Short-term Effects of Sleeve Gastrectomy on Type 2 Diabetes Mellitus in Severely Obese Subjects

Background Data on the effectiveness of sleeve gastrectomy (SG) in improving or resolving type 2 diabetes mellitus (T2DM) are scarce. Methods A 4-month prospective study was conducted on the changes in glucose homeostasis in 35 severely obese T2DM subjects undergoing laparoscopic SG (LSG) and 50 subjects undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP), matched for DM duration, type of DM treatment, and glycemic control. Results At 4-months after surgery, LSG and LRYGBP operated subjects lost a similar amount of weight (respectively, 20.6 ± 0.7% and 21.0 ± 0.6%). T2DM had resolved respectively in 51.4% and 62.0% of the LSG and LRYGBP operated subjects (P = 0.332). A shorter preoperative DM duration (P < 0.05), a preoperative DM treatment not including pharmacological agents, and a better pre-surgical fasting plasma glucose (P < 0.01) or HbA1c (P < 0.01), were significantly associated with a better type 2 DM outcome in both surgical groups. Conclusions Our data show that LSG and LRYGBP result in a similar rate of type 2 DM resolution at 4-months after surgery. Moreover, our data suggest that mechanisms beyond weight loss may be implicated in DM resolution following LSG and LRYGBP.     

Short-term Changes in Insulin Resistance following Weight Loss Surgery for Morbid Obesity: Laparoscopic Adjustable Gastric Banding versus Laparoscopic Roux-en-Y Gastric Bypass

Background: Laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGBP) both effectively treat the insulin resistance associated with type 2 diabetes mellitus (T2DM). Restriction of caloric consumption, alterations in the entero-insular axis or weight loss may contribute to lowering insulin resistance after these procedures. The relative importance of these mechanisms, however, following LAGB and LRYGBP remain unclear. The aim of this study was to compare directly the short-term changes in insulin resistance following LAGB and LRYGBP in similar populations of patients. Methods: Patient preference determined operation type. The Homeostasis Model Assessment for Insulin Resistance (HOMA IR) was used to measure insulin resistance. Preoperative values were compared to postoperative levels obtained within 90 days of surgery. Significant differences between groups were tested by ANOVA. Results: There were no significant preoperative differences between groups. The 56 LAGB patients had a mean age of 42.5 years (25.7-63), BMI of 45.5 kg/m² (35-66) and preoperative HOMA IR of 4.1 (1.4-39.2). 75% of LAGB patients were female and 43% had T2DM. The 61 LRYGBP patients had a median age of 39.9 years (22.1-64.3), BMI of 45.0 kg/m² (36-62), and preoperative HOMA IR of 5.0 (0.6-56.5). 79% of LRYGBP patients were women and 44.3% had T2DM. Median follow-up for LAGB patients was 45 days (18-90) and for LRYGBP patients 46 days (8-88 days). LAGB patients had a median of 14.8% excess weight loss (6.9%-37.0%) and LRYGB patients 24.2% (9.8%-51.4%). Postoperative HOMA IR was significantly less after LRYGBP, 2.2 (0.7-12.2), than LAGB, 2.6 (0.8-29.6), although change in HOMA IR was not significantly different. Change in HOMA IR for both groups did not vary with length of follow-up or weight loss but correlated best with preoperative HOMA IR (LAGB r=0.8264; LRYGBP r=0.9711). Conclusions: Both LAGB and LRYGBP significantly improved insulin resistance during the first 3 months following surgery. Both operations generated similar changes in HOMA IR, although postoperative HOMA IR levels were significantly lower after LRYGBP. These findings suggest that caloric restriction plays a significant role in improving insulin resistance after both LAGB and LRYGBP.     

Effects of Obesity Surgery on Type 2 Diabetes Mellitus Asian Patients

Background  Obesity is a major risk factor for the development of type 2 diabetes mellitus (T2DM). Surgery is the most effective treatment for morbid obesity, and it has been shown to lead to dramatic improvement in type T2DM. However, data concerning obese Asian patients have not been reported, and the mechanism of improving T2DM after bariatric surgery in this population remains speculative. Methods  From April 1997 to March 2006, 1,375 patients undergoing obesity surgery were recruited for our study of the effects of weight loss surgery on type 2 diabetes mellitus (T2DM). Laparoscopic vertical banded gastric partition (LVBG) was performed in 552 patients (40.1%), laparoscopic gastric bypass in 660 patients (48.0%), and laparoscopic adjustable gastric banding (LAGB) in 140 patients (10.2%). Another 23 patients (1.7%) received open or revision surgery. We evaluated the clinical data and effect of obesity surgery on T2DM, impaired fasting glucose (IFG) and compared the changes with those with normal fasting glucose. Results  Among all the patients, 166 (12.1%) had impaired fasting glucose (IFG) and 247 (18.0%) had T2DM. Patients with IFG or DM were significantly older, more central obese, and they had higher insulin resistance and a higher HbA1C level than those with normal fasting glucose. The mean total weight loss for the population was 28.6%, 29.1%, 28.5%, 23.8%, and 24.4% (at 1, 2, 3, 5, and 7 years after surgery). There was no increase of surgical risk in T2DM or IFG patients. One year after operation, fasting plasma glucose returned to normal in 78.5% of T2DM patients and 94.7% of IFG patients. The HbA1C level returned to under 7.0 in 81.5% of T2DM and in 100% of IFG patients. Laparoscopic gastric bypass patients had a greater weight loss and a higher rate of glucose normalization (93.1%) than the LVBG patients (85.3%) and LAGB patients (73.9%), but no difference in HbA1C normalization. Conclusions  Obesity surgery resulted in significant and sustained weight loss with a cure rate of T2DM up to 80% in morbidly obese Asian patients. Gastric bypass surgery had a better result in T2DM cure rate than LVBG and LAGB because of better weight reduction.     

Staged Laparoscopic Sleeve Gastrectomy Followed by Roux-en-Y Gastric Bypass for Morbidly Obese Patients: A Risk Reduction Strategy

Background  In our centre laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the most effective weight loss surgical procedure performed. However, LRYGBP may be associated with higher risk of peri- and postoperative complications in contrast to a purely restrictive procedure to justify this procedure on all comers. Laparoscopic sleeve gastrectomy (LSG) as a staged procedure may be an alternate risk reduction strategy. The aim of this study is to report on the short-term outcomes of LSG, the effect on operative risk reduction and resolution of comorbidities. Methods  A prospective review of 138 patients who underwent consecutive LSG from November 2004 to November 2006 was performed. Data were collected on all patients who attended the three to six monthly clinical follow-up and/or the patient questionnaire. Data collection included demographics, degree of weight reduction, postoperative complications, and changes in comorbidities. Results  Median BMI was 50.60 kg/m² (33–82). Of the patients, 46.38% had a BMI ≥50 kg/m². The overall median postoperative excess weight loss (EWL) was 43.26%, 31.08% at 6 months, 54.50% at 12 months, 51.47% at 18 months and 46.05% at 24 months. Of the patients, 39% had resolution of type 2 diabetes mellitus, 48% had resolution of dyslipidemia, 29% in hypertension, 52% in obstructive sleep apnea. Complication rate was 5.07% and four patients needed further surgical intervention. The mortality rate was zero. Conclusion  LSG does minimize postoperative complication rates significantly on high-risk patients and achieves effective short-term weight loss with resolutions in comorbidities. Additional studies are required to evaluate LSG as a stand-lone procedure.     

Laparoscopic Roux-En-Y Gastric Bypass is a Safe and Effective Operation for the Treatment of Morbid Obesity in Patients Older than 55 Years

Background: Bariatric surgery in patients >50 years has been controversial. We investigated the safety and efficacy of laparoscopic Roux-en-Y gastric bypass (LRYGBP) in patients >55 years of age. Methods: Prospective data on 71 patients (54 females and 17 males) undergoing LRYGBP were reviewed. The patients were followed for a mean of 17 months (range 2-35 months). Results: The mean age was 59 years (range 55-67 years), and the mean preoperative BMI was 50.2 kg/m² (range 37-65 kg/m²). There were no conversions to open technique. Mean percent of excess weight loss (%EWL) was 20%, 48%, 64% and 67% at 1, 6, 12 and 24 months respectively. 89% of patients had at least a 50% EWL at 1 year postoperatively. There was a significant decrease in the number of patients requiring medical treatment for co-morbidities associated with morbid obesity: diabetes mellitus 87%, hypertension 70% and sleep apnea 86%. There was no inpatient mortality. 1 patient died suddenly 2 weeks postoperatively of possible myocardial infarction or pulmonary embolism. 16 patients developed 22 complications. The median length of hospital stay was 3 days. Conclusion: LRYGBP is a safe and well-tolerated surgical option for the treatment of morbid obesity in patients >55 years old. These patients demonstrate a satisfactory weight loss and resolution of co-morbidities.     

Randomized clinical trial of laparoscopic Roux-en-Y gastric bypass versus laparoscopic vertical banded gastroplasty for obesity

BACKGROUND: Laparoscopic techniques have been developed for performing Roux-en-Y gastric bypass (LRYGBP) and vertical banded gastroplasty (LVBG) in patients with morbid obesity. It is not certain, however, which is the better technique in non-superobese patients (body mass index less than 50 kg/m(2)). METHODS: Eighty-three patients (LRYGBP 37, LVBG 46) were assessed in a randomized clinical trial. Perioperative complications were recorded together with preoperative and postoperative respiratory function and mobilization rate. Patients were monitored for 2 years after operation with regard to weight change and the need for remedial surgery. RESULTS: There were no conversions to open surgery. The mean operating time was longer for LRYGBP than LVBG (138 versus 105 min). Five early reoperations were performed after LRYGBP (three for haemorrhage, one for ileus and one suspected leak) and one after LVBG (suspected leak). There were no differences in postoperative respiratory function or mobilization. Weight reduction was greater after LRYGBP (excess weight loss 78.3 versus 62.9 per cent 1 year after surgery, P = 0.009; 84.4 versus 59.8 per cent at 2 years, P < 0.001). Remedial surgical intervention was required in eight patients after LVBG (conversion to Roux-en-Ygastric bypass) and none after LRYGBP. CONCLUSION: LRYGBP and LVBG were comparable in terms of operative safety and postoperative recovery, but weight reduction was better after LRYGBP.     

Results of Laparoscopic Gastric Bypass in Patients ≥55 Years Old

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a commonly performed surgical intervention for morbid obesity. Some authors considered age ≥55 years as a relative contraindication to bariatric surgery. We examined the operative outcomes, weight loss, hospital stay and resolution of co-morbidities in patients ≥55 years old compared with those <55 years old undergoing LRYGBP. Methods: From Jan 2000 to Feb 2005, 350 LRYGBPs were performed. 48 patients ≥55 years old (13.7%) were compared to the remaining patients. Results: Analysis of the 48 patients ≥55 years old compared with 302 patients <55 revealed no difference in complication rate, although the older patients had a significantly greater percentage of serious complications. Younger patients lost more weight than older patients. Both groups demonstrated resolution of comorbidities, although the difference was not significant. Conclusions: LRYGBP is safe and well tolerated in morbidly obese patients ≥55 years. The older patients had more serious complications and lost less weight; however, their weight loss and resolution of co-morbidities improved their quality of life. Age should not be a contraindication to bariatric surgery.     

Gastric banding for the treatment of type 2 diabetes mellitus in morbidly obese.

BACKGROUND: To assess the efficacy of the Swedish adjustable gastric band in the treatment of type 2 diabetes mellitus (T2DM), impaired glucose tolerance (IGT), and the metabolic syndrome (MS) in the morbidly obese. METHODS: We identified all patients with T2DM, IGT, or the MS at surgery from our database of 905 consecutive patients who had undergone placement of the Swedish adjustable gastric band between January 2001 and April 2007. The patients were followed up by our multidisciplinary team, and their T2DM was managed by their treating primary care physician and/or endocrinologist. RESULTS: A total of 682 patients had >6 months of follow-up. Of these, 78 patients had T2DM, 64 had IGT, and 100 had the MS. At a median follow-up of 12.5 months, patients with T2DM had a mean +/- SD excess weight loss of 38% +/- 15%. This was associated with hemoglobin A1c and fasting blood sugar levels decreasing from 8.0% +/- 1.7% to 6.1% +/- 1.0% (P <.0001) and from 9.6 +/- 3.4 mmol/L to 5.7 +/- 1.5 mmol/L (P <.0001), respectively. Remission and/or improvement in patients with T2DM was judged by the complete cessation and/or reduction in medication and normalization of laboratory values. This occurred in 81% of those taking oral hypoglycemic agents. Of the patients taking a combination of oral hypoglycemic agents and insulin, 43% ceased and/or reduced their oral hypoglycemic agents, and 93% ceased and/or reduced their insulin requirements. Of those on insulin only, 75% ceased and/or reduced their insulin. No patient with IGT developed diabetes or progressed to require medications. Remission and/or improvement in the MS occurred in 88% of patients. Remission of T2DM was dependent on both the magnitude of excess weight loss (P = .008) and the duration of the pre-existing T2DM. Using binary logistic regression analysis, a duration of T2DM of <5 years before surgery was 6.5 times more likely to lead to resolution of T2DM after the weight loss (P = .004). CONCLUSION: Weight loss after Swedish adjustable gastric band placement is an effective treatment of T2DM in morbidly obese patients, with early intervention offering the greatest chance of remission. It might even prevent the occurrence of T2DM in patients with IGT.     

Laparoscopic Gastric Bypass in Patients on Thyroid Replacement Therapy for Subnormal Thyroid Function – Prevalence and Short-Term Outcome

Background: Hypothyroidism is associated with increased body weight. Weight gain may occur despite normal levels of serum thyroid stimulating hormone (TSH) and thyroxine (T4) achieved by replacement therapy. We evaluated the prevalence of patients on thyroid replacement for subnormal thyroid function who were operated on for morbid obesity and monitored their postoperative weight loss pattern. Methods: Data was identified from a prospectively accrued database of patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) or laparoscopic adjustable gastric banding (LAGB) for morbid obesity from February 2000 to November 2001. All patients with subnormal thyroid function, diagnosed by past thyroid function tests and treated by an endocrinologist, who were on thyroid replacement therapy, were identified; 5 of these were matched for age, gender, preoperative body mass index (BMI) and surgical procedure (LRYGBP) to 5 non-hypothyroid patients. Weight loss at 3 and 9 months after surgery was compared between the 2 groups. Results: 192 patients underwent LRYGBP (n=155) or LAGB (n=37). Of the 21 patients (10.9%) on thyroid replacement identified, 14 were primary, 4 were postablative, and 3 were post-surgical; 17 underwent LRYGBP. All patients had normal preoperative serum levels of TSH and T4. Comparison of the 2 matched groups of patients revealed no difference in weight loss at 3 and 9 months after surgery (P=1.0). Conclusions: The prevalence of euthyroid patients on thyroid replacement for subnormal thyroid function who undergo surgical intervention for morbid obesity is high. Short-term weight loss in these patients is comparable to normal thyroid patients. Longer follow-up may be necessary to demonstrate the weight loss pattern in this group.     

Metabolic Surgery for the Treatment of Type 2 Diabetes in Patients with BMI <35 kg/m<Superscript>2</Superscript>: An Integrative Review of Early Studies

Type 2 diabetes mellitus (T2DM) resolution in morbidly obese patients following metabolic surgery suggests the efficacy of T2DM surgery in non-morbidly obese patients (body mass index [BMI] <35 kg/m²). This literature review examined research articles in English over the last 30 years (1979–2009) that addressed surgical resolution of T2DM in patients with a mean BMI <35. Weighted and simple means (95% CI) were calculated to analyze study outcomes. Sixteen studies met inclusion criteria; 343 patients underwent one of eight procedures with 6–216 months follow-up. Patients lost a clinically meaningful, not excessive, amount of weight (from BMI 29.4 to 24.2; −5.1), moving from the overweight into the normal weight category. There were 85.3% patients who were off T2DM medications with fasting plasma glucose approaching normal (105.2 mg/dL, −93.3), and normal glycated hemoglobin, 6% (−2.7). In subgroup comparison, BMI reduction and T2DM resolution were greatest following malabsorptive/restrictive procedures, and in the preoperatively mildly obese (30.0–35.0) vs overweight (25.0–25.9) BMI ranges. Complications were few with low operative mortality (0.29%). Novel and/or known mechanisms of T2DM resolution may be engaged by surgery at a BMI threshold ≤30. The majority of low-BMI patients experienced resolution of laboratory and clinical manifestations of T2DM without inappropriate weight loss.     

Laparoscopic Roux-en-Y versus mini-gastric bypass for the treatment of morbid obesity: a prospective randomized controlled clinical trial

OBJECTIVES: This prospective, randomized trial compared the safety and effectiveness of laparoscopic Roux-en-Y gastric bypass (LRYGBP) and laparoscopic mini-gastric bypass (LMGBP) in the treatment of morbid obesity. SUMMARY BACKGROUND DATA: LRYGBP has been the gold standard for the treatment of morbid obesity. While LMGBP has been reported to be a simple and effective treatment, data from a randomized trial are lacking. METHODS: Eighty patients who met the NIH criteria were recruited and randomized to receive either LRYGBP (n = 40) or LMGBP (n = 40). The minimum postoperative follow-up was 2 years (mean, 31.3 months). Perioperative data were assessed. Late complication, excess weight loss, BMI, quality of life, and comorbidities were determined. Changes in quality of life were assessed using the Gastro-Intestinal Quality of Life Index (GIQLI). RESULTS: There was one conversion (2.5%) in the LRYGBP group. Operation time was shorter in LMGBP group (205 versus 148, P < 0.05). There was no mortality in each group. The operative morbidity rate was higher in the LRYGBP group (20% versus 7.5%, P < 0.05). The late complications rate was the same in the 2 groups (7.5%) with no reoperation. The percentage of excess weight loss was 58.7% and 60.0% at 1 and 2 years, respectively, in the LPYGBP group, and 64.9% and 64.4% in the LMGBP group. The residual excess weight <50% at 2 years postoperatively was achieved in 75% of patients in the LRYGBP group and 95% in the LMGBP group (P < 0.05). A significant improvement of obesity-related clinical parameters and complete resolution of metabolic syndrome in both groups were noted. Both gastrointestinal quality of life increased significantly without any significant difference between the groups. CONCLUSION: Both LRYGBP and LMGBP are effective for morbid obesity with similar results for resolution of metabolic syndrome and improvement of quality of life. LMGBP is a simpler and safer procedure that has no disadvantage compared with LRYGBP at 2 years of follow-up.     

Re-emergence of diabetes after gastric bypass in patients with mid- to long-term follow-up

BackgroundStudies have shown that type 2 diabetes (T2DM) improves or resolves shortly after Roux-en-Y gastric bypass (RYGB). Few data are available on T2DM recurrence or the effect of weight regain on T2DM status.MethodsA review of 42 RYGB patients with T2DM and ≥3 years of follow-up and laboratory data was performed. Postoperative weight loss and T2DM status was assessed. Recurrence or worsening was defined as hemoglobin A1c >6.0% and fasting glucose >124 mg/dL and/or medication required after remission or improvement. Patients whose T2DM recurred or worsened were compared with those whose did not, and patients whose T2DM improved were compared with those whose T2DM resolved.ResultsT2DM had either resolved or improved in all patients (64% and 36%, respectively); 24% (10) recurred or worsened. The patients with recurrence or worsening had had a lower preoperative body mass index than those without recurrence or worsening (47.9 versus 52.9 kg/m2; P = .05), regained a greater percentage of their lost weight (37.7% versus 15.4%; P = .002), had a greater weight loss failure rate (63% versus 14%; P = .03), and had greater postoperative glucose levels (138 versus 102 mg/dL; P = .0002). Patients who required insulin or oral medication before RYGB were more likely to experience improvement rather than resolution (92% versus 8%, P ≤.0001; and 85% versus 15%; P = .0006, respectively).ConclusionOur results have shown that beyond 3 years after RYGB, the incidence of T2DM recurrence or worsening in patients with initial resolution or improvement was significant. In our patients, a greater likelihood of recurrence or worsening of T2DM was associated with a lower preoperative body mass index. Before widespread acceptance of bariatric surgery as a definitive treatment for those with T2DM can be achieved, additional study of this recurrence phenomenon is indicated.     

Type 2 Diabetes Mellitus and the Metabolic Syndrome Following Sleeve Gastrectomy in Severely Obese Subjects

BACKGROUND: Data on the effectiveness of sleeve gastrectomy in improving or resolving type 2 diabetes mellitus (T2DM) and the metabolic syndrome (MS) are scarce. METHODS: A twelve-month prospective study on the changes in glucose homeostasis and the MS in 91 severely obese T2DM subjects undergoing laparoscopic SG (SG; n = 39) or laparoscopic Roux-en-Y gastric bypass (GBP; n = 52), matched for DM duration, type of DM treatment, and glycemic control was conducted. RESULTS: At 12 months after surgery, subjects undergoing SG and GBP lost a similar amount of weight (%EBL: SG: 63.00 +/- 2.89%, BPG: 66.06 +/- 2.34%; p = 0.413). On that evaluation, T2DM had resolved, respectively, in 33 out of 39 (84.6%) and 44 out of 52 (84.6%) subjects after SG and GBP (p = 0.618). The rate of resolution of the MS (SG: 62.2%, BPG: 67.3%; p = 0.392) was also comparable. A shorter DM duration (p < 0.05), a DM treatment not including pharmacological agents (p < 0.05), and a better glycemic control (p < 0.05), were significantly associated with T2DM resolution in both surgical groups. Weight loss was not associated with T2DM resolution after SG or GBP, but was associated with resolution of the MS following the two surgical procedures (p < 0.05). CONCLUSIONS: Our data show that at 12 months after surgery, SG is as effective as GBP in inducing remission of T2DM and the MS. Furthermore, our data suggest that SG and GBP represent a successful an integrated strategy for the management of the different cardiovascular risk components of the MS in subjects with T2DM.     

Obesity Surgery Results Depending on Technique Performed: Long-Term Outcome

Background  Many techniques have excellent results at 2 years of follow-up but some matters regarding their long-term efficacy have arisen. This is why bariatric surgery results must be analyzed in long-term follow-up. The aim of this study was to extend the analysis over 5 years, evaluating weight loss, morbidity, and mortality of the surgical procedures performed. Methods  This was a retrospective cohort study of the different procedures for morbid obesity practiced in our Department of Surgery for morbid obesity. The results have been analyzed in terms of weight loss, morbidity improvement, and postoperative morbidity (Bariatric Analysis And Reporting Outcome System). Results  One hundred twenty-five patients were operated on open vertical banded gastroplasty (VBG), 150 patients of open biliopancreatic diversion (BPD) of Scopinaro, 100 patients of open modified BPD (common limb 75 cm; alimentary limb 225 cm), and 115 patients of laparoscopic Roux-en-Y gastric bypass (LRYGBP). Mean follow-up was: VBG 12 years, BPD 7 years, and LRYGBP 4 years. An excellent initial weight loss was observed at the end of the second year of follow-up in all techniques, but from this time an important regain of weight was observed in VBG group and a discrete weight regain in LRYGBP group. Only BPD groups kept excellent weight results so far in time. Mortality was: VBG 1.6%, BPD 1.2%, and LRYGBP 0%. Early postoperative complications were: VBG 25%, BPD 20.4%, and LRYGBP 20%. Late postoperative morbidity was: protein malnutrition 11% in Scopinaro BPD, 3% in Modified BPD group, and no cases reported either in VBG group or LRYGBP group; iron deficiency 20% VBG, 62% Scopinaro BPD, 40% modified BPD, and 30.5% LRYGBP. A 14.5% of VBG group required revision surgery to gastric bypass or to BPD due to 100% weight regain or vomiting. A 3.2% of Scopinaro BPD with severe protein malnutrition required revision surgery to lengthen common limb to 100 cm. A 0.8% of LRYGBP required revision surgery to distal LRYGBP (common limb 75 cm) due to 100% weight regain. Conclusions  The most complex bariatric procedures increase the effectiveness but unfortunately they also increase morbidity and mortality. LRYGBP is safe and effective for the treatment of morbid obesity. Modified BPD (75–225 cm) can be considered for the treatment of superobesity (body mass index > 50 kg/m²), and restrictive procedures such as VBG should only be performed in well-selected patients due to high rates of failure in long-term follow-up.     

Laparoscopic Gastric Bypass beyond Age 60

Background: Previous reports have questioned the safety and efficacy of gastric bypass in older patients. We examine our results in the older group of patients to shed some light on the appropriateness of offering gastric bypass to senior patients. Methods: A retrospective review of a prospectively collected database on all laparoscopic Roux-en-Y gastric bypass (LRYGBP) cases performed from March 2001 to October 2003 was conducted. Patients >60 years of age were compared to the overall group. Results: A total of 550 patients underwent LRYGBP: all were completed laparoscopically. In the 527 patients <60 years of age, there were no deaths and there were 15 complications (2.8% perioperative morbidity). In the group of patients >60 years old, there were 23 patients; mean age was 64.4 years (60-75 years). There was 1 death in this group (4.3% mortality rate) and 1 postoperative complication (4.3% morbidity rate). In the >60 year group at an average of 12 months follow-up, weight loss was 43.2 kg (28.6-73.2 kg), change in BMI was 16.5 (11-23), and excess weight loss was 65% (40-110%). Also, diabetes resolved in 3 out of 4 patients (75%), obstructive sleep apnea in 2 of 3 (67%), hypercholesterolemia in 3 of 5 (60%) and hypertension resolved or improved in 10 of 11 patients (91%). Conclusion: While patients >60 years of age had a higher morbidity and mortality, their risk/benefit ratio was acceptable. Older patients achieve significant weight loss and resolution of obesity-associated comorbidities.     

Sleeve Gastrectomy with Jejunal Bypass for the Treatment of Type 2 Diabetes Mellitus in Patients with Body Mass Index <35?kg/m2. A cohort study

The objective of this study was to evaluate sleeve gastrectomy with jejunal bypass (SGJB) as a surgical treatment for type 2 diabetes mellitus (T2DM) in patients with a body mass index (BMI) <35 kg/m(2). This is a prospective cohort study. Patients with T2DM and BMI <35 kg/m(2) who underwent SGJB between January 2009 and June 2011 at DIPRECA Hospital, in Santiago, and Hospital Base, Osorno, Chile were included. SGJB consists of creating a gastric tube, which preserves the pylorus, and performing a jejunoileal anastomosis 300 cm distal to the angle of Treitz. Excess weight loss (EWL) and complete or partial remission of T2DM were reported. Forty-nine patients met the inclusion criteria. The mean age was 49 years (36-62), and 53 % of patients were female. Mean preoperative BMI was 31.6 kg/m(2) (25-34.9 kg/m(2)). Operation time was 123 ± 14 min, with 94.7 % of operations performed laparoscopically. Mean postoperative hospital stay was 2 days. Mean postoperative follow-up was 12 months. Median EWL at 1, 3, 6, 12, and 18 months postoperatively was 31.9 %, 56.9 %, 76.1 %, 81.5 %, and 76.1 %, respectively. Complete T2DM remission was achieved in 81.6 % of patients (40/49) and partial remission in 18.4 % (9/49). Forty of 41 patients (97.6 %) on oral hypoglycemic agents achieved complete T2DM remission, and 100 % of insulin-dependent patients stopped using insulin but were still being treated for T2DM. One patient experienced postoperative gastrointestinal bleeding. There were no deaths. SGJB is an effective treatment for T2DM in patients with BMI <35 kg/m(2).     

Type 2 diabetes in obese patients with body mass index of 30-35 kg/m2: sleeve gastrectomy versus medical treatment

BackgroundType 2 diabetes mellitus (T2DM) and obesity are diseases of epidemic proportions. Long-term realistic weight loss by nonsurgical methods has a variable effect on glycemic control, and only a proportion of patients with T2DM have a worthwhile response. Laparoscopic sleeve gastrectomy (LSG) has been proposed as an advantageous bariatric procedure for patients with a lower body mass index (BMI). Our objective was to compare the effects of LSG and medical therapy on patients with T2DM and a BMI of <35 kg/m².MethodsA total of 18 nonmorbidly obese patients with T2DM, diagnosed according to the American Diabetes Association guidelines, were consecutively enrolled. Of these patients, 9 underwent LSG (group A) and 9 underwent conventional medical therapy (group B). The 2 groups were matched for BMI, glycated hemoglobin (HbA1c) and C-peptide levels, pretrial therapy type, and number of patients with a T2DM duration of >10 years.ResultsIn group A, T2DM resolution was achieved in 8 (88.8%) of the 9 patients (T2DM duration 5.2 yr). Hypertension was controlled in all 8 of 9 patients. Dyslipidemia was corrected. In 1 patient, obstructive sleep apnea syndrome improved. In group B, all 9 patients continued to have T2DM and required hypertensive and hypolipemic therapies throughout the observation period. At baseline, 3 patients were affected by obstructive sleep apnea syndrome and remained affected 1 year later.ConclusionThe results of the present study have confirmed the efficacy of LSG in the treatment of nonmorbidly obese T2DM patients, with a remission rate of 88.8% without undesirable excessive weight loss. The results in this group of patients add to those obtained by us in patients with a BMI >35 kg/m².     

Preoperative Fasting Plasma C-Peptide Level May Help to Predict Diabetes Outcome After Gastric Bypass Surgery

Background

To evaluate whether preoperative measurement of fasting plasma C-peptide levels is useful to predict diabetes outcome after Roux-en-Y gastric bypass (RYGB) surgery.

Materials and Methods

Diabetes outcome after RYGB was evaluated in 126 obese patients: 41 non-diabetic controls (NDC), 29 with impaired glucose tolerance (IGT) and 56 had type 2 diabetes mellitus (T2DM). Body weight, fasting plasma glucose, fasting C-peptide levels, and HbA1c were measured at baseline and 3.6?±?0.16 years after GBS. Complete resolution of diabetes was defined as: fasting glucose <7.0 mmol/l, HbA1c <6.5 %, achieved without anti-diabetic medication.

Results

Patients with complete resolution of diabetes had a more recent diagnosis of T2DM, lower preoperative HbA1c levels and lower daily doses of metformin and insulin use. These parameters were related to postoperative HbA1c levels but they failed to mark the specific patients who had not reached complete resolution of T2DM. Fasting preoperative C-peptide levels had better predictive power: 90 % of T2DM patients with preoperative fasting C-peptide levels >1.0 nmol/l achieved a postoperative HbA1c <6.5 %, and 74 % achieved complete resolution of their diabetes. In contrast, none of the T2DM patients with a preoperative fasting C-peptide <1.0 nmol/l attained these goals.

Conclusions

A preoperative fasting plasma C-peptide level <1.0 nmol/l in severely obese T2DM patients indicates partial β-cell failure, and is associated with a markedly reduced chance of complete resolution of T2DM after RYGB. We therefore advocate measuring C-peptide levels in all diabetic patients up for bariatric surgery to improve the prediction of outcome.     

Indications and Mid-Term Results of Conversion from Sleeve Gastrectomy to Roux-en-Y Gastric Bypass

Sleeve gastrectomy (SG) is currently considered as a primary bariatric surgery. This is because of its relative simplicity and satisfactory results. As observed with other bariatric procedures, surgeons are confronted with insufficient weight loss or weight regain, insufficient resolution of metabolic disorders, and intractable severe reflux. A retrospective analysis of conversion from SG to Roux-en-Y gastric bypass (RYGBP) was performed to assess weight loss, diabetes resolution, and relief of reflux symptoms. The mean interval between the two procedures was almost 24 months. Eighteen patients underwent conversion from SG to RYGBP for insufficient weight loss (n?=?9), severe reflux (n?=?6), and persistence of type 2 diabetes mellitus (T2DM) (n?=?3). The median follow-up was 15.5 months. Weight loss was significantly improved with a mean percentage of excess of body mass index loss at 64.6 % after conversion versus 47.1 % before conversion. All reflux symptoms were immediately relieved without any medication at the end of the follow-up. The three patients who had an operation for persistence of T2DM are now free of medication. Only one postoperative complication was observed as a small bowel injury, which was treated surgically. Conversion from SG to RYGBP is safe. Severe reflux is definitely treated and is an incontestable indication with this procedure. Additionally, weight loss and diabetes are clinically improved. Our results appear to be similar to those with a primary RYGBP.     

腹腔镜袖带胃切除术治疗病态性肥胖合并2型糖尿病的疗效评价

目的评估腹腔镜袖带胃切除术（LSG）治疗病态性肥胖2型糖尿病的疗效。方法2007年1月至7月,对来自全美的30例体质量指数（BMD大于或等于35、且合并2型糖尿病的病态性肥胖志愿患者行LSG,术后所有病例随访6个月。分析患者手术前后血糖控制情况、BMI变化和超重体重下降百分比（EWL％）及血糖指标变化情况和Ghrelin激素。结果本组30例患者在接受LSG后6个月,糖尿病治愈率达63％（19／30）,缓解率达37％（11／30）,术后6个月总有效率为100％。结论LSG对病态性肥胖2型糖尿病有着良好的短期治疗效果。