Long-Limb Roux-en-Y Reconstruction for Glycemic Control in Patients with Gastric Cancer and Type 2 Diabetes: One-Year Outcomes of Oncometabolic Surgery

Although type 2 diabetes (T2D) remission after gastric cancer surgery has been reported, little is known about the predictors of postoperative T2D remission. This study used data from a nationwide cohort provided by the National Health Insurance Service in Korea. We developed a diabetes prediction (DP) score, which predicted postoperative T2D remissions using a logistic regression model based on preoperative variables. We applied machine-learning algorithms [random forest, XGboost, and least absolute shrinkage and selection operator (LASSO) regression] and compared their predictive performances with those of the DP score. The DP score comprised five parameters: baseline body mass index (< 25 or ≥ 25kg/m2), surgical procedures (subtotal or total gastrectomy), age (< 65 or ≥ 65years), fasting plasma glucose levels (≤ 130 or > 130mg/dL), and antidiabetic medications (combination therapy including sulfonylureas, combination therapy not including sulfonylureas, single sulfonylurea, or single non-sulfonylurea]). The DP score showed a clinically useful predictive performance for T2D remission at 3years after surgery [training cohort: area under the receiver operating characteristics (AUROC) 0.73, 95% confidence interval (CI), 0.71-0.75; validation cohort: AUROC 0.72, 95% CI 0.69-0.75], which was comparable to that of the machine-learning models (random forest: AUROC 0.71, 95% CI 0.68-0.74; XGboost: AUROC 0.70, 95% CI 0.67-0.73; LASSO regression: AUROC 0.75, 95% CI 0.73-0.78 in the validation cohort). It also predicted the T2D remission at 6 and 9years after surgery. The DP score is a useful scoring system for predicting T2D remission after gastric cancer surgery.

The objective is to access the role of Roux-en-Y gastric bypass (RYGB) biliopancreatic limb (BPL) length in type 2 diabetes (T2D) outcomes.RYGB is more effective than medical intervention for T2D treatment in obese patients. Despite the scarcity of available data, previous reports suggest that modifications of the RYGB limb lengths could improve the antidiabetic effects of the surgery.A cohort of obese T2D patients (n = 114) were submitted to laparoscopic RYGB, either with a standard BPL (SBPL) (n = 41; BPL 84 ± 2 cm) or long BPL (LBPL) (n = 73; BPL = 200 cm) and routinely monitored for weight loss and diabetic status up to 5 years after surgery.Baseline clinical features in the 2 patient subgroups were similar. After surgery, there was a significant reduction of body mass index (BMI) in both the groups, although the percentage of excess BMI loss (%EBMIL) after 5 years was higher for LBPL (75.50 ± 2.63 LBPL vs 65.90 ± 3.61 SBPL, P = .04). T2D remission rate was also higher (73% vs 55%, P < .05), while disease relapse rate (13.0% vs 32.5%; P < .05) and antidiabetic drug requirement in patients with persistent diabetes were lower after LBPL. Preoperative T2D duration predicted disease remission, but only for SBPL.RYGB with a longer BPL improves %EBMIL, T2D remission, and glycemic control in those with persistent disease, while it decreases diabetes relapse rate over time. The antidiabetic effects of LBPL RYGB also are less influenced by the preoperative disease duration. These data suggest the RYGB procedure could be tailored to improve T2D outcomes.

Review Question/Objective The objective of this systematic review is to synthesise the best available evidence on the effectiveness of physical leisure time activities on glycaemic control in adult patients with diabetes type 2. The specific review question is: What is the effectiveness of physical leisure time activities on glycaemic control in patients with diabetes type 2? Types of participants This review will consider adults over 18 years old diagnosed with type 2 diabetes mellitus according to 2003 American Diabetes Association criteria. Patients receiving oral or insulin medicine treatment will be considered for inclusion, regardless of severity of diabetes or other treatment regimes, but patients who had recently undergone serious operations or who had myocardial infarction, stroke, severe liver or kidney diseases, or any illness limiting participation in the physical activity program, or who were participating in a physical exercise program at the same time will be excluded from the study. Types of Interventions Regular physical leisure time activities for people with type 2 diabetes are defined as at least 150 minutes of moderate-intensity physical activity (50-70% of maximum heart rate) per week, or at least 90 minutes of vigorous-intensity physical activity (>70% of maximum heart rate) per week.26 The minimum duration of the intervention will be at least two months. The review will include the following forms of moderate or vigorous leisure time activities: (1) tai chi exercise (2) walking (3) swimming (4) gardening (5) gigong (an ancient Chinese breathing exercise that combines aerobics, isometric, and isotonic movements and meditation) (6) jogging (7) riding a bicycle (8) dancing. Types of outcomes The outcome measures will include long-term and short-term glycaemic control indicators to reflect the patients’ immediate and two to three months blood sugar changing condition. Therefore, haemoglobin A1c (HbA1c), fasting plasma glucose (FPG), and postprandial plasma glucose (PPG) indicators will be included in this study.

Factors associated with complete and partial remission, improvement, or unchanged diabetes status of obese adults 1 year after sleeve gastrectomy.

This review provides a comprehensive analysis of phase-specific management strategies for type 2 diabetes (T2D) in patients undergoing gastric cancer (GC) surgery, encompassing the preoperative, intraoperative and postoperative phases within the context of oncodiabetology. In the preoperative phase, predicting T2D remission and evaluating antidiabetic medications while considering their adverse event profiles are important. These medications include metformin and sodium-glucose cotransporter 2 inhibitors, which may help prevent both T2D progression and GC advancement. Regarding surgical approaches, Roux-en-Y reconstructions are associated with better T2D remission rates than Billroth I/II reconstructions, likely because of enhanced glucose metabolism. The considerable effects of gastrectomy and reconstruction on glucose levels have led to the development of a new surgical approach, known as oncometabolic surgery. This approach integrates oncologic treatment with metabolic benefits and has gained attention as a promising strategy for managing T2D in patients undergoing GC surgery. In the postoperative phase, glucose monitoring, individualized medication adjustments, weight management, and patient education are essential for maintaining remission and preventing relapse. A comprehensive, stage-specific approach to glycemic care is crucial for improving both metabolic and oncologic outcomes in patients with GC.

Introduction Metabolic surgery is an effective treatment for type 2 diabetes (T2D). At present, there is no authoritative standard for predicting postoperative T2D remission in clinical use. In general, East Asian patients with T2D have a lower body mass index and worse islet function than westerners. We aimed to look for clinical predictors of T2D remission after metabolic surgery in Chinese patients, which may provide insights for patient selection. Methods Patients with T2D who underwent metabolic surgery at the Third Xiangya Hospital between October 2008 and March 2017 were enrolled. T2D remission was defined as an HbA1c level below 6.5% and an FPG concentration below 7.1 mmol/L for at least one year in the absence of antidiabetic medications. Results (1) Independent predictors of short-term T2D remission (1-2 years) were age and C-peptide area under the curve (C-peptide AUC); independent predictors of long-term T2D remission (4–6 years) were C-peptide AUC and fasting plasma glucose (FPG). (2) The optimal cutoff value for C-peptide AUC in predicting T2D remission was 30.93 ng/ml, with a specificity of 67.3% and sensitivity of 75.8% in the short term and with a specificity of 61.9% and sensitivity of 81.5% in the long term, respectively. The areas under the ROC curves are 0.674 and 0.623 in the short term and long term, respectively. (3) We used three variables (age, C-peptide AUC, and FPG) to construct a remission prediction score (ACF), a multidimensional 9-point scale, along which greater scores indicate a better chance of T2D remission. We compared our scoring system with other reported models (ABCD, DiaRem, and IMS). The ACF scoring system had the best distribution of patients and prognostic significance according to the ROC curves. Conclusion Presurgery age, C-peptide AUC, and FPG are independent predictors of T2D remission after metabolic surgery. Among these, C-peptide AUC plays a decisive role in both short- and long-term remission prediction, and the optimal cutoff value for C-peptide AUC in predicting T2D remission was 30.93 ng/ml, with moderate predictive values. The ACF score is a simple reliable system that can predict T2D remission among Chinese patients.

The main goal of this study was to determine the effects of incretins on type 2 diabetes (T2D) remission after Roux-en-Y gastric bypass (RYGB) surgery for patients taking insulin. Type 2 diabetes is a chronic disease with potentially debilitating consequences. RYGB surgery is one of the few interventions that can remit T2D. Preoperative use of insulin, however, predisposes to significantly lower T2D remission rates. A retrospective cohort of 690 T2D patients with at least 12 months follow-up and available electronic medical records was used to identify 37 T2D patients who were actively using a Glucagon-like peptide 1 (GLP-1) agonist in addition to another antidiabetic medication, during the preoperative period. Here, we report that use of insulin, along with other antidiabetic medications, significantly diminished overall T2D remission rates 14 months after RYGB surgery (9%) compared with patients not taking insulin (56%). Addition of the GLP-1 agonist, however, increased significantly T2D early remission rates (22%), compared with patients not taking the GLP-1 agonist (4%). Moreover, the 6-year remission rates were also significantly higher for the former group of patients. The GLP-1 agonist did not improve the remission rates of diabetic patients not taking insulin as part of their pharmacotherapy. Preoperative use of antidiabetic medication, coupled with an incretin agonist, could significantly improve the odds of T2D remission after RYGB surgery in patients also using insulin.

A334 - Does Coexistence of Non-alcoholic Fatty Liver Disease and Type-2 Diabetes Impact Weight Loss or Remission of Type 2 Diabetes after Gastric Bypass?

Roux-en-Y gastric bypass (RYGBP) is a validated technique for the treatment of morbid obesity and results in a significant rate of remission of type 2 diabetes (T2D). Omega gastric bypass (OGBP) is an effective and simpler alternative for weight loss, but its effect on T2D is unclear. Between December 2006 and September 2012, 804 laparoscopic OGBPs were carried out in our centre. Among these, 100 (12.4%) patients had T2D at the time of the intervention. Remission of T2D was defined by a glycated haemoglobin (HbA1c) level of <6% without concomitant treatment. Postoperative follow-up was completed by 81 patients (mean age: 49 ± 11 years; mean weight at surgery: 133 ± 29 kg; mean body mass index (BMI): 47 ± 9 kg/m(2)). Mean preoperative HbA1c was 8 ± 2 g/dL. Before OGBP, seven patients (9%) had received no oral hypoglycaemic treatment, 30 (37%) had received monotherapy, 26 (32%) bitherapy, six (7%) tritherapy and 12 (15%) patients had used insulin. Over a mean follow-up of 26 months (range 1-75), mean weight decreased to 94 ± 23 kg and mean BMI to 35 kg/m(2). Seventy-one (88%) patients had complete remission of T2D and the other 10 (12%) had reduced their treatment. Seven patients (58%) initially treated with insulin no longer required this treatment. Mean time to remission of T2D for patients receiving one or more oral therapies versus insulin was 6.9 versus 17.9 months. OMBP is effective treatment for obesity in terms of weight loss and remission of T2D.

Background: Nonalcoholic steatohepatitis (NASH) is considered the hepatic manifestation of insulin resistance. Therefore, we aimed to assess the association between biopsy-proven liver steatosis and long-term remission of type 2 diabetes (T2D) 8 years following different bariatric procedures. Methods: In a retrospective cohort study including 249 patients with and without T2D, the association between biopsy-proven NASH and long-term remission of T2D 8 years following sleeve gastrectomy (SG) and Roux-enY-gastric bypass (RYGB) has been assessed. Results: Out of 249 patients, 15.3% showed NASH and T2D at the time of surgery. 8 years after surgery, T2D remission was achieved in 44.7% of patients with NASH compared to 76.0% without NASH. Patients with T2D remission were younger, had higher BMI, displayed lower HbA1c and lower preoperative insulin use (p&amp;lt;0.001) . Patients without remission of T2D showed higher steatosis scores (p&amp;lt;0.05) . In a multivariate logistic regression, higher preoperative HbA1c (OR 0.41) , insulin use (OR 0.16) and preexisting liver fibrosis (OR 0.19) decreased the probability of long-term T2D remission (p&amp;lt;0.05) . Liver steatosis, hepatocyte ballooning or lobular inflammation were not significantly associated with T2D remission. Patients without T2D were predominantly female, of younger age (p&amp;lt;0.001) and displayed lower scores of steatosis, hepatocyte ballooning and lobular inflammation (p&amp;lt;0.05) . With regard to type of surgery, there was no significant difference in T2D remission. Discussion and Conclusion: Our data suggest that long-term remission of T2D after bariatric surgery (BS) is associated with lower preoperative insulin use and lower biopsy-proven steatosis scores in patients with NASH. Furthermore, T2D remission might be less likely in patients with liver fibrosis. Type of surgery did not affect T2D remission. Our results might help identify patients with NAFLD who benefit most from BS with regard to glycemic outcomes long-term. Disclosure A.Lautenbach: Advisory Panel; Novo Nordisk, Speaker's Bureau; Boehringer Ingelheim International GmbH, Novo Nordisk. M.Wernecke: None. S.M.Meyhöfer: None. S.Meyhöfer: None. F.D.Stoll: None. J.Aberel: Advisory Panel; Novo Nordisk, Speaker's Bureau; Novo Nordisk.

Three-year follow-up comparing metabolic surgery versus medical weight management in patients with type 2 diabetes and BMI 30–35. The role of sRAGE biomarker as predictor of satisfactory outcomes

Bariatric surgery among patients with obesity and type 2 diabetes (T2D) can induce complete remission. However, it remains unclear whether sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) has better T2D remission within a population-based daily practice. To compare patients undergoing RYGB and SG on the extent of T2D remission at the 1-year follow-up. Nationwide, population-based study including all 18 hospitals in the Netherlands providing metabolic and bariatric surgery. Patients undergoing RYGB and SG between October 2015 and October 2018 with 1 year of complete follow-up data were selected from the mandatory nationwide Dutch Audit for Treatment of Obesity (DATO). The primary outcome is T2D remission within 1 year. Secondary outcomes include ≥20% total weight loss (TWL), obesity-related co-morbidity reduction, and postoperative complications with a Clavien-Dindo (CD) grade ≥III within 30 days. We compared T2D remission between RYGB and SG groups using propensity score matching to adjust for confounding by indication. A total of 5015 patients were identified from the DATO, and 4132 (82.4%) had completed a 1-year follow-up visit. There were 3350 (66.8%) patients with a valid T2D status who were included in the analysis (RYGB = 2623; SG = 727). RYGB patients had a lower body mass index than SG patients, but were more often female, with higher gastroesophageal reflux disease and dyslipidemia rates. After adjusting for these confounders, RYGB patients had increased odds of achieving T2D remission (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.14-2.1; P < .01). Groups were balanced after matching 695 patients in each group. After matching, RYGB patients still had better odds of T2D remission (OR, 1.91; 95% CI, 1.27-2.88; P < .01). Also, significantly more RYGB patients had ≥20%TWL (OR, 2.71; 95% CI, 1.96-3.75; P < .01) and RYGB patients had higher dyslipidemia remission rates (OR, 1.96; 95% CI, 1.39-2.76; P < .01). There were no significant differences in CD ≥III complications. Using population-based data from the Netherlands, this study shows that RYGB leads to better T2D remission rates at the 1-year follow-up and better metabolic outcomes for patients with obesity and T2D undergoing bariatric surgery in daily practice.

BackgroundAlthough bariatric surgery is an effective treatment for type 2 diabetes (T2D) in patients with morbid obesity, further studies are needed to evaluate factors influencing the chance of achieving diabetes remission. The objective of the present study was to investigate the association between T2D duration and the chance of achieving remission of T2D after bariatric surgery.Methods and findingsWe conducted a nationwide register-based cohort study including all adult patients with T2D and BMI ≥ 35 kg/m2 who received primary bariatric surgery in Sweden between 2007 and 2015 identified through the Scandinavian Obesity Surgery Registry. The main outcome was remission of T2D, defined as being free from diabetes medication or as complete remission (HbA1c < 42 mmol/mol without medication). In all, 8,546 patients with T2D were included. Mean age was 47.8 ± 10.1 years, mean BMI was 42.2 ± 5.8 kg/m2, 5,277 (61.7%) were women, and mean HbA1c was 58.9 ± 17.4 mmol/mol. The proportion of patients free from diabetes medication 2 years after surgery was 76.6% (n = 6,499), and 69.9% at 5 years (n = 3,765). The chance of being free from T2D medication was less in patients with longer preoperative duration of diabetes both at 2 years (odds ratio [OR] 0.80/year, 95% CI 0.79–0.81, p < 0.001) and 5 years after surgery (OR 0.76/year, 95% CI 0.75–0.78, p < 0.001). Complete remission of T2D was achieved in 58.2% (n = 2,090) at 2 years, and 46.6% at 5 years (n = 681). The chance of achieving complete remission correlated negatively with the duration of diabetes (adjusted OR 0.87/year, 95% CI 0.85–0.89, p < 0.001), insulin treatment (adjusted OR 0.25, 95% CI 0.20–0.31, p < 0.001), age (adjusted OR 0.94/year, 95% CI 0.93–0.95, p < 0.001), and HbA1c at baseline (adjusted OR 0.98/mmol/mol, 95% CI 0.97–0.98, p < 0.001), but was greater among males (adjusted OR 1.57, 95% CI 1.29–1.90, p < 0.001) and patients with higher BMI at baseline (adjusted OR 1.07/kg/m2, 95% CI 1.05–1.09, p < 0.001). The main limitations of the study lie in its retrospective nature and the low availability of HbA1c values at long-term follow-up.ConclusionsIn this study, we found that remission of T2D after bariatric surgery was inversely associated with duration of diabetes and was highest among patients with recent onset and those without insulin treatment.

Although bariatric surgery is an effective treatment for type 2 diabetes (T2D) in patients with morbid obesity, further studies are needed to evaluate factors influencing the chance of achieving diabetes remission. The objective of the present study was to investigate the association between T2D duration and the chance of achieving remission of T2D after bariatric surgery. We conducted a nationwide register-based cohort study including all adult patients with T2D and BMI ≥ 35 kg/m2 who received primary bariatric surgery in Sweden between 2007 and 2015 identified through the Scandinavian Obesity Surgery Registry. The main outcome was remission of T2D, defined as being free from diabetes medication or as complete remission (HbA1c < 42 mmol/mol without medication). In all, 8,546 patients with T2D were included. Mean age was 47.8 ± 10.1 years, mean BMI was 42.2 ± 5.8 kg/m2, 5,277 (61.7%) were women, and mean HbA1c was 58.9 ± 17.4 mmol/mol. The proportion of patients free from diabetes medication 2 years after surgery was 76.6% (n = 6,499), and 69.9% at 5 years (n = 3,765). The chance of being free from T2D medication was less in patients with longer preoperative duration of diabetes both at 2 years (odds ratio [OR] 0.80/year, 95% CI 0.79-0.81, p < 0.001) and 5 years after surgery (OR 0.76/year, 95% CI 0.75-0.78, p < 0.001). Complete remission of T2D was achieved in 58.2% (n = 2,090) at 2 years, and 46.6% at 5 years (n = 681). The chance of achieving complete remission correlated negatively with the duration of diabetes (adjusted OR 0.87/year, 95% CI 0.85-0.89, p < 0.001), insulin treatment (adjusted OR 0.25, 95% CI 0.20-0.31, p < 0.001), age (adjusted OR 0.94/year, 95% CI 0.93-0.95, p < 0.001), and HbA1c at baseline (adjusted OR 0.98/mmol/mol, 95% CI 0.97-0.98, p < 0.001), but was greater among males (adjusted OR 1.57, 95% CI 1.29-1.90, p < 0.001) and patients with higher BMI at baseline (adjusted OR 1.07/kg/m2, 95% CI 1.05-1.09, p < 0.001). The main limitations of the study lie in its retrospective nature and the low availability of HbA1c values at long-term follow-up. In this study, we found that remission of T2D after bariatric surgery was inversely associated with duration of diabetes and was highest among patients with recent onset and those without insulin treatment.

Effectiveness of preoperative hospitalization for glycemic control in patients with diabetes undergoing gastric or colorectal cancer surgery.