Association of Baseline Triglyceride-Glucose Index with Poor Glycemic Control and Diabetes Remission After Metabolic Surgery.

PURPOSE: The utility of insulin resistance (IR) as a predictor of diabetes remission after metabolic surgery is not well-defined. We assessed the association of baseline surrogate IR indices including triglyceride-glucose (TyG) index and homeostatic model assessment for IR (HOMA-IR) with glycemic control and diabetes remission after metabolic surgery. MATERIALS AND METHODS: Patients with type 2 diabetes scheduled for metabolic surgery were recruited at a single-center (n = 149; age: 44 ± 10 years, 47.7% men, body mass index: 41.5 ± 7.5 kg/m2), and followed-up for 12 months postoperatively. The relationships between the IR indices and poor glycemic control (HbA1c ≥ 7%) at baseline or complete diabetes remission (HbA1c < 6% without glucose-lowering medications at 12 months) post-surgery were examined. RESULTS: Elevated TyG index was associated with poor glycemic control cross-sectionally. Compared with non-remitters, lower baseline TyG index levels were observed in individuals with complete diabetes remission after surgery (P = 0.012); whereas HOMA-IR was not significantly different. Consistently, the proportion of diabetes non-remitters (compared to remitters) increased with increasing TyG tertiles from 1 to 3 (P = 0.015). Both TyG index (relative risk = 0.62, 95% CI = 0.42-0.91, P = 0.014) and TyG tertile 1 (relative risk = 1.99, 95% CI = 1.25-3.24, P = 0.003) independently predicted diabetes remission. The TyG index identified diabetes remission with an area under the curve of 0.68. The optimal TyG threshold was 9.41, yielding a sensitivity of 69.6%, specificity of 60.9%, positive predictive value of 64.0%, and negative predictive value of 66.7%. CONCLUSION: TyG index, previously suggested to predominantly reflect muscle IR, outperforms HOMA-IR as an IR indicator associated with glycemic control and diabetes remission after metabolic surgery.

Efficacy and safety of one anastomosis gastric bypass versus Roux-en-Y gastric bypass for type 2 diabetes remission (ORDER): protocol of a multicentre, randomised controlled, open-label, superiority trial.

INTRODUCTION: Previous studies have demonstrated that one anastomosis gastric bypass (OAGB) is not inferior to Roux-en-Y gastric bypass (RYGB) in treating obesity. However, high level evidence comparing the efficacy and safety of both procedures in type 2 diabetes (T2D) treatment is still lacking, which is another main aim of bariatric surgery. The presented trial has been designed to aim at investigating the superiority of OAGB over the reference procedure RYGB in treating T2D as primary endpoint. And diabetes-related microvascular and macrovascular complications, cardiovascular comorbidities, weight loss, postoperative nutritional status, quality of life and overall complications will be followed up for 5 years as secondary endpoints. METHODS AND ANALYSIS: This prospective, multicentre, randomised superiority open-label trial will be conducted in patients of Asian descent. A total of 248 patients (BMI≥27.5 kg/m2) who are diagnosed with T2D will be randomly assigned (1:1) to OAGB or RYGB with blocks of four. The primary endpoint is the complete diabetes remission rate defined as HbA1c≤6.0% and fasting plasma glucose≤5.6 mmol/L without any antidiabetic medications at 1 year after surgery. All secondary endpoints will be measured at different follow-up visit points, which will start at least 3 months after enrolment, with a continuous annual follow-up for five postoperative years in order to provide solid evidence on the efficacy and safety of OAGB in patients with T2D. ETHICS AND DISSEMINATION: The study has been approved by the ethics committee of leading centre (Beijing Friendship Hospital, Capital Medical University, no. 2021-P2-037-03). The results generated from this work will be disseminated to academic audiences and the public via publications in international peer-reviewed journals and conferences. The data presented will be imported into a national data registry. Findings are expected to be available in 2025, which will facilitate clinical decision-making in the field. TRIAL REGISTRATION NUMBER: NCT05015283.

Roux-en-Y gastric bypass versus best medical treatment for type 2 diabetes mellitus in adults with body mass index between 27 and 32 kg/m2: A 5-year randomized controlled trial.

AIMS: To evaluate the effects of Roux-en-Y gastric bypass (RYGB) versus best medical treatment in Asians with type 2 diabetes mellitus (T2DM) and class I obesity. METHODS: In this 5-year single-centre, open-label randomized controlled trial, participants were randomized to RYGB or medical treatment including newer classes of diabetes medications (ClinicalTrials.gov:NCT02041234). The primary endpoint was diabetes remission defined as HbA1c ≤ 6% (≤42 mmol/mol) and discontinuation of glucose-lowering medication at 12 months post-intervention and beyond. Glycaemia and weight changes were assessed. Continuous glucose monitoring was performed. RESULTS: Of 28 subjects randomized, 26 were analyzed in the final cohort (14 medical, 12 RYGB; age:44 ± 10 years, 34.6% males, BMI:29.4 ± 1.6 kg/m2). At 12 months, 50% of RYGB subjects achieved diabetes remission; 83% stopped all glucose-lowering medications. By year 5, 42% were in remission. None attained diabetes remission in the medical group. Percentage declines in fasting plasma glucose, HbA1c and BMI were significantly greater in the RYGB arm (all P < 0.05). Early improvements in glycaemic variability and time in range were similar in both treatment arms. Hypoglycaemia and surgical complications were observed in some RYGB subjects. CONCLUSIONS: Over 5 years, RYGB outperforms best medical treatment in glycemia and weight improvements for Asians with T2DM and class I obesity.

Long-Term Observation of a Man With Severe Obesity and Undiagnosed Monogenic Diabetes Serendipitously Treated With Metabolic Surgery.

A 43-year-old man, with severe obesity (43 kg/m2) and diabetes (presumed as type 2 diabetes [T2D]), underwent vertical sleeve gastrectomy in 2009 and Roux-en-Y gastric bypass in 2013. Recently, whole exome sequencing (conducted to search for monogenic obesity) serendipitously revealed that the individual harbored a heterozygous glucokinase (GCK) variant p.(Arg422Leu) that was bioinformatically strongly predicted to be likely pathogenic. Therefore, he is likely to have concomitant maturity-onset diabetes of the young (MODY) type 2 (GCK-MODY). A retrospective evaluation of the clinical data showed that the subject was diagnosed with T2D (given his severe obesity) in 2005 and was treated with oral antidiabetic monotherapy. His hyperglycemia was mostly mild (HbA1c [hemoglobin] < 8.1%), consistent with that of MODY2, despite severe obesity. After vertical sleeve gastrectomy, complete diabetes remission (HbA1c <6.0% and fasting plasma glucose <5.6 mmol/L without use of antidiabetic medication) was achieved. The percentage of maximum body weight loss attained after surgery was 23.6%. Euglycemia was maintained during the subsequent decade, up to the last follow-up in 2019, without any sign of hypoglycemia. In conclusion, we report a decade-long clinical experience of a man with severe obesity and diabetes likely due to the coexistence of GCK-MODY and T2D, serendipitously treated with metabolic surgery. Interestingly, metabolic surgery was effective and safe for him.

Correlation of Telomere Length in Adipose Tissue and Leukocytes and its Association with Postsurgical Weight Loss.

OBJECTIVE: The aim of this study was to determine the relationship between telomere length (TL) in subcutaneous adipose tissue (SAT), visceral adipose tissues (VAT), and leukocytes, as well as to examine the associations of TL in these tissues with postsurgical weight loss in Asians with severe obesity. METHODS: Presurgery TL was measured in leukocytes, SAT, and VAT of 91 patients who underwent weight loss surgery. Correlation between TL in multiple tissues was assessed using Pearson correlation. The association of presurgery TL and postsurgical weight loss at 6 or 12 months, expressed as a percentage of weight loss, was determined using linear regression in 70 patients. RESULTS: Telomeres were longer in VAT compared with those in leukocytes and SAT (P < 0.001) but were highly correlated between tissues. The strongest correlation was observed between TL in VAT and leukocytes (r = 0.739, P = 6.22 × 10-17 ). Compared with individuals in the highest tertile, those in the lowest tertile of VAT TL showed greater weight loss (ß = 6.23, SE = 3.10, P = 0.044) independent of age, sex, ethnicity, types of surgery, diabetes condition, preoperative BMI, and follow-up period. CONCLUSIONS: Among patients with severe obesity, TL in leukocytes and adipose tissue was highly correlated. However, there was variability in the association of TL in these tissues with weight loss after surgery.

Metabolic Surgery Diabetes Remission (MDR) Score: a New Preoperative Scoring System for Predicting Type 2 Diabetes Remission at 1 Year After Metabolic Surgery in the Singapore Multi-ethnic Asian Setting.

PURPOSE: The utility of available scoring systems for type 2 diabetes (T2D) remission prediction after metabolic surgery has not been defined in a multi-ethnic Asian population like Singapore. We sought to assess the predictive performance of the Asia-developed ABCD scoring system for T2D remission after metabolic surgery, and develop a new algorithm to improve prediction. MATERIALS AND METHODS: We conducted a retrospective analysis of adults with T2D who underwent either Roux-en-Y gastric bypass or sleeve gastrectomy between 2007 and 2018, and followed for 1 year postoperatively (n = 114, mean age 46 ± 9 years, 48.2% men, body mass index 40.1 ± 6.6 kg/m2). The primary outcome was complete T2D remission defined as HbA1c < 6% without the use of anti-diabetic medication at 1 year after surgery. RESULTS: Complete T2D remission was observed in 47.4% of subjects at 1 year post-surgery. Stepwise logistic regression identified preoperative age, T2D duration, HbA1c, and ß-cell function (estimated by the homeostasis model) as predictors of complete T2D remission. Based on these four variables, we constructed a new 10-point scoring system named Metabolic surgery Diabetes Remission (MDR) score. Compared with ABCD, MDR produced fewer misclassifications at the mid-high scores, achieving a predictive accuracy of 71-100% at 6 points and above. In addition, MDR achieved a higher area under the receiver operating characteristic curve than ABCD for the primary outcome (0.79 versus 0.67, P = 0.007). CONCLUSION: MDR may serve as a useful clinical scoring system for predicting short-term T2D remission after metabolic surgery in Singapore's multi-ethnic Asian cohort.

Weight Loss After Bariatric Surgery Predicts an Improvement in the Non-alcoholic Fatty Liver Disease (NAFLD) Fibrosis Score.

PURPOSE: Non-alcoholic fatty liver disease (NAFLD) is present in up to 90% of bariatric surgery patients. Previous literature has demonstrated an improvement in liver steatosis and fibrosis in post-bariatric surgery patients. Our study aims to investigate if bariatric surgery results in an improvement in NAFLD fibrosis scores, and if this correlates with weight loss. METHODS: A retrospective study was conducted on all patients who underwent bariatric surgery from 2010 to 2016 in our institution. Patients who had a redo bariatric surgery or concomitant gastric pathologies were excluded. Indications for bariatric surgery followed the Asia-Pacific Metabolic and Bariatric Surgery Society guidelines. RESULTS: There were 192 patients in this study, with the majority being females (n = 120, 63%). Mean age was 42.7 ± 10.2 years old. Pre-operative mean weight and body mass index (BMI) were 113 ± 27.9 kg and 41.6 ± 7.98 kg/m2 respectively. The mean pre-operative NAFLD fibrosis score was - 1.27. Six-month and 1-year follow-up post-surgery demonstrated a decrease in mean weight to 90.6 and 85.9 kg and a decrease in mean BMI to 33.8 and 31.6 kg/m2. Mean NAFLD scores improved from - 1.27 to - 1.56 to - 2.00. The correlation between weight loss and NAFLD fibrosis score improvement was statistically significant at the first post-operative year (r-coefficient = 0.36, p value ≤ 0.001). CONCLUSION: Bariatric surgery results in weight reduction as well as an improvement in the NAFLD fibrosis score. The degree of weight loss predicts the extent of improvement in NAFLD fibrosis scores. More long-term studies need to be conducted to assess if this effect is permanent.

HSCRP as surrogate marker in predicting long term effect of bariatric surgery on resolution of non-alcoholic steatohepatitis.

BACKGROUND: Nonalcoholic steatohepatitis (NASH) is closely associated with obesity and is one of the important etiologies of hepatocellular carcinoma (HCC and liver failure. Bariatric surgery is proven to be effective in causing weight loss and improvement of NASH) but there is limited long term data. OBJECTIVES: To identify the predictors of NASH in morbidly obese patients and evaluate long term data of bariatric surgery effects on NASH. METHODS: 308 bariatric patients (mean age 30.2 years old, body mass index (BMI) 45.0 kg/m2) with concurrent liver biopsy form 2003 to 2008 were included. We compared the clinical data between the NASH and non-NASH group and identify predictors of NASH in this cohort of patients. Remission of NASH was evaluated using the predictor of NASH. RESULTS: Prevalence of NASH was 43.8%. At baseline, the NASH and non-NASH groups both had similar age, BMI and sex ratio but the NASH group had significantly worse glycemic control, liver enzymes, triglycerides and uric acid. Highly sensitive-C Reactive Protein (HSCRP) level was identified as the only independent predictor of NASH. Ten years follow up (60.4% loss to follow up) showed good weight loss, resolution of co-morbidities and reduction of HSCRP. Patients with bypass surgery had better weight loss and lower levels of HSCRP. (HSCRP 0.2 ± 0.1 mg/dL vs. 0.8 ± 0.7 mg/dL, p = 0.009). than non-bypass group. CONCLUSION: NASH is common in bariatric patients. HSCRP is the only independent predictor of NASH and can be used as a surrogate marker in predicting long term effect of Bariatric Surgery on resolution of non-alcoholic steatohepatitis Bypass procedure was better in resolution of NASH than non-bypass procedure.

Improvement in Non-alcoholic Fatty Liver Disease Score Correlates with Weight Loss in Obese Patients Undergoing Laparoscopic Sleeve Gastrectomy: a Two-Centre Study from an Asian Cohort.

PURPOSE: Incidence of non-alcoholic fatty liver disease (NAFLD) is on the rise and is one of the most common causes of chronic liver disease worldwide. Obesity and metabolic syndrome are considered the most significant risk factors. Bariatric surgery is the only treatment modality in morbid obesity which allows long-term weight loss with improvement in associated co-morbid conditions. However, the effects of bariatric surgery on NAFLD are not well established. NAFLD fibrosis score (NFS) is a validated non-invasive scoring system used to assess advanced fibrosis. We used the NFS to analyse the impact of weight loss on NAFLD following sleeve gastrectomy. MATERIALS AND METHODS: 174 patients who underwent bariatric surgery between 2010 and 2016 were retrospectively reviewed. Multivariate analysis was performed using pre-operative patient characteristics, biochemical markers and TANITA body analysis measurements to determine significant risk factors for NFS > 0.675. Additionally, the NFS was calculated at 6 months, 1 year and 2 years post-operatively to determine correlation with weight loss. RESULTS: Pre-operatively, 13.8% of our patients had significant fibrosis by NFS. Mean change in NFS was - 0.46 ± 1.02, - 0.55 ± 0.98 and - 0.55 ± 1.12 at 6 months, 1 year and 2 years respectively. This was significantly correlated with percent of total weight loss with R coefficients of 0.253, 0.292 and 0.274 respectively (P < 0.05). 79.2% of patients with NFS > 0.675 achieved resolution by 2 years post-operatively. CONCLUSION: Based on our study, we conclude that sleeve gastrectomy may be a viable treatment option for management of NAFLD in the obese.

Long-term effect of bariatric surgery on resolution of nonalcoholic steatohepatitis (NASH): An external validation and application of a clinical NASH score.

BACKGROUND: Nonalcoholic steatohepatitis (NASH) is an important etiology of end-stage liver disease. Long-term effect of bariatric surgery in improvement of NASH is not clear. OBJECTIVES: To validate a scoring system for predicting NASH in morbidly obese patients and using it to evaluate the long-term effect of bariatric surgery on NASH. SETTING: Tertiary referral hospital, Taiwan. METHODS: A new 5-point clinical NASH (C-NASH) score incorporating body mass index, alanine aminotransferase, and triglyceride was validated in a group of 307 bariatric patients (mean age 30.2 years, incorporating body mass index 45.0 kg/m2) with concurrent liver biopsy from 2003 to 2008. Remission of NASH in 5741 obese patients undergoing bariatric/metabolic surgery with long-term follow-up was then evaluated using the C-NASH score. RESULTS: Among 307 patients with liver biopsy, the prevalence of NASH was 44.0%. At baseline, the NASH group had significantly worse fasting glucose levels, triglycerides, uric acid, aspartate aminotransferase, alanine aminotransferase, gamma glutamyl transferase, and glycated hemoglobin. The diagnostic sensitivity of C-NASH score was 84.4%, and the accuracy was 68.4%. Among 5741 bariatric patients, the prevalence of high risk for NASH evaluated by C-NASH score was 40.9%. Postoperative follow-up showed good weight loss and almost complete remission of high risk for NASH up to 10 years. Patients with gastric banding had less weight loss, higher mean level of C-NASH score, and a higher incidence of high risk for NASH compared with other procedures at follow-up. CONCLUSION: This study demonstrated that improvement in C-NASH score suggesting remission of NASH is durable up to 10 years in all kinds of bariatric procedures.

Prevalence and Determinants of Vitamin D Deficiency Among the Overweight and Obese Singaporeans Seeking Weight Management Including Bariatric Surgery: a Relationship with Bone Health.

PURPOSE: Low vitamin D status is prevalent worldwide and has been linked to a variety of pathologies including obesity in adults. The severity of vitamin D deficiency amongst the overweight and obese Singaporeans is not well documented. The purpose of this prospective observational study was to assess the prevalence and determinants of vitamin D deficiency in a multi-ethnic Asian population referred for weight management, including those seeking bariatric surgery. MATERIALS AND METHODS: This was a cross-sectional study conducted among 111 consecutive subjects referred to a single institution weight management service in Singapore. The data collected included their anthropometric data, body mass index (BMI), body fat percentage, waist circumference, 25-hydroxyvitamin D [25(OH)D] and other bone turnover markers. RESULTS: The average BMI among the 111 subjects was 40.1 ± 8.2 kg/m2 and mean age of 40 ± 10 years. Vitamin D deficiency was found in 75.7% of the population. There was a significant negative association of vitamin D with adiposity markers including BMI (r = - 0.31), body fat percentage (r = - 0.34) and waist circumference (r = - 0.26). Predictors of vitamin D deficiency included age > 50 years, female gender, waist circumference and body fat percentage. CONCLUSION: Vitamin D deficiency is prevalent among this target population in Singapore regardless of ethnicity. In particular, the elderly, females, those with larger waist circumference and body fat percentage were significantly associated with lower serum 25(OH)D level. Hence, routine screening for the overweight and obese subjects in multi-ethnic Singapore seeking weight management is indicated.

Chimney Stent-Graft Repair for Concurrent Inferior Mesenteric Artery Aneurysm and Infrarenal Abdominal Aortic Aneurysm: Case Report.

PURPOSE: To report a rare case of concurrent inferior mesenteric artery (IMA) aneurysm and infrarenal abdominal aortic aneurysm (AAA) with a novel indication for the use of chimney stent-graft technique in this patient. CASE REPORT: An 82-year-old man with an asymptomatic 4.4-cm fusiform AAA and 3.6-cm IMA aneurysm, coupled with chronic occlusion of celiac artery and superior mesenteric artery at the ostia, underwent endovascular repair of both aneurysms. Preservation of the IMA and treatment of both aneurysms were achieved with IMA aneurysm stenting, aortic aneurysm stenting and IMA chimney stenting. At 1, 6, and 12 months surveillance, the grafts remained patent without endoleak. CONCLUSIONS: The IMA chimney with aortic stenting technique may be safely used in patients who require preservation of the IMA during AAA and IMA aneurysm repairs.

Laparoscopic Removal of Intrahepatic Foreign Body: A Novel Technique for Management of an Unusual Cause of Liver Abscess--Fish Bone Migration.

BACKGROUND: Fish bone migration from the gastrointestinal tract into the liver is an unusual cause of liver abscess. MATERIALS AND METHODS: We describe successful laparoscopic removal of intrahepatic fish bones in 2 patients who presented with liver abscesses. Both patients were admitted to our institution with a 2-week history of right upper quadrant pain, fever, chills, and rigors. Radiological imaging revealed the presence of a linear calcified foreign body within a hepatic abscess in the left lateral section of the liver. These findings were suggestive of infection secondary to migration of fish bone from the stomach to the liver. RESULTS: Both patients underwent percutaneous drainage of liver abscesses with control of sepsis, followed by laparoscopic removal of intrahepatic fish bones. Localization of the fish bones was facilitated by intraoperative ultrasonographic examination of the liver. Postoperative recovery was fast and uneventful. CONCLUSIONS: This is the first report of two consecutive cases of liver abscess caused by fish bone migration where our patients were successfully treated by percutaneous drainage of the abscess followed by laparoscopic removal of intrahepatic fish bone.