The long-term impact of biliopancreatic diversion on glycemic control in the severely obese with type 2 diabetes mellitus in relation to preoperative duration of diabetes

doi:10.1016/j.soard.2015.05.012

Surgery for Obesity and Related Diseases

Volume 12, Issue 2, February 2016, Pages 345-349

https://doi.org/10.1016/j.soard.2015.05.012 Get rights and content

Abstract

Background

Bariatric surgery has been shown to be effective in severely obese patients with type 2 diabetes mellitus (T2DM).

Objective

Evaluate the long-term efficacy of biliopancreatic diversion (BPD) for the treatment of T2DM depending on the preoperative duration of T2DM.

Setting

University Hospital.

Methods

Retrospective analysis investigating 2 subsets of severely obese patients who had undergone BPD from 1984 to 1995. The first included 52 patients with a preoperative T2DM duration of ~1 year (SD group – 49 on oral agents and 3 on insulin), and the second included 68 patients who had been diabetic for>5 years before BPD (LD group – 52 on oral agents and 16 on insulin). Postoperatively, T2DM was regarded as in remission when fasting serum glucose (FSG) was lower than 100 mg/dL on regular diet and without antidiabetic therapy.

Results

In the SD patients, the number of individuals without T2DM remission were lower both at 5–10 (0/31, 0% of patients, versus 8/54, 15% of patients, p<.04) and at>15 years (1/28, 3% of patients, versus 10/41, 24% of patients, p<.0012). Furthermore, after BPD, the number of patients with dyslipidemia strongly reduced (p<.001) in both groups, values at 5–10 years remaining very similar to those observed at>15 years.

Conclusion

These results indicate that severely obese patients with longer T2DM duration have a worse metabolic outcome maintained at long and very long term following BPD.

Introduction

In recent years, strong evidence of remission or sharp improvement of diabetic status in obese type 2 diabetics after all types of bariatric surgery has emerged [1], [2], [3]. The metabolic outcome seems to be substantially related to the extent of weight reduction, the best results being observed following the surgeries that induce consistent loss of body mass: after adjustable gastric banding, only a 20–30% of type 2 diabetes patients succeed in normalizing or reducing fasting serum glucose level; after laparoscopic Roux-en-Y gastric bypass (LRYGBP) or biliopancreatic diversion (BPD), a successful metabolic outcome after the surgery is observed in 60–70% and 85–95% of the operated patients, respectively, most likely from postoperative changes in enterohormonal pattern [4], [5], [6], [7], [8]. Nevertheless, few data are available to evaluate the metabolic results’ stability over a very long term [9].

The purpose of this retrospective analysis is to ascertain the maintenance of a normal metabolic state at very long term in severely obese patients and the role of preoperative diabetes duration in the long term diabetes remission following BPD.

Section snippets

Material and methods

The analysis was carried out in the vast cohort of severely obese patients with type 2 diabetes having consecutively undergone BPD at the Surgical Department of Genoa University, Italy, from May 1984 to May 1999 [10]. Patients were considered to have type 2 diabetes when fasting serum glucose concentration (FSG) was higher than 125 mg/dL either before or during their preoperative evaluation and/or if they were on chronic use of antidiabetic therapy. Among this cohort, 2 groups of patients were

Results

In both the SD and LD group, at 5–10 years following the surgery, a sharp and significant reduction of both body weight (BW) and body mass index (BMI) were found. These values remained substantially unchanged at>15 years; the percent of weight loss at 5–10 years was substantially similar to that observed at>15 years (Table 1). Likewise, the values of FSG, total cholesterol, and triglyceride levels decreased at 5–10 years in both groups, which strictly maintained at>15 years, and an increase of

Discussion

There is ample evidence in the literature that all types of bariatric surgeries lead to an improvement in the diabetic status in obese individuals, with BPD and Roux-en-Y gastric bypass leading to better metabolic outcome compared with a purely restrictive procedure like gastric banding [1], [2], [12], [13], [14]. However, few results at very long term are available, and very little work has been done to study and establish the preoperative factors that can reliably predict postoperative

Conclusion

In obese patients with overt type 2 diabetes undergoing BPD, the diabetes duration and the type of therapy are factors that predict the very long term postoperative metabolic outcome. In the population under study, the rate of diabetes remission is significantly lower in patients with long-duration diabetes before surgery compared with those patients who had a recent diagnosis of diabetes. In the latter group, whose diagnosis of diabetes was ~1 year before surgery, diabetes remission was

References (25)

W.J. Lee et al.
Predicting success of metabolic surgery: age, body mass index, C-peptide, and duration score
Surg Obes Relat Dis
(2013)
L. Sjöström et al.
Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications
JAMA
(2014)
H. Buchwald et al.
Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis
Am J Med
(2009)
M. Maggard-Gibbons et al.
Bariatric surgery for weight loss and glycemic control in nonmorbidly obese adults with diabetes: a systematic review
JAMA
(2013)
J.B. Dixon et al.
Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial
JAMA
(2008)
N.T. Nguyen et al.
A prospective randomized trial of laparoscopic gastric bypass versus laparoscopic adjustable gastric banding for the treatment of morbid obesity: outcomes, quality of life, and costs
Ann Surg
(2009)
F.M. van Dielen et al.
Laparoscopic adjustable gastric banding versus open vertical banded gastroplasty: a prospective randomized trial
Obes Surg
(2005)
Bhasker AG, Remedios C, Batra P, Sood A, Shaikh S, Lakdawala M. Predictors of remission of T2DM and metabolic effects...
E. Ferrannini et al.
Impact of different bariatric surgical procedures on insulin action and beta-cell function in type 2 diabetes
Diabetes Care
(2009)
N. Puzziferri et al.
Long-term follow-up after bariatric surgery: a systematic review
JAMA
(2014)

N. Scopinaro et al.

Biliopancreatic diversion

World J Surg

(1998)

Reiner Z, Catapano AL, De Backer G, et al. European Association for Cardiovascular Prevention & Rehabilitation, ESC...

Cited by (16)

Pyrrhic victory? Long-term results of biliopancreatic diversion on patients with type 2 diabetes and severe obesity
2023, Surgery for Obesity and Related Diseases
The long-term results after biliopancreatic diversion (BPD) in patients with type 2 diabetes (T2D) and severe obesity is still being debated.
Retrospective evaluation of the long-term metabolic and clinical conditions of patients with T2D following BPD.
University hospital.
A total of 173 patients with T2D and severe obesity were investigated prior to and at 3–5 and 10–20 years after BPD. Anthropometric, biochemical, and clinical findings preoperatively and throughout follow-up were considered. The long-term data were compared with those of a cohort of 173 T2D patients with obesity treated with conventional therapy.
T2D resolved within the first postoperative phases in most patients, and in the long and very long term, the fasting blood glucose level remained above the normal range in only 8% of patients. Likewise, a stable improvement of blood lipid pattern was observed (follow-up rate 63%). In contrast, in nonsurgical patients in the long term, the glucose and lipid metabolic parameters remained in the pathologic range in all cases. In the BPD group, a very high number of severe BPD-related complications was recorded, and 27% of the BPD patients died, whereas in the control group, 87% of patients were still alive at the end of the follow-up period (P < .02).
Despite the high T2D stable resolution rate and the normalization of most metabolic data at 10–20 years following surgery, these results indicate that BPD should be indicated with caution in the surgical treatment of T2D in patients with severe obesity.
Ten-year remission rates in insulin-treated type 2 diabetes after biliopancreatic diversion with duodenal switch
2020, Surgery for Obesity and Related Diseases
Citation Excerpt :
Patients with short duration of diabetes were more likely to have T2D remission at 5 to 10 (100%) and >15 (97%) years. When further divided by diabetes treatment, patients using insulin before surgery had remission rates of 64.8% at 5 to 10 years and 60% at >15 years [10]. Our results were contrary to findings by Scorpinaro et al. [30], which suggest that disease duration was only a predictor of early T2D remission when type of preoperative glycemic treatment was not considered [30].
Biliopancreatic diversion with duodenal switch (BPD-DS) confers the highest rate of type 2 diabetes (T2D) remission compared with other bariatric procedures. Previous studies suggest that type of antidiabetic therapy used before surgery and duration of disease influence postsurgical glycemic outcomes. Short-term, progressive improvement in insulin sensitivity and beta-cell function after metabolic surgery in patients with noninsulin-treated T2D has been demonstrated. Whether patients with more advanced disease can achieve sustained remission remains unclear.
The aim of this study was to assess long-term glycemic outcomes in insulin-treated patients with T2D after BPD-DS and identify predictors of sustained diabetes remission or relapse.
University-affiliated tertiary care center.
Data from 141 patients with insulin-treated T2D who underwent BPD-DS between 1994 and 2006 with 10 years of follow-up data were collected from a prospective electronic database.
Follow-up was available in 132 patients (91%). At 10 years after metabolic surgery, 90 patients (68.1%) had a complete remission of diabetes, 3 (2.3%) had a partial remission, 21 (15.9%) had an improvement, and 3 (2.3%) were unchanged in their diabetes status. Fourteen patients died during the 10-year follow-up period. Relapse after an initial period of remission occurred in 15 (11.4%) patients. Insulin discontinuation was achieved in 97%. Duration of diabetes was an independent predictor of nonremission at 10 years.
The BPD-DS maintains remission at 10 years postoperatively in patients with more advanced diabetes. Long-term benefits of the BPD-DS on weight loss and glycemic control should be considered when offering metabolic surgery to patients with insulin-treated T2D.
Serum levels of osteopontin predict diabetes remission after bariatric surgery
2019, Diabetes and Metabolism
Citation Excerpt :
For this pilot observational retrospective analysis, 41 patients with T2DM undergoing bariatric surgery were enrolled from July 2007 to July 2009 at the Surgery Department of the Ospedale Policlinico San Martino in Genoa, Italy. After a multidisciplinary evaluation (including a psychologist, a psychiatrist, a diabetologist, a dietitian and a nurse), patients underwent either biliopancreatic diversion (BPD) or Roux-en-Y gastric bypass (RYGB), as described elsewhere [7,8]. Briefly, BPD was achieved by partial (two-thirds) distal gastrectomy and small-bowel transection 300 cm proximal to the ileocaecal valve.
Bariatric surgery has been shown to effectively improve glycaemic control in morbidly obese subjects. However, the molecular bases of this association are still elusive and may act independently of weight loss. Here, our retrospective study has investigated the inflammatory molecule osteopontin (OPN) as a potential predictor of type 2 diabetes mellitus (T2DM) remission.
Baseline serum levels of OPN were analyzed in 41 T2DM patients who underwent bariatric surgery. Anthropometric measures and biochemical variables, including insulin sensitivity indices (HOMA2), were assessed at baseline and at 1 and 3 years after surgery.
At baseline, patients who experienced T2DM remission had increased waist circumference, body weight and BMI, and higher serum OPN, compared with non-remitters. Patients with and without T2DM remission improved their lipid and glucose profiles, although insulin resistance indices were only improved in the T2DM remission group. In the overall cohort of both T2DM remission and non-remission patients, baseline circulating levels of OPN significantly correlated with reductions of body weight and BMI over time, and insulin sensitivity improved as well. However, only the HOMA2-%S remained independently associated with serum OPN on multivariate linear regression analysis (B: 0.227, 95% CI: 0.067–0.387, β = 0.831; P = 0.010). Baseline values of OPN predicted 3-year T2DM remission independently of body weight loss, lower BMI and duration of diabetes (OR: 1.046, 95% CI: 1.004–1.090; P = 0.033).
Although larger studies are still needed to confirm our preliminary results, pre-operative OPN serum levels might be useful for predicting 3-year T2DM remission independently of weight loss in patients undergoing bariatric surgery.
Early reduction of matrix metalloproteinase-8 serum levels is associated with leptin drop and predicts diabetes remission after bariatric surgery
2017, International Journal of Cardiology
Citation Excerpt :
Finally, effects of leptin stimulation on human primary neutrophil degranulation and integrin expression were investigated in vitro. This pilot observational retrospective study has been performed in a single-center cohort enrolling 47 patients with T2DM undergoing bariatric surgery from July 2007 to July 2009 at the Surgical Department of Genoa University Hospital as already reported [11,12]. After a first analysis, serum samples were available for 44 of 47 patients.
We aimed at investigating whether the acute abrogation of leptin after bariatric surgery is able to reduce neutrophil activation and potentially affect type 2 diabetes mellitus (T2DM) remission.
Metabolic and inflammatory parameters (i.e. leptin, IL-6 and neutrophil products) were compared at baseline (before bariatric surgery), one month, one and three years after surgery in morbid obese (MOB) T2DM patients (n = 12) and non-MOB controls (n = 32). In vitro, the effects of leptin on Il-6-induced human neutrophil degranulation and integrin upregulation were assessed.
At baseline, MOB T2DM patients had a similar demographic, lipid and glycemic profiles than non-MOB T2DM controls, but higher levels of inflammatory mediators, such as CRP, fibrinogen, neutrophil-to-lymphocyte ratio (NLR), matrix metalloproteinase (MMP)-8 and leptin. One month after surgery, CRP, fibrinogen and MMP-8 were reduced only in MOB T2DM patients, while serum leptin was reduced in both groups. In the overall cohort, leptin and MMP-8 drops from baseline to one month post-surgery were positively correlated (Δleptin vs. ΔMMP8: r = 0.391, p = 0.025). Moreover, ΔMMP8 inversely correlated with fasting glucose levels at one-year follow-up and with glycated hemoglobin at both one- and three-year. At the cut-off point identified by ROC curve analysis (> 0 ng/mL), ΔMMP8 predicted complete T2DM remission at 3-year follow-up. In vitro, leptin increased IL-6-induced MMP-8 release and abrogated CD18 up-regulation.
Bariatric surgery is associated to an acute abrogation of leptin that could affect MMP-8 levels, particularly in MOB T2DM patients. This beneficial event is associated with T2DM remission at 3-year follow-up.
High baseline C-reactive protein levels predict partial type 2 diabetes mellitus remission after biliopancreatic diversion
2017, Nutrition, Metabolism and Cardiovascular Diseases
Several studies demonstrated that surgery can improve inflammation parameters, such as C-reactive protein (CRP). Few biomarkers have been investigated to potentially predict type 2 diabetes mellitus (T2DM) remission. We aimed at determining whether pre-surgery serum CRP levels could predict T2DM remission after 3 years in patients undergoing bariatric surgery, especially biliopancreatic diversion (BPD).
This study was conducted from 2007 to 2009 at the Surgical Department of the University of Genoa, Italy. Forty-four patients with T2DM undergoing BPD (n = 38) or Roux-en-Y gastric bypass (n = 6) were enrolled. The primary endpoint was to evaluate whether pre-surgery CRP levels could predict T2DM partial remission at 3-year follow-up. Secondary endpoints were to assess whether glycaemic, lipid, and inflammatory parameters modified during the follow-up. At baseline, patients with T2DM ranged from overweight to morbid obesity, had mild dyslipidaemia, and a low-grade inflammation. Bariatric surgery improved body weight, lipid and glycaemic profile both at 1- and 3-year follow-up. Pre-surgery CRP levels progressively decreased at 1- and 3-year follow-up. Among inflammatory pre-surgery parameters, only high CRP levels were shown to predict T2DM partial remission after 3 years. Multivariate analysis confirmed the predictive value of pre-surgery CRP levels independently of age, gender, type of surgery, and body mass index.
Bariatric surgery, in particular BPD, improved both metabolic and inflammatory biomarkers at 1- and 3-year follow-up. Pre-surgery high CRP levels predicted 3-year T2DM partial remission, indicating a promising target population to be especially treated with BPD.
Efficacy of single anastomosis sleeve ileal (SASI) bypass for type-2 diabetic morbid obese patients: Gastric bipartition, a novel metabolic surgery procedure: A retrospective cohort study
2016, International Journal of Surgery
Citation Excerpt :
Bariatric operations have demonstrated to be an effective method to treat T2DM [26]. All successful operations significantly improve insulin resistance and diabetes, but those based on malabsorptive principles get higher resolution rates [27]. SASI Bypass comprises all the possible mechanisms involved in diabetes improvement, which are a function restriction responsible of reduction in the caloric intake, a rapid entrance of undigested chyme into the distal intestine which amplifies the nutritive stimulation of the distal gut and at the same time a smaller part of the meal empties through the duodenum, diminishing the nutritive overstimulation of the proximal gut but not reducing it completely, and in the short run, maintained weight loss.
The single anastomosis sleeve ileal (SASI) bypass is a Novel Metabolic/Bariatric Surgery operation based on mini gastric bypass operation and Santoro's operation in which a sleeve gastrectomy is followed by a side to side gastro-ileal anastomosis. The purpose of this Study is to report the clinical results of the outcomes of SASI bypass as a therapeutic option for obese T2DM patients.
We conducted a retrospective cohort study of type 2 diabetic obese patients who underwent SASI bypass at one hospital from March 1, 2013 to December 31, 2014. Patients with previous bariatric surgery, history of upper laparotomy, and with less than one year follow up, were excluded. Sleeve gastrectomy was performed over a 36-Fr bougie, 6 cm from the pylorus, and 250 cm from the ileocecal valve the ileum brought to be anastomosis side to side with the antrum. Data collected included comorbidity resolution, percent excess weight loss (% EWL), and one-year morbidity and mortality.
During the study period, 61 underwent laparoscopic SASI bypass. Ultimately, 50 patients with a mean BMI of 48.7 ± 7.6 kg/m2 met inclusion criteria and were evaluated. %EWL reached 90% at one year and all patients have normal glucose level in the first 3 months after surgery. Hypertension remitted in 86%, hypercholesterolemia in 100% and hypertriglyceridemia in 97% of patients. There were 6 postoperative complications. One pulmonary embolism, one postoperative bleeding, one leak from biliary limb and one complete obstruction at the gastro-ileal anastomosis. Six months postoperative, one patient was diagnosed with marginal ulcer, 12 months after surgery, another patient was re-operated for fear of more excessive weight loss.
SASI bypass is a promising operation that offers excellent weight loss and diabetic resolution.

View all citing articles on Scopus

View full text

Original articleThe long-term impact of biliopancreatic diversion on glycemic control in the severely obese with type 2 diabetes mellitus in relation to preoperative duration of diabetes

Abstract

Background

Objective

Setting

Methods

Results

Conclusion

Introduction

Section snippets

Material and methods

Results

Discussion

Conclusion

Surg Obes Relat Dis

Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications

JAMA

Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis

Am J Med

Bariatric surgery for weight loss and glycemic control in nonmorbidly obese adults with diabetes: a systematic review

JAMA

Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial

JAMA

A prospective randomized trial of laparoscopic gastric bypass versus laparoscopic adjustable gastric banding for the treatment of morbid obesity: outcomes, quality of life, and costs

Ann Surg

Laparoscopic adjustable gastric banding versus open vertical banded gastroplasty: a prospective randomized trial

Obes Surg

Impact of different bariatric surgical procedures on insulin action and beta-cell function in type 2 diabetes

Diabetes Care

Long-term follow-up after bariatric surgery: a systematic review

JAMA

Biliopancreatic diversion

World J Surg

Original article
The long-term impact of biliopancreatic diversion on glycemic control in the severely obese with type 2 diabetes mellitus in relation to preoperative duration of diabetes