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

Late relapse of diabetes after bariatric surgery should not be considered as a failure

Background: Although the impressive metabolic effects of bariatric surgery in patients with Type 2 Diabetes (T2DM) are known, bariatric surgery is criticized for late relapse of diabetes. Methods: Outcomes of 736 patients with T2DM who underwent Roux-en-Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (SG) at an academic center (2004-2012) and had ≥5-year glycemic follow-up were assessed. Out of 736 patients, 425 (58%) experienced diabetes remission (HbA1c <6·5% off medications) in the first year after surgery. The latter subgroup was followed to characterize late relapse of T2DM which was defined as fasting glucose (FBG) or HbA1c in the diabetic range (≥126mg/dL and ≥6·5%, respectively) or need for antidiabetic medication after initial remission. Findings: The median postoperative follow-up time was 8 years (range, 5- 14). Of those 425 patients who initially achieved remission in shortterm, 136 (32%) had a late relapse of T2DM. Independent predictors of late relapse were the preoperative number of diabetes medications (OR:1·85,95%CI:1·35-2·53, p=0·0001), duration of T2DM (OR:1·08,95%CI:1·02- 1·15,p=0·012), and SG vs RYGB (OR:1·95,95%CI:1·00-3·70,p=0·049). In patients who experienced late relapse, a significant improvement in glycemic control, number of diabetes medications including the use of insulin, blood pressure, and lipid profile was still observed at longterm. Among patients with relapse, 77% maintained glycemic control (HbA1c <7%). Interpretation: While late relapse is a real phenomenon (one-third of our cohort), relapse of T2DM years after bariatric surgery should not be considered as a failure, as the trajectory of cardio-metabolic risk factors is changed by surgery. Earlier surgical intervention and RYGB (compared with SG) would be associated with less diabetes relapse in long-term

Long-term impact of bariatric surgery in diabetic nephropathy

Background: Bariatric surgery has been shown to improve and resolve diabetes. However, limited literature about its impact on end-organ complications of diabetes is available. The aim of this study was to examine the long-term effect of bariatric surgery on albuminuria. Methods: We studied 101 patients with pre-operative diabetes and albuminuria [defined as urine albumin:creatinine ratio (uACR) > 30 mg/g] who underwent bariatric surgery at an academic center from 2005 to 2014. Results: Fifty-seven patients (56%) were female with a mean age of 53 (± 11) years. The mean pre-operative BMI and glycated hemoglobin (HbA1c) were 43.1 (± 7.6) kg/m2 and 8.4 (± 1.8)%, respectively. The median pre-operative uACR was 80.0 (45.0-231.0) mg/g. Bariatric procedures included Roux-en-Y gastric bypass (n = 75, 74%) and sleeve gastrectomy (n = 26, 26%). The mean follow-up period was 61 (± 29) months. At last follow-up, the mean BMI was 33.8 (± 8.3) kg/m2. The overall glycemic control improved after bariatric surgery. At last follow-up, 73% had good glycemic control (HbA1c < 7%) and 27% met diabetes remission criteria. The mean HbA1c at last follow-up was 6.7 (± 1.0)% and the median uACR was 30 (IQR 7-94) mg/g. Albuminuria improved in 77% and resolved in 51% of patients at long-term. Conclusions: Bariatric surgery has a significantly positive impact on albuminuria in patients with obesity and type 2 diabetes. Our data showed almost an 80% improvement in albuminuria at the short- and long-term period after bariatric surgery

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

Efficacy of adjuvant weight loss medication after bariatric surgery

Background: Some patients do not achieve optimal weight loss or regain weight after bariatric surgery. In this study, we aimed to determine the effectiveness of adjuvant weight loss medications after surgery for this group of patients. Setting: An academic medical center. Methods: Weight changes of patients who received weight loss medications after bariatric surgery from 2012 to 2015 at a single center were studied. Results: Weight loss medications prescribed for 209 patients were phentermine (n = 156, 74.6%), phentermine/topiramate extended release (n = 25, 12%), lorcaserin (n = 18, 8.6%), and naltrexone slow-release/bupropion slow-release (n = 10, 4.8%). Of patients, 37% lost>5% of their total weight 1 year after pharmacotherapy was prescribed. There were significant differences in weight loss at 1 year in gastric banding versus sleeve gastrectomy patients (4.6% versus .3%, P = .02) and Roux-en-Y gastric bypass versus sleeve gastrectomy patients (2.8% versus .3%, P = .01).There was a significant positive correlation between body mass index at the start of adjuvant pharmacotherapy and total weight loss at 1 year (P = .025). Conclusion: Adjuvant weight loss medications halted weight regain in patients who underwent bariatric surgery. More than one third achieved>5% weight loss with the addition of weight loss medication. The observed response was significantly better in gastric bypass and gastric banding patients compared with sleeve gastrectomy patients. Furthermore, adjuvant pharmacotherapy was more effective in patients with higher body mass index. Given the low risk of medications compared with revisional surgery, it can be a reasonable option in the appropriate patients. Further studies are necessary to determine the optimal medication and timing of adjuvant pharmacotherapy after bariatric surgery

Adjustments to warfarin dosing after gastric bypass and sleeve gastrectomy

Background: Warfarin dosing after bariatric surgery may be influenced by alterations in gastrointestinal pH, transit time, absorptive surface area, gut microbiota, food intake, and adipose tissue. Objectives: The aim of this study was to describe trends in warfarin dosing after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). Setting: Single academic center. Methods: All patients chronically on warfarin anticoagulation before RYGB or SG were retrospectively identified. Indications for anticoagulation, history of bleeding or thrombotic events, perioperative complications, and warfarin dosing were collected. Results: Fifty-three patients (RYGB n = 31, SG n = 22) on chronic warfarin therapy were identified (56.6% female, mean 54.4 ± 11.7 yr of age). Of this cohort, 34.0% had prior venous thromboembolic events, 43.4% had atrial fibrillation, and 5.7% had mechanical cardiac valves. Preoperatively, the average daily dose of warfarin was similar in the RYGB group (8.3 ± 4.1 mg) and SG group (6.9 ± 2.8 mg). One month after surgery, mean daily dose of warfarin was reduced 24.1% in the RYGB group (P<.001) and 23.2% in the SG group (P = .002). At 12 months postoperatively, the required daily warfarin dose compared with baseline remained statistically different (RYGB: 6.8 ± 3.8 mg; SG: 6.1 ± 2.0 mg). Conclusions: The warfarin dose is expected to be decreased by approximately 25% from preoperative levels after both RYGB and SG. Lower dose requirement within the first month after bariatric surgery is followed by a trend toward increased warfarin dose requirements, but remain less than baseline. Because dose requirements change constantly over time, frequent postoperative monitoring of the international normalized ratio is recommended

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

Patients with clinically metabolically healthy obesity are not necessarily healthy subclinically: further support for bariatric surgery in patients without metabolic disease?

Background: Nonalcoholic fatty liver disease (NAFLD) increases the risk of liver cirrhosis and hepatocellular carcinoma and is also strongly correlated with extrahepatic diseases, including cardiovascular disease and type 2 diabetes. This risk of NAFLD among obese individuals who are otherwise metabolically healthy is not well characterized. Objectives: To determine the prevalence and characteristics of NAFLD in individuals with metabolically healthy obesity. Setting: A tertiary, academic, referral hospital. Methods: All patients who underwent bariatric surgery with intraoperative liver biopsy from 2008 to 2015 were identified. Patients with preoperative hypertension, dyslipidemia, or prediabetes/diabetes were excluded to identify a cohort of metabolically healthy obesity patients. Liver biopsy reports were reviewed to determine the prevalence of NAFLD. Results: A total of 270 patients (7.0% of the total bariatric surgery patients) met the strict inclusion criteria for metabolically healthy obesity. The average age was 38 ± 10 years and the average body mass index was 47 ± 7 kg/m2. Abnormal alanine aminotransferase (>45 U/L) and asparate aminotransferase levels (>40 U/L) were observed in 28 (10.4%) and 18 (6.7%) patients, respectively. A total of 96 (35.5%) patients had NAFLD with NALFD Activity Scores 0 to 2 (n = 61), 3 to 4 (n = 25), and 5 to 8 (n = 10). A total of 62 (23%) patients had lobular inflammation, 23 (8.5%) had hepatocyte ballooning, 22 (8.2%) had steatohepatitis, and 12 (4.4%) had liver fibrosis. Conclusion: Even with the use of strict criteria to eliminate all patients with any metabolic problems, a significant proportion of metabolically healthy patients had unsuspected NAFLD. The need and clinical utility of routine screening of obese patients for fatty liver disease and the role of bariatric surgery in the management of NAFLD warrants further investigation

Late relapse of diabetes after bariatric surgery: not rare, but not a failure

Objective: To characterize the status of cardiometabolic risk factors after late relapse of type 2 diabetes mellitus (T2DM) and to identify factors predicting relapse after initial diabetes remission following bariatric surgery to construct prediction models for clinical practice. Research design and methods: Outcomes of 736 patients with T2DM who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at an academic center (2004–2012) and had ≥5 years’ glycemic follow-up were assessed. Of 736 patients, 425 (58%) experienced diabetes remission (HbA1c <6.5% [48 mmol/mol] with patients off medications) in the 1st year after surgery. These 425 patients were followed for a median of 8 years (range 5–14) to characterize late relapse of diabetes. Results: In 136 (32%) patients who experienced late relapse, a statistically significant improvement in glycemic control, number of diabetes medications including insulin use, blood pressure, and lipid profile was still observed at long-term. Independent baseline predictors of late relapse were preoperative number of diabetes medications, duration of T2DM before surgery, and SG versus RYGB. Furthermore, patients who relapsed lost less weight during the 1st year after surgery and regained more weight afterward. Prediction models were constructed and externally validated. Conclusions: While late relapse of T2DM is a real phenomenon (one-third of our cohort), it should not be considered a failure, as the trajectory of the disease and its related cardiometabolic risk factors is changed favorably after bariatric surgery. Earlier surgical intervention, RYGB (compared with SG) and more weight loss (less late weight regain) are associated with less diabetes relapse in the long-term