The Effect of Bariatric Surgery on Diabetic Retinopathy: Good, Bad, or Both?

Bariatric surgery, initially intended as a weight-loss procedure, is superior to standard lifestyle intervention and pharmacological therapy for type 2 diabetes in obese individuals. Intensive medical management of hyperglycemia is associated with improved microvascular outcomes. Whether or not the reduction in hyperglycemia observed after bariatric surgery translates to improved microvascular outcomes is yet to be determined. There is substantial heterogeneity in the data relating to the impact of bariatric surgery on diabetic retinopathy (DR), the most common microvascular complication of diabetes. This review aims to collate the recent data on retinal outcomes after bariatric surgery. This comprehensive evaluation revealed that the majority of DR cases remain stable after surgery. However, risk of progression of pre-existing DR and the development of new DR is not eliminated by surgery. Instances of regression of DR are also noted. Potential risk factors for deterioration include severity of DR at the time of surgery and the magnitude of glycated hemoglobin reduction. Concerns also exist over the detrimental effects of postprandial hypoglycemia after surgery. In vivo studies evaluating the chronology of DR development and the impact of bariatric surgery could provide clarity on the situation. For now, however, the effect of bariatric surgery on DR remains inconclusive

Does bariatric surgery prior to total hip or knee arthroplasty reduce post-operative complications and improve clinical outcomes for obese patients? Systematic review and meta-analysis.

AIMS: Our aim was to determine whether, based on the current literature, bariatric surgery prior to total hip (THA) or total knee arthroplasty (TKA) reduces the complication rates and improves the outcome following arthroplasty in obese patients. METHODS: A systematic literature search was undertaken of published and unpublished databases on the 5 November 2015. All papers reporting studies comparing obese patients who had undergone bariatric surgery prior to arthroplasty, or not, were included. Each study was assessed using the Downs and Black appraisal tool. A meta-analysis of risk ratios (RR) and 95% confidence intervals (CI) was performed to determine the incidence of complications including wound infection, deep vein thrombosis (DVT), pulmonary embolism (PE), revision surgery and mortality. RESULTS: From 156 potential studies, five were considered to be eligible for inclusion in the study. A total of 23 348 patients (657 who had undergone bariatric surgery, 22 691 who had not) were analysed. The evidence-base was moderate in quality. There was no statistically significant difference in outcomes such as superficial wound infection (relative risk (RR) 1.88; 95% confidence interval (CI) 0.95 to 0.37), deep wound infection (RR 1.04; 95% CI 0.65 to 1.66), DVT (RR 0.57; 95% CI 0.13 to 2.44), PE (RR 0.51; 95% CI 0.03 to 8.26), revision surgery (RR 1.24; 95% CI 0.75 to 2.05) or mortality (RR 1.25; 95% CI 0.16 to 9.89) between the two groups. CONCLUSION: For most peri-operative outcomes, bariatric surgery prior to THA or TKA does not significantly reduce the complication rates or improve the clinical outcome. This study questions the previous belief that bariatric surgery prior to arthroplasty may improve the clinical outcomes for patients who are obese or morbidly obese. This finding is based on moderate quality evidence. Cite this article: Bone Joint J 2016;98-B:1160-6

Eligibility for bariatric surgery among adults in England: analysis of a national cross-sectional survey.

This study aimed to determine the number eligible for bariatric surgery and their sociodemographic characteristics.We used Health Survey for England 2006 data, representative of the non-institutionalized English population.The number of people eligible for bariatric surgery in England based on national guidance is unknown. The UK National Institute for Health and Clinical Excellence criteria for eligibility are those with body mass index (BMI) 35-40 kg/m(2) with at least one comorbidity potentially improved by losing weight or a BMI > 40 kg/m(2).Of 13,742 adult respondents (≥18 years), we excluded participants with invalid BMI (n = 2103), comorbidities (n = 2187) or sociodemographic variables (n = 27) data, for a final study sample of 9425 participants.The comorbidities examined were hypertension, type 2 diabetes, stroke, coronary heart disease and osteoarthritis. Sociodemographic variables assessed included age, sex, employment status, highest educational qualification, social class and smoking status.5.4% (95% CI 5.0-5.9) of the non-institutionalized adult population in England could meet criteria for having bariatric surgery after accounting for survey weights. Those eligible were more likely than the general population to be women (60.1% vs. 39.9%, p<0.01), retired (22.4% vs. 12.8% p<0.01), and have no formal educational qualifications (35.7% vs. 21.3%, p<0.01).The number of adults potentially eligible for bariatric surgery in England (2,147,683 people based on these results and 2006 population estimates) far exceeds previous estimates of eligibility. In view of the sociodemographic characteristics of this group, careful resource allocation is required to ensure equitable access on the basis of need

Metabolic Comparison of One-Anastomosis Gastric Bypass, Single-Anastomosis Duodenal-Switch, Roux-en-Y Gastric Bypass, and Vertical Sleeve Gastrectomy in Rat

Background One-anastomosis gastric bypass (OAGB) and single-anastomosis duodenal switch (SADS) have become increasingly popular weight loss strategies. However, data directly comparing the effectiveness of these procedures with Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (SG) are limited. Objectives To examine the metabolic outcomes of OAGB, SADS, RYGB, and SG in a controlled rodent model. Setting Academic research laboratory, United States. Methods Surgeries were performed in diet-induced obese Long-Evans rats, and metabolic outcomes were monitored before and for 15 weeks after surgery. Results All bariatric procedures induced weight loss compared with sham that lasted throughout the course of the study. The highest percent fat loss occurred after OAGB and RYGB. All bariatric procedures had improved glucose dynamics associated with an increase in insulin (notably OAGB and SADS) and/or glucagon-like protein-1 secretion. Circulating cholesterol was reduced in OAGB, SG, and RYGB. OAGB and SG additionally decreased circulating triglycerides. Liver triglycerides were most profoundly reduced after OAGB and RYGB. Circulating iron levels were decreased in all surgical groups, associated with a decreased hematocrit value and increased reticulocyte count. The fecal microbiome communities of OAGB, SADS, and RYGB were significantly altered; however, SG exhibited no change in microbiome diversity or composition. Conclusions These data support the use of the rat for modeling bariatric surgical procedures and highlight the ability of the OAGB to meet or exceed the metabolic improvements of RYGB. These data point to the likelihood that each surgery accomplishes metabolic improvements through both overlapping and distinct mechanisms and warrants further research

Metabolic Effects of Bariatric Surgery in Mouse Models of Circadian Disruption

Background/Objectives: Mounting evidence supports a link between circadian disruption and metabolic disease. Humans with circadian disruption (for example, night-shift workers) have an increased risk of obesity and cardiometabolic diseases compared with the non-disrupted population. However, it is unclear whether the obesity and obesity-related disorders associated with circadian disruption respond to therapeutic treatments as well as individuals with other types of obesity. Subjects/Methods: Here, we test the effectiveness of the commonly used bariatric surgical procedure, Vertical Sleeve Gastrectomy (VSG), in mouse models of genetic and environmental circadian disruption. Results: VSG led to a reduction in body weight and fat mass in both ClockΔ19 mutant and constant-light mouse models (PP\u3e0.05). Within circadian-disrupted models, VSG also led to improved glucose tolerance and lipid handling (P\u3c0.05). Conclusions: Together these data demonstrate that VSG is an effective treatment for the obesity associated with circadian disruption, and that the potent effects of bariatric surgery are orthogonal to circadian biology. However, as the effects of bariatric surgery are independent of circadian disruption, VSG cannot be considered a cure for circadian disruption. These data have important implications for circadian-disrupted obese patients. Moreover, these results reveal new information about the metabolic pathways governing the effects of bariatric surgery as well as of circadian disruption

Early and late complications of bariatric operation.

Weight loss surgery is one of the fastest growing segments of the surgical discipline. As with all medical procedures, postoperative complications will occur. Acute care surgeons need to be familiar with the common problems and their management. Although general surgical principles generally apply, diagnoses specific to the various bariatric operations must be considered. There are anatomic considerations which alter management priorities and options for these patients in many instances. These problems present both early or late in the postoperative course. Bariatric operations, in many instances, result in permanent alteration of a patient\u27s anatomy, which can lead to complications at any time during the course of a patient\u27s life. Acute care surgeons diagnosing surgical emergencies in postbariatric operation patients must be familiar with the type of surgery performed, as well as the common postbariatric surgical emergencies. In addition, surgeons must not overlook the common causes of an acute surgical abdomen-acute appendicitis, acute diverticulitis, acute pancreatitis, and gallstone disease-for these are still among the most common etiologies of abdominal pathology in these patients

Bariatric surgery and brain health: A longitudinal observational study investigating the effect of surgery on cognitive function and gray matter volume

Dietary modifications leading to weight loss have been suggested as a means to improve brain health. In morbid obesity, bariatric surgery (BARS)—including different procedures, such as vertical sleeve gastrectomy (VSG), gastric banding (GB), or Roux-en-Y gastric bypass (RYGB) surgery—is performed to induce rapid weight loss. Combining reduced food intake and malabsorption of nutrients, RYGB might be most effective, but requires life-long follow-up treatment. Here, we tested 40 patients before and six months after surgery (BARS group) using a neuropsychological test battery and compared them with a waiting list control group. Subsamples of both groups underwent structural MRI and were examined for differences between surgical procedures. No substantial differences between BARS and control group emerged with regard to cognition. However, larger gray matter volume in fronto-temporal brain areas accompanied by smaller volume in the ventral striatum was seen in the BARS group compared to controls. RYGB patients compared to patients with restrictive treatment alone (VSG/GB) had higher weight loss, but did not benefit more in cognitive outcomes. In sum, the data of our study suggest that BARS might lead to brain structure reorganization at long-term follow-up, while the type of surgical procedure does not differentially modulate cognitive performance

Is type 2 diabetes really resolved after laparoscopic sleeve gastrectomy? Glucose variability studied by continuous glucose monitoring

The study was carried out on type 2 diabetic obese patients who underwent laparoscopic sleeve gastrectomy (LSG). Patients underwent regular glycemic controls throughout 3 years and all patients were defined cured from diabetes according to conventional criteria defined as normalization of fasting glucose levels and glycated hemoglobin in absence of antidiabetic therapy. After 3 years of follow-up, Continuous Glucose Monitoring (CGM) was performed in each patient to better clarify the remission of diabetes. In this study, we found that the diabetes resolution after LSG occurred in 40% of patients; in the other 60%, even if they showed a normal fasting glycemia and A1c, patients spent a lot of time in hyperglycemia. During the oral glucose tolerance test (OGTT), we found that 2 h postload glucose determinations revealed overt diabetes only in a small group of patients and might be insufficient to exclude the diagnosis of diabetes in the other patients who spent a lot of time in hyperglycemia, even if they showed a normal glycemia (&lt;140 mg/dL) at 120 minutes OGTT. These interesting data could help clinicians to better individualize patients in which diabetes is not resolved and who could need more attention in order to prevent chronic complications of diabetes

Structural changes in intestinal enteroendocrine cells after ileal interposition in normal rats

INTRODUCTION: No therapeutic approach has significantly impacted the progression of diabetes. As early improvement of glicaemic control is observed after bariatric surgeries, there is currently a search for surgical procedures that can promote euglycemia also in non-obese patients. Glicaemic control can be achieved by increasing the blood concentration of GLP-1, a hormone produced by L cells that are more densely concentrated in the terminal ileum. The interposition of ileal segment to a more anterior region (proximal jejunum) can promote a greater stimulation of the L cells by poorly digested food, increasing the production of GLP-1 and reflecting on glicaemic control.&#xd;&#xa;AIMS: To investigate long-term histological modifications of intestinal mucosa of rats submitted to interposition of ileum segment to a proximal region (jejunum).&#xd;&#xa;METHODS: Forty 8-week old male Wistar-EPM1 rats (Rattus norvegicus albinus) were randomly distributed into 3 groups: the Interposition Group (IG) was subjected to ileal interposition, the Sham Group (SG) was subjected to sham operations, and the Control Group (CG) was not subjected to surgery. All animals were followed until the 60th postoperative day (8 postoperative week) when they were euthanized. Segments of jejunum and ileum from all groups were collected and analyzed by optical microscopy and immunohistochemistry.&#xd;&#xa;RESULTS: No structural nor histological changes in intestinal L cells in the interposed intestinal segment and other intestinal segments were noted after ileal interposition surgery. &#xd;&#xa;CONCLUSION: As L cells endocrine characteristics were likely maintained, the use of metabolic surgical techniques for the treatment of metabolic diseases, especially diabetes, seems to be justified