The Role of Metabolic Surgery in Non-alcoholic Steatohepatitis Improvement.

PURPOSE OF REVIEW: Non-alcoholic fatty liver disease (NAFLD) is frequently associated with obesity and overweight. It has a broad spectrum of clinical and histological presentations, such as steatosis, inflammation (known as non-alcoholic steatohepatitis or NASH), fibrosis, and cirrhosis. There is increasing evidence that marked weight loss following bariatric surgery is associated with NASH resolution; however, little is known about the mechanisms that may lead to this beneficial condition and if it is due to weight loss alone. In this review, the authors present the latest data regarding NASH resolution following metabolic surgery and try to answer the following questions: is NASH resolution due to weight loss alone or is it related to weight-independent effects similarly to T2D? In such case, can NASH be considered as a sole criterion for metabolic surgery? RECENT FINDINGS: Most data evaluating NAFLD and bariatric and metabolic surgery are derived from cohort studies. Available data are extremely variable, but in general show a dramatic regression of steatosis, inflammatory changes, and in some cases even fibrosis that is probably linked to major weight loss following surgery. There are no randomized controlled trials evaluating the effects of metabolic surgery over NASH vs. lifestyle modifications. To consider NASH a sole indication for metabolic surgery regardless of BMI, such studies are desperately needed and should be the primary focus of future research in metabolic surgery.

Changing Guidelines for Metabolic Surgery: Now It's the Time!

The governing criteria for bariatric surgery dates back from 1991 and is based solely on body mass index (BMI) as the primary operative criterion, restricting surgery to severely obese patients. Although this was a tremendous step forward in standardizing practice, these guidelines now have important limitations. During the two decades since they were crafted, bariatric surgery has evolved. Also, new procedures are now being performed, as demonstrated by level-1 evidence from randomized controlled trials comparing surgical versus clinical approaches to obesity and related diseases. Although simple and inexpensive, BMI is not a good tool to choose the best treatment option. There is little doubt that BMI alone is not an appropriate indication for surgery and could exclude many patients who could benefit from this life-saving treatment, especially patients with T2DM and lower BMIs. In this matter, new guidelines are urgently needed in order to guarantee, regulate, and reimburse metabolic surgery.

How Durable Are the Effects After Metabolic Surgery?

Bariatric surgery was initially developed as a tool for weight reduction only, but it is gaining popularity because of its remarkable effect on glucose metabolism in morbidly obese and less obese patients. Recent publications have shown the superiority of metabolic surgery over medical treatment for diabetes, creating a new field of clinical research that is currently overflowing in the medical community with outstanding high-quality data. Metabolic surgery is effective in treating diabetes, even in non-morbidly obese patients.

Role of metabolic surgery in less obese or non-obese subjects with type 2 diabetes: influence over cardiovascular events.

Bariatric surgery was initially developed as a tool for weight reduction only, but it is gaining increasing popularity because of its remarkable effect on glucose metabolism in morbidly obese and less obese patients. Recent publications have shown the good results of metabolic surgery, creating a new field of clinical research that is currently overflowing in the medical community with outstanding high-quality data. In morbidly obese population, there is compelling data on long term cardiovascular risk reduction and mortality, coming from longitudinal prospective studies and systematic reviews. Numbers range from 33 to 92% of decrease in fatal and nonfatal cardiovascular events . In low body mass index (BMI) diabetics, there is an increasing number of reported good outcomes after metabolic surgery with the aim to treat type 2 diabetes (T2DM). There is scarce information on cardiovascular outcomes in non-morbidly obese subjects, but the extraordinary glucose, lipid and blood pressure control in the published series are suggesting good long-term effects on cardiovascular risk profile and mortality. The papers review was comprehensive, including the available randomized controlled trials, long-term prospective series and systematic reviews.

Early and late results of topical diltiazem and bethanechol for chronic anal fissure: a comparative study.

BACKGROUND/AIMS: Late efficacy of medical treatment of chronic anal fissure remains controversial due to high recurrence. This study aimed at analyzing safety and efficacy of topical diltiazem and bethanechol regarding healing and symptoms relief, safety, recurrence, and need for surgery. METHODOLOGY: This was a single-center nonrandomized trial. Outcomes of 30 patients with chronic anal fissure treated with 2% diltiazem were compared to 30 patients treated with 0.1% bethanechol, both for eight weeks. Patients were assessed after seven days and eight weeks. RESULTS: In diltiazem group, after seven days, 31% were symptomatic; after bethanechol, 71% (p = 0.06). After seven days, fissure healing occurred in 19% after diltiazem and in 11% after bethanechol. After eight weeks, in both groups, 64% were asymptomatic; after diltiazem, 53% healed; after bethanechol, 50% (p = 0.80). Success was the same for both groups: 63.3%. Groups were similar regarding complications. After diltiazem, 9 (30%) patients were operated on; and 11 (36.7%) after bethanechol (p = 0.60). Recurrence occurred in 4 (13.3%) patients in both groups. Median time to recurrence after diltiazem was 15 (10-24) months and 7.5 (2-15) after bethanechol - p = 0.15. CONCLUSIONS: Both treatments are safe and effective. Diltiazem may be associated to earlier relief and more sustained response.

Effect of Gastric Bypass vs Best Medical Treatment on Early-Stage Chronic Kidney Disease in Patients With Type 2 Diabetes and Obesity: A Randomized Clinical Trial.

Importance: Early-stage chronic kidney disease (CKD) characterized by microalbuminuria is associated with future cardiovascular events, progression toward end-stage renal disease, and early mortality in patients with type 2 diabetes. Objective: To compare the albuminuria-lowering effects of Roux-en-Y gastric bypass (RYGB) surgery vs best medical treatment in patients with early-stage CKD, type 2 diabetes, and obesity. Design, Setting, and Participants: For this randomized clinical trial, patients with established type 2 diabetes and microalbuminuria were recruited from a single center from April 1, 2013, through March 31, 2016, with a 5-year follow-up, including prespecified intermediate analysis at 24-month follow-up. Intervention: A total of 100 patients with type 2 diabetes, obesity (body mass indexes of 30 to 35 [calculated as weight in kilograms divided by height in meters squared]), and stage G1 to G3 and A2 to A3 CKD (urinary albumin-creatinine ratio [uACR] >30 mg/g and estimated glomerular filtration rate >30 mL/min) were randomized 1:1 to receive best medical treatment (n = 49) or RYGB (n = 51). Main Outcomes and Measures: The primary outcome was remission of albuminuria (uACR <30 mg/g). Secondary outcomes were CKD remission rate, absolute change in uACR, metabolic control, other microvascular complications, quality of life, and safety. Results: A total of 100 patients (mean [SD] age, 51.4 [7.6] years; 55 [55%] male) were randomized: 51 to RYGB and 49 to best medical care. Remission of albuminuria occurred in 55% of patients (95% CI, 39%-70%) after best medical treatment and 82% of patients (95% CI, 72%-93%) after RYGB (P = .006), resulting in CKD remission rates of 48% (95% CI, 32%-64%) after best medical treatment and 82% (95% CI, 72%-92%) after RYGB (P = .002). The geometric mean uACRs were 55% lower after RYGB (10.7 mg/g of creatinine) than after best medical treatment (23.6 mg/g of creatinine) (P < .001). No difference in the rate of serious adverse events was observed. Conclusions and Relevance: After 24 months, RYGB was more effective than best medical treatment for achieving remission of albuminuria and stage G1 to G3 and A2 to A3 CKD in patients with type 2 diabetes and obesity. Trial Registration: ClinicalTrials.gov Identifier: NCT01821508.

Incidence and management of colonoscopic colon perforations: 10 years' experience.

BACKGROUND/AIMS: This paper aimed to review experience with diagnostic and therapeutic colonoscopies performed by a colorectal surgeon with special interest in colonoscopy over a 10-yr period and to assess incidence and management of colonic perforations. METHODOLOGY: All colonoscopies performed between 1997 and 2007 were studied. Data on patients, colonoscopic reports and procedure-related complications were collected from computerized database. Medical records of patients with colonic perforation were reviewed. RESULTS: 7,804 colonoscopies were performed. Five colonoscopic perforations were identified (0.06%). Three occurred during diagnostic and two during therapeutic colonoscopy. All were suspected during or immediately after colonoscopy except for one therapeutic perforation diagnosed two days after the procedure. All perforations were surgically managed by the author. Surgery included conventional and laparoscopic repair, colectomy and proctocolectomy. There was need for stoma in one patient with pancolonic Crohn's disease with sigmoid colon stenosis. This patient underwent total proctocolectomy. There were no deaths. CONCLUSIONS: The rate of perforation during colonoscopy is low and can be managed with no mortality. Early diagnosis and treatment are essential. Early operative intervention through primary repair represents is safe and effective. Managing colonic pathology demanding resection in the urgent setting may benefit selected patients with colonoscopy perforation.

Stapled hemorrhoidectomy vs closed diathermy-excision hemorrhoidectomy without suture-ligation: a case-controlled trial.

BACKGROUND/AIMS: We compared stapled hemorrhoidectomy to closed diathermy-excision hemorrhoidectomy without suture-ligation regarding postoperative pain, complications and long-term efficacy. METHODOLOGY: A series of 108 patients had indication for stapled hemorrhoidectomy. Patients who underwent stapled hemorrhoidectomy (76) were compared to patients submitted to closed diathermy-excision hemorrhoidectomy (32) due to non-insurance cover. Primary endpoints were postoperative pain, complications, and clinical results after one year. Patients completed a 10-cm visual analog pain scale postoperatively and fulfilled a questionnaire before and 12 months after surgery. RESULTS: After seven days, median and maximum daily pain scores were lower in the stapled group (P < 0.001). Resumption of activities occurred after 9 days (mean; range 2 to 17 days) after stapling and 14 days (7 to 24) after diathermy surgery - P < 0.001. There was no difference regarding complications during the follow-up. After one year, 45 (80.4%) patients in the stapled group and 18 (78.3%) in the diathermy group were asymptomatic (P = 1.000). After one year, none of the patients needed a second operation and there was no fecal incontinence. CONCLUSIONS: Stapled hemorrhoidectomy selectively indicated is less painful, not associated to greater morbidity and has the same long-term efficacy when compared to closed diathermy excision without suture-ligation.

Colorectal cancer among patients aged 75 years or over.

BACKGROUND/AIMS: The aim of this study is to evaluate the risk factors for mortality, morbidity, and long-term survival in elderly patients with colorectal cancer when compared to younger patients. METHODOLOGY: Patients operated on with colorectal cancer were divided into 2 groups according to age: Group 1 (75 years old or older, n=90) and group 2 (<75 years, n=430). RESULTS: Preoperative hemoglobin levels were lower in group 1 (p = 0.008). Poorer clinical status defined by ASA score (p = 0.008) results and blood transfusions (p = 0.003) were more frequent in group 1 when compared to group 2. Group 1 had a significantly higher operative mortality rate than group 2 (p = 0.01). Regarding cancer-related survival after 1, 2, and 4 years, there was no significant difference between the 2 groups. CONCLUSIONS: Poorer clinical conditions with special regard to anemia are more frequent among patients of 75 years and older and this finding may lead to an increase in operative mortality when compared to younger patients. Even though, senior patients with colorectal cancer should not be denied surgical and adjuvant therapy on account of age alone since cancer-related survival remains comparable to younger patients' results.

Mechanisms of Action of Surgical Interventions on Weight-Related Diseases: the Potential Role of Bile Acids.

Surgical interventions for weight-related diseases (SWRD) may have substantial and sustainable effect on weight reduction, also leading to a higher remission rate of type 2 diabetes (T2D) mellitus than any other medical treatment or lifestyle intervention. The resolution of T2D after Roux-en-Y gastric bypass (RYGB) typically occurs too quickly to be accounted for by weight loss alone, suggesting that these operations have a direct impact on glucose homeostasis. The mechanisms underlying these beneficial effects however remain unclear. Recent research suggests that changes in the concentrations of plasma bile acids might contribute to these metabolic changes after surgery. In this review, we aimed to outline the potential role of bile acids in SWRD. We systematically reviewed MEDLINE, SCOPUS, and Web of Science for articles reporting the effect of SWRD on outcomes published between 1969 and 2016. We found that changes in circulating bile acids after surgery may play a major role through activation of the farnesoid X receptor A (FXRA), the fibroblast growth factor 19 (FGF19), and the G protein-coupled bile acid receptor (TGR5). Bile acid concentration increased significantly after RYGB. Some studies suggest that a transitory decrease occurs at 1 week post-surgery, followed by a gradual increase. Most studies have shown the increase to be proportionate by all bile acid subtypes. Bile acids can regulate glucose metabolism through the expression of TGR5 receptor in L cells, resulting in a release of glucagon-like peptide 1 (GLP-1). It may also induce the synthesis and secretion of FGF19 in ileal cells, thereby improving insulin sensitivity and regulating glucose metabolism. All the present SWRD are involved with changes in food stimulation to the stomach. This implies that discovering and developing the antagonists to TGR5 and FXRA may effectively control metabolic syndrome and the elucidation of the mechanisms underlying the physiological effects related to weight loss and T2D remission after surgery may help to identify new drug targets.

Microvascular Outcomes after Metabolic Surgery (MOMS) in patients with type 2 diabetes mellitus and class I obesity: rationale and design for a randomised controlled trial.

INTRODUCTION: There are several randomised controlled trials (RCTs) that have already shown that metabolic/bariatric surgery achieves short-term and long-term glycaemic control while there are no level 1A of evidence data regarding the effects of surgery on the microvascular complications of type 2 diabetes mellitus (T2DM). PURPOSE: The aim of this trial is to investigate the long-term efficacy and safety of the Roux-en-Y gastric bypass (RYGB) plus the best medical treatment (BMT) versus the BMT alone to improve microvascular outcomes in patients with T2DM with a body mass index (BMI) of 30-34.9 kg/m2. METHODS AND ANALYSIS: This study design includes a unicentric randomised unblinded controlled trial. 100 patients (BMI from 30 to 34.9 kg/m2) will be randomly allocated to receive either RYGB plus BMT or BMT alone. The primary outcome is the change in the urine albumin-to-creatinine ratio (uACR) captured as the proportion of patients who achieved nephropathy remission (uACR<30 mg/g of albumin/mg of creatinine) in an isolated urine sample over 12, 24 and 60 months. ETHICS AND DISSEMINATION: The study was approved by the local Institutional Review Board. This study represents the first RCT comparing RYGB plus BMT versus BMT alone for patients with T2DM with a BMI below 35 kg/m2. TRIAL REGISTRATION NUMBER: NCT01821508; Pre-results.

Innovative metabolic operations.

Bariatric surgery was developed with the aim of weight reduction. Success was defined only by excess weight loss. Other indices of resolution of metabolic co-morbidities were reported but were mostly secondary. Several communications have reported that regardless of body mass index (BMI), complete or partial remission of type 2 diabetes (T2D) is possible with such traditional gastrointestinal operations as the Roux-en-Y gastric bypass, bileopancreatic diversion, and sleeve gastrectomy. These results mostly occur before weight loss, positioning metabolic surgery as a good tool for controlling the current T2D epidemic. Surgery aimed mainly at the diseases, such as diabetes, and not weight loss are referred to as metabolic surgery. Metabolic surgery can effectively treat T2D in individuals with any BMI, including that below 35 kg/m(2). Concurrently, some new procedures were developed to treat patients that in theory do not need massive weight loss, focusing on a pathophysiological approach to T2D. Those new techniques, mainly duodenal jejunal bypass, ileal transposition, single-anastomosis duodenal ileal or jejunal bypass with sleeve gastrectomy, and the endoscopic duodenal liner, are experimental procedures, most reporting good metabolic control initially without relation to weight variation.

The Diabetes Surgery Summit II Guidelines: a Disease-Based Clinical Recommendation.

There is mounting evidence, derived from mechanistic studies, RCTs, and other high-quality studies that there are weight loss independent antidiabetic effects of gastrointestinal surgery. Additionally, there appears to be no relation between the positive metabolic outcomes to baseline BMI. The outdated US National Health Institutes guidelines from 1991 were centered on BMI only criterion and often misleading. The Second Diabetes Surgery Summit held in collaboration with leading diabetes organizations and endorsed by a large group of international Professional Societies developed guidelines that defined eligibility based on the severity and degree of T2D medical control while referring to obesity as a qualifier and not the sole criterion. That is the first time that guidelines are provided to put metabolic surgery into the T2D treatment algorithms.

Role of biological mesh in surgical treatment of paracolostomy hernias.

BACKGROUND: Paracolostomy hernia is a frequent complication of intestinal stoma. Its correction can be made through relocation of the colostomy or by keeping it in place and performing abdominal wall reinforcement through direct suturing with or without a prosthesis. METHOD: Results of surgical treatment of paracolostomy hernias were analyzed in 22 patients who underwent surgery in our hospital during the past 15 years, with or without biological mesh (bovine pericardium). All patients had terminal colostomies after abdominoperineal excision of the rectum. RESULTS: In 15 (68.2%) patients, hernia correction was made by maintaining the colostomy in place, in 2 of them (9.1%) without reinforcement, and in the other 13 (59.1%) through reinforcement of the aponeurosis with biological mesh. In the 7 (31.8%) other patients, hernia correction was accomplished by relocation of the colostomy. The mean follow-up period was 50.2 months. Recurrence was observed in 3 (13.6%) patients after a median of 16 months post-correction. CONCLUSION: Paracolostomy hernia remains a surgical challenge due to its high recurrence rate. Primary repair using a prosthesis of biological material may be preferable since muscle-aponeurotic weakness is frequently observed.

Bariatric and metabolic surgery and microvascular complications of type 2 diabetes mellitus.

INTRODUCTION: Metabolic dysregulation is the defining characteristic of type 2 diabetes mellitus (T2DM) and may lead to microvascular complications, specifically retinopathy, nephropathy and neuropathy. Medical treatment and lifestyle interventions targeting risk factors for microvascular complications can yield therapeutic gains, particularly retinopathy and nephropathy. Bariatric/metabolic surgery is superior to the best medical treatment in several randomized controlled trials. Consequently, evidence of the effect of bariatric/metabolic surgery on microvascular complications is now emerging in the literature. METHODS: A search of the recent published evidence base on the effects of bariatric/metabolic surgery on microvascular complications reveals further evidence that supports the efficacy of surgery in preventing the incidence and progression of albuminuria and preserving renal functional decline. DISCUSSION: Data on retinopathy are ambivalent representing the potential in some cases for an influence of reactive hypoglycaemia over the retina but the majority of data emphasize that the metabolic control can halt the progression of the eye disease. A significant gap in the literature remains in relation to the effects of surgery on diabetic neuropathy, although some information sheds a light on the benefits secondary to the surgical metabolic control. CONCLUSION: Overall, although data so far is exciting, there is a pressing need for prospective randomized controlled trials examining long-term microvascular outcomes following bariatric/metabolic surgery in patients with T2DM.

[Efficacy of contrast chromoendoscopy of the colon after oral administration of indigo carmine dye]. / Eficácia da cromoendoscopia de contraste do cólon com emprego do índigo-carmim administrado por via oral.

INTRODUCTION: Indigo carmine dye is usually spread directly over the colon in many chromoscopic techniques aiming better visualization of a lesion already detected by conventional colonoscopy. Examination of the colon already stained by oral administration of indigo carmine dye may increase detection of small lesions resulting in higher sensibility of the colonoscopy in diagnosing diminutive lesions. OBJECTIVE: Analyze the results regarding the quality of chromoscopic technique and the indigo carmine dye distribution over the colon after oral administration. PATIENTS AND METHODS: Fifty patients undergoing colonoscopy were evaluated. A capsule containing 100 mg of indigo carmine dye was offered to these patients 30 min before oral mannitol prep routinely used. The indigo carmine dye contrast effect was graded as bad, regular or good according to preestablished criteria in three segments of the colon: right and left colon and the rectum. RESULTS: In the right colon, good indigo carmine dye contrast effect was observed in only 9 (18.8%) patients, while it was considered regular and bad in 32 (66.6%) and in 7 (14.6%) patients, respectively. A good indigo carmine dye contrast effect was never observed in this series for the left colon or in the rectum. As a matter of fact, no indigo carmine dye was observed in the left colon in 80.9% and in the rectum in 92% of patients in this series. CONCLUSION: Although it may be simple and desirable, oral administration of indigo carmine dye seems ineffective for enhancing detection of diminutive lesions by chromoscopy as result of poor colonic distribution of indigo carmine dye mainly at distal colonic sites.

Metabolic Surgery for Type 2 Diabetes in Patients with a BMI of <35 kg/m(2): A Surgeon's Perspective.

Bariatric surgery was developed with the aim of weight reduction. Success was defined only by excess weight loss. Other indices of resolution of metabolic comorbidities were reported, but were mostly secondary. Several communications have reported that regardless of body mass index (BMI), complete or partial remission of type 2 diabetes mellitus (T2DM) is possible. These results mostly occur before weight loss, positioning metabolic surgery as a good tool for controlling the current T2DM epidemic. Medical treatment is evolving, but is expensive and not risk-free. Surgery aimed mainly at diseases such as diabetes and not weight loss are referred to as "metabolic surgery." Metabolic surgery has been proven to be safe and effective, and although more data are needed, it is unquestionable that a new discipline has been founded. Metabolic surgery can effectively treat T2DM in individuals with any BMI, including that below 35 kg/m(2).

Glycemic control after stomach-sparing duodenal-jejunal bypass surgery in diabetic patients with low body mass index.

BACKGROUND: Bariatric surgery frequently results in the resolution of type 2 diabetes mellitus (T2DM). One of the many factors that could explain such findings is the duodenal exclusion of the alimentary tract. To test this hypothesis, a surgical model that induces glycemic control without significant weight loss would be ideal. In the present study, we evaluated the early metabolic changes that occur in overweight diabetic patients after laparoscopic duodenal-jejunal bypass (DJB) and determined the factors associated with success in T2DM resolution. The setting was a private practice. METHODS: A total of 35 patients (20 men and 15 women) were included in the present study. The mean preoperative body mass index was 28.4 ± 2.9 kg/m(2). DJB was performed in all patients, and the anthropometric data and blood samples were collected at baseline (preoperatively) and 3, 6, 9, and 12 months after surgery. Success was defined when patients reached a glycated hemoglobin level of <7% without diabetic medication. RESULTS: T2DM remission was observed in 14 (40%) of 35 patients. No differences in the homeostasis model assessment insulin resistance index levels and patient weight were observed before and 12 months after DJB surgery. Gender, duration of T2DM, previous use of insulin, preoperative homeostasis model assessment insulin resistance index, and C-peptide levels were not significant predictive factors of success or nonsuccess. The only factor that significantly predicted postoperative positive outcomes was a waist circumference reduction of ≥ 7% compared with baseline within the first 6 months after surgery. CONCLUSION: DJB improves glycemic control; however, it does not increase insulin sensitivity in overweight diabetic patients. These changes were observed without significant weight loss.

Cirurgia bariátrica e metabólica e complicações microvasculares do diabetes mellitus tipo 2 (DM2) / Bariatric and metabolic surgery and microvascular complications of type 2 diabetes mellitus

ResumoIntrodução:O diabetes mellitus tipo 2 (DM2) é caracterizado por uma desregulação metabólica, originando complicações microvasculares, mais especificamente a retinopatia, nefropatia e a neuropatia. A prevenção e tratamento das complicações são alvo da farmacoterapia, porém, evidências demonstram que a cirurgia bariátrica/metabólica é superior ao melhor tratamento farmacológico, pois apresenta melhor controle da glicemia, hipertensão e dislipidemias.Métodos:Por meio de pesquisa no PubMed, são discutidas as recentes publicações que evidenciam o efeito positivo das intervenções cirúrgicas sobre as complicações microvasculares, como melhora da microalbuminúria e mesmo preservação de função renal.Discussão:Existem evidências de benefício das operações bariátricas/metabólicas sobre a nefropatia diabética. Os dados sobre retinopatia são ainda ambivalentes. Na literatura, há uma diferença significativa no benefício da cirurgia em neuropatia.Conclusão:Apesar de resultados surpreendentes e positivos, para que se estabeleça definitivamente o papel da cirurgia bariátrica/metabólica nas complicações micovasculares do DM2, há a necessidade de novos estudos randomizados controlados e prospectivos.

AbstractIntroduction:Metabolic dysregulation is the defining characteristic of type 2 diabetes mellitus (T2DM) and may lead to microvascular complications, specifically retinopathy, nephropathy and neuropathy. Medical treatment and lifestyle interventions targeting risk factors for microvascular complications can yield therapeutic gains, particularly retinopathy and nephropathy. Bariatric/metabolic surgery is superior to the best medical treatment in several randomized controlled trials. Consequently, evidence of the effect of bariatric/metabolic surgery on microvascular complications is now emerging in the literature.Methods:A search of the recent published evidence base on the effects of bariatric/metabolic surgery on microvascular complications reveals further evidence that supports the efficacy of surgery in preventing the incidence and progression of albuminuria and preserving renal functional decline.Discussion:Data on retinopathy are ambivalent representing the potential in some cases for an influence of reactive hypoglycaemia over the retina but the majority of data emphasize that the metabolic control can halt the progression of the eye disease. A significant gap in the literature remains in relation to the effects of surgery on diabetic neuropathy, although some information sheds a light on the benefits secondary to the surgical metabolic control.Conclusion:Overall, although data so far is exciting, there is a pressing need for prospective randomized controlled trials examining long-term microvascular outcomes following bariatric/metabolic surgery in patients with T2DM.