Major cardiovascular events after metabolic surgery in patients with previous heart disease with or without type 2 diabetes: a nationwide cohort study

BackgroundWhile metabolic surgery is known to improve type 2 diabetes (T2D) as well as established heart disease separately, it is not known whether the outcome is influenced by T2D status in patients with established heart disease.ObjectivesTo evaluate the risks for major cardiovascular events (MACE) or mortality in patients with established heart disease with or without T2D.SettingNationwide and registry-based (Sweden).MethodsPatients with established heart disease operated with sleeve gastrectomy or Roux-en-Y gastric bypass in Sweden from 2007–2019 were matched 1:1 to normal population controls using 2-staged matching (exact matching on T2D, followed by optimal matching on propensity score for age, sex, dyslipidemia, chronic obstructive pulmonary disease, type of heart disease, T2D duration, county of residence, and level of education). The risk for MACE was evaluated separately depending on T2D status.ResultsIn total, 1513 patients who underwent surgery and 1513 matched controls were included. Reduced risk for MACE and mortality were seen after metabolic surgery for patients with heart disease and T2D compared with controls (adjusted hazard ratio [HR] = .59, 95% confidence interval [CI]: .48–.72, P < .001, and adjusted HR = .52, 95% CI: .40–.67, P < .001, respectively), and for patients with heart disease alone compared with controls (adjusted HR = .73, 95% CI: .57–.94, P = .016, and adjusted HR = .63, 95% CI: .45–.89, P = .008, respectively).ConclusionMetabolic surgery was associated with a reduced risk for MACE and mortality in patients with preexisting heart disease and T2D as well as in patients with heart disease without T2D. Patients with heart disease and T2D seem to experience the highest risk reduction.     

The effect of metabolic surgery on nonobese patients (BMI<30 kg/m2) with type 2 diabetes: a systematic review

Background

The influence of metabolic surgery on the glucose and lipid profiles of nonobese body mass index<30 kg/m² patients with type 2 diabetes, particularly the effect ≥1 year, remains unknown.

胃肠外科手术治疗肥胖症及2型糖尿病

肥胖症是现今社会所面临的最严重的公共健康问题之一,手术治疗是使肥胖症患者获得长期而稳定的减重效果的唯一方法。自从1954年报道第1例减肥手术以来,外科手术治疗肥胖症在全球范围内获得了很大的发展,逐渐成为治疗病态性肥胖的＂金标准＂。随着研究的不断深入,越来越多的证据表明,胃肠外科手术不仅能减重,同时可以改善甚至治愈肥胖症相关的多种代谢性疾病,尤其是2型糖尿病。目前国内外的胃肠外科医师们正致力于将手术推广到2型糖尿病的治疗中去。外科手术治疗肥胖症及2型糖尿病将有巨大的发展空间。     

代谢手术治疗肥胖症和2型糖尿病的相关问题

代谢手术治疗肥胖症和2型糖尿病在国际上越来越受到重视。在我国经过10余年的发展,目前已经广泛开展。随着这一新的外科领域的发展,许多相关问题不断产生。临床医师既要吸取国外的相关经验,又要根据我国患者和学科发展的实际情况逐步形成自己的实践经验。因此,笔者对代谢手术治疗肥胖症和2型糖尿病的相关问题进行探讨,以期促进代谢手术在我国的健康发展。     

The effects of bariatric surgery on dyslipidemia and insulin resistance in overweight patients with or without type 2 diabetes: a systematic review and network meta-analysis

Obesity has become an epidemic in several regions globally; it may lead to cardiovascular diseases, diabetes, and dyslipidemia. Despite many therapies, all bariatric procedures fail in some patients. There is a lack of literature comparing treatment effects on specific metabolic indexes. PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched for relevant articles. GeMTC and R software were used to perform a network meta-analysis, draw forest plots, investigate the possibility of statistical heterogeneity, generate I² statistics, rank probabilities, and evaluate relative effects of surgical procedures. All analyses were based on a Bayesian consistency model. We included 35 randomized controlled trials, comprising 2198 individuals and 13 interventions. For patients with high insulin resistance, single-anastomosis (mini-) gastric bypass (SAGB) and sleeve gastrectomy (SG) may be effective options, with mean differences (95% confidence intervals [CIs]) of −4.45 (−9.04 to −.34) and −4.23 (−6.74 to −2.22), respectively, compared with control groups. For patients with severe dyslipidemia, in addition to SAGB and SG, duodenal switch (DS) may be an effective surgery, with mean differences (95% CIs) of −.97 (−1.39 to −.55), −1.98 (−3.76 to −.19), .53 (.04 to 1.04), and −.94 (−1.66 to −.16) compared with control groups in terms of triglycerides, total cholesterol, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) concentrations, respectively. In adult overweight patients with or without diabetes, SAGB and SG are most effective at ameliorating insulin resistance. SAGB, Roux-en-Y gastric bypass + omentectomy, and DS are useful for reducing triglycerides, total cholesterol, and LDL-C. SG + omentectomy elevates HDL-C concentrations best. Adjustable gastric band and biliopancreatic diversion may not control insulin resistance or dyslipidemia well.     

手术治疗2型糖尿病合并肥胖症26例

目的：探讨胃肠外科手术在治疗2型糖尿病（T2DM）合并肥胖症中的意义。方法：对26例T2DM合并肥胖症的患者行胃减容和胃肠短路手术,观察术后血糖、体质指数（BMI）等指标的变化。结果：术后1年空腹血糖4.9-8.8 mmol/L,平均6.3 mmol/L。治疗T2DM有效率100%,治愈率42.3%。体质量降低5-42 kg,平均降低17.5 kg。BMI降至20.8-32.0,平均25.5。结论：胃减容和胃肠短路手术是治疗T2DM合并肥胖症可行、有效的方法。     

手术与多学科综合治疗肥胖症及2型糖尿病

单纯性肥胖症及2型糖尿病的治疗应是多学科的综合治疗,包括饮食结构调整、增加身体活动量、行为纠正和药物治疗。一些病态肥胖患者还需要进行微创减肥手术治疗。尽管近年来微创减肥手术对于治疗单纯性肥胖症及2型糖尿病的疗效明显,但存在的问题是：缺乏相关科室的协作与多学科综合治疗以及患者随访率低,这是手术风险增加、疗效差和并发症增多的主要原因。因此,单纯性肥胖症和2型糖尿病及其合并症应该予以微创胃肠外科与相关多学科的综合治疗并进行长期随诊。     

Different metabolic/obesity phenotypes are differentially associated with development of prediabetes in adults: Results from a 14-year cohort study

BACKGROUND The risk of developing prediabetes based on the metabolic/obesity phenotypes has been poorly investigated.AIM To examine the association of baseline metabolic/obesity phenotypes and their changes over time with the risk of prediabetes development.METHODS In a population-based cohort study, 1741 adults(aged 19 years) with normal blood glucose were followed for 14 years. Anthropometric and biochemical measures were evaluated regularly during the follow-up period. According to body mass index and metabolic health status, participants were categorized into four groups: Metabolically healthy normal weight(MHNW), metabolically healthy obese(MHO), metabolically unhealthy normal weight(MUNW) and metabolically unhealthy obese(MUO). Multivariable Cox regression analysis was used to measure the risk of prediabetes according to the baseline metabolic/obesity phenotype and their changes during the follow-up.RESULTSIn the whole population with a mean(95 CCI for mean) follow up duration of 12.7 years(12.6-12.9), all three MUNW, MHO, MUO groups were at higher risk for developing prediabetes compared to the MHNW group(P = 0.022). The MUNW group had the highest risk for developing prediabetes(hazard ratio(HR): 3.84,95%CI: 1.20, 12.27). In stratified analysis by sex, no significant association was found in men, while women in the MUNW group were at the greatest risk for prediabetes(HR: 6.74, 95%CI: 1.53, 29.66). Transforming from each phenotype to MHNW or MHO was not related to the risk of prediabetes development, whereas transforming from each phenotype to MUO was associated with an increased risk of prediabetes(HR 1; P 0.05).CONCLUSION Our findings indicate that MHO is not a high risk, unless it transforms into MUO over time. However, people in the MUNW group have the greatest risk for developing prediabetes, and therefore, they should be screened and treated.     

The effects of metabolic surgery on microvascular complications in obese patients with type 2 diabetes: a meta-analysis

BackgroundMetabolic surgery is a standard treatment for obesity with type 2 diabetes (T2D), although the effects of metabolic surgery on the incidence rate of microvascular complications remain controversial.ObjectivesWe aimed to evaluate the effect of metabolic surgery versus nonsurgical treatments on the incidence rate of microvascular complications in obesity with T2D.SettingA meta-analysis of published studies.MethodsWe searched PubMed, Web of Science, and the Cochrane Library to identify clinical studies assessing the effect of metabolic surgery on the incidence rate of microvascular diabetic complications compared with that of nonsurgical treatments. We extracted the primary outcomes, including the incidence rate of microvascular complications after metabolic surgery.ResultsA total of 32,756 participants from 12 studies were identified. Metabolic surgery reduced the incidence rate of microvascular complications (odds ratios [OR], .34; 95% confidence intervals [CI], .30–.39; P < .001) compared with that of nonsurgical treatments in obesity with T2D. Moreover, metabolic surgery also reduced the incidence of diabetic nephropathy (OR, .39; 95% CI, .30–.50; P < .001), diabetic retinopathy (OR, .52; 95% CI, .42–.65; P < .001) and diabetic neuropathy (OR, .27; 95% CI, .22–.34; P < .001) compared with nonsurgical treatments in obesity with T2D.ConclusionMetabolic surgery was superior to nonsurgical treatments in reducing the incidence of microvascular complications in obesity with T2D. Prospective studies, preferably randomized controlled trials, with evaluations of different types of metabolic surgery are warranted to provide guidelines for treatment preferences in obesity with T2D.     

Metabolic effects of bariatric surgery on patients with type 2 diabetes: a population-based study

BackgroundBariatric surgery among patients with obesity and type 2 diabetes (T2D) can induce complete remission. However, it remains unclear whether sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) has better T2D remission within a population-based daily practice.ObjectivesTo compare patients undergoing RYGB and SG on the extent of T2D remission at the 1-year follow-up.SettingNationwide, population-based study including all 18 hospitals in the Netherlands providing metabolic and bariatric surgery.MethodsPatients undergoing RYGB and SG between October 2015 and October 2018 with 1 year of complete follow-up data were selected from the mandatory nationwide Dutch Audit for Treatment of Obesity (DATO). The primary outcome is T2D remission within 1 year. Secondary outcomes include ≥20% total weight loss (TWL), obesity-related co-morbidity reduction, and postoperative complications with a Clavien-Dindo (CD) grade ≥III within 30 days. We compared T2D remission between RYGB and SG groups using propensity score matching to adjust for confounding by indication.ResultsA total of 5015 patients were identified from the DATO, and 4132 (82.4%) had completed a 1-year follow-up visit. There were 3350 (66.8%) patients with a valid T2D status who were included in the analysis (RYGB = 2623; SG = 727). RYGB patients had a lower body mass index than SG patients, but were more often female, with higher gastroesophageal reflux disease and dyslipidemia rates. After adjusting for these confounders, RYGB patients had increased odds of achieving T2D remission (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.14–2.1; P < .01). Groups were balanced after matching 695 patients in each group. After matching, RYGB patients still had better odds of T2D remission (OR, 1.91; 95% CI, 1.27–2.88; P < .01). Also, significantly more RYGB patients had ≥20%TWL (OR, 2.71; 95% CI, 1.96–3.75; P < .01) and RYGB patients had higher dyslipidemia remission rates (OR, 1.96; 95% CI, 1.39–2.76; P < .01). There were no significant differences in CD ≥III complications.ConclusionUsing population-based data from the Netherlands, this study shows that RYGB leads to better T2D remission rates at the 1-year follow-up and better metabolic outcomes for patients with obesity and T2D undergoing bariatric surgery in daily practice.     

Risk factors in patients with type 2 diabetes in Bengaluru: A retrospective study

BACKGROUND Risk factors such as hereditary, ecological, and metabolic are interrelated and contribute to the development of type 2 diabetes mellitus. Family history(FH) of diabetes mellitus, age, obesity, and physical inactivity are some of the risk factors for the development of type 2 diabetes.AIM To study various aetiological determinants and risk factors for type 2 diabetes in Bangalore, India. This retrospective study examined questionnaire from patients attending the Diabetes Clinic.METHODS Data on various parameters were obtained through a questionnaire from 533 patients on the first visit to the diabetes clinic. Data regarding various aetiological determinants and risk factors viz.: Genetic risk factor and few modifiable risk factors were collected. Chi-squared test was used for statistical analysis.RESULTS A higher incidence of type 2 diabetes in males and younger population was observed in Bangalore, India. Obesity and FH were significant risk factors for not only type 2 diabetes but also early onset of diabetes. In addition, maternal history of type 2 diabetes and consanguinity increased incidence of early onset type 2 diabetes.CONCLUSION Risk factors such as obesity and FH(maternal history of type 2 diabetes) and consanguinity may play an important role in screening of family members of type 2 diabetes patients which may lead to early intervention and reduced risk of subsequent complications. Moreover, susceptible population can be counselled for the management of the type 2 diabetes including periodic investigation of blood glucose levels and lifestyle changes.     

Metabolic surgery for inadequately controlled type 2 diabetes in nonseverely obese Japanese: a prospective,single-center study

Background

The beneficial effects of metabolic surgery on weight loss, glycemic control, and cardiovascular improvement for the morbidly obese patient has been vast and undeniable. It is also expected to be effective in diabetic patients with less severe obesity, but the evidence is yet to yield significant impact.

Bariatric and metabolic surgery in patients with morbid obesity and multiple sclerosis - a nationwide,matched cohort study

BackgroundDespite an association between obesity and multiple sclerosis (MS), very little is known regarding the safety and efficacy outcomes for patients with MS and severe obesity undergoing metabolic surgery.ObjectivesThe aim of the present study was to evaluate early complications and efficacy outcomes of metabolic surgery in patients with severe obesity and MS.SettingNationwide, Sweden.MethodsIn this, matched cohort study, 196 patients with an MS diagnosis in the Swedish MS register who were undergoing metabolic surgery (gastric bypass or sleeve gastrectomy) with a registration in the Scandinavian Obesity Surgery Registry (SOReg) were matched 1:10 with a control group without MS diagnosis from the SOReg. A 2-stage matching procedure was used (exact match by surgical method, followed by propensity Score matching, including age, sex, preoperative BMI, surgical center, surgical access, year of surgery, hypertension, diabetes, sleep apnea, and dyslipidemia).ResultsWeight loss at 2 years after surgery was similar for patients with MS and controls (total weight loss 31.6 ± 9.1 versus 31.8 ± 9.2, P = .735). No significant differences were seen in either the overall postoperative complication rate (7.9% versus 7.2%, P = .778), or serious postoperative complications (3.7% versus 2.8%, P = .430). All aspects of health-related quality of life (HRQoL) improved in both groups but less so for the physical aspects of HRQoL in patients with MS.ConclusionMetabolic surgery is a safe and efficient treatment for severe obesity in patients with MS, and it leads to subsequent improvements in HRQoL. Further studies addressing the effects of metabolic surgery on MS-related symptoms are needed.     

Impact of metabolic surgery on 10-year cardiovascular disease risk in Chinese individuals with type 2 diabetes

BackgroundIn recent years, many reports have highlighted that metabolic surgery may ameliorate the cardiovascular risk in morbidly obese patients with or without type 2 diabetes (T2D). However, few studies have evaluated the long-term cardiovascular disease (CVD) risk after metabolic surgery in T2D patients with a low body mass index (BMI).ObjectivesTo use the Prediction for ASCVD Risk in China (China-PAR) equations and United Kingdom Prospective Diabetes Study (UKPDS) risk engine to assess the 10-year CVD risk in low-BMI T2D patients after metabolic surgery.SettingUniversity hospital, China.MethodsWe retrospectively reviewed our prospectively collected data of T2D patients who underwent metabolic surgery at our hospital between 2010 and 2018. We included patients who met the criteria for calculating a 10-year cardiovascular risk score by the China-PAR equations and UKPDS risk engine. Demographic characteristics, anthropometric variables, and glycolipid metabolic parameters were assessed preoperatively and during a 4-year follow-up period. Patients with a BMI < 30 kg/m² were compared with those with a BMI > 30 kg/m².ResultsWe evaluated 117 patients, of whom 62 (53%) had a BMI < 30 kg/m² and 55 (47%) had a BMI > 30 kg/m². Patients with a BMI < 30 kg/m² were significantly older and had a longer duration of diabetes. The rate of complete T2D remission in the group of patients with BMIs < 30 kg/m² was significantly lower than that in the group with BMIs > 30 kg/m² (35.2% versus 56.1%, respectively; P = .042). The overall 10-year and lifetime atherosclerotic cardiovascular disease risks were reduced from 4.2% to 2.3% and 25.3% to 13.9%, respectively (both P < .05), at 1 year postoperatively using the China-PAR equation. The overall 10-year coronary heart disease (CHD) and fatal CHD risks were reduced by 48.1% and 53.1%, respectively, at 1 year after surgery using the UKPDS risk engine. The advantages of metabolic surgery in reducing CVD risks are similar in both BMI groups, whether using the China-PAR equation or the UKPDS risk engine.ConclusionThe 10-year CVD risk in T2D patients with BMIs < 30 kg/m² and BMIs > 30 kg/m² were significantly reduced after metabolic surgery, although the rate of complete T2D remission T2Din patients with BMIs < 30 kg/m² was lower than that in patients with BMIs > 30 kg/m². The China-PAR equation is a reliable and useful clinical tool for CVD risk evaluation in Chinese patients after metabolic surgery.     

Efficacy of video-based education program in improving metabolic surgery perception among patients with obesity and diabetes

Background

Metabolic surgery remains underutilized despite its efficacy and safety. Poor perception of surgery has been cited as one of the major reasons.

Spinal cord injury increases the risk of Type 2 diabetes: a population-based cohort study

Background contextPrevious studies on the risk and prevalence of diabetes among spinal cord injury (SCI) patients are limited and controversial.PurposeTo compare the risk and incidence rate (IR) of Type 2 diabetes in SCI and non-SCI patients.Study designThis is a population-based retrospective cohort study.Patient sampleData from Taiwan's National Health Insurance Research Database for the period 1997 to 2010 were analyzed. Patients aged 20 years and older newly identified with SCIs during this period were included in the SCI cohort. A non-SCI comparison cohort was randomly selected from National Health Insurance beneficiaries and matched with the SCI cohort based on age, sex, and index date.Outcome measuresBoth cohorts were followed until the first of the following occurred: the diagnosis of Type 2 diabetes (International Classification of Disease, Ninth Revision, Clinical Modification codes 250), withdrawal from the insurance system, the end of 2010, or death.MethodsA Cox proportional hazards regression analysis was used to estimate the risk of developing diabetes.ResultsTaiwan possesses an older SCI population, with a mean age of 51.6 years. The IR for diabetes in patients with and without SCIs was 22.1 per 10,000 person-years and 17.2 per 10,000 person-years, respectively. The adjusted hazard ratio (HR) for diabetes was 1.33 times higher in patients with SCIs than in those without SCIs. In patients with SCIs, men (adjusted HR=1.23, 95% confidence interval (CI)=1.04–1.44), older people (adjusted HR=4.26 in patients older than 65 years, 95% CI=3.16–5.74), patients with comorbidity (adjusted HR=1.36, 95% CI=1.14–1.62), and patients with a complete thoracic SCI (T-spine injury) (adjusted HR=2.13, 95% CI=0.95–4.79) were more likely to be diagnosed with diabetes than other patient subgroups.ConclusionsOur findings may facilitate the prioritizing of preventive health strategies and planning of long-term care for SCI patients.     

Metabolic surgery: A paradigm shift in type 2 diabetes management

Obesity and type 2 diabetes mellitus (T2DM) are major public health issues globally over the past few decades. Despite dietary interventions, lifestyle modifications and the availability of several pharmaceutical agents, management of T2DM with obesity is a major challenge to clinicians. Metabolic surgery is emerging as a promising treatment option for the management of T2DM in the obese population in recent years. Several observational studies and a few randomised controlled trials have shown clear benefits of various bariatric procedures in obese individuals in terms of improvement or remission of T2DM and multiple other health benefits such as improvement of hypertension, obstructive sleep apnoea, osteoarthritis and non-alcoholic fatty liver disease. Uncertainties about the long-term implications of metabolic surgery such as relapse of T2DM after initial remission, nutritional and psychosocial complications and the optimal body mass index for different ethnic groups exist. The article discusses the major paradigm shift in recent years in the management of T2DM after the introduction of metabolic surgery.     

两种代谢手术治疗肥胖型2型糖尿病的对比分析

目的评价两种手术方式对治疗肥胖伴有2型糖尿病(T2DM)的优势。 方法回顾分析2012年1月至2019年2月两家医院收治的64例肥胖伴有T2DM的临床资料,根据手术干预情况分为两组,腹腔镜下SG(LSG组) 30例和腹腔镜下胃旁路手术(L-RYGB组) 34例,采用SPSS 17软件进行统计分析。生化指标等计量资料以( ±s)表示,采用独立t检验。术后并发症等计数资料采用χ²检验,采用logistic回归(逐步)模型,分析T2DM缓解与否的危险因素,P<0.05为差异有统计学意义。 结果两组患者术后1年血脂相关指标除甘油三酯外,两种手术方法均未获得明显改善。两组间BMI和血糖比较差异无统计学意义(P>0.05);L-RYGB对血糖的缓解率(88.2%)优于LSG(76.7%)P<0.05。而术后1年,两组接受治疗的患者的HbA1c、收缩压和舒张压减少值均明显降低(P＝0.016; P＝0.029和P＝0.017),多因素logistic回归分析,BMI、空腹血糖、HbA1c可作为1年时T2DM缓解的独立危险因素(P＝0.001; P＝0.001; P＝0.008)。L-RYGB显示出T2DM缓解率明显高于LSG (OR＝1.79, 95%CI: 1.133～2.829, P＝0.013)。两组患者均未发生30d内死亡和胃肠瘘。在深静脉血栓形成的并发症中,L-RYGB的发生率较高(11.8% vs.3.3%, P＝0.022)。 结论在T2DM缓解方面,术后1年的结论,L-RYGB优于LSG。远期持久缓解的结果,仍需更长时间的随访研究。     

Association of obesity with hypertension and type 2 diabetes mellitus in India: A meta-analysis of observational studies

AIM To perform a meta-analysis of the association of obesity with hypertension and type 2 diabetes mellitus(T2DM) in India among adults. METHODS To conduct meta-analysis, we performed comprehensive, electronic literature search in the PubM ed, CINAHL Plus, and Google Scholar. We restricted the analysis to studies with documentation of some measure of obesity namely; body mass index, waist-hip ratio, waist circumference and diagnosis of hypertension or diagnosis of T2DM. By obtaining summary estimates of all included studies, the meta-analysis was performed using both RevM an version 5 and "metan" command STATA version 11. Heterogeneity was measured by I~2 statistic. Funnel plot analysis has been done to assess the study publication bias.RESULTS Of the 956 studies screened, 18 met the eligibility criteria. The pooled odds ratio between obesity and hypertension was 3.82(95%CI: 3.39 to 4.25). The heterogeneity around this estimate(I~2 statistic) was 0%, indicating low variability. The pooled odds ratio from the included studies showed a statistically significant association between obesity and T2DM(OR = 1.14, 95%CI: 1.04 to 1.24) with a high degree of variability.CONCLUSION Despite methodological differences, obesity showed significant, potentially plausible association with hypertension and T2DM in studies conducted in India. Being a modifiable risk factor, our study informs setting policy priority and intervention efforts to prevent debilitating complications.