Global 30-Day Morbidity and Mortality of Primary Bariatric Surgery Combined with Another Procedure: The BLEND Study.

BACKGROUND: No robust data are available on the safety of primary bariatric and metabolic surgery (BMS) alone compared to primary BMS combined with other procedures. OBJECTIVES: The objective of this study is to collect a 30-day mortality and morbidity of primary BMS combined with cholecystectomy, ventral hernia repair, or hiatal hernia repair. SETTING: This is as an international, multicenter, prospective, and observational audit of patients undergoing primary BMS combined with one or more additional procedures. METHODS: The audit took place from January 1 to June 30, 2022. A descriptive analysis was conducted. A propensity score matching analysis compared the BLEND study patients with those from the GENEVA cohort to obtain objective evaluation between combined procedures and primary BMS alone. RESULTS: A total of 75 centers submitted data on 1036 patients. Sleeve gastrectomy was the most commonly primary BMS (N = 653, 63%), and hiatal hernia repair was the most commonly concomitant procedure (N = 447, 43.1%). RYGB accounted for the highest percentage (20.6%) of a 30-day morbidity, followed by SG (10.5%). More than one combined procedures had the highest morbidities among all combinations (17.1%). Out of overall 134 complications, 129 (96.2%) were Clavien-Dindo I-III, and 4 were CD V. Patients who underwent a primary bariatric surgery combined with another procedure had a pronounced increase in a 30-day complication rate compared with patients who underwent only BMS (12.7% vs. 7.1%). CONCLUSION: Combining BMS with another procedure increases the risk of complications, but most are minor and require no further treatment. Combined procedures with primary BMS is a viable option to consider in selected patients following multi-disciplinary discussion.

Trends and safety of bariatric revisional surgery in Italy: multicenter, prospective, observational study.

BACKGROUND: Revisional bariatric surgery (RBS) represents a further solution for patients who experience inadequate weight loss (IWL) following primary bariatric surgery (BS) or significant weight regain (WR) following initial satisfactory response. RBS guidelines are lacking; however, an increased trend in further BS offerings has been reported recently. OBJECTIVE: Analyze trend, mortality, complication, readmission, and reoperation rates for any reason at 30 days after RBS in Italy. SETTING: Ten Italian high-volume BS centers (university hospitals and private centers). METHODS: Prospective, observational, multicenter study enrolling patients undergoing RBS between October 1, 2021, and March 31, 2022, registering reasons for RBS, technique, mortality, intraoperative and perioperative complications, readmissions, and reinterventions for any reason. Patients undergoing RBS during the same calendar interval in 2016-2020 were considered control patients. RESULTS: A total of 220 patients were enrolled and compared with 560 control-group patients. Mortality was .45% versus .35% (n.s), with an overall mortality of .25%, while open surgery or conversion to open surgery was registered in 1%. No difference was found for mortality, morbidity, complications, readmission (1.3%), and reoperation rates (2.2%). IWL/WR was the most frequent cause, followed by gastroesophageal reflux disease; Roux-en-Y gastric bypass was the most used revisional procedure (56%). Sleeve gastrectomy was the most revised procedure in the study group, while gastric banding was the most revised in the control group. RBS represents up to 9% of the total BS in the Italian participating centers. CONCLUSIONS: Laparoscopy represents the standard approach for RBS, which appears safe. Current Italian trends show a shift toward sleeve gastrectomy being the most revised procedure and Roux-en-Y gastric bypass being the most frequent revisional procedure.

Pyrrhic victory? Long-term results of biliopancreatic diversion on patients with type 2 diabetes and severe obesity.

BACKGROUND: The long-term results after biliopancreatic diversion (BPD) in patients with type 2 diabetes (T2D) and severe obesity is still being debated. OBJECTIVE: Retrospective evaluation of the long-term metabolic and clinical conditions of patients with T2D following BPD. SETTING: University hospital. METHODS: A total of 173 patients with T2D and severe obesity were investigated prior to and at 3-5 and 10-20 years after BPD. Anthropometric, biochemical, and clinical findings preoperatively and throughout follow-up were considered. The long-term data were compared with those of a cohort of 173 T2D patients with obesity treated with conventional therapy. RESULTS: T2D resolved within the first postoperative phases in most patients, and in the long and very long term, the fasting blood glucose level remained above the normal range in only 8% of patients. Likewise, a stable improvement of blood lipid pattern was observed (follow-up rate 63%). In contrast, in nonsurgical patients in the long term, the glucose and lipid metabolic parameters remained in the pathologic range in all cases. In the BPD group, a very high number of severe BPD-related complications was recorded, and 27% of the BPD patients died, whereas in the control group, 87% of patients were still alive at the end of the follow-up period (P < .02). CONCLUSION: Despite the high T2D stable resolution rate and the normalization of most metabolic data at 10-20 years following surgery, these results indicate that BPD should be indicated with caution in the surgical treatment of T2D in patients with severe obesity.

Enhanced recovery after bariatric surgery: an Italian consensus statement.

BACKGROUND: Enhanced recovery after bariatric surgery (ERABS) is an approach developed to improve outcomes in obese surgical patients. Unfortunately, it is not evenly implemented in Italy. The Italian Society for the Surgery of Obesity and Metabolic Diseases and the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care joined in drafting an official statement on ERABS. METHODS: To assess the effectiveness and safety of ERABS and to develop evidence-based recommendations with regard to pre-, intra-, and post-operative care for obese patients undergoing ERABS, a 13-member expert task force of surgeons and anesthesiologists from Italian certified IFSO center of excellence in bariatric surgery was established and a review of English-language papers conducted. Oxford 2011 Levels of Evidence and U.S. Preventive Services Task Force Grade Definitions were used to grade the level of evidence and the strength of recommendations, respectively. The supporting evidence and recommendations were reviewed and discussed by the entire group at meetings to achieve a final consensus. RESULTS: Compared to the conventional approach, ERABS reduces the length of hospital stay and does not heighten the risk of major post-operative complications, re-operations, and hospital re-admissions, nor does it increase the overall surgical costs. A total of 25 recommendations were proposed, covering pre-operative evaluation and care (7 items), intra-operative management (1 item, 11 sub-items), and post-operative care and discharge (6 items). CONCLUSIONS: ERABS is an effective and safe approach. The recommendations allow the proper management of obese patients undergoing ERABS for a better outcome.

Advice of General Practitioner, of Surgeon, of Endocrinologist, and Self-determination: the Italian Road to Bariatric Surgery.

PURPOSE: Bariatric surgery (BS) is considered the most efficient treatment for severe obesity. International guidelines recommend multidisciplinary approach to BS (general practitioners, endocrinologists, surgeons, psychologists, or psychiatrists), and access to BS should be the final part of a protocol of treatment of obesity. However, there are indications that general practitioners (GPs) are not fully aware of the possible benefits of BS, that specialty physicians are reluctant to refer their patients to surgeons, and that patients with obesity choose self-management of their own obesity, including internet-based choices. There are no data on the pathways chosen by physicians and patients to undergo BS in the real world in Italy. METHODS: An exploratory exam was performed for 6 months in three pilot regions (Lombardy, Lazio, Campania) in twenty-three tertiary centers for the treatment of morbid obesity, to describe the real pathways to BS in Italy. RESULTS: Charts of 2686 patients (788 men and 1895 women, 75.5% in the age range 30-59 years) were evaluated by physicians and surgeons of the participating centers. A chronic condition of obesity was evident for the majority of patients, as indicated by duration of obesity, by presence of several associated medical problems, and by frequency of previous dietary attempts to weight loss. The vast majority (75.8%) patients were self-presenting or referred by bariatric surgeons, 24.2% patients referred by GPs and other specialists. Self-presenting patients were younger, more educated, more professional, and more mobile than patients referred by other physicians. Patients above the age of 40 years or with a duration of obesity greater than 10 years had a higher prevalence of all associated medical problems. CONCLUSIONS: The majority of patients referred to a tertiary center for the treatment of morbid obesity have a valid indication for BS. Most patients self-refer to the centers, with a minority referred by a GP or by specialists. Self-presenting patients are younger, more educated, more professional, and more mobile than patients referred by other physicians. Older patients and with a longer duration of obesity are probably representative of the conservative approach to BS, often regarded as the last resort in an endless story.

Laparoscopic bariatric surgery is safe during phase 2-3 of COVID-19 pandemic in Italy: A multicenter, prospective, observational study.

BACKGROUND: Sars-Cov-2 epidemic in Italy caused one of the greatest 2020 European outbreaks, with suspension of elective bariatric/metabolic surgery (BMS). From May 2020 a significant decline of the epidemic has been observed (phase 2); National Health Service protocols permitted elective BMS' resumption. A new, more severe COVID-19 surge, the "second wave", started on October 2020 (phase 3). AIM: The primary end point was to analyze the outcomes of any Sars-Cov-2 infection and related morbidity/mortality within 30 POD after laparoscopic BMS during phase 2-3; secondary end points were readmission and reoperation rates. METHODS: Study design prospective, multicenter, observational. SETTING: Eight Italian high-volume bariatric centers. All patients undergoing BMS from July 2020 through January 2021 were enrolled according to the following criteria: no Sars-Cov-2 infection; primary procedures; no concomitant procedure; age > 18 < 60 years; compensated comorbidities; informed consent including COVID-19 addendum; adherence to specific admission, in-hospital and follow-up protocols. Data were collected in a prospective database. Patients undergone BMS during July-December 2019 were considered a control group. RESULTS: 1258 patients were enrolled and compared with 1451 operated on in 2019, with no differences for demographics, complications, readmission, and reintervention rates. Eight patients (0·6%) tested positive for Sars-Cov-2 infection after discharge, as well as and 15 healthcare professionals, with no related complications or mortality. CONCLUSIONS: Introduction of strict COVID-19 protocols concerning the protection of patients and health-care professionals guaranteed a safe resumption of elective BMS in Italy. The safety profile was, also, maintained during the second wave of outbreak, thus allowing access to a cure for the obese population.

Bariatric and metabolic surgery during COVID-19 outbreak phase 2 in Italy: why, when and how to restart.

In Italy elective bariatric and metabolic surgery was cancelled on February 21,2020 at the beginning of the so-called phase 1 of the SARS-CoV-2 outbreak. Gradually it was restarted on May 4,2020 at the beginning of the so-called phase 2, when epidemiological data showed containment of the infection. Before the outbreak in eight high-volume bariatric centers 840 patients were surgically treated developing a Covid-19 infection, during phase 1, in only 5 cases (0.6%) without mortality. The post-operative complication rate was similar when compared to the 836 subjects submitted to bariatric surgery the year before. Since the high prevalence of infection in subjects with BMI > 30, it was argued that early intervention on obesity during phase 2 could help to minimize the effects of the disease in the event of a possible reversion to a SARS-CoV-2 outbreak phase 1. At the same time a prospective observational study from July 1 till the WHO declaration of the end of the pandemic has started in the eight high volume centers to monitor the post-operative outcome and its effect on SARS-CoV-2 infection.

Value-Based Healthcare and Enhanced Recovery After Surgery Implementation in a High-Volume Bariatric Center in Italy.

BACKGROUND: Bariatric surgery is the most effective treatment for patients affected by morbid obesity. The Enhanced Recovery After Surgery (ERAS) protocol increases clinical outcomes, but the most recent literature shows incomplete patients' adherence. This study aims to demonstrate the feasibility of applying a Value-Based Healthcare (VBHC) strategy associated with ERAS to increase patients' engagement and outcomes. METHOD: A multiprofessional team redesigned the process considering ERAS recommendations and patients' feedbacks. Outcomes that matter to patients were defined with structured patients' interviews and collected in the electronic clinical record. Adherence to the pathway and the cost of the cycle of care were measured to demonstrate sustainability. A model was developed to grant its replicability. RESULTS: A total of 2.122 patients were included. The lowest adherence to the protocol for a single item was 82%. 74% of excess weight loss; 90% better comorbidities control; 77.5% had no pain after surgery; 61% no postoperative nausea and vomiting. Zero mortality; 1.8% overall morbidity; 0.4% readmission and reoperation rate within 30 days. The average length of stay is 2.1 days. Patient-Reported Outcome Measures (PROMs) documented increased productivity and quality of life. CONCLUSION: Building a caring relationship by a multidisciplinary team, adding patient wellness in a VBHC framework on top of ERAS as a patient-centered approach, increases patients' engagement and adherence to the pathway of care, resulting in better health outcomes (clinical and PROMs). The Value-Based Model is sustainable and replicable; it represents the prototype for redesigning other pathways and may become a model for other organizations.

Enhanced recovery after bariatric surgery (ERABS) in a high-volume bariatric center.

BACKGROUND: The growing demand for bariatric surgery has been accompanied by an expensive technological evolution and the need to contain healthcare costs and to increase the quality of care. The enhanced recovery after surgery (ERAS) protocols applied to the bariatric setting can be the answer to all these different issues. OBJECTIVES: Feasibility and safety of ERAS protocol in a single, high-volume bariatric center. SETTING: Humanitas Research Hospital, Rozzano MI, Italy. METHODS: Our ERAS bariatric protocol is based on the following 3 steps: (1) preoperative: optimization of all co-morbidities, counseling patients and family with information and education, and shortening fasting times (clear fluids up to 2 hr and solids up to 4 hr before induction of anesthesia); (2) intraoperative: premedication, parallel team work, awake patient positioning, standardized multimodal anesthesia and analgesia, noninvasive monitoring, video-laryngoscopy in reverse Trendelenburg position, short-acting anesthetic agents, and standardized laparoscopic surgery avoiding the nasogastric tube, catheter, and drain; and (3) postoperative: analgesia, early mobilization, early oral fluid, thromboprophylaxis, discharge planning, and follow-up telephone call. Clinical pathways were established and outcomes were retrospectively collected. RESULTS: Comparison between conventional care and ERAS protocol reveals a reduction of the length of hospital stay (from 4.7 to 2.1 d) and a low morbidity rate. From July 2015 to July 2018, a total of 2400 consecutive patients underwent primary or revisional bariatric surgery (2122 sleeve gastrectomies and 278 Roux-en-Y gastric bypasses [RYGB]). Mean body mass index was 44.9 kg/m2, mean age was 41.9 years, and the male to female ratio was 1:2.5. Total mean operative time was 85 minutes, with a surgical time of 65 minutes and an anesthesiologic/patient induction time of 4 minutes. Early complication rate was 3.5% with no perioperative mortality. Mean hospital stay was 2.1 days and the rate of readmission was .9%. CONCLUSIONS: This study demonstrates that our ERAS protocol is safe, feasible, and efficient. Patient preparation and multidisciplinary/parallel team work are crucial points.

Laparoscopic sleeve gastrectomy in a patient with situs viscerum inversus totalis: is the life easy upside-down?

INTRODUCTION: Obesity is an epidemic on the rise [1]. The number of bariatric procedures has increased worldwide. Laparoscopic sleeve gastrectomy (LSG) is a valid therapeutic option, leading to a sustained weight loss with a low complication rate [2]. Situs viscerum inversus totalis (SIT) is the complete transposition of all the abdominal organs, occurring in about 1 in 10,000 people [3]. Laparoscopic approach in SIT is challenging due to the mirror image anatomy. MATERIALS AND METHODS: We present the case of a 41-year-old man with a body mass index of 46.4 kg/m2 (131 kg; 1.68 m) previously diagnosed with SIT who has undergone LSG. RESULTS: In this video, we show a LSG performed in a patient with SIT. There were no changes in the technique compared to the "standard anatomy." The patient was placed on the operative table in anti-trendelenburg position with legs abducted. The surgeon stood between the legs while the assistant was on the right side of the patient and the scrub nurse on the opposite side. A 12-mm trocar was inserted with a direct technique in the right lateral flank. Carbon dioxide insufflation was done under vision. Other three trocars (12, 10, and 5 mm) were positioned in the left lateral flank, supraumbilical, and subxiphoid areas, respectively. Gastroepiploic dissection started at 5 cm from the pylorus up to the right crus. After the insertion of a 36-Fr boogie, an accurate stapling of the stomach was performed. The proximal side of the sleeve was reinforced with a non-absorbable suture. Titanium clips were placed leading to a complete haemostasis. The procedure lasted 45 min. The patient followed a "fast-track" protocol afterwards, with no changes in the perioperative workup compared to "standard anatomy" patients. He was discharged on day 2 postoperatively and no complication occured in the perioperative period. CONCLUSION: SIT is a rare condition leading to a mirror image that can be challenging for a laparoscopic surgeon. LSG is feasible and safe also for morbidly obese patients with SIT, not requiring any change in the surgical technique and perioperative management, as long as the surgeon is well beyond the learning curve.

Sleeve gastrectomy leads to easy management of hormone replacement therapy and good weight loss in patients treated for craniopharyngioma.

The aim of this study is to investigate the effects of sleeve gastrectomy on hormone replacement therapy and on hypothalamic obesity in patients affected by craniopharyngioma with post-surgical pan-hypopituitarism. A retrospective review of three patients, treated for hypothalamic obesity with laparoscopic sleeve gastrectomy, who have previously undergone surgery for craniopharyngioma in their childhood, was done. Patients' mean age and BMI were 22.3 years (range 21-24) and 49.2 kg/m2 (range 41.6-58.1), respectively. The mean time of delay between neurosurgery and bariatric surgery was 12.3 years (range 6-16). There were no major complications or deaths. At 24 months follow-up, the mean BMI was 35.3 kg/m2 (range 31.2-40.6). No hydrocortisone and sex steroids dose changes were observed, while levothyroxine was decreased in two patients. Growth hormone replacement therapy was increased in two patients, whereas it was started in one patient. Desmopressin was significantly decreased in all of them. Patients with surgically induced pan-hypopituitarism after craniopharyngioma who become obese, can expect good results from sleeve gastrectomy: this procedure does not have significant negative effects on hormone substitution and leads to a good stabilization of body weight in a mid-term follow-up.

Dietary habits and body weight at long-term following biliopancreatic diversion.

AIM: This study aims to evaluate the role of simple carbohydrates and alcohol intake in determining weight of stabilization at long-term following malabsorptive bariatric surgery. MATERIAL AND METHODS: Sixty patients at more than 2 years following biliopancreatic diversion (BPD) were submitted to an alimentary interview for evaluating the daily consumption of simple sugar, fruits, ice-cream, sweets, and caloric and alcoholic beverages. Eating behavior was assessed by Three Factors Eating Questionnaire. RESULTS: The mean estimated daily energy consumption intake was 2,852 kcal, with a mean daily intake of simple carbohydrates of 89 g that represented 12% of the total energy intake. The current body weight was positively and independently related to the preoperative body weight and to simple carbohydrate and alcohol intake and negatively related to physical activity, while no association with total energy consumption and eating behavior was found. DISCUSSION: These findings confirm that following BPD the body weight is independent of energy intake and eating behavior. Furthermore, these data suggest that in post-BPD subjects the simple carbohydrates and alcohol absorption is fully preserved, and that the operated subjects could regulate their body weight by reducing simple carbohydrates and alcoholic intake and increasing physical activity.

A comparison of a personal series of biliopancreatic diversion and literature data on gastric bypass help to explain the mechanisms of resolution of type 2 diabetes by the two operations.

BACKGROUND: Roux-en-Y gastric bypass (RYGBP) and biliopancreatic diversion (BPD) are highly beneficial operations for type 2 diabetes mellitus (T2DM) in obese patients, leading to complete T2DM resolution in 75-90 and 97-99% of cases, respectively. In both RYGBP and BPD, the foregut is excluded from the food stream and the distal small bowel receives the food stimulation, while following BPD fat intestinal absorption is also extremely limited. This study was carried out to identify clinical features that could give insight on the different mechanisms of action on diabetes resolution. METHODS: The files of 443 severely obese patients with T2DM undergoing BPD from May 1976 to May 2007 were examined, and the presence of T2DM (fasting serum glucose >125 mg/ml) at 1-2 months, at 1 year, at 10 years, and at > or =20 years following the operation was recorded. RESULTS: The percentage of patients cured (fasting serum glucose reduced to < or =110 mg/dl, on free diet and with no therapy) was 74% at 1 month, 97% at 1 and 10 years, and 91% at > or =20 years, the 26% of uncured patients at 1 month being those with most severe preoperative T2DM. CONCLUSIONS: As the early results after BPD resemble those reported after RYGBP, it can be hypothesized that the duodenal exclusion and the distal small bowel stimulation are the first mechanisms acting in BPD, immediately after the operation, that only subsequently the myocellular fat depletion, which cannot be immediate, takes over, and that the minimal fat absorption is the mechanism accounting for the long-term results of BPD.

Histological alterations following bariatric surgery: pilot study.

BACKGROUND: Macroscopic clinical evidence of tissue damaging following bariatric surgery pushed plastic surgeons to presume microscopic alterations as well. METHODS: Five preliminary cases studied randomly, and compared with healthy tissues, confirmed these initial suspects. A deeper and wider study has then been structured. RESULTS: Preliminary results are so evident to encourage us to carry on an estimated 2-3 years multidisciplinary study. CONCLUSIONS: What we want to study is if histological post-bariatric alterations are confirmed, and if these can be considered responsible for higher complication rate in body contouring following bariatric surgery.

Behavioral characteristics of severely obese patients seeking bariatric surgery: cross-sectional study with alimentary interview.

The authors' aim in this study was to gain insight on the eating behaviors of severely obese patients seeking bariatric surgery. The authors compared anthropometric and alimentary interview data on 50 patients applying for biliopancreatic diversion with data obtained from 50 severely obese individuals enrolling in a behavior modification weight-loss program. The severely obese patients seeking bariatric surgery were metabolically more compromised than were their counterparts enrolled in the conservative treatment group, whereas the latter more often reported compromised eating behaviors. These unexpected results could reflect changes in the widespread attitudes toward bariatric surgery-that unlike in the past, it is now considered a safe and effective method to treat a serious disease.

Does biliopancreatic diversion carry increased risk for colorectal cancer? A cohort study.

BACKGROUND: Because of the rearrangement of the gastrointestinal tract, biliopancreatic diversion (BPD) could lead to an increased risk of colorectal cancer caused by possible carcinogenetic action of the unabsorbed food and bile acid on colonic mucosa. METHODS: The incidence of colorectal cancer in 1,898 obese subjects submitted to BPD from May 76 to July 2002 with a minimum follow-up of 5 years was retrospectively evaluated. RESULTS: Among 28,811 person-years, seven cases of colorectal cancer were detected, for an overall incidence of 29.4 per 100,000, which is not different from that observed in the general Italian population, and lower than that reported for obese and type 2 diabetes patients. Logistic regression model suggests that occurrence of colorectal cancer is positively related to the time elapsed from BPD. CONCLUSION: This study indicates that BPD does not carry any increased risk for colorectal cancer. The complete postoperative restoration of insulin sensibility could exert a valuable protective action.

Biliopancreatic diversion reduces QT interval and dispersion in severely obese patients.

OBJECTIVES: The objectives were to evaluate QT interval (QTc) and QT-interval dispersion (QTd) in severely obese individuals and to determine the effects of biliopancreatic diversion (BPD) and weight loss after BPD on ventricular repolarization parameters. BACKGROUND: People with severe obesity (SO) have a 50% to 100% increased risk of death associated with a 1.6-fold increased risk of sudden death. BPD surgery induces rapid and considerable weight loss through severe lipid malabsorption, thus achieving long-term weight control. RESEARCH METHODS AND PROCEDURES: A total of 85 subjects with SO (age, 42 +/- 12 years; 66 females; mean body weight, 120 +/- 29 kg; BMI, 45 +/- 11 kg/m(2)) of 330 who had a bariatric surgical consultation between January 2001 and July 2002 were enrolled. Inclusion criteria were sinus rhythm, unremarkable 12 leads surface electrocardiogram, no atrioventricular blocks and/or bundle branch blocks, normal serum electrolyte profile, and no medical therapies exerting known effects on QTc. Exclusion criteria were previous diagnosis of coronary artery disease, known cardiovascular disease, atrial fibrillation or any other known cardiac arrhythmias, cancer, or renal dysfunction. RESULTS: A total of 86% of patients had QTc >440 ms and/or QTd >60 ms. Subjects with SO showed a mean maximum QTc of 446 +/- 28 ms and a mean QTd of 52 +/- 20 ms. A close correlation was found between QTc and QTd (p < 0.0001; R(2) = 0.33). One month after BPD, mean QTc was 420 ms and remained stable at follow-up; QTd was 32 ms at 1 and 6 months and became 35 ms at 1 year. CONCLUSIONS: Ventricular repolarization abnormalities are significantly increased in subjects with SO. Reduction of QT abnormalities after BPD is independent of weight loss and is caused by the 100% reduction of glucose plasma shortly after surgery. This effect may be related to surgical interruption of the entero-insular axis.

Long-term control of type 2 diabetes mellitus and the other major components of the metabolic syndrome after biliopancreatic diversion in patients with BMI < 35 kg/m2.

BACKGROUND: Bariatric operations are the most powerful means of curing type 2 diabetes mellitus (T2D) and the other major components of the metabolic syndrome. Despite the very frequent occurrence of metabolic disturbances in patients with BMI from 30 to 35, there is a general reluctance to operate on these patients, as their disease is considered less severe. METHODS: 7 T2D obese patients with mean BMI < 35 underwent BPD between 1976 and 1996 at the Azienda Ospedaliera Universitaria San Martino of Genoa, Italy. Mean age was 49 years, mean body weight 91 kg, and mean waist circumference 115 (M) and 98 (F) cm. The mean follow-up was 13 (10-18) years. All 7 patients had abnormally high values of serum triglyceride, serum cholesterol, and arterial pressure. RESULTS: In all patients, serum glucose was normalized at 1,2, and 3 years. In 5 patients, a slight increase of serum glucose above 125 mg/dl was observed at or around 5 years, the values being maintained at all subsequent times, with no one value higher than 160 mg ever being recorded. The other 2 patients showed full resolution of diabetes at all follow-up times. Both serum cholesterol and triglyceride values fell to normal 1 year after BPD, and remained within the normal range in all 7 patients during the entire follow-up observation. Arterial pressure normalized in 6 cases and was improved in 1 case. No patient had excessive weight loss at any postoperative time. CONCLUSIONS: T2D patients with BMI < 35 have very severe metabolic disturbances. Surgical therapy for these patients is warranted, and it should be performed as soon as possible, before the rapid evolution of the pattern leads them to a point where even the most effective metabolic surgery operation could be insufficient to yield complete and permanent control of their diabetes.