Hypoglycaemia one-year after laparoscopic sleeve gastrectomy: Experience of Padua Bariatric Unit

Introduction: It\u2019s known that after Roux-en-x-en-Y gastric bypass (RYGB) about 30% of patients experienced post-prandial hyperinsulinemic hypoglycaemia following surgery. There are very few data about development of post-prandial hypoglycaemia after laparoscopic sleeve gastrectomy (LSG). Methods: We analyzed 39 non-diabetic morbidly obese patients, undergoing LSG. All patients were submitted to 3-hour OGTT for glucose (BG) and insulin plasma level measurement before surgery and one-year after LSG. The HOMA index was also calculated. Hypoglycaemia was defined as BG 64 3.3 mmol/L and severe hypoglycaemia as BG 64 2.7 moml/l. Results: After LSG 21 patients (53.8%) experienced at least one asymptomatic hypoglycaemia provoked by OGTT and 10 patients (25.6%) had at least one severe hypoglycaemia episode. Hypoglycaemic events occurred from 120\u2019 to 180\u2019 and the highest frequency was observed at 150\u2019 in 16 subjects (41%). Severe hypoglycaemia occurred only from 150\u2019 on. Homa index (HOMA-IR) significantly decreased 1-year after LSG either in patients with or without hypoglycaemia. The insulin AUC 1-year after LSG was statistically higher (p < 0,0002) in patients with hypoglycaemia. Conclusion: These findings confirm the high incidence of post-prandial hypoglycaemia 1-year after LSG emphasising also in this population the high frequency of late severe hypoglycemia. A normalization of HOMA- IR occurred in all patients thus suggesting an improvement of insulin sensitivity. The persistent insulin hyper response to an oral glucose load after surgery in most of the patients with hypoglycaemia explains, at least in part, the phenomenon

Metabolic flexibility after bariatric surgery-induced weight loss: does diabetes impair a proper substrates utilization?

The onset of type 2 diabetes is a critical step for the prognosis of obese patients, being crucial for disease evolution and complications development. Obese diabetic subjects generally obtain poorer outcomes in terms of weight loss as compared to non-diabetic ones after treatment. Our aim was to assess if the metabolic flexibility in substrates utilization following bariatric surgery was different in diabetic, pre-diabetic and normoglycemic obese subjects.We examined 95 consecutive morbid obese females (mean-age 44.1\ub111.1, BMI 44.7\ub17.5), undergoing laparoscopic sleeve gastrectomy (LSG), before (T0) and 12 months after (T1) bariatric surgery. Among them 61 were normoglycemic, 17 pre- diabetic and 17 diabetic. Evaluation included anthropometric parameters, blood samples collection, resting energy expenditure (REE) and body composition assessment.At T0, diabetic patients were older than normoglycemic and pre-diabetic subjects and had higher basal glucose levels (6.8\ub11.8 mmol/L vs 5.6\ub10.6 mmol/L in pre-diabetic and 5.2\ub10.5 mmol/L in normoglycemic respectively). The three subgroups did not differ significantly in BMI, waist circumference, REE and body composition. Percent weight loss was 30.5\ub110.2% in normoglycemic, 27.6\ub18.9% in pre-diabetic and 25.9\ub1 6.7% in diabetic patients (p<0,05 vs normoglycemic). After weight loss, all patients showed a statistically significative decrease in REE (1760\ub1358 kcal/die vs 1285\ub1236 kcal/die) and no differences were found among subgroups. Respiratory quotient (RQ) tends to decrease after surgery (0.816 T0 vs 0.779 T1; p=0.22). Analyzing separately the three subgroups, a reduction in RQ was observed in normoglycemic (0.820 vs 0.781; p=0.52) and in prediabetic patients (0.821 vs 0,748; p=0,03), but not in diabetic patients (0.806 vs 0.806; p=1.00).Weight loss was associated to a metabolic shift toward an increased fat oxidation (RQ reduction) in normoglycemic and pre-diabetic patients, whereas RQ in diabetic females did not show any change. This impaired metabolic flexibility could partly explain the lower weight loss observed in diabetic patients after LSG

Characterization of subcutaneous and omental adipose tissue in patients with obesity and with different degrees of glucose impairment

Abstract Although obesity represents a risk factor for the development of type 2 diabetes mellitus (T2DM), the link between these pathological conditions is not so clear. The manner in which the different elements of adipose tissue (AT) interplay in order to grow has been suggested to have a role in the genesis of metabolic complications, but this has not yet been fully addressed in humans. Through IHC, transmission electron microscopy, cytometry, and in vitro cultures, we described the morphological and functional changes of subcutaneous and visceral AT (SAT and VAT) in normoglycemic, prediabetic and T2DM patients with obesity compared to lean subjects. In both SAT and VAT we measured a hypertrophic and hyperplastic expansion, causing similar vascular rarefaction in obese patients with different degrees of metabolic complications. Capillaries display dysfunctional basement membrane thickening only in T2DM patients evidencing VAT as a new target of T2DM microangiopathy. The largest increase in adipocyte size and decrease in adipose stem cell number and adipogenic potential occur both in T2DM and in prediabetes. We showed that SAT and VAT remodeling with stemness deficit is associated with early glucose metabolism impairment suggesting the benefit of an AT-target therapy controlling hypertrophy and hyperplasia already in prediabetic obese patients