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.

     

Metabolic Laparoscopic Gastric Bypass for Obese Patients with Type 2 Diabetes

Background  

Bariatric surgery has been proposed as the most effective treatment for patients with type 2 diabetes mellitus (T2DM) and body mass index (BMI) above 35 kg/m². The purpose of our study was to access remission rate and improvement of metabolic control of T2DM after gastric bypass.     

Gastric Bypass Does Not Influence Olfactory Function in Obese Patients

Morbidly obese individuals have altered sense of taste and smell. Gastric bypass (GBP) alters taste but olfactory function has not been evaluated. Changes in these senses may influence dietary preferences following GBP. Our aim was to evaluate the effect of abdominal operation, specifically GBP, and weight loss on olfactory function. Fifty-five persons undergoing GBP and cholecystectomy and 40 persons undergoing cholecystectomy (CC) alone were administered the Cross Cultural Smell Identification Test (CC-SIT) preoperatively and 2 and 6 weeks postoperatively. Patients undergoing GBP underwent further tests at 3, 6, 9, and 12 months. Body mass index (BMI) was also assessed. Mean BMI was significantly greater preoperatively in the GBP group (50.6 ± 8.0 vs. 30.6 ± 7.3 kg/m², p < 0.05). Significantly more GBP patients had abnormal CC-SIT results preoperatively (12.7% vs. 5.0%). There were no significant differences in percentage of abnormal tests at 2 and 6 weeks within groups but remained lower in CC patients (2 weeks, GBP 6.2% vs. CC 5.7%; 6 weeks, GBP 9.8% vs. CC 3.2%, p < .05). BMI decreased in the GBP group at 12 months (50.6 ± 8.0 preoperatively to 31.9 ± 6.9 p < 0.05). Absolute olfactory dysfunction (AOD) was present at each interval up to 12 months after GBP. Only 22% of patients with AOD remained obese. GBP does not appear to influence olfactory function. AOD present in morbidly obese persons is not affected by weight loss. These findings support that olfactory dysfunction may be a contributing factor to the development of obesity.     

Behavior of Type 2 Diabetes Mellitus in Morbid Obese Patients Submitted to Gastric Bypass

Introduction Surgical treatment of obesity has not only resulted in weight loss, but also the control of associated diseases in the postoperative period. The aim of this study was to determine the post-op response of type 2 diabetes mellitus (DM2) to gastric bypass. Methods A historical cohort study was performed involving all the diabetic, morbid obese patients who underwent gastric bypass during the period of May 2000 to October 2006 at the Centro da Obesidade Mórbida. Patient records were reviewed with regard to sex, age, anthropometric measurements, glycemia, glycosylated hemoglobin, pre-op insulin, and DM2 outcome. Results A total of 125 diabetic, morbid obese patients were operated; they had a mean age of 42.6 ± 9.7 years and body mass index of 49 ± 8.3 kg/m². Of these patients, 63 (50.4%) required medication for control of DM2, and the rest managed only with diet. Of these 63 patients, 43 (68.2%) achieved control of DM2 and were discharged without the need for antidiabetic medication, and 20 (31.7%) were discharged still on medication. One month after surgery, seven more patients discontinued medication for DM2, and 18 months after surgery, 97.6% of the patients showed control of DM2. Conclusion Gastric bypass is effective in controlling DM2 in morbid obese patients.     

Obese Patients with Type 2 Diabetes Submitted to Banded Gastric Bypass: Greater Incidence of Dumping Syndrome

Background  

Dumping syndrome is one of ten most common complications in morbidly obese patients operated. Recent studies in relation to type 2 diabetes mellitus (DM2) in patients submitted to gastric bypass led us to examine the different outcomes in this group of patients. Our objective was to determine the difference in the prevalence of dumping syndrome in patients with DM2 submitted to gastric bypass.     

Safety and Efficacy of Roux-en-Y Gastric Bypass to Treat Type 2 Diabetes Mellitus in Non-severely Obese Patients

The efficacy of Roux-en-Y gastric bypass (RYGB) to control type 2 diabetes mellitus (T2DM) has been demonstrated in morbidly obese patients. Surgical procedures primarily focused on T2DM control in patients with body mass index (BMI) < 35 kg/m² have shown to effectively induce remission of T2DM. However, only few reports have evaluated the safety and efficacy of RYGB in this group of patients. The aim of this study is to assess the safety and efficacy of RYGB in TD2M patients with BMI < 35 kg/m². All T2DM patients with BMI < 35 kg/m² and at least 12 months of follow-up who underwent laparoscopic RYGB were included. Safety of the procedure was evaluated according to mortality, need of reoperation/conversion, and complication rates. Metabolic parameters were evaluated at baseline and 6, 12, and 24 months after surgery. Thirty patients were included. Seventeen (56.6%) were women. Age, BMI, and duration of diabetes were 48 ± 9 years, 33.7 ± 1.2 kg/m², 4 ± 2.9 years, respectively. No mortality was observed. No conversion/reoperation was needed. Average length of stay was 3.2 ± 0.9 days. Early and late postoperative complications were observed in five (16.6%) and five (16.6%) patients, respectively. Twelve months after surgery, remission was observed in 25 of 30 patients (83.3%). After 2 years, remission was achieved in 13 of 20 patients (65%), and hemoglobin A1c decreased from 8.1 ± 1.8% to 5.9 ± 1.1% and homeostasis model assessment of insulin resistance from 5.7 ± 3.2 to 1.9 ± 0.8 after 12 months. RYGB is a safe and effective procedure to induce T2DM remission in otherwise not eligible patients for bariatric surgery. Evidence from prospective studies is needed to validate this approach.     

Long-Term Results of Gastric Bypass Surgery in Morbidly Obese Type 1 Diabetes Patients

Background  

Long-term effects of bariatric surgery in morbidly obese type 1 patients are unknown. Five to eight-year experience in the case series of type 1 diabetes subjects is presented.     

Iron-Deficiency Anemia After Laparoscopic Roux-en-Y Gastric Bypass in Chinese Obese Patients with Type 2 Diabetes: a 2-Year Follow-Up Study

Background

This study was conducted to evaluate the prevalence of iron-deficiency anemia (IDA) after Roux-en-Y gastric bypass (RYGB) in Chinese obese patients with type 2 diabetes (T2DM). Furthermore, we evaluate potential predicting factors for onset of IDA after RYGB.

Methods

A total of 184 obese T2DM individuals who underwent RYGB were enrolled in the study. Patients were divided into three groups: male, premenopausal female, and postmenopausal female. Hematologic parameters were obtained prior to and after surgery on standardized time intervals up to 24 months postoperatively.

Results

At baseline, 6.0 % of patients were anemic, with similar percentages of anemic patients in each group. The relative decrease in the mean hemoglobin (Hb) level was significantly more pronounced for premenopausal female than for postmenopausal female or male. The percentage of anemia in male group had increased to 15.2 and 17.0 % at 6 and 12 months, respectively, and then decreased to 4.5 % at 24-month visit. In postmenopausal female group, the percentages of anemia constantly increase to 34.0 % at 6-month follow-up. Then, it decreased gradually to 25.0 and 26.7 % at 12- and 24-month visits, respectively. In premenopausal female group, the anemia percentages dramatically increased to 62.5 % at 24-month follow-up. Multiple logistic regression indicated that lower serum ferritin level preoperative and female were associated with higher possibility to suffer IDA 2 years after RYGB.

Conclusions

Iron-deficiency and IDA are extremely frequent after RYGB in Chinese obese patients with T2DM. Premenopausal female presents unexpectedly high incidence of IDA during the 2-year observation.

     

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/m² 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/m², 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/m², 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/m² 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/m².     

Glycemic Control after Sleeve Gastrectomy and Roux-En-Y Gastric Bypass in Obese Subjects with Type 2 Diabetes Mellitus

Background

Roux-en-Y gastric bypass (LRYGB) has weight-independent effects on glycemia in obese type 2 diabetic patients, whereas sleeve gastrectomy (LSG) is less well characterized. This study aims to compare early weight-independent and later weight-dependent glycemic effects of LRYGB and LSG.

Methods

Eighteen LRYGB and 15 LSG patients were included in the study. Glucose, insulin, GLP-1, and GIP levels were monitored during a modified 30 g oral glucose tolerance test before surgery and 2 days, 3 weeks, and 12 months after surgery. Patients self-monitored glucose levels 2 weeks before and after surgery.

Results

Postoperative fasting blood glucose decreased similarly in both groups (LRYGB vs. SG; baseline—8.1?±?0.6 vs. 8.2?±?0.4 mmol/l, 2 days—7.8?±?0.5 vs. 7.4?±?0.3 mmol/l, 3 weeks—6.6?±?0.4 vs. 6.6?±?0.3 mmol/l, respectively, P <?0.01 vs. baseline for both groups; 12 months—6.6?±?0.4 vs. 5.9?±?0.4, respectively, P <?0.05 for LRYGB and P <?0.001 for LSG vs. baseline, P =?ns between the groups at all times). LSG, but not LRYGB, showed increased peak insulin levels 2 days postoperatively (mean?±?SEM; LSG +?58?±?14%, P <?0.01; LRYGB ??8?±?17%, P =?ns). GLP-1 levels increased similarly at 2 days, but were higher in LRYGB at 3 weeks (AUC; 7525?±?1258 vs. 4779?±?712 pmol?×?min, respectively, P <?0.05). GIP levels did not differ. Body mass index (BMI) decreased more after LRYGB than LSG (??10.1?±?0.9 vs. ??7.9?±?0.5 kg/m², respectively, P <?0.05).

Conclusion

LRYGB and LSG show very similar effects on glycemic control, despite lower GLP-1 levels and inferior BMI decrease after LSG.

     

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.

     

Six Months of Balloon Treatment does Not Predict the Success of Gastric Banding

Background We studied whether weight loss by intragastric balloon would predict the outcome of subsequent gastric banding with regard to weight loss and BMI reduction. Methods A prospective cohort of patients with a body mass index (BMI) >40 kg/m² received an intragastric balloon for 6 months followed by laparoscopic adjustable gastric banding (LAGB). Successful ballooninduced weight loss was defined as ≥10% weight loss after 6 months. Successful surgical weight loss was defined as an additional 15% weight loss in the following 12 months. Patients were divided in group A, losing ≥10% of their initial weight with 6 months’ balloon treatment, and group B, losing <10% of their initial weight. Results In 40 patients (32 female, 8 male; age 36.6 yr, range 26–54), the mean BMI decreased from 46.5 to 40.5 kg/m² (P < 0.001) after 6 months of balloon treatment and to 35.2 kg/m² (P < 0.001) 12 months after LAGB. Group A (25 patients) and group B (15 patients) had a significant difference in BMI decrease, 12.4 vs 9.0 kg/m² (P < 0.05), after the total study duration of 18 months. However, there was no difference in BMI reduction (4.7 kg/m² vs 5.8 kg/m²) in the 12 months after LAGB. 6 patients in group A lost ≥10% of their starting weight during 6 months balloon treatment as well as ≥15% 12 months following LAGB. 6 patients in group B lost <10% of their starting weight after 6 months of BIB, but also lost ≥15% 12 months following LAGB. Conclusion Intragastric balloon did not predict the success of subsequent LAGB.     

FGF 19 and Bile Acids Increase Following Roux-en-Y Gastric Bypass but Not After Medical Management in Patients with Type 2 Diabetes

Background

This study aims to quantify changes in fibroblast growth factor 19 (FGF19) and bile acids (BAs) in patients with uncontrolled type 2 diabetes randomized to Roux-en-Y gastric bypass (RYGB) vs intensive medical management (IMM) and matched for similar reduction in HbA1c after 1 year of treatment.

Methods

Blood samples were drawn from patients who underwent a test meal challenge before and 1 year after IMM (n?=?15) or RYGB (n?=?15).

Results

Mean HbA1c decreased from 9.7 to 6.4 % after RYGB and from 9.1 to 6.1 % in the IMM group. At 12 months, the number of diabetes medications used per subject in the RYGB group (2.5?±?0.5) was less than in the IMM group (4.6?±?0.3). After RYGB, FGF19 increased in the fasted (93?±?15 to 152?±?19 pg/ml; P?=?0.008) and postprandial states (area under the curve (AUC), 10.8?±?1.9 to 23.4?±?4.1 pg?×?h/ml?×?10³; P?=?0.006) but remained unchanged following IMM. BAs increased after RYGB (AUC ×10³, 6.63?±?1.3 to 15.16?±?2.56 μM?×?h; P?=?0.003) and decreased after IMM (AUC ×10³, 8.22?±?1.24 to 5.70?±?0.70; P?=?0.01). No changes were observed in the ratio of 12α-hydroxylated/non-12α-hyroxylated BAs. Following RYGB, FGF19 AUC correlated with BAs (r?=?0.54, P?=?0.04) and trended negatively with HbA1c (r?=??0.44; P?=?0.09); these associations were not observed after IMM.

Conclusions

BA and FGF19 levels increased after RYGB but not after IMM in subjects who achieved similar improvement in glycemic control. Further studies are necessary to determine whether these hormonal changes facilitate improved glucose homeostasis.

     

胃转流术治疗2型糖尿病的疗效及影响疗效的相关因素

目的探讨胃转流术治疗2型糖尿病的疗效及分析影响疗效的相关因素。方法回顾性分析2009年1月至2012年7月期间我院收治的33例行胃转流术治疗的2型糖尿病患者的临床资料及随访情况。结果33例患者治愈率为54．55％（18／33）,总有效率为90．91％（30／33）,无效3例。分析治愈及未治愈患者术前的临床资料发现,与未治愈患者比较,治愈患者的年龄更小、病程更短、2hBG更低、BMI更大及空腹C肽更高（P〈0．05）。结论从本组有限资料的初步结果看,胃转流术治疗2型糖尿病临床效果确切,而对于低龄、病程短、BMI及空腹c肽较高和2hBG较低的2型糖尿病患者可获得更好的治疗效果。     

Mechanism of Roux-en-Y Gastric Bypass Treatment for Type 2 Diabetes in Rats

Objectives

Roux-en-Y gastric bypass (RYGB) is a novel therapy for diabetes. We aimed to explore the therapeutic mechanism of RYGB.

Methods

After RYGB, animal models were established, and gene expression profile of islets was assessed. Additionally, gastrointestinal hormones were measured using enzyme-linked immunosorbent assays. Ca²⁺ was studied using confocal microscopy and patch-clamp technique. The morphology of islets and beta cells was observed using optical microscopy and electron microscopy.

Results

RYGB was an effective treatment in diabetic rats. Expression profiling data showed that RYGB produced a new metabolic environment and that gene expression changed to adapt to the new environment. The differential expression of genes associated with hormones, Ca²⁺ and cellular proliferation was closely related to RYGB and diabetes metabolism. Furthermore, the data verified that RYGB led to changes in hormone level and enhanced Ca²⁺ concentration changes and Ca²⁺ channel activity. Morphological data showed that RYGB induced the proliferation of islets and improved the function of beta cells.

Conclusions

RYGB promoted a new metabolic environment while triggering changes to adapt to the new environment. These changes promoted the cellular proliferation of islets and improved the function of beta cells. The quantity of beta cells increased, and their quality improved, ultimately leading to insulin secretion enhancement.     

Short-Term Insulin Requirements Following Gastric Bypass Surgery in Severely Obese Women with Type 1 Diabetes

Background

In severely obese type 2 diabetes patients, gastric bypass surgery (GB) reduces body mass index (BMI) and hemoglobin A1c (HbA1c) and allows reduced doses of insulin and other medications. Data regarding the effects of GB on severely obese patients with type 1 diabetes are limited.

Methods

Severely obese women with type 1 diabetes (n?=?9) were studied immediately before and after GB (7.7?±?5.8 weeks, mean ± SD).

Results

On average, GB reduced mean BMI by 11 % and mean HbA1c by 0.9 % (from 8.0 to 7.1 %), with a parallel 38 % decrease in basal insulin requirements (expressed per kilogram of body weight).

Conclusion

GB rapidly decreased BMI, HbA1c, and insulin requirements in severely obese women with type 1 diabetes. However, physiologic insulin replacement remains necessary in patients with type 1 diabetes.     

Endoscopic Dilation with Savary-Gilliard Bougies of Stomal Strictures After Laparosocopic Gastric Bypass in Morbidly Obese Patients

Background Anastomotic strictures after bariatric surgery are a frequent complication that requires endoscopic management, but the optimal technique for dilation remains to be determined. The aim of this study was to evaluate the safety and efficacy of dilation with Savary–Gilliard bougies (SGB) in morbidly obese patients treated with laparoscopic Roux-en-Y gastric bypass (RYGBP). Patients and Methods Retrospective review of prospectively collected data from a series of 474 consecutive patients with laparoscopic bariatric surgery. Four-hundred twenty four of these patients (90%) underwent a laparoscopic RYGBP. A total of 24 patients were referred for anastomotic stricture dilation with SGB from January 1998 to December 2006. Results A total of 24/424 patients (6%) developed a stricture that was successfully dilated with SGB. Patients were 17 females (71%) and seven males (29%) with a mean age of 41 ± 11 years (range 24–63) and a mean BMI of 48 ± 6 (range 40–69). The time between RYGBP and the appearance of stricture-related symptoms ranged from 29 to 154 days (mean, 69 days). The mean number of dilations was 1.6 ± 0.6. The majority of patients required one (n = 11; 46%) or two (n = 12; 50%) dilations and only one patient required three dilations. During the initial dilation, a final diameter of 11 ± 1.7 mm (range 7–12.8 mm) was achieved. In all cases, there was complete resolution of symptoms. There were no complications. Conclusions Dilation with SGB is an effective, safe, and durable method for managing anastomotic strictures after laparoscopic RYGBP. Presented at the 12th World Congress of the International Federation for the Surgery of Obesity, Porto, Portugal, September 7, 2007.     

Laparoscopic Sleeve Gastrectomy with Duodenojejunal Bypass for the Treatment of Type 2 Diabetes in Non-obese Patients: Technique and Preliminary Results

Background  

Medical treatment of type 2 diabetes has often insufficient clinical results at long term. Although the surgical option is a well-established alternative for obese patients, the procedures in non-obese are currently being developed.