Recent advances in bariatric/metabolic surgery:appraisal of clinical evidence

Obesity and associated type 2 diabetes mellitus（T2DM） are becoming a serious medical issue worldwide.Bariatric surgery has been shown to be the most effective and durable therapy for the treatment of morbid obese patients.Increasing data indicates bariatric surgery as metabolic surgery is an effective and novel therapy for not well controlled obese T2 DM patients.The review of recent developments in bariatric/metabolic surgery covers 4major fields.1） Improvement of safety：recent advances in laparoscopic/metabolic surgery has made this minimal invasive surgery more than ten times safer than a decade ago.The safety profile of laparoscopic/metabolic surgery is compatible with that of laparoscopic cholecystectomy now.2） New bariatric/metabolic surgery：laparoscopic sleeve gastrectomy（LSG） is becoming the leading bariatric surgery because of its simplicity and efficacy.Other new procedures,such as gastric plication,banded plication,single anastomosis（mini） gastric bypass and Duodeno-jejunal bypass with sleeve gastrectomy have all been accepted as treatment modalities for bariatric/metabolic surgery.3）Mechanism of bariatric/metabolic surgery：Restriction is the most important mechanism for bariatric surgery.Weight regain after bariatric surgery is usually associated with loss of restriction.Recent studies demonstrated that gut hormone,microbiota and bile acid changes after bariatric surgery may play an important role in durable weight loss as well as in T2 DM remission.However,weight loss is still the cornerstone of T2 DM remission after metabolic surgery.4） Patient selection：patients who may benefit most from bariatric surgery was found to be patients with insulin resistance.For Asian T2 DM patients,the indication of metabolic surgery has been set to those with not well2controlled（Hb A1 c.7.5%） disease and with their BMI.27.5 Kg/m.A novel diabetes surgical score,ABCD score,is a simple system for predicting the success of surgical therapy for T2 DM.

Which predictors could effect on remission of type 2 diabetes mellitus after the metabolic surgery:A general perspective of current studies?

BACKGROUND The alarming rise in the worldwide prevalence of obesity is paralleled by an increasing burden of type 2 diabetes mellitus(T2DM).Metabolic surgery is the most effective means of obtaining substantial and durable weight loss in individual obese patients with T2DM.There are randomized trials that justify the inclusion of metabolic surgery into the treatment algorithm for patients with T2DM,but remission rates of T2DM after metabolic surgery can display great variability.AIM To discuss the most commonly used surgical options including vertical sleeve gastrectomy,adjustable gastric banding,Roux-en-Y gastric bypass,and biliopancreatic diversion with duodenal switch.METHODS We also report from observational and randomized controlled studies on rate of remission of T2DM after the surgical procedures.RESULTS In light of the recent findings,metabolic surgery is a safe and effective treatment option for obese patient with T2DM,but further studies are needed to clarify better the rate of diabetes remission.CONCLUSION In light of the recent findings,metabolic surgery is a safe and effective treatment option for obese patients with T2DM,but further studies are needed to clarify better the rate of diabetes remission.

Metabolic surgery:present and future

Several articles in this issue of the Journal cover a broad range of the new concepts of metabolic surgery, the mechanisms that leads to sustained metabolic syndrome remission, the new surgical procedures, and the perspective of surgeons and endocrinologists.

Expert opinion on the preoperative medical optimization of adults with diabetes undergoing metabolic surgery

Diabetes mellitus(DM)and obesity are interrelated in a complex manner,and their coexistence predisposes patients to a plethora of medical problems.Metabolic surgery has evolved as a promising therapeutic option for both conditions.It is recommended that patients,particularly those of Asian origin,maintain a lower body mass index threshold in the presence of uncontrolled DM.However,several comorbidities often accompany these chronic diseases and need to be addressed for successful surgical outcome.Laparoscopic Roux-en-Y gastric bypass(RYGB)and laparoscopic sleeve gastrectomy(LSG)are the most commonly used bariatric procedures worldwide.The bariatric benefits of RYGB and LSG are similar,but emerging evidence indicates that RYGB is more effective than LSG in improving glycemic control and induces higher rates of long-term DM remission.Several scoring systems have been formulated that are utilized to predict the chances of remission.A glycemic target of glycated hemoglobin<7%is a reasonable goal before surgery.Cardiovascular,pulmonary,gastrointestinal,hepatic,renal,endocrine,nutritional,and psychological optimization of surgical candidates improves perioperative and long-term outcomes.Various guidelines for preoperative care of individuals with obesity have been formulated,but very few specifically focus on the concerns arising from the presence of concomitant DM.It is hoped that this statement will lead to the standardization of presurgical management of individuals with DM undergoing metabolic surgery.

Sleeve Gastrectomy with Duodenal Transit Bipartition (S-DTB): Preliminary Results and Technical Aspects of Its Metabolic Structure

Obesity is a significant and escalating health issue both in Brazil and globally, with over 650 million overweight adults worldwide. The treatment of obesity can be performed clinically, endoscopically or surgically;surgical treatment proves to be safe and more effective in terms of weight loss and long-term maintenance. Objective: This study aimed to monitor the progress of weight loss and comorbidity control in patients undergoing sleeve gastrectomy with duodenal bipartition. Methods: This pilot project involved 8 patients divided into 2 arms. In the first arm, patients underwent sleeve gastrectomy with Roux-en-Y duodenoileal transit bipartition (S-RYDITB), while in the second arm, patients underwent sleeve gastrectomy with Roux-en-Y duodenojejunal transit bipartition (S-RYDJTB). Both procedures involved Roux-en-Y reconstruction without duodenal exclusion. In S-RYDITB, the duodenal-ileal anastomosis was performed 300 cm from the ileocecal valve (ICV), creating a 250 cm common channel and a 50 cm alimentary channel. In S-RYDJTB, a biliopancreatic loop was created 200 cm from the angle of Treitz, with a 1 m alimentary channel. Results: Five patients underwent the procedures, with one undergoing S-RYDITB and four undergoing S-RYDJTB. No adverse events such as hospitalizations, readmissions, reoperations, fistulas, bleeding, pulmonary embolism, diarrhea, dumping syndrome, or hypoglycemia occurred during the study period. The mean length of hospital stay was 2 days. The average BMI decreased from 37.27 kg/m2 preoperatively to 29.48 kg/m2 after 6 months. The significant percentage of weight loss was 21.22%, with excess weight loss of 63.6%. Ninety-five percent remission of comorbidities, including hypercholesterolemia, hypertriglyceridemia, diabetes, hypertension, steatosis, and pre-diabetes. Two patients underwent sleeve gastrectomy with duodenal bipartition using a single anastomosis. Conclusion: Duodenal switch surgery has gained worldwide recognition for its safety and efficacy in treating obesity and its associated comorbidities. In efforts to maintain the positive outcomes of the classic technique while minimizing adverse effects such as malnutrition and diarrhea, modifications to the original procedure have been proposed. Among these adaptations, Sleeve gastrectomy with bipartition of duodenal transit (S-DTB) emerges as a promising variant, offering alternative strategies to optimize patients’ nutritional safety while preserving endoscopic access to the duodenum. Initial results of S-DTB, whether performed in Roux-en-Y or single anastomosis (loop) configuration without intestinal exclusions, demonstrate the procedure’s safety and effectiveness in managing obesity and its comorbidities.

Metabolic surgery in China: present and future

Obesity and its related complications comprise a serious public health problem worldwide,and obesity is increasing in China.Metabolic surgery is a new type of treatment with unique advantages in weight loss and obesity-related metabolic complications.The pathogenesis of obesity is complex and not yet fully understood.Here,we review the current efficacy and safety of metabolic surgery,as well as recent progress in mechanistic studies and surgical procedures in China.The exciting and rapid advances in this field provide new opportunities for patients with obesity and strike a balance between long-term effectiveness and safety.

Bile acids and metabolic surgery

The epidemic of obesity and its co-mortalities has reached an alarming level worldwide.Currently,metabolic surgeries,especially the Roux-en-Y gastric bypass and vertical sleeve gastrectomy,are the most effective and sustainable treatments for obesity,type 2 diabetes,non-alcoholic steatohepatitis,as well as other metabolic diseases.However,the invasive nature of the surgeries limits their broad ap-plications to the general public.Therefore,developing alternative non-invasive approaches to mimic metabolic surgery is an important direction of the field.Recent studies have identified several potential metabolic surgery-induced downstream endocrine mediators,among which bile acids are key candidate signaling molecules.Bile acids are profoundly altered by metabolic surgery,which contributes to the metabolic effects of the surgery.In this review,we focus on the most recent studies on the roles of bile acids and bile acid receptors farnesoid X receptor and Takeda G protein-coupled receptor 5 in mediating the metabolic effects of metabolic surgery.We conclude that targeting bile acid pathways may be a promising pharmacological approach to mimic the beneficial effects of metabolic surgery.

Comparative effectiveness of medical treatment vs.metabolic surgery for histologically proven non-alcoholic steatohepatitis and fibrosis:a matched network meta-analysis

Background:Non-alcoholic steatohepatitis(NASH)comprises a major healthcare problem affecting up to 30%of patients with obesity and the associated risk for cardiovascular and liver-related mortality.Several new drugs for NASH-treatment are currently investigated.No study thus far directly compared surgical and non-surgical therapies for NASH.This network meta-analysis compares for the first time the effectiveness of different therapies for NASH using a novel statistical approach.Methods:The study was conducted according to the PRISMA guidelines for network meta-analysis.PubMed,CENTRAL and Web of Science were searched without restriction of time or language using a validated search strategy.Studies investigating therapies for NASH in adults with liver biopsies at baseline and after at least 12 months were selected.Patients with liver cirrhosis were excluded.Risk of bias was assessed with ROB-2 and ROBINS-I-tools.A novel method for population-adjusted indirect comparison to include and compare single-arm trials was applied.Main outcomes were NASH-resolution and improvement of fibrosis.Results:Out of 7,913 studies,twelve randomized non-surgical studies and twelve non-randomized surgical trials were included.NASH-resolution after non-surgical intervention was 29%[95%confidence interval(CI):23-40%]and 79%(95%CI:72-88%)after surgery.The network meta-analysis showed that surgery had a higher chance of NASH-resolution than medication[odds ratio(OR)=2.68;95%CI:1.44-4.97]while drug treatment was superior to placebo(OR=2.24;95%CI:1.55-3.24).Surgery(OR=2.18;95%CI:1.34-3.56)and medication(OR=1.79;95%CI:1.39-2.31)were equally effective to treat fibrosis compared to placebo without difference between them.The results did not change when only new drugs specifically developed for the treatment of NASH were included.Conclusions:Metabolic surgery has a higher effectiveness for NASH-therapy than medical therapy while both were equally effective regarding improvement of fibrosis.Trials directly comparing surgery with medication must be urgently conducted.Patients with NASH should be informed about surgical treatment options.

Metabolic bariatric surgery and type 2 diabetes mellitus:an endocrinologist's perspective

Traditional treatment of T2 DM consisting of modification of diet,an exercise regimen,and pharmacotherapy has problems of poor lifestyle modifications and fail tend of treatment over time,now bariatric surgery is recommended for treatment of obese patients with T2 DM because its great improvements on weight loss and metabolic.In this article,effects of bariatric surgery on diabetes and diabetes-related complications are reviewed.

Weight loss maintenance after bariatric surgery

Metabolic and bariatric surgery(MBS)is an effective treatment for patients with morbid obesity and its comorbidities.However,many patients experience weight regain(WR)after achieving their nadir weight.Establishing the definition of WR is challenging as postoperative WR has various definitions.Risk factors for WR after MBS include anatomical,racial,hormonal,metabolic,behavioral,and psychological factors,and evaluating such factors preoperatively is necessary.Long-term regular follow-up and timely treatment by a multidisciplinary team are important because WR after surgery is multi-factorial.Although lifestyle interventions that focus on appropriate dietary education,physical activity education or interventions,and behavioral psychological interventions are suggested,more well-designed studies are needed because studies evaluating intervention methods and the effectiveness of WR prevention are lacking.Antiobesity drugs can be used to prevent and manage patients with WR after MBS;however,more research is needed to determine the timing,duration,and type of anti-obesity drugs used to prevent WR.

The success of sleeve gastrectomy in the management of metabolic syndrome and obesity

The rapid reversal of diabetes,hypertension,hyperlipidaemia and obesity by surgical means has challenged accepted doctrines regarding the management of metabolic syndrome.Sleeve gastrectomy,which developed initially as a preparatory procedure for biliopancreatic diversion with duodenal switch,has seen an exponential rise in popularity as an effective lone laparoscopic bariatric procedure.Superior excess weight loss,a low complication rate,and excellent food tolerance,combined with a short hospital stay,have made this the procedure of choice for patients and surgeons across the globe.High volume centres nurture the ongoing development of experienced and specialized teams,pathways and regimens.Optimum surgical outcomes allow minimization of metabolic syndrome,reducing cardiovascular and cerebrovascular risk.

Bariatric surgery in old age:a comparative study of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in an Asia centre of excellence

Bariatric surgery has been proved to be the safest and efficient procedure in treating morbid obese patients,but data is still lacking in the elderly population.The aim of our study was to compare the safety and efficacy of laparoscopic Roux-en-Y gastric bypass（LRYGB） and sleeve gastrectomy（LSG） in patients aged more than 55 years.We performed2 a retrospective review of a prospectively collected database.All patients with body mass index（BMI） §32 kg/mand aged more than 55 years undergoing LRYGB or LSG in BMI Surgery Centre,E-Da Hospital between January 2008 and December 2011 with at least one year of follow up were included for the analysis.Demography,peri-operative data,weight loss and surgical complications were all recorded and analyzed.Mean age and BMI of these 68 patients22（22 males and 46 female） were 58.8 years（55-79 years） and 39.5 kg/m（32.00-60.40 kg/m）.LRYGB was performed in 44 patients and LSG in 24 patients.The two groups were comparable in their preoperative BMI,American Society of Anaesthesia（ASA） score and gender distribution.LSG patients were significantly older than patients receiving LRYGB.The proportion of type 2 diabetes preoperatively was significantly higher in LRYGB patients as compared to LSG patients（88.63% vs.50%; P,0.01）.The prevalence of other co-morbidities was similar and comparable2 between the groups.Mean BMI in the LRYGB and LSG groups at the end of 1 year were 28.8 kg/mand228.2 kg/m,respectively,and there was no statistically significant difference in mean percentage of excess weight loss（%EWL） at 1 year.The percentage of resolution of diabetes was significantly higher in LRYGB（69.2%） as compared to LSG（33.3%）.On the other hand,there was no statistical difference in the percentage of resolution of hypertension,hyperlipidemia and fatty liver hepatitis.The overall morbidity and re-operation rate was higher in LRYGB patients.In morbidly elderly patients,both surgeries achieved good weight loss and resolution of comorbidities.LRYGB is superior to LSG in terms of diabetes remission but carries higher complication rates even at high volume centres.

Management of diabesity:Current concepts

The global prevalence of obesity is increasing rapidly with an exponential rise in incidence of type 2 diabetes mellitus in recent years.‘Diabesity’,the term coined to show the strong interlink between obesity and diabetes,is the direct cons-equence of the obesity pandemic,and poses significant challenges in the management of the disease.Without addressing the clinical and mechanistic complications of obesity such as metabolic-associated fatty liver disease and obstructive sleep apnoea,a rational management algorithm for diabesity cannot be developed.Several classes of anti-diabetic medications including insulins,sulphonylureas,thiazolidinediones and meglitinides are associated with the risk of weight gain and may potentially worsen diabesity.Therefore,appropriate selection of antidiabetic drug regimen is crucial in the medical management of diabesity.The role of non-pharmacological measures such as dietary adjustments,exercise interventions and bariatric procedures should also be emphasised.Unfortunately,the importance of appropriate and optimal management of diabesity is often overlooked by medical professionals when achieving adequate glycemic control which results in inappropriate management of the disease and its complications.This review provides a narrative clinical update on the evidence behind the management of diabesity.

SADI-S with Extended Duodeno-Bulb Preservation: Case Report

Obesity has been growing in Brazil and in the world. It is reaching epidemic proportions, and bariatric surgery is the most effective treatment for patients with this disease. Among the procedures described in the literature, ileal surgeries such as biliopancreatic diversion with duodenal switch (BPD-DS) and single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) present better long-term results in terms of weight loss and comorbidities control. However, there are concerns regarding long term nutritional problems with these procedures. In this case report the aim is to demonstrate the technical feasibility of preserving an extended duodenal bulb segment, in the SADIS-S procedure, when there are difficulties in dissecting the retrobulbar region, as occurred here, due to fibrosis in this area. This assures the maintenance of the proposed surgical technique, in such a situation. The dissection and transection of the duodenum was done 7 cm distally to the pylorus, under endoscopic view, proximally to the papillae, where the tissue was normal. Additionally, due the importance of the duodenal mucosa on minerals and trace elements absorption and the release of important hormones in this region, this case report elicits the evaluation of the impact of this technical modification, which occurred casually, in the nutritional, hormonal and metabolic results, long term. In this case report, the extended duodenal length has demonstrated reasonable weight loss, adequate comorbidities control and good nutritional status, so far. These aspects must be evaluated in the long term, by clinical trials.

Roux-en-Y gastric bypass for Chinese type 2 diabetes mellitus patients with a BMI,28kg/m^2:a multi-institutional study

Roux-en-Y gastric bypass surgery（RYGB） has been demonstrated to be successful for treating type-II diabetes2mellitus（T2DM） patients with a body mass index（BMI）,30 kg/m,but reports of RYGB for T2 DM patients with22 a BMI,28 kg/mare lacking.T2 DM patients with a BMI,28 kg/mwere prospectively recruited to participate in this study in four hospitals.The endpoint was T2 DM remission（defined by fasting blood glucose（FBG） level,110 mg/d L and hemoglobin（Hb）A1c level,6.0% at 12 months postoperatively）.Predictors of remission were investigated by univariate and multivariate analyses.Eighty-six patients were assessed.Eighty-five patients underwent RYGB,with one conversion to open surgery.We compared the values of various variables before and after2 surgery.The mean BMI decreased from 24.68±2.12 to 21.72±2.43 kg/m（P,0.001）.Fifty-eight（67.4%） patients were not treated by drugs or insulin after surgery,and 20 patients（23.3%） had complete remission of T2 DM at12 months after surgery with an acceptable number of complications.The mean Hb A1 c level in the remission group was significantly lower than that in the non-remission group.Patients with a higher weight,lower Hb A1 c level,higher C-peptide level,and higher FBG level were more likely to have T2 DM remission in multivariate2 analyses.In conclusion,RYGB was effective and safe for treating T2 DM patients with a BMI,28 kg/m.Complete remission can be predicted by cases having a higher weight,lower Hb A1 c level,higher C-peptide level,and higher FBG level.

Extreme Obesity Treated with Integrated Traditional Chinese and Western Medicine and Construction of an Innovative Obesity Diagnosis and Treatment Model: A Case Report

Background:The incidence of obesity is increasing each year,and is often accompanied by multi-system metabolic disorders,typically chronic diseases and multi-disease superposition disease states.Metabolic surgery is an important treatment option for patients with extreme obesity;however,surgical difficulties and perioperative complications are more serious in these patients.Therefore,there is an urgent need for a new comprehensive diagnosis and treatment model to reduce the weight of patients prior to surgery,subsequently reducing the risks of surgery.Case summary:This model combines traditional Chinese medicine(TCM),external TCM treatment,and health management with western technique of metabolic surgery.Obesity is recognized and treated by multidisciplinary,multi-channel,and multi-means,constituting an innovative diagnosis and treatment model of obesity in integrated traditional Chinese and Western medicine.The application of this model in the treatment of a patient with extreme obesity having multiple systemic diseases is described herein.Conclusion:The integrated traditional Chinese and Western medicine obesity diagnosis and treatment model can be used for precise syndrome differentiation,individualized treatment,and follow-up management of patients with extreme obesity,with strong scalability and significant clinical efficacy.

Gastric Bypass with Long Pouch and Transit Bipartition for Endoscopic Access to the Remaining Stomach

Introduction: obesity has a complex and multifactorial etiology, difficult treatment and increasing incidence rates in recent decades. The treatment involves clinical and pharmacological approaches and, in case of lack of results, surgical interventions. Roux-en-Y gastric bypass (RYGB) is one of these surgical interventions in which the stomach is divided, creating a small pouch, and the remaining portion of the stomach become excluded and left without endoscopic access. Objective: to evaluate the results of modified RYGB with long pouch and endoscopic access to the remaining stomach. Materials and Methods: prospective clinical trial with sample selected among patients seen at the Alberto Rassi General State Hospital of Goi&#226nia (HGG) and indicated for bariatric and metabolic surgery confirmed by the medical and multidisciplinary team. The study was conducted from January 2020 to August 2021. Clinical history and laboratory test results of the selected patients were collected through consultations with the medical and multidisciplinary team. Results: twelve participants were included in the study. Of these, 11 (91.7%) were women and the mean age was 46.3 years. The weight before surgery was 112.17 kg (92.00 - 150.00) and the Body Mass Index (BMI) was 44.89 (35.06 - 74.39). After 18 months of surgery, the mean weight was 80.77 kg (±11.92) and the mean BMI was 29.46 (±11.00), showing a significant reduction in both (p = 0.003 and p = 0.002, respectively). All patients underwent endoscopic evaluation of the pouch, remaining stomach and duodenum at 12 months postoperatively. The mean percentage of lost excess weight loss was 68.21%. Conclusion: We conclude that the proposed changes in RYGB (GBLP + GIB – Roux-en-Y gastric bypass with long pouch and gastrointestinal bipartition) did not compromise weight loss or control of type 2 diabetes and other comorbidities and proved to be a safe and effective alternative without gastroduodenal exclusion, enabling a better postoperative follow-up.