The long-term effect of bariatric/metabolic surgery versus pharmacologic therapy in type 2 diabetes mellitus patients: A systematic review and meta-analysis.

Metabolic/bariatric surgery as a treatment for obesity and related diseases, such as type 2 diabetes mellitus (T2DM), has been increasingly recognised in recent years. However, compared with conventional pharmacologic therapy, the long-term effect (≥ 5 years) of metabolic surgery in T2DM patients is still unclear. This study aimed to evaluate the diabetes remission rate, incidence of diabetic microvascular complications, incidence of macrovascular complications, and mortality in T2DM patients who received metabolic surgery versus pharmacologic therapy more than 5 years after the surgery. Searching the database, including PubMed, Embase, Web of Science, and Cochrane Library from the inception to recent (2024), for randomised clinical trials (RCTs) or cohort studies comparing T2DM patients treated with metabolic surgery versus pharmacologic therapy reporting on the outcomes of the diabetes remission rate, diabetic microvascular complications, macrovascular complications, or mortality over 5 years or more. A total of 15 articles with a total of 85,473 patients with T2DM were eligible for review and meta-analysis in this study. There is a significant long-term increase in diabetes remission for metabolic surgery compared with conventional medical therapy in the overall pooled estimation and RCT studies or cohort studies separately (overall: OR = 4.58, 95% CI: 1.89-11.07, P < 0.001). Significant long-term decreases were found in the pooled results of microvascular complications incidence (HR = 0.57, 95% CI: 0.41-0.78, P < 0.001), macrovascular complications incidence (HR = 0.59, 95% CI: 0.50-0.70, P < 0.001) and mortality (HR = 0.53, 95% CI: 0.53-0.79, P = 0.0018). Metabolic surgery showed more significant long-term effects than pharmacologic therapy on diabetes remission, macrovascular complications, microvascular complications incidence, and all-cause mortality in patients with T2DM using currently available evidence. More high-quality evidence is needed to validate the long-term effects of metabolic surgery versus conventional treatment in diabetes management.

Changes in thyroid hormones predict weight regain in patients with obesity who undergo metabolic surgery.

AIM: To investigate the relationship between thyroid function and weight regain in patients with obesity after metabolic surgery. METHODS: This retrospective study enrolled 162 patients who underwent metabolic surgery. Correlations between decreases in thyroid hormone levels and changes in weight, waist circumference (WC) and the Chinese visceral adiposity index (CVAI) were assessed. Binary logistic regression and receiver operating characteristic (ROC) curves were used to identify predictors and clinically useful cut-off values, respectively. RESULTS: The levels of thyroid-stimulating hormone (TSH) and free triiodothyronine (FT3) decreased markedly at 1 year after surgery, as did weight, body mass index (BMI), triglycerides, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, WC and CVAI. Decreases in TSH and FT3 after metabolic surgery were associated with changes in weight, BMI and CVAI. Binary logistic regression and ROC curve analyses confirmed that decreases in TSH can predict good weight loss after metabolic surgery to some extent. Finally, binary logistic regression and ROC curve analyses confirmed that changes in TSH can predict weight regain after metabolic surgery. CONCLUSIONS: Changes in TSH and FT3 after metabolic surgery were correlated with changes in weight and CVAI. Changes in thyroid hormones can predict weight regain in patients with obesity who underwent metabolic surgery.

Readability of American Society of Metabolic Surgery's Patient Information Publications.

INTRODUCTION: Appropriate education and information are the keystones of patient autonomy. Surgical societies support this goal through online informational publications. Despite these recommendations, many of these sources do not provide the appropriate level of reading for the average patient. Multiple national organizations, including the AMA and NIH, have recommended that such materials be written at or below a 6th-grade level. We therefore aimed to evaluate the readability of patient information publications provided by the American Society of Metabolic and Bariatric Surgery (ASMBS). METHODS: Patient information publications were collected from the ASMBS webpage (https://asmbs.org/patients) and evaluated for readability. Microsoft Office was utilized to calculate Flesch Reading Ease (FRE) and Flesch-Kincaid Grade Level (FKGL) scores. Flesch Reading Ease (FRE) is a 0-100 score, with higher scores equating to easier reading (≥80 = 6th-grade reading level). Flesch-Kincaid Grade Level (FKGL) rates text on a US grade school level. Qualitative and univariate analyses were performed. RESULTS: Eleven patient information publications were evaluated. None of the publications achieved an FRE score of 80 or an FKGL of a 6th-grade reading level. The average FRE score was 35.8 (range 14.9-53.6). The average FKGL score was 13.1 (range 10.1-17.5). The publication with the highest FRE and lowest FKGL (best readability) was that for benefits of weight loss. The brochure with the lowest FRE and highest FKGL (worst readability) was that for Medical Tourism. CONCLUSIONS: Although the ASMBS patient information publications are a trusted source of patient literature, none of the 11 publications met the recommended criteria for patient readability. Further refinement of these will be needed to provide the appropriate reading level for the average patient.

Prediabetes remission after bariatric surgery: a 4-years follow-up study.

BACKGROUND: Bariatric surgery leads to weight loss and to cardiometabolic risk improvement. Although prediabetes remission after bariatric surgery is biologically plausible, data on this topic is scarce. We aimed to assess prediabetes remission rate and clinical predictors of remission in a 4 year follow up period. METHODS: Observational longitudinal study including patients with obesity and prediabetes who had undergone bariatric surgery in our centre. Prediabetes was defined as having a baseline glycated haemoglobin (A1c) between 5.7% and 6.4% and absence of anti-diabetic drug treatment. We used logistic regression models to evaluate the association between the predictors and prediabetes remission rate. RESULTS: A total of 669 patients were included, 84% being female. The population had a mean age of 45.4 ± 10.1 years-old, body mass index of 43.8 ± 5.7 kg/m2, and median A1c of 5.9 [5.8, 6.1]%. After bariatric surgery, prediabetes remission rate was 82%, 73%, 66%, and 58%, respectively in the 1st, 2nd, 3rd, and 4th years of follow-up. Gastric sleeve (GS) surgery was associated with higher prediabetes remission rate than Roux-en-Y gastric bypass surgery in the 3rd year of follow-up. Men had a higher remission rate than women, in the 1st and 3nd years of follow-up in the unadjusted analysis. Younger patients presented a higher remission rate comparing to older patients in the 3rd year of follow-up. CONCLUSION: We showed a high prediabetes remission rate after bariatric surgery. The remission rate decreases over the follow-up period, although most of the patients maintain the normoglycemia. Prediabetes remission seems to be more significant in patients who had undergone GS, in male and in younger patients.

Comparison of Eastern and Western patients undergoing bariatric surgery at two US and Korean institutions: a retrospective analysis of differing bariatric patient populations.

BACKGROUND: Currently, there are differences in both demographics and indications for bariatric surgery between Eastern and Western countries. We compared postoperative outcomes between Korean and American bariatric programs in order to assess how bariatric surgery differently affects these populations. METHODS: We enrolled 540 patients who underwent bariatric surgery at University of California, Los Angeles (UCLA) and 85 patients who underwent surgery at Kosin University Gospel Hospital (KUGH) between January 2019 and December 2020. We compared demographics, complications, weight loss, and metabolic parameters between these groups. RESULTS: There was a difference in age between the UCLA and KUGH patient groups (44.3 years vs 37.6 years, P < 0.01). Frequencies of T2DM and OSA were also different (4.2% vs 50.6%, 34.1% vs 85.9% P < 0.01. Length of hospital stay varied (1.55 days vs 6.68 days, P < 0.01), but there was no difference in operating time and complications. There was no difference in percent of excess weight loss between the two groups at 6 months (29.7 vs 33.8, P = 0.13). Hepatic steatosis index (HSI) was higher in the UCLA group both before (54.2 vs 51.5, P < 0.01) and after (44.4 vs 40.0, P = 0.02) surgery. LSG was the most frequently performed operation, and robotic surgery and revisions were performed only in the UCLA program. CONCLUSION: There were differences in age, BMI, length of stay, and choice of operation between Korean and American bariatric patients. Also, there were differences in the degree of fatty liver disease using HSI and liver enzymes before and after surgery. There was no significant differences in operation time and complications. These findings suggest differences in bariatric practices and reactions to bariatric surgery in Eastern and Western settings.

Midterm outcomes of one anastomosis gastric bypass for patients with BMI < 35 kg/m2 from a large single center.

BACKGROUND: One-anastomosis gastric bypass (OAGB) is gaining more attention in patients with severe obesity and recently is used for patients with body mass index (BMI) < 35 kg/m2. In this 5-year single center experience we aim to report our outcomes of using OAGB for patients with BMI < 35 kg/m2. METHODS: This is a retrospective analysis of prospectively collected data recorded in to our national obesity registry database. Variables including age, sex, weight, BMI, any associated disease, blood levels of metabolic markers, nutrients, and vitamins before and after surgery were extracted and analyzed. RESULTS: 173 patients with mean age and BMI of 41 ± 10 years and 33 ± 1 kg/m2 underwent OAGB and at least one of the obesity-associated medical problems was found in 88 (50.5%) of them preoperatively. The mean duration of surgery and length of hospital stay were 60.7 ± 7.4 min and 1.3 ± 1.4 days. 78% and 70% of patients had available data at 24 and 60 months, respectively. The mean BMI was 23.9 ± 2.2 kg/m2 1 year after surgery and each year after that till 5 years was 24 ± 2, 24.4 ± 2.6, 25.1 ± 2.7, and 25.5 ± 2.7 kg/m2. Significant improvement in levels of fasting blood glucose, lipid profile, and liver enzymes were observed. CONCLUSION: OAGB for BMI < 35 kg/m2 has significant effects in weight loss, helps remit diabetes and hypertension in the majority of cases, improves lipid profile, and has no increased burden of postoperative problems or deficiency in nutritional factors rather than what is known and predictable.

Obesity management for the treatment of type 2 diabetes: emerging evidence and therapeutic approaches.

Excess adiposity can contribute to metabolic complications, such as type 2 diabetes mellitus (T2DM), which poses a significant global health burden. Traditionally viewed as a chronic and irreversible condition, T2DM management has evolved and new approaches emphasizing reversal and remission are emerging. Bariatric surgery demonstrates significant improvements in body weight and glucose homeostasis. However, its complexity limits widespread implementation as a population-wide intervention. The identification of glucagon-like peptide 1 (GLP-1) and the development of GLP-1 receptor agonists (GLP-1RAs) have improved T2DM management and offer promising outcomes in terms of weight loss. Innovative treatment approaches combining GLP-1RA with other gut and pancreatic-derived hormone receptor agonists, such as glucose-dependant insulinotropic peptide (GIP) and glucagon (GCG) receptor agonists, or coadministered with amylin analogues, are demonstrating enhanced efficacy in both weight loss and glycemic control. This review aims to explore the benefits of bariatric surgery and emerging pharmacological therapies such as GLP-1RAs, and dual and triple agonists in managing obesity and T2DM while highlighting the caveats and evolving landscape of treatment options.

Is Sigstad's score really capable of detecting post-surgical late dumping syndrome?

BACKGROUND: This clinical trial explores the Sigstad score for late dumping syndrome in postoperative patients who have undergone sleeve gastrectomy (SG) or One Anastomosis Gastric Bypass (OAGB). The aims of this study are to investigate the correlations with late dumping syndrome, to evaluate the reliability and validity of the Sigstad score and to discuss a modified scoring system. METHODS: The study was conducted at the Obesity Center of the Westküstenklinikum Heide and included 271 patients. Data collection involved conducting interviews, diet diaries and measuring blood glucose levels. Non-parametric tests, logistic regression and McDonald's Omega were the selected statistical approaches. RESULTS: Body Mass Index (BMI) decreased over time (-9.67 kg/m2 at 4 months, -15.58 kg/m2 at 12 months). Preoperatively, the Sigstad score exhibited the highest value, and no occurrences of late dumping syndrome were observed. No significant differences were found in BMI concerning late dumping syndrome or Sigstad score among postoperative patients. Postoperative patients experienced an increase in gastrointestinal symptoms. The reliability test showed a McDonald's omega value of 0.509. The analysis conducted through binary logistic regression indicated dizziness as a significant predictor of late dumping syndrome; however, this finding did not hold up after performing Bonferroni correction. CONCLUSION: The Sigstad score is not a reliable or valid method for detecting late dumping syndrome after surgery for obesity and metabolic disorders. It is necessary to have alternatives that use objective measures and assess the quality of life, and that these alternatives be validated in large patient cohorts.

Risk factors for bariatric surgery in patients over 65 years of age-a multicenter retrospective cohort study.

PURPOSE: Societies are aging, life expectancy is increasing, and as a result, the percentage of elderly people in the population is constantly increasing. When qualifying patients over 65 years of age for bariatric surgery, the benefits and risks should be carefully assessed. Weighing risk factors against each other to improve the quality of life and better control of obesity-related diseases. The study aimed to determine risk factors for bariatric surgery among patients over 65 years of age. METHODS: A multicenter, retrospective analysis of patients undergoing laparoscopic bariatric procedures from 2008 to 2022. The patients were divided into two groups: complicated (C) and uncomplicated (UC). Uni- and multivariate logistic regression analysis was performed to obtain significant, independent risk factors. RESULTS: There were 20 (7.0%) patients in C group and 264 (93.0%) patients in UC group. The most common complication was intraperitoneal bleeding (8, 2.8). There was no postoperative mortality. The mean follow-up was 47.5 months. In a multivariate logistic regression analysis, length of stay and %EWL significantly corresponded to general complications (OR 1.173, OR 1.020). A higher weight loss before surgery lowered the risk for hemorrhagic events after surgery (OR 0.889). A longer length of stay corresponded to leak after surgery (OR 1.175). CONCLUSIONS: Bariatric and metabolic surgery appears to be a safe method of obesity treatment in patients over 65 years of age. The most common complication was intraperitoneal bleeding. A prolonged hospital stay may increase the risk of leakage, while a higher weight loss before the surgery may lower the risk of bleeding.

Clinical significance of colonoscopy before laparoscopic bariatric/metabolic surgery in Japanese patients.

PURPOSE: Obesity is known to be associated with colorectal adenoma (CRA) and colorectal cancer (CRC); yet colonoscopy is not considered an essential preoperative evaluation before bariatric/metabolic surgery. The aim of this study was to clarify the clinical significance of preoperative colonoscopy for obese Japanese patients. METHODS: The subjects of this retrospective study were 114 patients who underwent screening colonoscopy before bariatric/metabolic surgery. Multivariate analyses were performed to evaluate the independent predictors of CRA/CRC among the characteristics identified as significant or nearly significant by univariate analyses. RESULTS: Colonoscopy revealed abnormal findings indicating the need for biopsy or polypectomy in 20 of the 114 patients (17.5%), and CRA was diagnosed in 13 patients (11.4%). Three patients (2.6%), who were all ≥ 56 years old, had a CRA ≥ 10 mm in diameter. The multivariate analysis showed that older age and male sex were significant predictors of CRA/CRC, which was identified in 46.2% of the male patients aged ≥ 46 years. CONCLUSION: Our findings suggest that older age and male sex may be risk factors for CRA/CRC in obese Japanese candidates for bariatric/metabolic surgery; thus, preoperative colonoscopy should be considered for these high-risk patients.

Metabolic and bariatric surgery in patients with class I obesity; a two-year follow-up.

BACKGROUND: Patients with class I obesity may need metabolic and bariatric surgery (MBS) in the presence of obesity-associated medical problems, but MBS in this class of obesity is under debate. This study aimed to investigate the efficacy and safety of MBS in patients with class I obesity. METHODS AND MATERIALS: This study was a historical cohort carried out on 112 patients with class I obesity with body mass index (BMI) of 30-35 kg/m2 with a 24-month follow-up underwent MBS at Rasoul-e-Akram Hospital. The required data were extracted through the Iran National Obesity Surgery Database. The data required for the study consisted of demographic information such as age, gender, and obesity-associated medical problems like type-2 diabetes mellitus (T2DM), hypertension, obstructive sleep apnea, and dyslipidemia before surgery, 6, 12, and 24 months after surgery. RESULTS: Mean age of the patients was 38.10 ± 10.04 years; mean BMI was 32.96 ± 1.35 kg/m2 and 83.9% (n = 94) of patients were female. Out of 18 patients with T2DM, 11 patients (61.11%) had complete remission and seven patients (38.88%) had partial remission. Obstructive sleep apnea, hypertension, dyslipidemia, and gastroesophageal reflux disease were observed in 18 (16.07%), 23 (20.53%), 43 (38.39%), and 13 patients (11.60%) before surgery and resolved at 24-month follow-up. Post-operative complications during the 24-month follow-up were checked to assess safety and there were no De novo gastroesophageal reflux disease, intolerance, leakage, pulmonary thromboembolism, deep vein thrombosis, incisional hernia, hypoalbuminemia (Albumin < 3.5 g/dl), excessive weight loss (BMI < 18.5 kg/m2) at any time during 24-months follow-ups and mortality. Early complications occurred as splenic injury in one case (0.89%), wound infection in one patient (0.89%), and extra-luminal bleeding in 10 (8.92%) after surgery, without any mortality. CONCLUSION: MBS is safe and effective in class I obesity and can be considered in selected patients with obesity-associated medical problems.

A Matched Comparative Analysis of Type-2 Diabetes Mellitus Remission Between Roux-en-Y Gastric Bypass and Sleeve Gastrectomy.

OBJECTIVE: Multiple scores validate long-term type-2 diabetes mellitus (T2DM) remission after metabolic and bariatric surgery (MBS). However, studies comparing Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) have not adequately controlled for certain parameters, which may influence procedure selection. METHODS: We conducted a multicenter retrospective review of patients with T2DM who underwent RYGB or SG between 2008 and 2017. Data on demographics, clinical, laboratory, and metabolic values were collected annually for up to 14 years. Each eligible RYGB patient was individually matched to an eligible SG patient based on diabetes severity, weight loss, and follow-up duration. RESULTS: Among 1149 T2DM patients, 467 were eligible for matching. We found 97 matched pairs who underwent RYGB or SG. RYGB showed significantly higher T2DM remission rates (46.4%) compared to SG (33.0%) after matching. SG patients had higher insulin usage (35.1%) than RYGB patients (20.6%). RYGB patients also experienced greater decreases in HbA1c levels and diabetes medication usage than SG patients. CONCLUSIONS: RYGB demonstrates higher efficacy for T2DM remission compared to SG, regardless of baseline characteristics, T2DM severity, weight loss, and follow-up duration. Further studies are needed to understand the long-term metabolic effects of MBS and the underlying pathophysiology of T2DM remission after MBS.

Preoperative contributing factors and the remission of diabetes after metabolic surgery: the mediating role of preoperative triglyceride.

BACKGROUND AND OBJECTIVE: Limited understanding exists regarding the factors affecting the prognosis of surgical treatment for type 2 diabetes mellitus (T2DM), particularly in Chinese patients. In this study, we examined a cohort of early and intermediate obese T2DM patients to explore the potential impact of preoperative lipid metabolism in metabolic surgery on the postoperative remission of T2DM. METHODS: Participants with T2DM and obesity underwent metabolic surgery. Clinical data, including baseline body mass index, percentage of excess weight loss, and preoperative biochemical indicators, were collected and analyzed. A multidisciplinary team conducted patient follow-up. Remission was defined as sub-diabetic hyperglycemia (HbA1c < 48 mmol/mol, fasting glucose 100-125 mg/dl) without pharmacological intervention for at least 12 months. RESULTS: Over a median follow-up of 27 months, 96 T2DM patients with metabolic surgery were studied, with no laparotomies required. Among these patients, 61 (63.5%) achieved complete remission, and 85 (88.5%) experienced remission. In multivariable analysis models, preoperative fasting blood glucose (FBG) significantly correlated with all postoperative outcomes. Furthermore, mediation analysis indicated that preoperative triglycerides (TG) mediated 26.31% of the association between preoperative FBG and postoperative remission. Both preoperative FBG and TG were negatively associated with the postoperative remission of T2DM. CONCLUSION: In summary, our findings suggest that lower preoperative fasting glucose levels enhance the likelihood of postoperative T2DM remission. Moreover, preoperative TG could potentially play a mediating role in the postoperative remission of T2DM. Therefore, evaluating and managing fasting glucose and lipids before the procedure may aid in assessing the prognosis of metabolic surgery. Level of evidence Level III, designed cohort.

Gastric bypass - 10 years' results.

INTRODUCTION: Gastric bypass has not gained as much popularity in the Czech Republic as technically simpler restrictive bariatric procedures, frequently with a fading long-term effect. The aim of the presentation is to point out the long-term results after two types of gastric bypasses. METHOD: Retrospective analysis of prospectively collected data in an initial set of patients after laparoscopic RYGB (Roux Y gastric bypass) and OAGB/MGB (one anastomosis/mini gastric bypass) performed at Breclav Hospital in 2010-2013. Evaluation based on the BAROS system, according to weight development, comorbidities, psychological aspects, complications and reoperations. RESULTS: Data available for evaluation are from 32 patients out of a total of 60; the follow-up rate is 53%. The patients are lighter by 34 kg on average (0-64 kg); TBWL (total basic weight loss): 25.7%. The majority of operated diabetics are free of signs of diabetes, and all others have a reduced need for antidiabetic medication. Hypertension, sleep apnea and psychological assessment of life in 6 domains improved. Eight of the 32 followed patients underwent reoperation during 10 years; only 2 of these procedures were acute for complications (anastomotic ulceration), both in smokers; further elective reoperations included 2 conversions of OAGB/MGB to RYGB due to reflux, 2 corrective surgeries, and 2 procedures for a suspected internal hernia. There was no conversion from laparoscopic to open surgery, no peritonitis associated with a leak, and no mortality within 30 days. The BAROS score (5.56) indicates a "very good result" of the gastric bypasses after 10 years. CONCLUSION: Gastric bypasses are safe and provide a high and lasting metabolic effect that meets the general expectations of an invasive intervention that can fundamentally improve the quality of treatment for otherwise incurable chronic diseases related to adiposity (so-called ABCD), especially type 2 diabetes.

[Results of the first All-Russian consensus conference on bariatric surgery]. / Rezul'taty pervoi vserossiiskoi konsensus-konferentsii po bariatricheskoi khirurgii.

Until now, there has not been organized consensus for standardization in bariatric surgery In Russia. We present the results of the first Bariatric Surgery Consensus Conference conducted in Barnaul (March, 2023). A list of questions was proposed within 6 blocks: 1) general issues of bariatric surgery, 2) sleeve gastrectomy, 3) one-anastomosis gastric bypass («mini-gastric bypass¼), 4) Roux-en-Y Gastric Bypass, 5) Single Anastomosis Duodenal Switch and other options for biliopancreatic bypass, 6) rare procedures. Consensus (>70% agreement) was reached for 51 out of 96 statements. Stratification by the level of expertise was carried out, and responses of the expert group were compared with responses of all participants.

Postprandial plasma GLP-1 levels are elevated in individuals with postprandial hypoglycaemia following Roux-en-Y gastric bypass - a systematic review.

BACKGROUND AND AIMS: Bariatric surgery is the most effective treatment in individuals with obesity to achieve remission of type 2 diabetes. Post-bariatric surgery hypoglycaemia occurs frequently, and management remains suboptimal, because of a poor understanding of the underlying pathophysiology. The glucoregulatory hormone responses to nutrients in individuals with and without post-bariatric surgery hypoglycaemia have not been systematically examined. MATERIALS AND METHODS: The study protocol was prospectively registered with PROSPERO. PubMed, EMBASE, Web of Science and the Cochrane databases were searched for publications between January 1990 and November 2021 using MeSH terms related to post-bariatric surgery hypoglycaemia. Studies were included if they evaluated individuals with post-bariatric surgery hypoglycaemia and included measurements of plasma glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), insulin, C-peptide and/or glucagon concentrations following an ingested nutrient load. Glycated haemoglobin (HbA1c) was also evaluated. A random-effects meta-analysis was performed, and Hedges' g (standardised mean difference) and 95% confidence intervals were reported for all outcomes where sufficient studies were available. The τ2 estimate and I2 statistic were used as tests for heterogeneity and a funnel plot with the Egger regression-based test was used to evaluate for publication bias. RESULTS: From 377 identified publications, 12 were included in the analysis. In all 12 studies, the type of bariatric surgery was Roux-en-Y gastric bypass (RYGB). Comparing individuals with and without post-bariatric surgery hypoglycaemia following an ingested nutrient load, the standardised mean difference in peak GLP-1 was 0.57 (95% CI, 0.32, 0.82), peak GIP 0.05 (-0.26, 0.36), peak insulin 0.84 (0.44, 1.23), peak C-peptide 0.69 (0.28, 1.1) and peak glucagon 0.05 (-0.26, 0.36). HbA1c was less in individuals with hypoglycaemia - 0.40 (-0.67, -0.12). There was no evidence of substantial heterogeneity in any outcome except for peak insulin: τ2 = 0.2, I2 = 54.3. No publication bias was evident. CONCLUSION: Following RYGB, postprandial peak plasma GLP-1, insulin and C-peptide concentrations are greater in individuals with post-bariatric surgery hypoglycaemia, while HbA1c is less. These observations support the concept that antagonism of GLP-1 would prove beneficial in the management of individuals with hypoglycaemia following RYGB.PROSPERO Registration Number: CRD42021287515.

Patients hospitalized with alcohol-related liver disease and prior bariatric surgery are more prone to develop acute-on-chronic liver failure.

BACKGROUND & AIMS: Patients with a history of bariatric surgery (BS) are susceptible to developing alcohol use disorder. We and others have previously shown that these patients can develop severe alcohol-related liver disease (ARLD). Our aim was to describe the demographics, co-morbidities and mortality of a hospitalized population diagnosed with alcohol-related liver disease, in relation to BS. METHODS: We included 299 patients hospitalized with ARLD at the Ghent University Hospital between 1 January 2018 and 31 December 2022. Clinical, biochemical and outcome data were retrospectively retrieved from the most recent hospitalization. Statistical analysis was performed using the t test, Mann-Whitney U and χ2 tests. RESULTS: Thirteen per cent (39/299) of patients admitted with ARLD had a history of bariatric surgery, of whom 25 (64.1%) had undergone Roux-en-Y gastric bypass. Patients with a history of BS were predominantly female (76.9%), in contrast to the non-BS population (29.2%) (p < .0001), and despite being significantly younger (p < .0001) and had a similar survival (61.5% vs. 58.1%). Bariatric surgery and older age at diagnosis were both significantly associated with poorer transplant-free survival. The cause of death was acute-on-chronic liver failure in 73.3% of BS patients, compared to only 19.2% of those without a history of BS (p < .0001). The weekly amount of alcohol consumed (p = .012) and duration of use (p < .0001) were significantly lower/shorter in the BS population. CONCLUSIONS: BS patients hospitalized with ARLD are predominantly younger women with a lower cumulative alcohol consumption compared to those without prior BS. BS impacted transplant-free survival, with ACLF as the predominant cause of death in these patients.

Defining Physiological Ketosis Following Very-Low-Calorie Diets.

INTRODUCTION: Very low-calorie diets (VLCDs) are used preoperatively in bariatric-metabolic surgery; however, this can lead to physiological ketosis. Euglycemic ketoacidosis is an increasingly recognized complication in diabetic patients on sodium-glucose-cotransporter-2 inhibitors (SGLT2i) undergoing surgery and requires assessment of ketones for diagnosis and monitoring. VLCD induced ketosis may confound monitoring in this group. We aimed to evaluate the influence of VLCD, compared to standard fasting, on perioperative ketone levels and acid-base balance. MATERIALS AND METHODS: Twenty-seven patients were prospectively recruited to the intervention group and 26 to the control group from two tertiary referral centres in Melbourne, Australia. Intervention group patients were severely obese (body mass index) (BMI) (≥35), undergoing bariatric-metabolic surgery, and prescribed 2 wk of VLCD preoperatively. Control group patients underwent general surgical procedures and prescribed standard procedural fasting only. Patients were excluded if diabetic or prescribed SGLT2i. Ketone and acid-base measurements were taken at regular intervals. Univariate and multivariate regression was utilised with significance defined as P < 0.005. CLINICALTRIALS: gov ID: NCT05442918. RESULTS: Patients on VLCD, compared to standard fasting, had an increased median preoperative (0.60 versus 0.21 mmol/L), immediate postoperative (0.99 versus 0.34 mmol/L) and day 1 postoperative (0.69 versus 0.21 mmol/L) ketone level (P < 0.001). Preoperative acid-base balance was normal in both groups, however VLCD patients were found to have a metabolic acidosis immediately postoperatively (pH 7.29 versus pH 7.35) (P = 0.019). Acid-base balance had normalized in VLCD patients on postoperative day 1. CONCLUSIONS: Preoperative VLCD resulted in increased pre- and postoperative ketone levels with immediate postoperative values consistent with metabolic ketoacidosis. This should be considered particularly when monitoring diabetic patients prescribed SGLT2i.

The Metabolic Health Index Identifies Patients That Will Benefit From Metabolic Surgery.

INTRODUCTION: Metabolic syndrome is a modern world's major health hazard related to comorbidities like type 2 diabetes and cardiovascular disease. Bariatric surgery is well known to lower this health risk in patients with obesity. There is a need for an objective measure to assess the intended reduction in health hazard and indirectly the eligibility for bariatric surgery. The Metabolic Health Index (MHI) quantitatively summarizes the cumulative impact of the metabolic syndrome on health status on a scale from 1 to 6. This study describes the use of the MHI as a supportive tool in the decision for and outcome assessment of bariatric surgery. METHODS: The general usability of the MHI was tested by extending its application to patient data of five other bariatric centers in the Netherlands. Retrospective laboratory and national bariatric quality registry data of 11,501 patients were collected. RESULTS: The quantification of (improvement in) metabolic health burden as measured by the MHI was independent of the dataset that was used to derive the MHI model. Patients with MHI > 2.8 prior to surgery improved significantly more in MHI 12 mo after surgery compared to patients with MHI ≤ 2.8 (1.1 compared to 0.4 MHI points, respectively; P < 0.001). CONCLUSIONS: The MHI is robust between centers and is suitable for general use in clinical decision-making. As changes in MHI over time reflect metabolic health alterations, it is suitable as an outcome measure of surgery. An MHI cut-off value of 2.8 helps to predict the likelihood of significant improvement after surgery, independent of body mass index and known metabolic comorbidities.

Video Capsule Endoscopy after Bariatric Surgery: A Tertiary Referral Center Experience.

BACKGROUND AND AIM: Minimal data are available regarding the performance of video capsule endoscopy (VCE) in patients who underwent bariatric surgery. We aimed to report indications, feasibility, and safety of VCE performed after bariatric surgery, specifically focusing on diagnosis rates of Crohn's disease (CD) in this population. METHODS: A retrospective analysis of all VCE procedures was performed between January 2015 and December 2019. All patients who underwent bariatric surgery prior to VCE were included. Indication for VCE, ingestion methods, completion rates, retention rates, and endoscopic findings were recorded. RESULTS: A total of 1,255 patients underwent VCE examination during the study period, of which 31 (2.5%) underwent bariatric surgery prior to VCE. The most common bariatric surgery was laparoscopic sleeve gastrectomy (16 patients, 51.6%), and the most common indication for VCE was evaluation of iron deficiency anemia (14 patients, 45.1%). The majority of patients ingested the capsule independently, without endoscopic assistance (20, 64.5%). Although a patency capsule was not used in our cohort, no events of capsule retention were documented. Mean transit time was 4.32 h. Only 4 events of incomplete examination were recorded. Over a median follow-up of 27.5 months (IQR 13.0-34.2), 10 patients (31.2%) had a final diagnosis of CD with a median Lewis score of 225 (IQR 135-900). CONCLUSION: VCE is a feasible and safe procedure after bariatric surgery. Oral ingestion does not carry risk of retention. It is an effective means of diagnosis of small-bowel CD in this population.