Yi-Chih Lee

Laparoscopic sleeve gastrectomy for diabetes treatment in nonmorbidly obese patients: Efficacy and change of insulin secretion

BACKGROUNDnSleeve gastrectomy is a new bariatric surgery, and many reports have showed that patients who have undergone sleeve gastrectomy have experienced rapid resolution of type 2 diabetes. The mechanisms accounting for the beneficial effects of sleeve gastrectomy on glucose homeostasis are not well understood and remain speculative. This trial assessed prospectively the effect of sleeve gastrectomy on type 2 diabetes and the serial changes of insulin secretion to oral glucose loads.nnnMETHODSnProspective study on the response of insulin secretion to oral glucose loads in 20 severe diabetic patients (body mass index [BMI] >25 and <35, HbA1C >7.5%) before and at 1, 4, 12, 26, and 52 weeks after sleeve gastrectomy. The insulin secretion was measured by insulinogenic index and area under the curve (AUC) during a standard oral glucose tolerance test (OGTT). Remission of type 2 diabetes was defined as fasting glucose level <126 mg/dL and HbA1C <6.5% without any glycemic therapy.nnnRESULTSnOf the 20 patients enrolled, the mean age was 46.3 + or - 8.0 years, mean BMI was 31.0 + or - 2.9 kg/m(2), and mean HbA1C was 10.1 + or - 2.2. The mean BMI and excess body weight loss at 1, 4, 12, 26, and 52 weeks after operation were 28.9 (22.1%), 27.4 (43.0%), 25.7 (55.1%), 24.9 (71.9%), and 24.6 (69.1%), respectively. The mean HbA1C at 1, 4, 12, 26, and 52 weeks after operation were 9.2, 8.4, 7.7, 7.3, and 7.1, respectively. Resolution of type 2 diabetes was achieved in 2 (20%) patients at 4 weeks, 6 (30%) at 12 weeks, 8 (40%) at 26 weeks, and 10 (50%) at 52 weeks after sleeve gastrectomy. Before operation, the mean fasting plasma glucose and insulin levels were 240.1 + 80.9 mg/dL and 16.8 + or - 15.4 uIU/mL, respectively. The OGTT test showed a blunted insulin secretion pattern with an AUC of 3,135 uIU x min/mL. At 1 week after operation, the fasting plasma glucose and insulin levels significantly decreased to 158 + or - 52 mg/dL and 5.6 + or - 3.2 uIU/mL, respectively. The AUC decreased to 2,988.7 uIU x min/mL. The AUC at 4, 12, 26, and 52 weeks after operation was 2,211, 1,584, 3,621, and 3,351 uIU x min/mL, respectively. The diabetes resolution rates for those with pre-operative C-peptide <3, 3-6, and >6 ng/mL were 1/7 (14.3%), 7/11 (63.6%), and 2/2 (100%), respectively (P < .05).nnnCONCLUSIONnLaparosopic gastric sleeve gastrectomy resulted in remission of poorly controlled nonmorbidly obese T2DM patients up to 50% at 1 year after operation. The effect is related more to the decreasing of insulin resistance because of calorie restriction and weight loss rather than to the increasing of insulin secretion. C-peptide >3 ng/mL is the most important predictor for a successful treatment.

Changes in postprandial gut hormones after metabolic surgery: a comparison of gastric bypass and sleeve gastrectomy.

BACKGROUNDnLaparoscopic gastric bypass (GB) is reportedly more effective than laparoscopic sleeve gastrectomy (SG) in the treatment of patients with a low body mass index and type 2 diabetes mellitus. However, the mechanism remains speculative. We compared the postprandial gut hormone patterns between patients undergoing laparoscopic GB and laparoscopic SG at 2 years after surgery in a hospital-based, prospective study.nnnMETHODSnA total of 16 laparoscopic GB and 16 laparoscopic SG patients were followed up and appraised for glucose homeostasis. Two years after surgery, the mixed meal test and gut hormones were evaluated in 13 laparoscopic GB and 13 laparoscopic SG patients who had been included in the previous randomized trial.nnnRESULTSnThe preoperative characteristics, such as body mass index, body weight, waist circumference, and duration of T2DM were comparable between the 2 groups. T2DM remission was achieved in 13 (81%) laparoscopic GB and 3 (19%) laparoscopic SG patients (P < .05) 2 years after surgery. The laparoscopic GB patients had lost more weight and had a smaller waist circumference and lower levels of glucose and hemoglobin A1c, and lower insulin resistance than the SG patients. Significant differences were found in acyl ghrelin, des-acyl ghrelin, cholecystokinin, and resistin between the 2 groups, but none in obestatin, gastric inhibitory peptide, glucagon-like peptide-1, and leptin.nnnCONCLUSIONSnBoth laparoscopic GB and laparoscopic SG have strong hindgut effects after surgery, but GB has a significant duodenal exclusion effect on cholecystokinin. The laparoscopic SG group had lower acyl ghrelin and des-acyl ghrelin levels but greater concentrations of resistin than the laparoscopic GB group.

Predicting success of metabolic surgery: age, body mass index, C-peptide, and duration score.

BACKGROUNDnSurgery is the most effective treatment of morbid obesity and leads to dramatic improvements in type 2 diabetes mellitus (T2DM). Gastrointestinal metabolic surgery has been proposed as a treatment option for T2DM. However, a grading system to categorize and predict the outcome of metabolic surgery is lacking. The study setting was a tertiary referral hospital (Taoyuan City, Taoyuan County, Taiwan).nnnMETHODSnWe first evaluated 63 patients and identified 4 factors that predicted the success of T2DM remission after bariatric surgery in this cohort: body mass index, C-peptide level, T2DM duration, and patient age. We used these variables to construct the Diabetes Surgery Score, a multidimensional 10-point scale along which greater scores indicate a better chance of T2DM remission. We then validated the index in a prospective collected cohort of 176 patients, using remission of T2DM at 1 year after surgery as the outcome variable.nnnRESULTSnA total of 48 T2DM remissions occurred among the 63 patients and 115 remissions (65.3%) in the validation cohort. Patients with T2DM remission after surgery had a greater Diabetes Surgery Score than those without (8 ± 4 versus 4 ± 4, P < .05). Patients with a greater Diabetes Surgery Score also had a greater rate of success with T2DM remission (from 33% at score 0 to 100% at score 10); A 1-point increase in the Diabetes Surgery Score translated to an absolute 6.7% in the success rate.nnnCONCLUSIONnThe Diabetes Surgery Score is a simple multidimensional grading system that can predict the success of T2DM treatment using bariatric surgery among patients with inadequately controlled T2DM.

Diabetes remission and insulin secretion after gastric bypass in patients with body mass index <35 kg/m2.

BackgroundMost morbidly obese patients who undergo gastric bypass experience rapid remission of type 2 diabetes mellitus (T2DM) but the response in non-morbidly obese patients is not clear. This trial prospectively assessed the effect of diabetes remission, glucose metabolism, and the serial changes of insulin secretion after gastric bypass in inadequately controlled T2DM patients with a BMI of 23–35xa0kg/m2.MethodsA total of 62 consecutive patients with T2DM and a BMI of 23–35xa0kg/m2 underwent gastric bypass. Data were prospectively collected before surgery and 1, 4, 12, 26, and 52xa0weeks and 2xa0years after surgery. Insulin secretion was measured by insulinogenic index and area under the curve (AUC) during a standard oral glucose tolerance test (OGTT). Remission of type 2 diabetes was defined as fasting glucose level <110xa0mg/dl and HbA1c <6.0% without any glycemic therapy.ResultsOf the 62 patients, 24 were men and 38 were women (age 43.1u2009±u200910.8xa0years). Their preoperative characteristics were as follows: BMI 30.1u2009±u20093.3xa0kg/m2, waist circumference 99.6u2009±u20099.6xa0cm, C-peptide 3.1u2009±u20091.4xa0ng/ml, and duration of T2DM 5.4u2009±u20095.1xa0years. The mean BMI decreased postoperatively to 22.6u2009±u20092.3xa0kg/m2 in 1xa0year and 23.0u2009±u20092.7xa0kg/m2 in 2xa0years. The mean HbA1c decreased from 9.7u2009±u20091.9% to 5.8u2009±u20090.5% in 1xa0year and 5.9u2009±u20090.5% in 2xa0years. Complete remission of T2DM was achieved in 57% in 1xa0year and 55% in 2xa0years after surgery. Before surgery, the OGTT test showed a blunted insulin secretion pattern with an insulinogenic index of 0.1u2009±u20090.2 and AUC of 2,324u2009±u20091,015xa0μIUxa0min/ml. In 1xa0week after surgery, the insulinogenic index increased to 0.16 and AUC decreased to 1,366xa0μIUxa0min/ml along with a rapid drop of insulin resistance. The insulinogenic index and AUC gradually increased to 0.27 and 3,220, respectively, 1xa0year after surgery and remained stable up to 2xa0years with a very low insulin resistance.ConclusionsLaparoscopic gastric bypass facilitates immediate improvement in the glucose metabolism of inadequately controlled non-severe obese T2DM patients, and the benefit is sustained up to 2xa0years after surgery. The benefit is regulated by the decrease in insulin resistance, increase in early insulin response, and total insulin secretion to glucose load.

C-peptide Predicts the Remission of Type 2 Diabetes After Bariatric Surgery

BackgroundC-peptide is a surrogate of the pancreatic beta cell mass. However, the clinical significance of C-peptide in a diabetic patient after bariatric surgery has not been studied clearly.MethodsFrom February 2005 to January 2009, a total of 205 (124 females and 81 males) consecutive morbidly obese patients with type 2 diabetes mellitus (T2DM) enrolled in a surgically supervised weight loss program with at least 1xa0year follow-up were examined. Among them, 147 patients (71.7%) received gastric bypass procedures, while the other 58 patients (28.3%) received restrictive-type procedures.ResultsThe mean C-peptide before the surgery was 5.3u2009±u20093.5xa0ng/ml. One hundred nineteen patients (58.0%) had an elevated C-peptide (>4xa0ng/ml), while 2 patients (1.0%) had a low C-peptide (<1.0xa0ng/ml). Multivariate analysis confirmed that waist circumference, triglycerides, and HbA1c were the independent predictors for the elevation of C-peptide. It was observed that the mean C-peptide levels decreased to 1.7u2009±u20090.9xa0ng/ml 1xa0year after bariatric surgery with a mean reduction of 64.1%. One year after surgery, 160 patients (78.0%) out of a total of 205 patients had a remission of their T2DM. Patients in the bypass group had a higher diabetes remission rate (91.2%; 134 out of 147) in comparison to patients in the restrictive group (44.8%; 26 out of 58, pu2009<u20090.001). The diabetes remission rates for those with preoperative C-peptide <3, 3–6, and >u20096xa0ng/ml were 26 out of 47 (55.3%), 87 out of 108 (82.0%), and 47 out of 52 (90.3%), pu2009<u20090.001, respectively.ConclusionsBaseline C-peptide is commonly elevated in morbidly obese patients with T2DM. There was a marked reduction in C-peptide after a significant weight reduction 1xa0year after surgery with a T2DM remission rate of 78.0%. Thus, bariatric surgery is recommended for obesity-related T2DM patients with elevated C-peptide.

Revisional surgery for laparoscopic minigastric bypass

BACKGROUNDnLaparoscopic minigastric bypass (LMGB), a sleeved gastric tube with Billroth II anastomosis, has been proposed as an alternative to laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity. However, the data regarding revision surgery after LMGB during long-term follow-up is not clear.nnnMETHODSnFrom January 2001 to December 2009, 1322 patients (996 women and 326 men, mean age 31.6 ± 9.1 years, mean body mass index 40.2 ± 7.4 kg/m(2)), who were enrolled in a surgically supervised weight loss program and had undergone LMGB were included. All the patients received regular yearly follow-up, and all the clinical data were prospectively collected and stored. The reasons and type of surgery for revision surgery were identified and analyzed.nnnRESULTSnThe excess weight loss and mean body mass index at 5 years after LMGB was 72.1% and 27.1 ± 4.6 kg/m(2). Of the 1322 patients, 23 (1.7%) had undergone revision surgery during a follow-up of 9 years. The estimated accumulated revision rate of 9 years was 2.69% for LMGB. The most common cause of revision was malnutrition in 9 (39.1%), followed by inadequate weight loss in 8 (34.7%), and intractable bile reflux and dissatisfaction each in 3 (13.0%). The type of revision surgery was LRYGB in 11 (47.8%), sleeve gastrectomy in 10 (43.5%), and conversion to a normal anatomic state in 2 (8.6%). All the revision procedures were performed using a laparoscopic approach, without major complications. Two patients underwent repeat second revision surgery to duodenal switch and biliopancreatic diversion each in 1 patient. All patients had satisfactory results after revision surgery. No patients had undergone revision surgery for internal hernia or ileus during the follow-up period.nnnCONCLUSIONnLMGB resulted in significant and sustained weight loss with an acceptably low revision rate at long-term follow-up. Revision surgery after LMGB can be performed using a laparoscopic approach with a low risk.

Effect of Bariatric Surgery vs Medical Treatment on Type 2 Diabetes in Patients With Body Mass Index Lower Than 35: Five-Year Outcomes.

IMPORTANCEnIt has been well recognized that metabolic surgery has short-term benefits for mildly obese patients with type 2 diabetes mellitus (T2DM), but how long these effects can be sustained is uncertain.nnnOBJECTIVEnTo compare the 5-year efficacy between gastrointestinal metabolic surgery and medical treatment on glycemic control and diabetes remission in patients with T2DM and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) lower than 35.nnnDESIGN, SETTING, AND PARTICIPANTSnThis retrospective cohort study compares long-term outcomes for mildly obese patients with T2DM receiving metabolic surgery (nu2009=u200952) vs medical treatment (nu2009=u2009299). The surgical group, enrolled from August 20, 2007, to June 25, 2008, and followed up through December 31, 2013, received standard sleeve gastrectomy (nu2009=u200919) or bypass (nu2009=u200933) procedures in a regional hospital. The medical group, selected from a nationwide community cohort that was recruited from August 27, 2003, to December 31, 2005, and followed up through December 31, 2012, was matched with the surgical group by age, BMI, and diabetes duration.nnnMAIN OUTCOMES AND MEASURESnGlycated hemoglobin (HbA1c) reduction and prolonged complete and partial diabetes remission (defined as HbA1c <6.0% and 6.0%-6.5% of total hemoglobin [Hb; to convert to proportion of total Hb, multiply by 0.01], respectively, for those who were exempted from any antidiabetic drugs for 5 years).nnnRESULTSnAt the end of the fifth year, the surgical group had a mean weight loss of 21.0% (from a mean [SD] BMI of 31.0 [2.4] to 24.5 [2.7]), their mean (SD) HbA1c decreased from 9.1% (2.1%) to 6.3% (1.1%) of total Hb, 18 participants (36.0%) had complete remission, 14 (28.0%) had partial remission, 1 (1.9%) died, and 1 (1.9%) had end-stage renal disease. In the same follow-up period in the medical group, 3 (1.2%) had complete remission, 4 (1.6%) had partial remission, 9 (3.0%) died, and 2 (0.7%) had end-stage renal disease; their mean HbA1c remained around 8% of total Hb (mean [SD], 8.1% [1.8%] of total Hb at baseline and 8.0% [1.6%] of total Hb at 5 years), and BMI also stayed similar (mean [SD], 29.1 [2.4] at baseline and 28.8 [2.6] at 5 years). The HbA1c reduction and complete and partial remission rates were all significantly larger in the surgical group as compared with the medical group (all Pu2009<u2009.001). However, the mortality rate and end-stage renal disease incidence were not significantly different in these 2 comparison groups (Pu2009=u2009.66 and .37, respectively).nnnCONCLUSIONS AND RELEVANCEnFor mildly obese patients with T2DM, the improvement in glycemic control from metabolic surgery lasts at least 5 years. However, the survival benefit and lifelong adverse outcomes require more than 5 years to be established.

Transumbilical 2-site laparoscopic Roux-en-Y gastric bypass: initial results of 100 cases and comparison with traditional laparoscopic technique

BACKGROUNDnSingle-site or single-incision laparosopic surgery has recently been developed, but it is difficult to use in more complicated gastric bypass surgery. We have introduced a 2-site modified single-incision laparosopic surgery technique for laparoscopic Roux-en-Y gastric bypass (LRYGB).nnnMETHODSnWe used the umbilical site incision to place 2 ports (12 and 10 mm) to serve as the video port and working port for the stapler. Another small skin incision was placed at a left lateral abdominal site for the 5-mm working port. Through these working channels, we could use conventional laparoscopic instruments to perform LRYGB. The data from 100 consecutive 2-site LRYGB procedures (February 2009 to September 2009) were compared with the data from 100 traditional LRYGB procedures (September 2008 to January 2009).nnnRESULTSnThe mean body mass index for the study group was 43 kg/m(2) (range 32-61), and mean age was 34 years (range 18-55). The procedures were successfully performed in all but 18 patients. These 18 patients had required an extra skin incision for a 5-mm port to complete the procedures. The mean operating time was 144 minutes (range 95-160), and blood loss was 56 mL (range 20-150). A total of 3 perioperative major complications (3%) occurred, and 6 patients (6%) had minor complications. The 2-site LRYGB group had a significantly longer operating time and more blood loss than the traditional LRYGB group but less pain and better cosmesis.nnnCONCLUSIONnTwo-site LRYGB generated minimal somatic pain and achieved excellent cosmetic results. We believe it can be applied as routine LRYGB surgery.