Suriya Punchai

Can Sleeve Gastrectomy "Cure" Diabetes? Long-term Metabolic Effects of Sleeve Gastrectomy in Patients With Type 2 Diabetes.

Objective: The aim of the study was to assess long-term metabolic effects of laparoscopic sleeve gastrectomy (LSG) in patients with type 2 diabetes (T2DM) and to identify predictive factors for long-term diabetes remission and relapse. Background: LSG has become the most common bariatric operation worldwide. Its long-term metabolic effects in patients with T2DM are, however, unknown. Methods: Outcomes of 134 patients with obesity with T2DM who underwent LSG at an academic center during 2005 to 2010 and had at least 5 years of follow-up were assessed. Results: At a median postsurgical follow-up of 6 years (range: 5–9), a mean body mass index loss of −7.8 ± 5.1 kg/m2 (total weight loss: 16.8% ± 9.7%) was associated with a reduction in mean glycated hemoglobin (HbA1c, −1.3 ± 1.8%, P < 0.001), fasting blood glucose (−37.8 ± 70.4 mg/dL, P < 0.001) and median number of diabetes medications (−1, P < 0.001). Long-term glycemic control (HbA1c <7%) was seen in 63% of patients (vs 31% at baseline, P < 0.001), diabetes remission (HbA1c <6.5% off medications) in 26%, complete remission (HbA1c <6% off medications) in 11%, and “cure” (continuous complete remission for ≥5 years) was achieved in 3%. Long-term relapse of T2DM after initial remission occurred in 44%. Among patients with relapse, 67% maintained glycemic control (HbA1c <7%). On adjusted analysis, taking 2 or more diabetes medications at baseline predicted less long-term remission (odds ratio 0.19, 95% confidence interval 0.07–0.55, P = 0.002) and more relapse of T2DM (odds ratio 8.50, 95% confidence interval: 1.40–49.20, P = 0.02). Significant improvement in triglycerides (−53.7 ± 116.4 mg/dL, P < 0.001), high-density lipoprotein (8.2 ± 12.9 mg/dL, P < 0.001), systolic (−8.9 ± 18.7 mmHg, P < 0.001) and diastolic blood pressure (−2.6 ± 14.5 mmHg, P = 0.04), and cardiovascular risk (13% relative reduction, P < 0.001) was observed. Conclusions: LSG can significantly improve cardiometabolic risk factors including glycemic status in T2DM. Long-term complete remission and “cure” of T2DM, however, occur infrequently.

Individualized Metabolic Surgery Score: Procedure Selection Based on Diabetes Severity

Objective: To construct and validate a scoring system for evidence-based selection of bariatric and metabolic surgery procedures according to severity of type 2 diabetes (T2DM). Background: Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) account for >95% of bariatric procedures in United States in patients with T2DM. To date, there is no validated model to guide procedure selection based on long-term glucose control in patients with T2DM. Methods: A total of 659 patients with T2DM who underwent RYGB and SG at an academic center in the United States and had a minimum 5-year follow-up (2005–2011) were analyzed to generate the model. The validation dataset consisted of 241 patients from an academic center in Spain where similar criteria were applied. Results: At median postoperative follow-up of 7 years (range 5–12), diabetes remission (HbA1C <6.5% off medications) was observed in 49% after RYGB and 28% after SG (P < 0.001). Four independent predictors of long-term remission including preoperative duration of T2DM (P < 0.0001), preoperative number of diabetes medications (P < 0.0001), insulin use (P = 0.002), and glycemic control (HbA1C < 7%) (P = 0.002) were used to develop the Individualized Metabolic Surgery (IMS) score using a nomogram. Patients were then categorized into 3 stages of diabetes severity. In mild T2DM (IMS score ⩽25), both procedures significantly improved T2DM. In severe T2DM (IMS score >95), when clinical features suggest limited functional &bgr;-cell reserve, both procedures had similarly low efficacy for diabetes remission. There was an intermediate group, however, in which RYGB was significantly more effective than SG, likely related to its more pronounced neurohormonal effects. Findings were externally validated and procedure recommendations for each severity stage were provided. Conclusions: This is the largest reported cohort (n = 900) with long-term postoperative glycemic follow-up, which, for the first time, categorizes T2DM into 3 validated severity stages for evidence-based procedure selection.

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. From 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. Of the 12 patients who developed …

Clinical features of symptomatic hypoglycemia observed after bariatric surgery

BACKGROUND Literature directly looking at post-bariatric surgery hypoglycemia consists mostly of small case series. The rate, severity, and outcomes of treatment in a large bariatric population are less characterized. OBJECTIVE To determine the rate of post-bariatric surgery hypoglycemia, its clinical features and management outcomes over a 13-year period at our institution. SETTING An academic center in the United States. METHODS Patients who underwent bariatric surgery at a single academic center between 2002 and 2015 and had a postdischarge glucose level of ≤70 mg/dL were studied. RESULTS Of 6024 patients who underwent bariatric procedure, 118 patients (2.0%) had a postoperative glucose level ≤70 mg/dL. Eighty-three patients (1.4%) had symptomatic hypoglycemia. The known underlying causes of symptomatic hypoglycemia included postprandial hyperinsulinemic hypoglycemia (n = 32, 38%), infection (n = 8, 10%), diabetic medications (n = 8, 10%), and poor oral intake (n = 8, 10%). Overall, 9 patients required intervention for nutritional supplementation including enteral (n = 9) and intermittent parenteral (n = 2) nutrition. No patients required reversal of their bariatric surgeries or pancreatic resection for management of hypoglycemia. The majority of the symptomatic patients had resolution of their symptoms (n = 76, 92%). Thirty-two patients had postprandial hypoglycemia with a median onset of hypoglycemia after bariatric surgery of 790 days (interquartile range 388-1334). All 32 patients with postprandial hypoglycemia had dietary adjustment and 53% received pharmacotherapy, which resulted in complete resolution of hypoglycemia (n = 29, 91%) and resolution with minimal disability (n = 3, 9%). CONCLUSION The rate of symptomatic hypoglycemia and postprandial hypoglycemia after bariatric surgery were 1.4% and .5%. The majority of patients were successfully managed with dietary counseling, nutritional intervention, and occasionally pharmacotherapy. No surgical reversal or pancreatic procedures were performed.

Bariatric surgery in patients with pulmonary hypertension

BACKGROUND Data regarding the outcomes of bariatric surgery in patients with pulmonary hypertension (PH) is limited. The aim of this study was to review our experience on bariatric surgery in patients with PH. SETTING An academic medical center. METHODS Patients with PH who underwent either a primary or revisional bariatric surgery between 2005 and 2015 and had a preoperative right ventricle systolic pressure (RVSP) ≥35 mm Hg were included. RESULTS Sixty-one patients met the inclusion criteria. Fifty (82%) were female with the median age of 58 years (interquartile range [IQR] 49-63). The median body mass index was 49 kg/m2 (IQR 43-54). Procedures performed included the following: Roux-en-Y gastric bypass (n = 33, 54%), sleeve gastrectomy (n = 24, 39%), adjustable gastric banding (n = 3, 5%), and banded gastric plication (n = 1, 2%). Four patients (7%) underwent revisional bariatric procedures. Median operative time and length of stay was 130 minutes (IQR 110-186) and 3 days (IQR 2-5), respectively. The 30-day complication rate was 16% (n = 10) with pulmonary complications noted in 4 patients. There was no 30-day mortality. One-year follow-up was available in 93% patients (n = 57). At 1 year, median body mass index and excess weight loss were 36 kg/m2 (IQR 33-41) and 51% (IQR 33-68), respectively. There was significant improvement in the RVSP after bariatric surgery at a median follow-up of 22 months (IQR 10-41). The median RVSP decreased from 44 (IQR 38-53) to 40 mm Hg (IQR 28-54) (P = .03). CONCLUSION Bariatric surgery can be performed without prohibitive complication rates in patients with PH. In our experience, bariatric patients with PH achieved significant weight loss and improvement in RVSP.