Development of de novo diabetes in long-term follow-up after bariatric surgery

Introduction: While bariatric surgery leads to significant prevention and improvement of type 2 diabetes, patients may rarely develop diabetes after bariatric surgery. The aim of this study was to determine the incidence and the characteristic of new-onset diabetes after bariatric surgery over a 17-year period at our institution. Methods: Non-diabetic patients who underwent bariatric surgery at a single academic center (1997–2013) and had a postoperative glycated hemoglobin (HbA1c) ≥ 6.5%, fasting blood glucose (FBG) ≥ 126 mg/dl, or positive glucose tolerance test were identified and studied. Results: Out of 2263 non-diabetic patients at the time of bariatric surgery, 11 patients had new-onset diabetes in the median follow-up time of 9 years (interquartile range [IQR], 4–12). Bariatric procedures performed were Roux-en-Y gastric bypass (n = 7), adjustable gastric banding (n = 3), and sleeve gastrectomy (n = 1). The median interval between surgery and diagnosis of diabetes was 6 years (IQR, 2–9). At the last follow-up, the median HbA1c and FBG values were 6.3% (IQR, 6.1–6.5) and 95 mg/dl (IQR, 85–122), respectively. Possible etiologic factors leading to diabetes were weight regain to baseline (n = 6, 55%), steroid-induced after renal transplantation (n = 1), pancreatic insufficiency after pancreatitis (n = 1), and unknown (n = 3). Conclusion: De novo diabetes after bariatric surgery is rare with an incidence of 0.4% based on our cohort. Weight regain was common (> 50%) in patients who developed new-onset diabetes suggesting recurrent severe obesity as a potential etiologic factor. All patients had good glycemic control (HbA1c ≤ 7%) in the long-term postoperative follow-up

Impact of early postbariatric surgery acute kidney injury on long-term renal function

Background: Bariatric surgery can improve renal dysfunction associated with obesity and diabetes. However, acute kidney injury (AKI) can complicate the early postoperative course after bariatric surgery. The long-term consequences of early postoperative AKI on renal function are unknown. Methods: Patient undergoing bariatric surgery from 2008 to 2015 who developed AKI within 60 days after surgery were studied. Patients on dialysis before surgery were excluded. Results: Out of 4722 patients, 42 patients (0.9%) developed early postoperative AKI after bariatric surgery of whom five had chronic kidney disease (CKD) preoperatively including CKD stage 3 (n = 2), stage 4 (n = 2), and stage 5 (n = 1). Etiologies of AKI included prerenal in 37 and renal in 5 patients. Nine patients (21%) underwent hemodialysis in early postoperative period for AKI. The median duration of follow-up was 28 months (interquartile range, 4–59). Of the 40 patients eligible for follow-up, 36 patients (90%) returned to their baseline renal function. However, four patients (10%) had worsening of renal function at follow-up. Conclusions: The incidence of early postoperative AKI after bariatric surgery is about 1%. The most common causes of AKI after bariatric surgery are dehydration and infectious complications. In our series, 10% of patients who developed AKI in early postoperative period had worsening of renal function in long-term follow-up. In the absence of severe sepsis and severe underlying kidney dysfunction (CKD stages 4 and 5), full recovery is expected after postoperative AKI

Metabolic Effects Of Duodenojejunal Bypass Surgery In A Rat Model Of Type 1 Diabetes

Background Metabolic surgery has beneficial metabolic effects, including remission of type 2 diabetes. We hypothesized that duodenojejunal bypass (DJB) surgery can protect against development of type 1 diabetes (T1D) by enhancing regulation of cellular and molecular pathways that control glucose homeostasis. Methods BBDP/Wor rats, which are prone to develop spontaneous autoimmune T1D, underwent loop DJB (n = 15) or sham (n = 15) surgery at a median age of 41 days, before development of diabetes. At T1D diagnosis, a subcutaneous insulin pellet was implanted, oral glucose tolerance test was performed 21 days later, and tissues were collected 25 days after onset of T1D. Pancreas and liver tissues were assessed by histology and RT-qPCR. Fecal microbiota composition was analyzed by 16S V4 sequencing. Results Postoperatively, DJB rats weighed less than sham rats (287.8 vs 329.9 g,P = 0.04). In both groups, 14 of 15 rats developed T1D, at similar age of onset (87 days in DJB vs 81 days in sham,P = 0.17). There was no difference in oral glucose tolerance, fasting and stimulated plasma insulin and c-peptide levels, and immunohistochemical analysis of insulin-positive cells in the pancreas. DJB rats needed 1.3 +/- 0.4 insulin implants vs 1.9 +/- 0.5 in sham rats (P = 0.002). Fasting and glucose stimulated glucagon-like peptide 1 (GLP-1) secretion was elevated after DJB surgery. DJB rats had reduced markers of metabolic stress in liver. After DJB, the fecal microbiome changed significantly, including increases inAkkermansiaandRuminococcus, while the changes were minimal in sham rats. Conclusion DJB does not protect against autoimmune T1D in BBDP/Wor rats, but reduces the need for exogenous insulin and facilitates other metabolic benefits including weight loss, increased GLP-1 secretion, reduced hepatic stress, and altered gut microbiome

The outcome of bariatric surgery in patients aged 75 years and older

Background: Bariatric surgery has been shown to be safe and effective in patients aged 60-75 years; however, outcomes in patients aged 75 or older are undocumented. Methods: Patients aged 75 years and older who underwent bariatric procedures in two academic centers between 2006 and 2015 were studied. Results: A total of 19 patients aged 75 years and above were identified. Eleven (58%) were male, the median age was 76 years old (range 75-81), and the median preoperative body mass index (BMI) was 41.4 kg/m2 (range 35.8-57.5). All of the bariatric procedures were primary procedures and performed laparoscopically: sleeve gastrectomy (SG) (n = 11, 58%), adjustable gastric band (AGB) (n = 4, 21%), Roux-en-Y gastric bypass (RYGB) (n = 2, 11%), banded gastric plication (n = 1, 5%), and gastric plication (n = 1, 5%). The median operative time was 120 min (range 75-240), and the median length of stay was 2 days (range 1-7). Three patients (16%) developed postoperative atrial fibrillation which completely resolved at discharge. At 1 year, the median percentage of total weight loss (%TWL) was 18.4% (range 7.4-22.0). The 1-year %TWL varied among the bariatric procedures performed: SG (21%), RYGB (22%), AGB (7%), and gastric plication (8%). There were no 30-day readmissions, reoperations, or mortalities. Conclusion: Our experience suggests that bariatric surgery in selected patients aged 75 years and older would be safe and effective despite being higher risk. Age alone should not be the limiting factor for selecting patients for bariatric surgery

Laparoscopic sleeve gastrectomy in heart failure patients with left ventricular assist device

Background: There is limited data in the literature evaluating outcomes of bariatric surgery in severely obese patients with left ventricular assist device (LVAD) as a bridge to make them acceptable candidates for heart transplantation. This study aims to assess the safety and effectiveness of laparoscopic sleeve gastrectomy (LSG) in patients with previously implanted LVAD at our institution. Methods: All the patients with end-stage heart failure (ESHF) and implanted LVAD who underwent LSG from2013 to January 2017 were studied. Results: Seven patients with end stage heart failure (ESHF) and implanted LVAD were included. The median age and median preoperative BMI were 39 years (range: 26–62) and 43.6 kg/m2 (range 36.7–56.7), respectively. The median interval between LVAD implantation and LSG was 38 months (range 15–48). The median length of hospital stay was 9 days (rang: 6–23) out of which 4 patients had planned postoperative ICU admission. Thirty-day complications were noted in 5 patients (3 major and 2 minor) without any perioperative mortality. The median duration of follow-up was 24 months (range 2–30). At the last available follow-up, the median BMI, %EWL, and %TWL were 37 kg/m2 , 47%, and 16%, respectively. The median LVEF before LSG and at the last follow-up point (before heart transplant) was 19% (range 15–20) and 22% (range, 16–35), respectively. In addition, the median NYHA class improved from 3 to 2 after LSG. Three patients underwent successful heart transplantations. Conclusion: Patients with morbid obesity, ESHF, and implanted LVAD constitute a high-risk cohort. Our results with 7 patients and result from other studies (19 patients) suggested that bariatric surgery may be a reasonable option for LVAD patients with severe obesity. Bariatric surgery appears to provide significant weight loss in these patients and may improve candidacy for heart transplantation

Comparative outcomes of bariatric surgery in patients with impaired mobility and ambulatory population

Purpose: This study aims to characterize complications, metabolic improvement, and change in ambulation status for patients with impaired mobility undergoing bariatric surgery. Material and methods: Individuals undergoing primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from February 2008 to December 2015 were included. Impaired mobility (WC) was defined as using a wheelchair or motorized scooter for at least part of a typical day. The WC group was propensity score matched to ambulatory patients (1:5 ratio). Comparisons were made for 30-day morbidity and mortality and 1-year improvement in weight-related comorbidities. Results: There were 93 patients in the WC group matched to 465 ambulatory controls. The median operative time (180 vs 159 min, p = 0.003) and postoperative length of stay (4 vs 3 days, p ≤ 0.001) was higher in the WC group. There were no differences in readmission or all-cause morbidity within 30 days. The median percent excess weight loss (%EWL) at 1 year was similar (WC group, 65% available, 53% EWL vs AMB group, 73% available, 54% EWL); however, patients with impaired mobility were less likely to experience improvement in diabetes (76 vs 90%, p = 0.046), hypertension (63 vs 82%, p < 0.005), and obstructive sleep apnea (53 vs 71%, p < 0.001). Within the WC group, 62% had improvement in their mobility status, eliminating dependence on wheelchair or scooter assistance. Conclusion: Patients with both obesity and impaired mobility experience similar rates of perioperative morbidity and weight loss at 1 year compared to ambulatory controls. However, improvement in weight-related comorbidities may be less likely with impaired mobility

Iron-induced kidney cell damage: insights into molecular mechanisms and potential diagnostic significance of urinary FTL

Background: Iron overload can lead to organ and cell injuries. Although the mechanisms of iron-induced cell damage have been extensively studied using various cells, little is known about these processes in kidney cells.Methods: In this study, we first examined the correlation between serum iron levels and kidney function. Subsequently, we investigated the molecular impact of excess iron on kidney cell lines, HEK293T and HK-2. The presence of the upregulated protein was further validated in urine.Results: The results revealed that excess iron caused significant cell death accompanied by morphological changes. Transcriptomic analysis revealed an up-regulation of the ferroptosis pathway during iron treatment. This was confirmed by up-regulation of ferroptosis markers, ferritin light chain (FTL), and prostaglandin-endoperoxide synthase 2 (PTGS2), and down-regulation of acyl-CoA synthetase long-chain family member 4 (ACSL4) and glutathione peroxidase 4 (GPX4) using real-time PCR and Western blotting. In addition, excess iron treatment enhanced protein and lipid oxidation. Supportively, an inverse correlation between urinary FTL protein level and kidney function was observed.Conclusion: These findings suggest that excess iron disrupts cellular homeostasis and affects key proteins involved in kidney cell death. Our study demonstrated that high iron levels caused kidney cell damage. Additionally, urinary FTL might be a useful biomarker to detect kidney damage caused by iron toxicity. Our study also provided insights into the molecular mechanisms of iron-induced kidney injury, discussing several potential targets for future interventions

Removal of gastric band does not always lead to significant weight gain

Background: Reported outcomes after removal of adjustable gastric band (AGB) are very limited, yet, important to direct patient and surgeon decision-making. The aim of this study was to investigate the medium-term weight changes in patients who underwent AGB removal without an additional bariatric procedure. Methods: In this retrospective study, we analyzed data of 25 patients who had undergone AGB removal without an additional bariatric surgery (2009–2016). Results: The reasons for the AGB removal included gastroesophageal reflux disease (n = 10, 40%), band slippage (n = 5, 20%), band prolapse (n = 5, 20%), band erosion (n = 4, 16%), and planned incisional hernia requiring mesh implantation (n = 1, 4%). At a median follow-up time of 2 years (interquartile range [IQR] 1–4) after laparoscopic AGB removal, the median weight and body mass index changes were +7.3 kg (IQR, −2 and +18) and +1.9 kg/m2 (IQR, −1 and +6), respectively. Forty-eight percent (n = 12) did not gain more than 3 kg of body weight after removal of their gastric band. All patients experienced resolution of their AGB-related symptoms. Conclusion: Recognizing that weight regain is not necessarily inevitable for all patients after gastric band removal may assist in decision-making