Mesenteric Vein Thrombosis following Sleeve Gastrectomy: A Case Report and Review of the Literature.

INTRODUCTION: Acute mesenteric ischemia (AMI) is a rare but lethal disease. Mesenteric vein thrombosis (VAMI) is a subtype of AMI. Morbid obesity is usually accompanied by hypertension, hyperlipidemia, or diabetes mellitus, which are risk factors associated with AMI. CASE PRESENTATION: We present a 28-year-old man with VAMI post-laparoscopic sleeve gastrectomy. He was first misdiagnosed with intestinal obstruction. Superior VAMI was confirmed after computed tomography angiography. Laparotomy, resection of the necrotic small bowel, and ostomy were performed immediately. CONCLUSION: Patients with morbid obesity accompanied by hypertension, hyperlipidemia, or diabetes mellitus have a high risk of AMI. Abdominal pain with sudden onset should be considered AMI. Anticoagulation therapy post-sleeve gastrectomy might help reduce the incidence of AMI.

Long-Term Health Outcomes of Limb Salvage Compared with Amputation for Combat-Related Trauma.

BACKGROUND: There are little long-term health data, particularly in terms of body composition and development of metabolic syndromes, to help surgeons to guide the decision between limb salvage and amputation in patients with limb-threatening trauma. The purpose of this study was to compare long-term health outcomes after high-energy lower-extremity trauma between patients who underwent attempted flap-based limb salvage or amputation. METHODS: We performed a retrospective review of servicemembers with a minimum 10-year follow-up who underwent flap-based limb salvage followed by unilateral amputation or continued limb salvage after combat-related, lower-extremity trauma between 2005 and 2011. Patient demographic characteristics, injury characteristics, and health outcomes including body mass index (BMI) and development of metabolic disease (e.g., hyperlipidemia, hypertension, heart disease, and diabetes) were compared between treatment cohorts. Adjusted BMIs were calculated for the amputation cohort to account for lost surface area. We performed multivariable and propensity score analysis to determine the likelihood of developing obesity or metabolic disease. RESULTS: In this study, 110 patients had available long-term follow-up (mean, 12.2 years) from the time of the injury. Fifty-six patients underwent limb salvage and 54 patients underwent unilateral amputation. There was no difference in preinjury BMI (p = 0.30). After adjusting for limb loss, the amputation cohort had a trend toward higher BMIs at ≥1 years after the injury, a higher rate of obesity, and a greater increase in BMI from baseline after the injury. The development of metabolic comorbidities was common after both amputation (23 [43%] of 54) and limb salvage (27 [48%] of 56). With the numbers available, we were unable to demonstrate a difference in risk for the development of hypertension, hyperlipidemia, diabetes, heart disease, or any comorbidity other than obesity (p > 0.05). CONCLUSIONS: Amputations may be medically necessary and may decrease pain, improve mobility, and/or expedite return to activity compared with limb salvage after similar injuries. However, limb loss may negatively impact metabolic regulation and may contribute to a higher risk of obesity despite beneficial effects on mobility. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

The Effect of Hyperlipidemia as a Risk Factor on Postoperative Complications in Patients Undergoing Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To analyze the effect of hyperlipidemia (HLD) on postoperative complications in patients who underwent anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: ACDF represents the standard procedure performed for focal anterior nerve root or spinal cord compression with low complication rates. HLD is well known as a risk factor for major complications after vascular and transplant surgery, and orthopedic surgery. To date, there have been no studies on HLD as a risk factor for cervical spine surgery. PATIENTS AND METHODS: Patients who underwent ACDF from 2010 through quarter 3 of 2020 were enrolled using the MSpine subset of the PearlDiver Patient Record Database. The patients were divided into single-level ACDF and multilevel ACDF groups. In addition, each group was divided into subgroups according to the presence or absence of HLD. The incidence of surgical and medical complications was queried using relevant International Classification of Disease and Current Procedural Terminology codes. Charlson Comorbidity Index was used as a broad measure of comorbidity. χ 2 analysis, with populations matched for age, sex, and Charlson Comorbidity Index, was performed. RESULTS: A total of 24,936 patients who underwent single-level ACDF and 26,921 patients who underwent multilevel ACDF were included. In the multilevel ACDF group, wound complications were significantly higher in the patients with HLD. Among medical complications, myocardial infarction, renal failure, and urinary tract infection/urinary incontinence were significantly higher in the patients with HLD in both groups. Revision surgery and readmission were significantly higher in the patients with HLD who underwent multilevel ACDF. CONCLUSIONS: In patients who underwent ACDF, several surgical and medical complications were found to be higher in patients with HLD than in patients without HLD. Preoperative serum lipid concentration levels and management of HLD should be considered during preoperative planning to prevent postoperative complications in patients undergoing ACDF.

Roux-en-Y Gastric Bypass in Patients with Super Obesity: Primary Response Criteria and Their Relationship with Comorbidities Remission.

BACKGROUND: The prevalence of super obesity has increased considerably in recent years, representing up to the 0.5% of the population. Even though bariatric surgery induces significant weight loss in these patients, it has been reported that up to 50% of the patients with super obesity will fail according to the current primary response criteria. OBJECTIVE: To evaluate and compare different primary response criteria and their impact regarding comorbidities remission. PATIENTS AND METHODS: A total of 104 patients with super obesity who underwent Roux-en-Y gastric bypass (RYGB) were identified in our institution from March 2004 to February 2019. An evaluation of the primary response at a 2-year follow-up was made using different criteria. A multivariate analysis was made to evaluate related variables to comorbidities remission. RESULTS: Two years later, the rate of patients who achieved an EWL > 50%, %EWL > 70%, and BMI < 35 kg/m2 were 84.5%, 52.1%, and 62%, respectively. Regarding the comorbidities, 85%, 84.8%, and 81.1% of the patients improved or remitted T2D, HBP, and hyperlipidemia, respectively. An EWL > 50% 2 years later was related to complete remission of hyperlipidemia (p = 0.047), whereas weight regain above 10% is a risk factor for failure of complete remission of HBP in 3 years. CONCLUSIONS: More than 75% of patients with super obesity yield an EWL > 50% 2 years later. In terms of hyperlipidemia, it is desirable to achieve an EWL of at least 50%. Whereas for T2D and HBP, a minimum of 25% TWL yields 72% and 60.5% of complete remission.

Patient-reported Comorbidity Assessment After Bariatric Surgery: A Potential Tool to Improve Longitudinal Follow-up.

OBJECTIVE: To determine the accuracy of postoperative patient-reported comorbidity assessment, as it may be an important mechanism for long-term follow-up in surgical patients. SUMMARY OF BACKGROUND DATA: Less than 1% of patients who qualify actually undergo bariatric surgery which may be due to concerns surrounding long-term efficacy. Longitudinal follow-up of patients' comorbidities remains a challenge. METHODS: Retrospective, cross-sectional study of bariatric surgery patients from 38 sites within a state-wide collaborative from 2017 to 2018. A minimum of 10 and maximum of 20 responses to a 1-year postoperative questionnaire from each site were randomly sampled. We examined percent agreement between patient-reported and medical chart audit comorbidity assessment and further evaluated agreement by intraclass correlation or κ statistic. Postoperative comorbidities assessed include weight, hyperlipidemia, hypertension, diabetes, depression, obstructive sleep apnea, gastroesophageal reflux disease (GERD), anxiety, and pain. RESULTS: Five hundred eighty-five patients completed postoperative questionnaires after laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass. The response rate was 64% during the study period. Patients reported weight with a mean difference of 2.7 lbs from chart weight (intraclass correlation = 0.964). Agreement between patient report and audit for all comorbidities was above 80% except for GERD (71%). κ statistics were greater than 0.6 (good agreement) for hyperlipidemia, hypertension, diabetes, and depression. Anxiety ( κ = 0.45) and obstructive sleep apnea ( κ = 0.53) had moderate agreement. Concordance for GERD and pain were fair (both κ = 0.38). CONCLUSIONS: Patient-reported comorbidity assessment has high levels of agreement with medical chart audit for many comorbidities and can improve understanding of long-term outcomes. This will better inform patients and providers with hopes of 1 day moving beyond the 1%.

Clinical factors influencing the development of extracranial-intracranial bypass graft for steno-occlusive cerebrovascular disease.

OBJECTIVEEffectively retaining the patency of the extracranial-intracranial (ECIC) bypass is one of the most important factors in improving long-term results; however, the factors influencing bypass patency have not been discussed much. Therefore, the authors investigated factors influencing the development of the bypass graft.METHODSIn this retrospective study, the authors evaluated 49 consecutive hemispheres in 47 adult Japanese patients who had undergone ECIC bypass for chronic steno-occlusive cerebrovascular disease. To evaluate objectively the development of the ECIC bypass graft, the change in the area of the main trunk portion of the superficial temporal artery (STA) from before to after bypass surgery (postop/preop STA) was measured. Using the interquartile range (IQR), the authors statistically analyzed the factors associated with excellent (> 3rd quartile) and poor development (< 1st quartile) of the bypass graft.RESULTSThe postop/preop STA ranged from 1.08 to 6.13 (median 1.97, IQR 1.645-2.445). There was a significant difference in the postop/preop STA between the presence and absence of concurrent diabetes mellitus (p = 0.0432) and hyperlipidemia (0.0069). Furthermore, logistic regression analysis revealed that only concurrent diabetes mellitus was significantly associated with poor development of the bypass graft (p = 0.0235).CONCLUSIONSDiabetes mellitus and hyperlipidemia influenced the development of the ECIC bypass graft. In particular, diabetes mellitus is the only factor associated with poor development of the bypass graft.

Roux-en-Y Gastric Bypass Is More Effective than Sleeve Gastrectomy in Improving Postprandial Glycaemia and Lipaemia in Non-diabetic Morbidly Obese Patients: a Short-term Follow-up Analysis.

PURPOSE: We aimed to compare the effects of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) on postprandial glucose and lipid metabolism in addition to weight loss and fasting metabolic profile, in non-diabetic patients undergoing bariatric surgery. METHODS: Seventy-one patients were consecutively recruited and studied preoperatively, 3 and 6 months after surgery. Of these, 28 underwent RYGB (7 males, age 38 ± 9 years, BMI 46.9 ± 5.0 kg/m2), and 43 SG (9 males, age 38 ± 9 years, BMI 50.2 ± 7.0 kg/m2). A semi-liquid mixed meal was consumed, and blood samples were taken before, and every 30 min after meal ingestion up to 180 min postprandially, for measurement of glucose, insulin, and lipids. The overall postprandial response was assessed as area under the concentration-time curve (AUC). RESULTS: Baseline metabolic parameters were similar between RYGB and SG. Both groups experienced comparable weight loss, and a similar improvement in fasting glucose, insulin, and insulin resistance. Total and LDL cholesterol levels were lower at 6 months after RYGB compared to SG, while there was no difference in HDL cholesterol or triglycerides. Glucose AUC was lower after RYGB compared to SG at both 3 (p = 0.008) and 6 months (p = 0.016), without any difference in postprandial insulin response. Triglyceride AUC was also lower in RYGB vs. SG at 3 and 6 months (p ≤ 0.001). CONCLUSIONS: RYGB is superior to SG in improving postprandial glycaemia and lipaemia and cholesterol profile 6 months postoperatively in non-diabetic, severely obese patients. These findings imply procedure-specific effects, such as the malabsorptive nature of RYGB, and less likely a different incretin postoperative response.

Metabolic Surgery and Diabesity: a Systematic Review.

Bariatric surgery is used to induce weight loss (baros = weight). Evidence has shown that bariatric surgery improves the comorbid conditions associated with obesity such as hypertension, hyperlipidemia, and type 2 diabetes mellitus T2DM. Hence, shifting towards using metabolic surgery instead of bariatric surgery is currently more appropriate in certain subset of patients. Endocrine changes resulting from operative manipulation of the gastrointestinal tract after metabolic surgery translate into metabolic benefits with respect to the comorbid conditions. Other changes include bacterial flora rearrangement, bile acids secretion, and adipose tissue effect. The aim of this systematic review is to examine clinical trials regarding long-term effects of bariatric and metabolic surgery on patients with T2DM and to evaluate the potential mechanisms leading to the improvement in the glycaemic control.

Early ventricular tachyarrhythmias after coronary artery bypass grafting surgery: Is it a real burden?

BACKGROUND: The prevalence of ventricular dysrhythmias (VD) [ventricular premature beats (VPBs), ventricular couplets (Vcouplets), ventricular runs (Vruns)] after coronary artery bypass grafting (CABG) has so far not been examined. The goal of this study is to examine characteristics of VD and whether they precede ventricular tachyarrhythmias (VTA) during a postoperative follow-up period of 5 days using continuous rhythm registrations. In addition, we determined predictive factors of VD/VTA. METHODS: Incidences and burdens of VD/VTA were calculated in patients (N=105, 83 male, 65±9 years) undergoing primary, on-pump CABG. Independent risk factors were examined using multivariate analysis. RESULTS: VPBs, Vcouplets, and Vruns occurred in respectively 100%, 82.9%, and 48.6% with corresponding burdens of 0.05%, 0%, and 0%. Sustained ventricular tachycardia (VT) and ventricular fibrillation (VF) did not occur in our cohort. Independent risk factors for VD included male gender, mitral valve insufficiency, hyperlipidemia, and age ≥60 years. CONCLUSIONS: VD are common in patients with coronary artery disease after CABG. Despite high incidences of these dysrhythmias, corresponding burdens are low and sustained VT or VF did not occur. Incidences were highest on the first postoperative day and diminished over time.

Partial ileal bypass affords protection from onset of type 2 diabetes.

BACKGROUND: Partial ileal bypass (PIB) in the National Institutes of Health-sponsored Program on the Surgical Control of the Hyperlipidemias (POSCH) randomized controlled trial was found to reduce plasma cholesterol, in particular low density lipoprotein cholesterol, with concomitant retardation of atherosclerotic cardiovascular disease and increased life expectancy. Glucagon-like peptide-1, related to amelioration of type 2 diabetes, is increased over 5-fold after PIB. We hypothesized that PIB, in addition to its action on cholesterol metabolism, may also prevent type 2 diabetes. METHODS: We surveyed by telephone inquiry of former POSCH patients the 30+year posttrial incidence of type 2 diabetes or prediabetes, the presence of which was a trial exclusion criteria. We were able to contact 17.4% (n = 838) of the original POSCH population. RESULTS: Of 66 control responders, 17 contracted type 2 diabetes (25.8%); of 80 PIB responders, 8 contracted type 2 diabetes (10%). The difference between groups was significant (P = .015 by Fisher exact test) with an odds ratio of .320 for the PIB group and an over 2-fold (2.6) increase in the incidence of type 2 diabetes in the controls. Including borderline type 2 diabetes (prediabetic) patients, these values were 22 of 66 controls (33.3%) and 10 of 80 PIB patients (12.5%), with an odds ratio of .286 and a P<.004, and again an over 2-fold (2.7) increase in the incidence of type 2 diabetes in the control patients. CONCLUSION: PIB appears to afford partial protection from the onset of type 2 diabetes for over 30 years.

Long-term and midterm outcomes of laparoscopic sleeve gastrectomy versus Roux-en-Y gastric bypass: a systematic review and meta-analysis of comparative studies.

OBJECTIVE: This study aimed to compare midterm and long-term weight loss and resolution of co-morbidity with laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). SUMMARY: LRYGB and LSG are the most common procedures performed in bariatric surgery. However, their weight loss efficacy in the midterm and long-term has not been well compared. METHODS: A meta-analysis was performed by systematically identifying comparative studies conducted until the end of June 2016 that investigated weight loss outcome and resolution of co-morbidities (type 2 diabetes mellitus, hypertension, hyperlipidemia, hypertriglyceridemia, and obstructive sleep apnea) with LRYGB and LSG in the midterm (3-5 years) and long term (≥5 years). The primary endpoint was weight loss after LRYGB versus LSG. The secondary endpoint was resolution of co-morbidities after these procedures. RESULTS: Fourteen studies comprising 5264 patients were eligible. Follow-up ranged from 36 months to 75.8±8.4 months. The pooled result for weight loss outcomes did not show any significant difference in midterm weight loss (standardized mean difference = -0.03; 95% confidence interval (CI), -0.38-.33; P = .88) but a significant difference in the long-term weight loss outcome favoring LRYGB (standardized mean difference = .17; 95% CI, .05-.28; P= .005). The pooled results demonstrated no significant difference for resolution of type 2 diabetes mellitus, hypertension, hyperlipidemia, and hypertriglyceridemia. CONCLUSION: Despite the insignificant difference between LRYGB and LSG in midterm weight loss, LRYGB produced better weight loss in the long-term. There was no significant difference between the 2 procedures for co-morbidity resolution.

A History of Bariatric Surgery: The Maturation of a Medical Discipline.

This article examines the progression of bariatric surgery since its creation more than 60 years ago with a focus on the effect of surgery on weight loss, comorbidity reduction, and safety. The success has been remarkable. It is possible to cure severe obesity, type 2 diabetes, and hyperlipidemia in addition to the many other manifestations of the metabolic syndrome with remarkable safety. Equally important are the opportunities for research afforded by the surgery and its outcomes. Until better treatments become available, bariatric surgery is the therapy of choice for patients with morbid obesity for weight control and comorbidity improvement.

Circulating ANGPTL8/Betatrophin Concentrations Are Increased After Surgically Induced Weight Loss, but Not After Diet-Induced Weight Loss.

BACKGROUND: ANGPTL8/betatrophin is a secreted protein reported to be involved in ß-cell replication that has recently been shown to be more related to lipid metabolism. Weight loss represents a clinical situation of improvement of glucose homeostasis and overall metabolic control. The aim of the present study was to analyze the impact of weight loss induced by either a conventional dietary treatment or bariatric surgery on ANGPTL8/betatrophin concentrations. METHODS: Serum concentrations of ANGPTL8/betatrophin were measured by ELISA in 158 subjects before and 1 year after weight loss induced either by conventional dietary treatment (n = 38) or bariatric surgery (sleeve gastrectomy, n = 20, or Roux-en-Y gastric bypass, n = 100). RESULTS: Massive surgery-induced weight loss after SG or RYGB was accompanied by a statistically significant increase in circulating levels of ANGPTL8/betatrophin (28.1 ± 13.9 to 40.3 ± 22.8 ng/mL, P = 0.001 after SG; 24.6 ± 10.9 to 41.7 ± 19.4 ng/mL, P < 0.001 after RYGB), while remaining unchanged 25.6 ± 13.3 to 25.4 ± 10.7 ng/mL (P = 0.891) after diet-induced weight loss. The change in ANGPTL8/betatrophin levels was positively correlated with the change in HDL-C concentrations. CONCLUSIONS: Our study showed that serum ANGPTL8/betatrophin concentrations were increased in obese subjects after surgically induced weight loss, but not after weight loss achieved by conventional dietary treatment. The change in ANGPTL8/betatrophin concentrations emerged as a significant predictor of the change in HDL-C levels after weight loss.

Five-year results of laparoscopic sleeve gastrectomy: effects on gastroesophageal reflux disease symptoms and co-morbidities.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is becoming the most performed bariatric procedure; however, data available on long-term follow-up are scanty. OBJECTIVES: The aim of the present study was to evaluate the 5-year efficacy of LSG on weight loss, gastroesophageal reflux disease (GERD) symptoms, and obesity-associated co-morbidities. SETTING: Tertiary-care referral hospital. METHODS: This study retrospectively analyzed 105 obese patients undergoing LSG from January 2006 to December 2009. The preoperative evaluation included demographic characteristics, evaluation of co-morbidities, a double-contrast barium swallow, and an upper-gastrointestinal endoscopy. The following data were collected at 1, 3, and 5 years after surgery: weight, improvement/remission of co-morbidities, complications, and revisional surgery. RESULTS: According to preoperative body mass index (BMI), patients were divided into Group 1 (n = 61) with BMI≤50 kg/m(2) and Group 2 (n = 44) with BMI>50 kg/m(2). The follow-up rate was 94% after 5 years (n = 99). Delta BMI (BMI at follow-up-preoperative BMI) was significantly higher in Group 2 than in Group 1 at 1-3 years and 5 years (P<.001). Furthermore, at 5 years, Group 2 showed a significantly higher percentage total weight loss (%TWL) (26.6%±18.3% versus 33.5%±12.9%, P = .006) than Group 1, whereas percentage excess weight loss was similar (58.4%±21.8% versus 55.3%±19.5%, P = .5).Younger age at surgery and absence of postoperative GERD were associated with a better %TWL at 5 years (P<.001 and P = .03). CONCLUSION: LSG is an effective procedure at long-term, with good weight loss outcomes and with a considerable improvement of obesity-associated co-morbidities. Younger age at surgery and absence of postoperative GERD were associated with a better %TWL at 5 years.

High-volume hemofiltration plus hemoperfusion for hyperlipidemic severe acute pancreatitis: a controlled pilot study.

BACKGROUND AND OBJECTIVES: The evidence for high-volume hemofiltration plus hemoperfusion (HVHF&HP) for hyperlipidemic severe acute pancreatitis (HL-SAP) is anecdotal. The purpose of our study was to evaluate the efficacy of HVHF&HP for HL-SAP in a prospective controlled study. DESIGN AND SETTING: Prospective controlled pilot study between May 2010 and May 2013 in a hospital intensive care unit. PATIENTS AND METHODS: HL-SAP patients chose conventional treatment alone (the control group) or conventional treatment combined with the experimental protocol (the HVHF&HP group) and were prospectively followed in our hospital. APACHE II score, SOFA score, ICU and hospital stay duration, and serum biomarkers were considered endpoints. RESULTS: Ten HL-SAP patients accepted conventional treatment alone (the control group) and 10 patients underwent HVHF&HP combined with conventional treatment (the HVHF&HP group). The APACHE II score, SOFA score, systolic blood pressure, diastolic blood pressure, heart rate, serum amylase, and serum creatinine were significantly reduced after the HVHF&HP treatment. The changes in these variables were significantly different between the HVHF&HP and control group at 48 hours after the initiation of treatment. Patients in the HVHF&HP group had a significantly shorter ICU stay (P=.015). The reduction in serum triglyceride and cholesterol in the HVHF&HP group after 2, 6, 12, 24, and 48 hours was greater than the control group. All of the tested serum cytokines were significantly decreased after HVHF&HP treatment (P < .05). However, in patients who underwent conventional treatment alone, there was no significant change in the serum cytokines. CONCLUSION: This study suggests that the addition of HVHF&HP to conventional treatment for HL-SAP patients may be superior to conventional treatment alone for the improvement of serum biomarkers and clinical outcomes.

Long-term effects of bariatric surgery on type II diabetes, hypertension and hyperlipidemia: a meta-analysis and meta-regression study with 5-year follow-up.

BACKGROUND: The first aim of the study was to estimate weight loss and major modifiable risk factors after bariatric surgery. The second aim was to investigate the relationship between the reduction in cardiovascular risk and weight loss over time. METHODS: A random effect of meta-analysis and dose-response meta-regression was used to evaluate weight loss and the risk of type II diabetes, hypertension and hyperlipidemia, 2-5 years after surgery. RESULTS: A search of the literature led to the selection of 22 papers. The body mass index (BMI) at the end of the observation period was 31.7 (95 % CI = 29.7-33.7; I(2) = 6 %). The risk of type II diabetes, hypertension and hyperlipidemia decreased after bariatric surgery, with relative risks of, respectively, 0.33 (95 % CI = 0.26-0.41; I(2) = 42 %), 0.54 (95 % CI = 0.46-0.64; I(2) = 68 %) and 0.33 (95 % CI = 0.22-0.46; I(2) = 74 %). Nonlinear meta-regression revealed different patterns of risk: Hypertension risk reached a minimum when the BMI fell 10 units. The risks of all cardiovascular outcomes reached a plateau, 20-40 months after surgery. CONCLUSIONS: The reduction in arterial hypertension reached a nadir earlier than the risk of diabetes and hyperlipidemia, thus indicating a possible link between weight reduction and positive hemodynamic effects.

[Clinical evidence for metabolic surgery]. / Klinische Evidenz der metabolischen Chirurgie.

The metabolic effect of bariatric surgery is well-established and is considered to be self-evident in morbidly obese patients with a body mass index (BMI) > 40 kg/m(2). Metabolic surgery performed on patients with obesity grades II (BMI 35-40 kg/m(2)) and I (BMI 30-35 kg/m(2)) according to the World Health Organization (WHO) has increased in recent years; however, the indications for metabolic surgery in obesity grades I and II are currently under debate due to insufficient evidence. In the last 5 years several highly qualified randomized clinical trials have been published which evaluated the effect of metabolic surgery in patients with obesity grades I and II in comparison to conservative therapy. Based on these data the efficacy of metabolic surgery in short-term follow-up (12-36 months) is unquestionable when compared to conservative therapy according to the current guidelines. Besides improved glycemic control and remission of diabetes, metabolic surgery has the potential to have a positive influence on diabetic complications, such as diabetic retinopathy, nephropathy and polyneuropathy, as well as on comorbidities, such as arterial hypertension and dyslipidemia. Future clinical trials should address the long-term (> 36 months) effects of metabolic surgery, patient selection criteria and choice of procedure.

Early improvement of postprandial lipemia after bariatric surgery in obese type 2 diabetic patients.

BACKGROUND: Bariatric surgery (BS) is able to positively influence fasting lipid profile in obese type 2 diabetic patients (T2DM), but no data is available on the impact of BS on postprandial lipid metabolism neither on its relation with incretin hormones. We evaluated the short-term (2 weeks) effects of BS on fasting and postprandial lipid metabolism in obese T2DM patients and the contribution of changes in active GLP-1. METHODS: We studied 25 obese T2DM patients (age = 46 ± 8 years, BMI = 44 ± 7 kg/m2), of which 15 underwent sleeve gastrectomy and 10 underwent gastric bypass. Lipid and incretin hormone concentrations were evaluated for 3 h after ingestion of a liquid meal before and 2 weeks after BS. RESULTS: After BS, there was a significant reduction in body weight (p < 0.001), fasting plasma glucose (p < 0.001), fasting plasma insulin (p < 0.05), HOMA-IR (p < 0.001), and fasting plasma lipids (p < 0.05). The meal response of plasma triglycerides, total cholesterol, and HDL cholesterol was significantly lower compared to pre-intervention (p < 0.05, p < 0.001). In particular, the incremental area under the curve (IAUC) of plasma triglycerides decreased by 60% (p < 0.005). The meal-stimulated response of active GLP-1 increased, reaching a statistical significance (p < 0.001). CONCLUSIONS: BS leads to an early improvement of fasting and postprandial lipemia. The fall in fasting triglycerides is associated with an improvement of insulin resistance, while the reduction of postprandial lipemia is likely related to reduced intestinal lipid absorption consequent to bariatric surgery.