Bariatric surgery in managing diabetes mellitus.

PURPOSE OF REVIEW: Obesity is a worldwide epidemic, having profound effects on Western populations. Bariatric surgery has long been employed to treat obesity and its related comorbidities. Over time, researchers have amassed significant data to support bariatric surgery in the pursuit of treating diabetes mellitus. This review serves to introduce the most recent findings and their relation to the various bariatric surgical options as bariatric surgery will continue to cement itself in the treatment paradigm of diabetes mellitus. RECENT FINDINGS: Numerous studies performed in the past 10 years have demonstrated the improvement or cessation of diabetes with bariatric surgical intervention. In comparing the vertical sleeve gastrectomy and Roux-en-Y gastric bypass, data demonstrate a more beneficial response of diabetes to the Roux-en-Y gastric bypass, and an even further exaggerated response with the biliopancreatic diversion/duodenal switch. The benefit has long been established, but what causes the improvement in diabetes mellitus after bariatric surgery? Recent data suggest a decrease in circulating bile salts as well as changes to inflammatory markers and circulating cytokines. Furthermore, tailoring of existing surgical procedures has led to the development of the SIPS procedure, and its benefit is demonstrated in bypassing a large portion of intestine while eliminating an enteroenterostomy, helping to reduce short gut syndrome and resultant diarrhea. SUMMARY: The surgical climate within the bariatric field is changing and will continue to do so in the future. As the understanding of the causes or mechanisms in which bariatric surgery improves metabolic disorders becomes more evident, the process of individualizing care for specific patients will become more prevalent.

Bariatric and metabolic surgery: current trends and what's to follow.

PURPOSE OF REVIEW: Obesity is a global epidemic and bariatric surgery remains an underperformed modality for its treatment. Even though the dangers of obesity are well understood, surgical intervention is underestimated. The purpose of this review is to discuss emerging trends in bariatric surgery. RECENT FINDINGS: Studies suggest that different operations have different effects on both obesity and its comorbidities. Combining the concepts of malabsorption and restriction, we are looking toward more advanced and efficient treatment options. Less-invasive techniques such as endoscopic devices are under investigation and their results remain to be determined. SUMMARY: A paradigm shift is occurring and both obesity and diabetes will be increasingly treated with surgical and endoscopic procedures. Bariatric care is a growing field for surgeons and therapeutic endoscopists with many future opportunities for improvement.

Endoscopic suturing for transoral outlet reduction increases weight loss after Roux-en-Y gastric bypass surgery.

BACKGROUND & AIMS: Weight regain or insufficient loss after Roux-en-Y gastric bypass (RYGB) is common. This is partially attributable to dilatation of the gastrojejunostomy (GJ), which diminishes the restrictive capacity of RYGB. Endoluminal interventions for GJ reduction are being explored as alternatives to revision surgery. We performed a randomized, blinded, sham-controlled trial to evaluate weight loss after sutured transoral outlet reduction (TORe). METHODS: Patients with weight regain or inadequate loss after RYGB and GJ diameter greater than 2 cm were assigned randomly to groups that underwent TORe (n = 50) or a sham procedure (controls, n = 27). Intraoperative performance, safety, weight loss, and clinical outcomes were assessed. RESULTS: Subjects who received TORe had a significantly greater mean percentage weight loss from baseline (3.5%; 95% confidence interval, 1.8%-5.3%) than controls (0.4%; 95% confidence interval, 2.3% weight gain to 3.0% weight loss) (P = .021), using a last observation carried forward intent-to-treat analysis. As-treated analysis also showed greater mean percentage weight loss in the TORe group than controls (3.9% and 0.2%, respectively; P = .014). Weight loss or stabilization was achieved in 96% subjects receiving TORe and 78% of controls (P = .019). The TORe group had reduced systolic and diastolic blood pressure (P < .001) and a trend toward improved metabolic indices. In addition, 85% of the TORe group reported compliance with the healthy lifestyle eating program, compared with 53.8% of controls; 83% of TORe subjects said they would undergo the procedure again, and 78% said they would recommend the procedure to a friend. The groups had similar frequencies of adverse events. CONCLUSIONS: A multicenter randomized trial provides Level I evidence that TORe reduces weight regain after RYGB. These results were achieved using a superficial suction-based device; greater levels of weight loss could be achieved with newer, full-thickness suturing devices. TORe is one approach to avoid weight regain; a longitudinal multidisciplinary approach with dietary counseling and behavioral changes are required for long-term results. ClinicalTrials.gov identifier: NCT00394212.

Response to glucose tolerance testing and solid high carbohydrate challenge: comparison between Roux-en-Y gastric bypass, vertical sleeve gastrectomy, and duodenal switch.

BACKGROUND: Hyperinsulinemic hypoglycemia is common after Roux-en-Y gastric bypass (RYGB) and may result in weight regain. The purpose of our investigation was to compare the effect of RYGB, vertical sleeve gastrectomy (VSG), and duodenal switch (DS) on insulin and glucose response to carbohydrate challenge. METHODS: Patients meeting National Institutes of Health criteria for bariatric surgery selected their bariatric procedure after evaluation and education in this prospective nonrandomized study. Preoperatively and at 6, 9, and 12 months' follow-up, patients underwent blood draw to determine levels of fasting glucose, fasting insulin, glycated hemoglobin (HbA1c), C-peptide, and 2-h oral glucose challenge test. Homoeostatic Model Assessment (HOMA)-IR, fasting to 1-h and 1- to 2-h ratios of glucose and insulin, were calculated. Statistical analysis was performed using ANOVA and Student's paired t test. All procedures were performed via a laparoscopic technique at a single institution. RESULTS: Data from a total of 38 patients (13 RYGB, 12 VSG, 13 DS) were available for analysis. At baseline, all groups were similar; the only statistically significant difference was that DS patients had a higher preoperative weight and body mass index (BMI). All operations caused weight loss (BMI 47.7 ± 10-30.7 ± 6.4 kg/m(2) in RYGB; 45.7 ± 8.5-31.1 ± 5.5 kg/m(2) in VSG; 55.9 ± 11.4-27.5 ± 5.6 kg/m(2) in DS), reduction of fasting glucose, and improved insulin sensitivity. RYGB patients had a rapid rise in glucose with an accompanying rise in 1-h insulin to a level that exceeded preoperative levels. This was followed by a rapid decrease in glucose level. In comparison, DS patients had a lower increase in glucose and 1-h insulin, and the lowest HbA1c. These differences were statistically significant at various data points. For VSG, the results were intermediary. CONCLUSIONS: Compared to gastric bypass, DS results in greater weight loss and improves insulin sensitivity and glucose homeostasis without causing a hyperinsulinemic response. Because the response to challenge after VSG is intermediary, pyloric preservation alone cannot account for this difference.

Obesity in the Workplace: Impact, Outcomes, and Recommendations.

OBJECTIVE: To conduct a comprehensive literature review to develop recommendations for managing obesity among workers to improve health outcomes and to explore the impact of obesity on health costs to determine whether a case can be made for surgical interventions and insurance coverage. METHODS: We searched PubMed from 2011 to 2016, and CINAHL, Scopus, and Cochrane Registry of Clinical Trials for interventions addressing obesity in the workplace. RESULTS: A total of 1419 articles were screened, resulting in 275 articles being included. Several areas were identified that require more research and investigation. CONCLUSIONS: Our findings support the use of both lifestyle modification and bariatric surgery to assist appropriate patients in losing weight.

Can Composite Nutritional Supplement Based on the Current Guidelines Prevent Vitamin and Mineral Deficiency After Weight Loss Surgery?

BACKGROUND: Nutritional deficiencies occur after weight loss surgery. Despite knowledge of nutritional risk, there is little uniformity of postoperative vitamin and mineral supplementation. The objective of this study was to evaluate a composite supplement based on the clinical practice guidelines proposed in 2008 regarding vitamin and mineral supplementation after Roux-en-Y gastric bypass. The composite included iron (Fe) and calcium as well. METHODS: A retrospective chart review of 309 patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) was evaluated for the development of deficiencies in iron and vitamins A, B1, B12, and D. Patients were instructed to take a custom vitamin and mineral supplement that was based on society-approved guidelines. The clinical practice guidelines were modified to include 1600 international units (IU) of vitamin D3 instead of the recommended 800 IU. RESULTS: The compliant patients' deficiency rates were significantly lower than those of the noncompliant patients for iron (p = 0.001), vitamin A (p = 0.01), vitamin B12 (p ≈ 0.02), and vitamin D (p < 0.0001). Women's menstrual status did not significantly influence the development of iron deficiency. CONCLUSIONS: Use of a composite based on guidelines proposed by the AACE, TOS, and the ASMBS appears to be effective for preventing iron and vitamins A, B1, B12, and D deficiencies in the LRYGB patients during the first postoperative year. Separation of calcium and Fe does not need to be mandatory. Even with simplification, compliance is far from universal.

Stomach Intestinal Pylorus Sparing (SIPS) Surgery for Morbid Obesity: Retrospective Analyses of Our Preliminary Experience.

BACKGROUND: Although the duodenal switch (DS) has been the most effective weight loss surgical procedure, it is a small minority of the total bariatric surgical cases performed. Modifications that can make the operation technically simpler and reduce a long-term risk of short bowel syndrome would be of benefit. The aim of this study was to detail our initial experience with a modified DS called stomach intestinal pylorus sparing (SIPS) procedure. METHODS: Data from patients who underwent a primary SIPS procedure performed by two surgeons at two centers from January 2013 to August 2014 were retrospectively analyzed. All revisions of prior bariatric procedures were excluded. Regression analyses were performed for all follow-up weight loss data. RESULTS: One hundred twenty-three patients were available. One hundred two patients were beyond 1 year postoperative, with data available for 64 (62 % followed up). The mean body mass index (BMI) was 49.4 kg/m(2). Two patients had diarrhea (1.6 %), four had abdominal hematoma (3.2 %), and one had a stricture (0.8 %) in the gastric sleeve. Two patients (1.6 %) were readmitted within 30 days. One patient (0.8 %) was reoperated due to an early postoperative ulcer. At 1 year, patients had an average change in BMI of 19 units (kg/m(2)), which was compared to an average of 38 % of total weight loss or 72 % of excess weight loss. CONCLUSIONS: Modification of the classic DS to one with a single anastomosis and a longer common channel had effective weight loss results. Morbidity seems comparable to other stapling reconstructive procedures. Future analyses are needed to determine whether a SIPS procedure reduces the risk of future small bowel obstructions and micronutrient deficiencies.

Outcomes in Patients with Helicobacter pylori Undergoing Laparoscopic Sleeve Gastrectomy.

BACKGROUND: In vertical sleeve gastrectomy (VSG), the majority of the stomach is resected and much of the tissue colonized with Helicobacter pylori and the bulk of acid producing cells are removed. In addition, the effect of H. pylori colonization of the stomach of patients undergoing stapling procedures is unclear. As a result, the need for detection and treatment of H. pylori in patients undergoing VSG is unknown. METHODS: Four hundred and eighty patients undergoing VSG are the subject of this study. Three surgeons at a single institution performed the procedures. The remnant stomach was sent to pathology and tested for the presence of H. pylori using immunohistochemistry. All patients were discharged on proton pump inhibitors. RESULTS: Of the 480 patients who underwent VSG, 52 were found to be H. pylori positive based on pathology. There was no statistically significant difference in age (p = 0.77), sex (p = 0.48), or BMI (p = 0.39) between the groups. There were 17 readmissions post-op. Five of these were in the H. pylori positive cohort. Six of these complications were classified as severe (anastomotic leak, intra-abdominal collection, or abscess), with two in the H. pylori positive cohort (Table 1). There was no statistically significant difference in the severe complication rates between the two groups (p = 0.67). There were no readmissions for gastric or duodenal ulceration or perforation. CONCLUSIONS: Our data suggests that there is no increase in early complications in patients with H. pylori undergoing VSG. If these findings are confirmed in a long-term follow-up, it would mean that preoperative H. pylori screening in patients scheduled for VSG is not necessary.

Abnormal glucose tolerance testing after gastric bypass.

BACKGROUND: Symptoms secondary to dumping have been suggested to help patients refrain from simple carbohydrate ingestion after Roux-en-Y gastric bypass (RYGB). During follow-up examinations, we noted many patients with weight regain complaining of fatigue shortly after eating. Thus, we decided to study the glucose tolerance test (GTT) results in a cohort of post-RYGB patients. METHODS: A total of 63 RYGB patients, >6 months postoperatively, were studied with a GTT and measurement of insulin levels. The mean age was 48.5 ± 10.8 years, mean preoperative body mass index was 49.0 ± 6.5 kg/m(2), mean percentage of excess body mass index lost was 64.5% ± 29.0%, mean weight regain at follow-up was 11.6 ± 12.4 lb, and mean follow-up period was 47.9 months. RESULTS: Of the 63 patients, 49 had abnormal GTT results. Of the 63 patients, 6 were diabetic; however, only 1 of these patients had an elevated fasting glucose level. All 6 patients were diabetic preoperatively. Of the 63 patients, 43 had evidence of reactive hypoglycemia at 1-2 hours after the glucose load. Of these patients, 22 had a maximum/minimum glucose ratio >3:1, including 7 with a ratio >4:1. CONCLUSION: The results of the present study have demonstrated that an abnormal GTT result is a common finding after RYGB. Reactive hypoglycemia was found in 43 of 63 patients, with insulin values that do not support nesidioblastosis. It is our hypothesis, that rather than preventing simple carbohydrate ingestion, the induced hypoglycemia that occurs might contribute to weight regain and maladaptive eating in certain post-RYGB patients.

Comparison between RYGB, DS, and VSG effect on glucose homeostasis.

BACKGROUND: Our group has reported a high incidence of reactive hypoglycemia following Roux-en-Y gastric bypass (RYGB) with specific interest in postprandial insulin and the ratio of 1- to 2-h serum glucose levels. The purpose of this study is to compare the 6-month response to oral glucose challenge in patients undergoing RYGB, duodenal switch (DS), and vertical sleeve gastrectomy (VSG). METHODS: Thirty-eight patients meeting the NIH criteria for bariatric surgery who have reached the 6-month postoperative mark are the basis of this report. Preoperatively and at 6 months follow-up, patients underwent blood draw to determine levels of fasting glucose, fasting insulin, HbA1c, C peptide, and 2 h oral liquid glucose challenge test (OGTT). HOMA-IR and 1 to 2 h ratios of glucose and fasting to 1 h ratio of insulin were calculated. RESULTS: All patients underwent a successful laparoscopic bariatric procedure (VSG =13, DS =13, and RYGB = 12). All operations reduced BMI, HgbA1c, fasting glucose, and fasting insulin. HOMA IR and glucose tolerance improved with all procedures. In response to OGTT at 6 months, there was a 20-fold increase in insulin at 1 h in RYGB, which was not seen in DS. At 6 months, 1-h insulin was markedly lower in DS (p < .05), yet HbA1C was also lower in DS (p < .05). This resulted in 1- to 2-h glucose ratio of 1.9 for RYGB, 1.8 for VSG, and 1.3 for DS (p < .05). CONCLUSIONS: All operations improve insulin sensitivity and decrease HgbA1c. Six-month weight loss was substantial in all groups between 22-29% excess body weight. RYGB results in marked rise in glucose following challenge with corresponding rise in 1-h insulin. VSG has a similar response to RYGB. In comparison, at 6 months following surgery, DS causes a much lower rise in 1-h insulin, with this difference being statistically significant at p < .05. As a result, DS results in a less abrupt reduction in blood glucose. Although 1-h insulin is lower, DS patients had the lowest HbA1C at 6 months (p < .05). We believe that these findings have important implications for the choice of bariatric procedure for both diabetic and non-diabetic patients.