 5-year results of the primary outcome were as an intention-to-treat analysis for HbA1c ≤6.5 % without glycemic therapy. Assessments of the incretin effect and β cell function were performed at baseline and between 36 and 60 months. The patients were randomly assigned to SAGB (n?=?30) and SG (n?=?30). At 60 months, 18 participants (60 %; 95 % confidence interval (CI), 42 to 78 %) in the SAGB group and nine participants (30 %; 95 % CI, 13 to 47 %) in the SG group achieved the primary end points (odds ratio (OR), 0.3; 95 % CI, 0.1 to 0.8 %). The participants assigned to the SAGB procedure had a similar percentage of weight loss as the SG patients (22.8?±?5.9 vs. 20.1?±?5.3 %; p?>?0.05) but achieved a lower level of HbA1c (6.1?±?0.7 vs. 7.1?±?1.2 %; p?Conclusions In mildly obese patients with T2DM, SG is effective at improving glycemic control at 5 years, but SAGB was more likely to achieve better glycemic control than SG and had a higher incretin effect compared to SG.     

Taste,Smell and Appetite Change After Roux-en-Y Gastric Bypass Surgery

Background

It is apparent from day-to-day practice that patients frequently report changes to their appetite, taste and smell after weight loss surgery. There has been surprisingly little written in the literature on this. The aim of the current study was to assess these parameters in a cohort of patients undergoing Roux-en-Y gastric bypass surgery.

Methods

Questionnaires relating to appetite, taste and smell were administered to 188 patients who had undergone Roux-en-Y gastric bypass surgery at our institution during the years 2000–2011.

Results

Responses were received from 103 patients (55 %). Sensory changes in appetite, taste and smell were noted by 97, 73 and 42 % of patients, respectively. Seventy-three percent of patients reported aversion to specific foods after surgery, with meat products the most commonly cited (33 %). Patients who experienced food aversions experienced more postoperative weight loss and reduction in BMI, compared to their counterparts without these features.

Conclusions

This study indicates that subjective changes in appetite, taste and smell are very common after Roux-en-Y gastric bypass. Patients are now routinely counselled about these changes as part of the informed consent process for surgery.     

Timing of Pregnancy After Gastric Bypass—a National Register-Based Cohort Study

Background

Current recommendations suggest postponing pregnancy by at least 1 year after gastric bypass. During the first postoperative year, women are in a catabolic phase with a rapid weight loss which may increase the risk of adverse pregnancy and neonatal outcomes. This study tested the hypothesis that the risk of adverse pregnancy and neonatal outcomes is increased in women who conceive during the first year after gastric bypass surgery.

Methods

This is a national register-based cohort study covering all Danish deliveries during 2004–2010 in women with prior Roux-en-Y gastric bypass surgery. Only the first postoperative birth was included. The risk of adverse pregnancy and neonatal outcomes was compared between women who conceived within the first postoperative year and women who conceived later. Data were extracted from the Danish National Patient Registry and The Danish Medical Birth Register.

Results

Of 286 women who had a singleton delivery after Roux-en-Y gastric bypass surgery, 158 women conceived within the first year and 128 later. There was no statistically significant difference (p?>?0.05) between the two groups regarding neonatal birth weight, gestational age, risk of preeclampsia, gestational diabetes mellitus, labor induction, cesarean section, postpartum hemorrhage (>500 ml), preterm birth (before 37 weeks), small for gestational age, large for gestational age, or Apgar score (5 min ) below 7, or in the need of neonatal intensive care.

Conclusions

This study showed no evidence to support a recommendation to delay pregnancy until after the first postoperative year. At present, the optimal time for pregnancy after gastric bypass is unknown.     

Gastric Bypass Surgery May Improve Beta Cell Apoptosis with Ghrelin Overexpression in Patients with BMI ≥ 32.5 kg/m2

Background

Roux-en-Y gastric bypass (RYGB) surgery can lead to long-term remission of type 2 diabetes mellitus, depending on changes in weight and circulating levels of gut hormones. The general objectives of this study were to evaluate changes in plasma levels of the ghrelin gene products following RYGB surgery and to determine the role of ghrelin in inhibiting apoptosis of INS-1 cells induced by hyperglycemia.

Methods

Sixteen obese Chinese patients with type 2 diabetes mellitus who underwent gastric bypass surgery were assessed in this investigation. Blood plasma levels of acylated ghrelin (AG), unacylated ghrelin (UAG), and obestatin (OB) were measured both before and 12 months after RYGB surgery. To determine the effect of ghrelin on inhibition of apoptosis, INS-1 cells were cultured in a high glucose concentration and treated with AG, UAG, or OB. Cell viability was assessed using the MTT assay, and apoptosis was evaluated by flow cytometry with Annexin-V FITC/PI double staining and transmission electron microscopy. Intracellular calcium trafficking was assessed using flow cytometry and confocal microscopy. All the data was processed using the SPSS statistical package and expressed as means ± SD, with p?<?0.05 considered statistically significant.

Results

Fasting and postprandial plasma levels of AG, UAG, and OB were significantly elevated 1 year after RYGB surgery. Mean fasting plasma AG, UAG, and OB increased from preoperative levels of 37.0, 462, and 69.4 pg/mL, respectively, to 61.4, 804, and 112 pg/mL (with p < 0.05) 1 year after surgery. Mean 120-min postprandial plasma AG, UAG, and OB increased from preoperative levels of 23.8, 287, and 53.8 pg/mL, respectively, to 39.7, 516, and 69.0 pg/mL (with p < 0.05) postoperatively. After a 1-week culture of INS-1 beta cell in high glucose, peptide treatment showed increased cell survival by 69 % (AG), 60 % (UAG), and 73 % (OB) and decreased apoptosis by 49 % (AG), 37 % (UAG), and 38 % (OB) compared to cells cultured in high glucose without peptides, respectively (with p < 0.05). Treatment with AG, UAG, and OB inhibited intracellular calcium mobilization and intramitochondrial calcium accumulation in INS-1 cells to protect the cells from hyperglycemia-induced apoptosis.

Conclusions

The remission of diabetes following RYGB surgery seems to be associated with increased plasma levels of AG, UAG, and OB. Moreover, the ghrelin gene products probably protect β cells by maintaining calcium homeostasis. Additional mechanisms, currently unclear, are likely to be involved as well.     

Predictors of remission and relapse in idiopathic nephrotic syndrome: a prospective cohort study

Background

Although most children with idiopathic nephrotic syndrome will respond to corticosteroid therapy, 80–90 % suffer one or more relapses.

Methods

Using Cox proportional hazard models, we analyzed predictors of remission and relapse in 1-year follow-up data on children aged below 15 years with new-onset nephrotic syndrome.

Results

Of 129 children, 107 achieved remission with corticosteroid therapy and 86 subsequently relapsed. Boys achieved remission more often than girls (adjusted hazard ratio [AHR] 1.52, 95 % confidence interval (CI) 1.02–2.3). Boys relapsed significantly more frequently than girls (AHR 1.77, 95 % CI 1.11–2.83) and were more likely to have frequently relapsing disease (AHR 3.3, 95 % CI 1.18–9.23). The risk of first relapse increased with the number of days to first remission (AHR 1.02, 95 % CI 1.01–1.04). The risk for a frequently relapsing course increased with a shorter time from remission to first relapse (AHR 0.92, 95 % CI 0.87–0.97).

Conclusions

In idiopathic nephrotic syndrome, boys are more likely to respond initially, more likely to relapse, and to be classified as having frequently relapsing nephrotic syndrome. A decrease in time from remission to first relapse predicts for a frequently relapsing course.     

The Predictive Factors for Diabetic Remission in Chinese Patients with BMI &gt; 30 kg/m<Superscript>2</Superscript> and BMI &lt; 30 kg/m<Superscript>2</Superscript> Are Different

Introduction

Roux-en-Y gastric bypass has been proven to be beneficial for patients with obesity and type 2 diabetes mellitus (T2DM). In less-obese patient (BMI 30–35 kg/m²), surgical treatment is indicated when medication fails to control the T2DM. Asian develops diabetes at a lower BMI. For lower-BMI patients, the rate of diabetes amelioration varies significantly with patients of higher BMI after surgical treatment. The factors that contribute to the post-operative diabetes response rate in lower-BMI patients have not been elucidated.

Methods

Between 2010 and 2014, a total of 144 patients who underwent gastric bypass for the treatment of T2DM were included for study. Patients were divided into two groups for subgroup analysis, namely BMI >?30 kg/m² and BMI <?30 kg/m². Factors affecting the remission rate were examined.

Results

Of the studied patients, the DM remission rate for the high-BMI group (BMI >?30 kg/m²) was 80% (n?=?90) whereas for the lower BMI (BMI <?30 kg/m²) was 50% (n?=?54), p?<?0.001. For high-BMI group, low HbA1c and high fasting C-peptide are predictive factors whereas for lower-BMI group, along with elevated C-peptide level, disease duration is the positive predictive factor for DM remission.

Conclusion

Patients with BMI >?30 kg/m² and those with BMI <?30 kg/m² have distinct remission predicting factors. Low HbA1c is a predictor of remission in low-high-BMI patients while duration of diabetes is for high-low-BMI patients. C-peptide is a predictor of remission in both groups. Further large-scale studies are required to define the predictors of diabetes remission after gastric bypass in low- and high-BMI patients.

     

Revision Surgery for Treatment of Weight Regain After Roux-En-Y Gastric Bypass

Background

This study aims to evaluate results on revision surgery for weight regain after gastric bypass, based on surgical technique and follow-up.

Methods

This study is a retrospective analysis of 29 patients who presented weight regain on follow-up after more than 5 years, divided into four groups according to revision surgery type: group 1 (n?=?9) includes patients who underwent an increase in the length of the alimentary limb to 200 cm; group 2 (n?=?13) are patients who underwent an increase in the length of the alimentary limb and placing of a silicon ring; group 3 (n?=?2) are patients who underwent an increase in the length of the alimentary limb and gastric plication, and group 4 (n?=?5) are patients who underwent gastric plication and placing of a silicon ring.

Results

The average preoperative weight before revision surgery was 117.8 kg, and the average postoperative follow-up for revision surgery was 13.7 months. Weight loss after revision surgery was observed in all groups but was greater in patients with longer revisional postoperative follow-up. Patients who underwent placing of a silicon ring presented greater weight loss than those who had had such a band since the original gastric bypass operation.

Conclusions

Data suggest that revision surgery may be a useful tool in achieving weight loss in patients presenting weight regain following gastric bypass, obesity, bariatric surgery, gastric bypass, weight regain, and revision surgery.