Published in June/July Issue             

Bariatric Surgery for Patients With Early-Onset vs Late-Onset Type 2 Diabetes
(JAMA Surgery)

This study compared type 2 diabetes remission following bariatric surgery in patients with early-onset (age < 40 years) and late-onset (age >=40 years) of the disease. In the study, 558 Taiwanese patients (339 early-onset vs. 219 late-onset) with a BMI above 25 had surgery between January 1, 2007 and December 31, 2013. Patients had a mean age of 33.5 for those with early-onset and 50.6 with late-onset. Those with early-onset had a higher mean preoperative BMI and hemoglobin A1C values compared to patients with late-onset. One year following surgery, patients with early-onset achieved greater weight loss, although the difference was not statistically significant. Patients with early-onset also experienced a higher rate of complete remission, compared to those with late-onset (193 vs. 110, respectively). Five years following surgery, patients with early-onset maintained a higher rate of weight loss (30.4% vs. 21.6%) and higher rate of remission compared to those with late-onset (47 of 72 vs. 26 of 48, respectively). Age at time of surgery, duration of diabetes and preoperative C-peptide level were independent predictors of remission. The remission rate was directly related to extent of weight loss. The findings suggest that bariatric surgery may achieve better and more long-lasting glycemic control in patients with early-onset type 2 diabetes than in those with late-onset. The study is the largest long-term investigation of bariatric surgery for patients with early-onset type 2 diabetes.

Gastric Bypass Surgery Leads to Long-term Remission or Improvement of Type 2 Diabetes and Significant Decrease of Microvascular and Macrovascular Complications
(Annals of Surgery)

The study compared long-term outcomes in patients with morbid obesity and type 2 diabetes treated with gastric bypass or medical management. The surgery group included 173 patients who had gastric bypass between January 2000 and July 2004 and were followed for at least 10 years. The control group included of 80 diabetic patients from the same period with similar BMI, age, race and severity of diabetes followed for 11 years. The surgery group had a greater %EWL than the control group, 66% vs. 1.6%, respectively. Forty-one patients (52.6%) in the surgery group had complete remission of diabetes and 5 (6.4%) had partial remission. Twelve patients (15.4%) had diabetes recurrence after initial remission. No patient in the control group had remission of diabetes. Compared with the medical management group, the surgery group had a significantly reduced incidence of microvascular complications (46.3% vs. 11.5%) and macrovascular complication (20.3% vs. 5%, respectively). The study demonstrates that after 10 years of follow-up, gastric bypass surgery, compared with nonsurgical medical management, resulted in significantly greater weight loss, reduction in hemoglobin A1c, and use of antidiabetic medications and a lower incidence of both microvascular and macrovascular complications in patients with obesity and type 2 diabetes.

10-Year Outcomes After Roux-en-Y Gastric Bypass (Annals of Surgery)

The aim of the study was to evaluate the clinical effectiveness and long-term durability of gastric bypass at an accredited center. 651 patients, including 335 open and 316 laparoscopic patients, were followed for 10 years. Patients undergoing open surgeries had a higher preoperative BMI. Otherwise, preoperative characteristics were similar. Postoperative incisional hernia rates were higher in open vs. laparoscopic patients (16.9% vs. 4.7%, respectively). Annual percentage reduction in excess BMI significantly improved over time, peaking at 74% by 24 months, with a slow trend down to 52% at 10 years. A highly significant decrease in obesity-related comorbid disease persisted 10 years following gastric bypass.

Changes in Prescription Drug Use After Gastric Bypass Surgery: A Nationwide Cohort Study (Annals of Surgery)

The study evaluated changes over time in drug use among patients undergoing gastric bypass compared to a matched cohort. The nationwide population-based cohort study included 9,908 patients undergoing surgery in Denmark from 2006 to 2010 and 99,080 matched general population members. At baseline, more surgery patients used any prescription drug (81.5% vs. 49.1%). After three years, the use had decreased slightly among the gastric bypass group, but increased in the comparison cohort. In the gastric bypass cohort, large, sustained decreases occurred for treatment of metabolic syndrome-related conditions, including glucose-lowering and lipid-modifying drugs. Use of inhalants for obstructive airway diseases also decreased. Use of neuropsychiatric drugs was two-fold higher at baseline in the RYGB cohort (22.8% vs. 10.9%) and increased further after gastric bypass. This included antidepressants, antipsychotics and potential treatment of neuropathy. Three years after gastric bypass, large reductions in the use of treatment of metabolic syndrome-related conditions, inhalants for obstructive airway diseases and glucocorticoid use. In contrast, to the large reductions in drug treatments for metabolic syndrome-related conditions, the study demonstrates frequent use of neuropsychiatric drugs further increased after surgery.

5-Year Outcomes of One-Stage Gastric Band Removal and Sleeve Gastrectomy (SOARD)

The study reports five-year outcomes of one-stage gastric band removal and conversion to sleeve gastrectomy with comparison to primary laparoscopic sleeve gastrectomy. The two study groups included 209 patients undergoing conversion procedures and 3,268 who underwent primary sleeve gastrectomies. No significant differences in age, BMI and gender distribution existed. For the conversion patients, baseline BMI was 47 and had spent an average of 6.2 years with the band before conversion. BMI at 1, 2, 3, 4, and 5 years was 37, 31, 29, 30, and 30, respectively. No significant difference in BMI change comparing the two groups existed. In the conversion group, one patient had a successfully stented leak, but he developed a gastrobronchial fistula one year later. In the primary group, three leak cases were reported and managed successfully through endoscopic stenting. One other patient had pulmonary embolism that responded to standard treatment, and three patients had postoperative bleeding. No other major complications occurred, and there was no mortality in either group. Additionally, no conversion patient required further bariatric intervention. The study demonstrates that one-stage gastric band removal and conversion to sleeve gastrectomy is as safe and effective as primary sleeve gastrectomy.

Long-Term Outcome After Laparoscopic Sleeve Gastrectomy in Patients Over 65 Years Old: A Retrospective Analysis (SOARD)

The study assessed the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) performed in older patients (>= 65 years old). Between May 1, 2007 and November 30, 2013, a total of 27 (90%) primary LSG and three revisional LSG (10%) were performed on patients with a mean age of 67.2 and mean pre-operative BMI of 44.1. Thirty-day morbidity included three cases of self-limiting nausea and vomiting and one case of gastric sleeve stenosis, requiring conversion to gastric bypass. No mortality reported. The overall mean %EWL and %TWL at 12 months were 53.8 and 23.9, respectively. At 36 months the overall mean %EWL and %TWL were 52.9 and 24, respectively. Age-adjusted mixed model analyses revealed that baseline BMI, BMI greater than 45 and having diabetes were associated with EWL< 50% across follow-up. The study suggests, LSG is effective and safe for patient >=65 years old.

Risk of Post-Gastric Bypass Surgery Hypoglycemia in Nondiabetic Individuals: A Single Center Experience (Obesity Surgery)

The study aimed to evaluate the risk of post-gastric bypass surgery hypoglycemia (PGBH) among nondiabetic patients and associated factors. PGBH was defined by any postoperative record of glucose < 60 mg/dL, diagnosis of hypoglycemia, or any medication use for treatment of PGBH. The study included 1,206 eligible patients who had a mean age of 43.7 years and a mean preoperative BMI of 48.7 who were followed for 4.8 years. The cumulative incidence of hypoglycemia at 1 and 5 years post-surgery was 2.7% and 13.3%, respectively. Incidence of PGBH was identified in 158 patients and was associated with lower preoperative BMI, lower preoperative HbA1c and higher 6-month %EWL. A lower preoperative HbA1c and higher 6-month %EWL remained independently correlated with increased risk for PGBH in multi-regression analysis.