Bartolome Burguera

How safe is metabolic/diabetes surgery?

Although recent studies have shown the impressive antidiabetic effects of laparoscopic Roux‐en‐Y gastric bypass (LRYGB), the safety profile of metabolic/diabetes surgery has been a matter of concern among patients and physicians. Data on patients with type 2 diabetes who underwent LRYGB or one of seven other procedures between January 2007 and December 2012 were retrieved from the American College of Surgeons National Surgical Quality Improvement Program database and compared. Of the 66u2009678 patients included, 16u2009509 underwent LRYGB. The composite complication rate of 3.4% after LRYGB was similar to those of laparoscopic cholecystectomy and hysterectomy. The mortality rate for LRYGB (0.3%) was similar to that of knee arthroplasty. Patients who underwent LRYGB had significantly better short‐term outcomes in all examined variables than patients who underwent coronary bypass, infra‐inguinal revascularization and laparoscopic colectomy. In conclusion, LRYGB can be considered a safe procedure in people with diabetes, with similar short‐term morbidity to that of common procedures such as cholecystectomy and appendectomy and a mortality rate similar to that of knee arthroplasty. The mortality risk for LRYGB is one‐tenth that of cardiovascular surgery and earlier intervention with metabolic surgery to treat diabetes may eliminate the need for some later higher‐risk procedures to treat diabetes complications.

A nationwide safety analysis of bariatric surgery in nonseverely obese patients with type 2 diabetes.

BACKGROUNDnBariatric surgery is more effective than medical therapy in treatment of type 2 diabetes (T2D) in patients with severe obesity. However, surgery is often not advocated for patients with T2D who are overweight or have mild obesity.nnnOBJECTIVEnTo assess the safety profile of bariatric surgery in patients with T2D and mild obesity.nnnSETTINGnDatabase of the American College of Surgeons-National Surgical Quality Improvement Program.nnnMETHODSnData of 1300 patients with T2D and a body mass index≥25 but<35 kg/m(2) who underwent bariatric surgery were retrieved from the American College of Surgeons-National Surgical Quality Improvement Program data set (2005-2014) to assess safety profile. Further stratified analyses were carried out between Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).nnnRESULTSnThe mean operative time and length of hospital stay were 109.4±58.3 minutes and 1.9±1.5 days, respectively. Incidence of all individual major complications was≤.5% in this cohort except for postoperative bleeding (1.7%). Thirty-day postoperative composite morbidity, serious morbidity, and mortality rates for total cohort were 4.2%, .7%, and .15%, respectively. Smoking (odds ratio = 2.75, 95% confidence interval: 1.34-5.64) and chronic obstructive pulmonary disease (odds ratio = 4.05, 95% confidence interval: 1.51-10.88) were predictors of composite morbidity. Thirty-day morbidity rates were not significantly different between those who underwent RYGB compared with SG.nnnCONCLUSIONnBariatric surgery, which is a 2-hour procedure requiring a 2-day hospital stay, is a relatively well-tolerated option in patients with T2D and mild obesity. RYGB and SG had comparable early postoperative morbidity. Smoking can be considered as a modifiable risk factor for early complications after bariatric surgery in patients with T2D and lower body mass index.

Bariatric Surgery in Obese Patients With Type 1 Diabetes

OBJECTIVE There is a paucity of data on the impact of bariatric surgery in type 1 diabetes (T1D). The aim of this review was to quantify the overall effects of bariatric surgery in obese patients with T1D. METHODS We searched PubMed, Scopus, ISI Web of Knowledge, and Google Scholar from their inception to December 2015 to identify all relevant studies of bariatric surgery in adult obese patients with T1D. RESULTS The review included 17 studies with 107 individuals, including 10 case series and 7 case reports. Overall, the dominant procedure was gastric bypass (n = 70; 65%). All studies reported a significant reduction in excess weight. A significant reduction in weight-adjusted daily insulin requirements was shown in all case series except one. Pooled mean ± SD of pre- and postoperative glycated hemoglobin (HbA1c) for the entire cohort with available data (n = 96) was 8.4 ± 1.3% and 7.9 ± 1.1%, respectively (P = 0.01). In addition to common postoperative complications, profound glycemic changes (diabetic ketoacidosis and hypoglycemia) and gastrointestinal dysmotility symptoms (prolonged ileus and acute gastric remnant dilation) have been reported. No surgical mortality was reported. CONCLUSIONS Bariatric surgery leads to significant weight loss in severely obese patients with T1D and results in a significant improvement in insulin requirements and glycemic status. The favorable metabolic effects of bariatric surgery may facilitate medical management of and cardiovascular risk reduction in T1D in the setting of severe obesity. Diabetic ketoacidosis and hypoglycemia are potentially serious complications. Short-term results of bariatric surgery in patients with T1D are encouraging, but larger and longer-term studies are needed.

Outcomes of bariatric surgery in type 2 diabetic patients with diminished pancreatic secretory reserve

Although the marked and durable effects of bariatric surgery on early type 2 diabetes is known, there are limited data on the impact of surgery in patients with reduced beta-cell function/reserve. Clinical outcomes of 15 morbidly obese patients with poorly controlled diabetes who underwent bariatric surgery in a 10-year period and had a baseline fasting serum c-peptide ≤0.5xa0ng/mL were assessed. All patients had glycated hemoglobin >7xa0% and were on insulin before surgery. Surgical procedures included laparoscopic gastric bypass (nxa0=xa09), sleeve (nxa0=xa05), and banding (nxa0=xa01) without any intraoperative complications. At a mean follow-up of 39.6xa0±xa022.9 months, a mean reduction in body mass index of 25.1xa0±xa09.2xa0% and a mean percent excess weight loss of 61.5xa0±xa019.7xa0% were associated with a significant improvement in daily insulin requirement and lipid profile. At the last follow-up point, three patients (20xa0%) were off insulin, five patients (33.3xa0%) had a glycated hemoglobin ≤7xa0%, and one patient (6.7xa0%) had remission of diabetes. Hypertension resolved or improved in 5 of 11 (45.5xa0%) hypertensive patients. In conclusion, bariatric surgery can result in improvement of glycemic status and comorbid conditions of obese diabetic patients with diminished beta-cell reserve and may facilitate medical management of diabetes.

Incidence and Clinical Features of Diabetic Ketoacidosis After Bariatric and Metabolic Surgery

Bariatric surgery is considered an effective (1,2) and relatively safe (3) option for the treatment of obesity and its comorbidities, including type 1 and type 2 diabetes. Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes, which mainly occurs in patients with type 1 diabetes but can present in patients with type 2 diabetes under stressful conditions (4,5). The characteristics of early postoperative DKA following bariatric surgery are largely unknown. The objective of this study is to determine the incidence and clinical circumstances underlying DKA after bariatric surgery.nnFrom January 2005 to December 2015, a total of 12 patients who developed DKA within 90 days following bariatric surgery at an academic center were identified in a database approved by an institutional review board. All patients met the American Diabetes Association criteria for the diagnosis of DKA (4,5). Two endocrinologists independently verified the diagnosis of DKA in the included patients. Baseline characteristics, intraoperative data, and postoperative outcomes were assessed.nnOf the 12 patients who developed …

Weight-Related Quality of Life in Spanish Obese Subjects Suitable for Bariatric Surgery is Lower Than in Their North American Counterparts: a Case–Control Study

BackgroundObesity impairs quality of life, but the perception of the impairment could be different from one country to another. The purpose was to compare weight-related quality of life (QOL) between cohorts from Spain and North America.MethodsA cross-sectional case–control study was performed between two populations. Four hundred Spanish and 400 North American obese subjects suitable for bariatric surgery closely matched for race, gender, age, and body mass index (BMI) were included. Two non-obese control groups matched for gender, age, and BMI from each population were also evaluated (nu2009=u2009400 in each group). The participants completed the Impact of Weight on Quality of Life—Lite (IWQOL—Lite) questionnaire, a measure of weight-related QOL.ResultsSpanish morbidly obese patients showed poorer QOL than their North American counterparts in physical function, sexual life, work, and total score. By contrast, Spanish non-obese control subjects reported better QOL in all domains than their North American counterparts. Women, both in Spain and North America, reported reduced QOL compared to men on the domain of self-esteem. In addition, North American women reported reduced QOL on the sexual life domain compared to men. BMI correlated negatively with all domains of QOL except for self-esteem in both national groups.ConclusionsSpanish obese subjects suitable for bariatric surgery report poorer weight-related quality of life than their North American counterparts, and obese women, regardless of nationality, perceive a reduced quality of life compared to men.

Primary Inadequate Weight Loss After Roux-en-Y Gastric Bypass Is not Associated with Poor Cardiovascular or Metabolic Outcomes: Experience from a Single Institution

BackgroundIt is well accepted that bariatric surgery has cardiovascular and metabolic effects independent of weight loss.MethodsWeight loss outcomes of patients undergoing Roux-en-Y gastric bypass (RYGB) at a high volume referral center were collected at 1xa0year postoperatively. Patients with failed primary weight loss were identified. Primary inadequate weight loss was defined as total body weight loss less than 15xa0%. Changes in hypertension (HTN), dyslipidemia, type 2 diabetes mellitus (T2DM), and metabolic syndrome profiles were investigated using Student’s t test.ResultsA total of 2500 patients underwent RYGB from the years 2001–2013 at our institution. One hundred five (4.2xa0%) patients had primary inadequate weight loss. Within this cohort, 81 (77.1xa0%) patients had hypertension, 67 (63.8xa0%) had dyslipidemia, 53 (50.5xa0%) had type 2 diabetes mellitus, and 66 (62.9xa0%) patients had metabolic syndrome. At 1xa0year postoperatively, all metabolic parameters were significantly improved. Measures of metabolic disease included high-density lipoprotein (HDL) (46.3xa0±xa011.6 versus 54.1xa0±xa012.7xa0mg/dL, pxa0<xa00.01), low-density lipoprotein (LDL) (103.6xa0±xa035.8 versus 89.2xa0±xa030.0xa0mg/dL, pxa0<xa00.01), triglycerides (177.3xa0±xa0139.1 versus 117.6xa0±xa059.3xa0mg/dL, pxa0<xa00.01), mean plasma glucose (128.9xa0±xa055.3 versus 102.7xa0±xa027.3xa0mg/dL, pxa0<xa00.01), and hemoglobin A1C (7.3xa0±xa01.9 versus 6.1xa0±xa01.0xa0%, pxa0<xa00.01). HTN was noted to improve in 27 (33.3xa0%) patients based on a decrease in the number of anti-hypertensives used (1.7xa0±xa01.0 versus 1.3xa0±xa01.3, pxa0<xa00.01), and 21 (31.8xa0%) patients had resolution of their metabolic syndrome.ConclusionImprovement in cardiometabolic comorbidities still occurs despite suboptimal weight loss following RYGB.

An intensive lifestyle intervention is an effective treatment of morbid obesity: The TRAMOMTANA study-a two-year randomized controlled clinical trial

Bariatric surgery is currently the most effective therapy to induce weight loss in morbidly obese patients. Objective. This controlled, clinical trial with a two-year intervention was aimed at comparing the efficacy of two nonsurgical approaches versus bariatric surgery, on body weight changes and metabolic parameters in morbidly obese patients. Methods. Patients were randomized to an Intensive Lifestyle Intervention (ILI) (n = 60) or Conventional Obesity Therapy (COT) (n = 46). The ILI group received behavioral therapy and nutritional counseling. The COT group received standard medical treatment. They were compared with a third group, Surgical Obesity Group (SOG) (n = 37). Results. Patients who received ILI had a greater percentage of weight loss than patients receiving COT (−11.3% versus −1.6%; p < 0.0044). Interestingly 31.4% of patients included in the ILI group were no longer morbidly obese after just six months of intervention, increasing to 44.4% after 24 months of intervention. The percentage weight loss in SOG was −29.6% after that same period of time. Conclusions. ILI was associated with significant weight loss when compared to COT, in a group of patients with obesity. An ILI approach could be an alternative therapy to patients with obesity, who are not candidates to undergo bariatric surgery. This trial is registered with EudraCT 2009-013737-24.

Functional high-intensity training improves pancreatic β-cell function in adults with type 2 diabetes

Type 2 diabetes (T2D) is characterized by reductions in β-cell function and insulin secretion on the background of elevated insulin resistance. Aerobic exercise has been shown to improve β-cell function, despite a subset of T2D patients displaying exercise resistance. Further investigations into the effectiveness of alternate forms of exercise on β-cell function in the T2D patient population are needed. We examined the effect of a novel, 6-wk CrossFit functional high-intensity training (F-HIT) intervention on β-cell function in 12 sedentary adults with clinically diagnosed T2D (54u2009±u20092 yr, 166u2009±u200916 mg/dl fasting glucose). Supervised training was completed 3 days/wk, comprising functional movements performed at a high intensity in a variety of 10- to 20-min sessions. All subjects completed an oral glucose tolerance test and anthropometric measures at baseline and following the intervention. The mean disposition index, a validated measure of β-cell function, was significantly increased (PRE: 8.4u2009±u20093.1, POST: 11.5u2009±u20093.5, P = 0.02) after the intervention. Insulin processing inefficiency in the β-cell, expressed as the fasting proinsulin-to-insulin ratio, was also reduced (PRE: 2.40u2009±u20090.37, POST: 1.78u2009± 0.30, P = 0.04). Increased β-cell function during the early-phase response to glucose correlated significantly with reductions in abdominal body fat (R2 = 0.56, P = 0.005) and fasting plasma alkaline phosphatase (R2 = 0.55, P = 0.006). Mean total body-fat percentage decreased significantly (Δ: -1.17 0.30%, P = 0.003), whereas lean body mass was preserved (Δ: +0.05u2009±u20090.68 kg, P = 0.94). We conclude that F-HIT is an effective exercise strategy for improving β-cell function in adults with T2D.

Functional high‐intensity exercise training ameliorates insulin resistance and cardiometabolic risk factors in type 2 diabetes

What is the central question of this study? Does short‐duration, high‐intensity exercise training that combines functional aerobic and resistance exercises into training sessions lasting 8–20 min benefit individuals with type 2 diabetes? What is the main finding and its importance? Functional high‐intensity training improves insulin sensitivity and reduces cardiometabolic risk in individuals with type 2 diabetes. This type of exercise training may be an effective exercise mode for managing type 2 diabetes. The increase in insulin sensitivity addresses a key defect in type 2 diabetes.