Non-severely Obese Patients Research Articles

Obesity increases the surgical complexity and risk of recurrence after midline primary ventral hernia repair: results on 2307 patients from the French Society of hernia surgery (SFCP-CH) registry database.

Obesity is a known risk factor of recurrence after hernia surgery, but available data often concern pooled cases of primary and incisional hernia, with short follow-up. We aimed to analyze the impact of severe obesity (BMI ≥ 35kg/m2) on the results of midline primary ventral hernia repair (mPVHR), in comparison with non-severely obese patients. Data were extracted from a multicentric registry, in which patients' data are consecutively and anonymously collected. We conducted a retrospective comparative study on patients with severe obesity (sOb) versus non-severely obese patients (non-sOb), who underwent surgery, with a minimal 2-year follow-up after their mPVHR. Among 2307 patients, 267 sOb and 2040 non-sOb matched inclusion criteria. Compared with non-sOb, sOb group gathered all the worse conditions and risk factors: more ASA3-4 (39.3% vs. 10.2%; p < 0.001), symptomatic hernia (15.7% vs. 6.8%; p < 0.001), defect > 4cm in diameter (24.3% vs. 8.8%; p < 0.001), emergency surgery (6.1% vs. 2.5%; p = 0.003), and Altemeir class > 1 (9.4% vs. 2.9%; p < 0.001). Laparoscopic IPOM was used more often in sOb patients (40% vs. 32%; p = 0.016), but with smaller Hauters' ratio (46 vs. 73; p < 0.001). Compared with the non-sOb, the rate of day-case surgery was lower (48% vs. 68%; p < 0.001), the surgical site occurrences were significantly more frequent (6.4 %vs. 2.5%; p < 0.001). The main outcome, 2-year recurrence, was 5.9% in the sOb vs. 2.1% (p = 0.008), and 2-year reoperations was 3% vs. 0.3% (p = 0.006). In the adjusted analysis, severe obesity was an independent risk factor for recurrence [OR = 2.82, (95%CI, 1.45; 5.22); p = 0.003]. In patients with severe obesity, mPVHR is technically challenging and recurrence rate is three times higher than that of non-severely obese patients.

Laparoscopic Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy for Type 2 Diabetes Mellitus in Nonseverely Obese Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Recently, randomized controlled trials (RCTs) have indicated that bariatric surgery in nonseverely obese patients with a body mass index (BMI) less than 35kg/m2 might be even superior to medical therapy with regard to type 2 diabetes mellitus (T2DM) remission, but the efficacy of laparoscopic Roux-en-Y gastric bypass (LRYGB) compared with laparoscopic sleeve gastrectomy (LSG) in nonseverely obese patients has not been conclusively determined. The objective of this study is to compare LRYGB versus LSG for T2DM in nonseverely obese patients. A meta-analysis identifying RCTs evaluating LRYGB versus LSG for T2DM in nonseverely obese patients was conducted. The primary outcome was T2DM remission. Additional analyses comprised percent excess weight loss (%EWL), BMI, waist circumference, hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), serum lipid level, medication use, quality of life, and adverse events. Four RCTs concerning total 296 patients were included. T2DM remission rate and %EWL were of no difference between the two bariatric procedures. LRYGB was associated with lower BMI, waist circumference, low-density lipoprotein, and higher high-density lipoprotein than LSG. However, HbA1c, FPG, total cholesterol, and triglyceride were not significantly different between the two surgical groups. The medication use and quality of life were improved in both two groups. The gastroesophageal reflux diseases of LRYGB group were less than that of LSG group. Dumping syndromes were noted more frequently in the LRYGB group. Both LRYGB and LSG have comparative effect on resolving T2DM in nonseverely obese patients at midterm follow-up. Further RCTs should address the potential risks and long-term effects of LRYGB and LSG in nonseverely obese patients.

Long-term clinical experience with laparoscopic ventral hernia repair using a ParietexTM composite mesh in severely obese and non-severe obese patients: a single center cohort study

Background: The treatment of incisional and ventral hernias is associated with significant complications and recurrences, especially in severely obese patients. Recent studies have shown a reduced rate of surgical site infections and length of hospital stay in severely obese patients undergoing a laparoscopic ventral hernia repair.Aim: This study aims to describe the clinical experience in terms of efficacy and safety with laparoscopic ventral hernia repair using the ParietexTM Composite mesh (Covidien Sofradim Production, Trevoux, France) in severely obese patients (body mass index ≥35) compared with non-severe obese patients in a seven-year single-center cohort.Material and methods: All patients with a primary ventral or incisional hernia admitted to our hospital from 2006 until December 2012 who underwent a laparoscopic repair with the Parietex Composite mesh were included in this study. Pain scores using a numeric rating were collected prospectively 24–48 hours postoperatively. Patient data were retrospectively collected.Results: A total number of 210 patients were included; 173 with a BMI <35 and 37 with a BMI ≥35. Mean follow-up was 31 months. No statistically significant differences were found with regard to operation time, hospital stay, use of analgesics and postoperative complications. The long-term follow up recurrence rate in non-severely obese patients was 13% compared to 16% in severely obese patients (p = .60).Conclusion: Laparoscopic ventral and incisional hernia repair using the Parietex Composite mesh is feasible and safe in severely obese patients compared to non-severely obese patients.

Gastric bypass simultaneously improves adipose tissue function and insulin-dependent type 2 diabetes mellitus.

The underlying causes of type 2 diabetes (T2DM) remain poorly understood. Adipose tissue dysfunction with high leptin, inflammation, and increased oxidative stress may play a pivotal role in T2DM development in obese patients. Little is known about the changes in the adipose tissue after Roux-Y gastric bypass (RYGB) in non-severely obese patients (BMI<35kg/m2) and since these patients have more T2DM-associated complications than obese patients ("obesity paradox"), we investigated changes in adipose tissue function in a cohort of BMI <35kg/m2 with insulin-dependent T2DM after RYGB surgery which resolves T2DM. Twenty patients with insulin-dependent T2DM and BMI <35kg/m2 underwent RYGB. Insulin-resistance, leptin, oxidative stress, and cytokines were determined over 24months. Expression of cytokines and NF-kappaB pathway genes were measured in leukocytes (PBMC). Adipose tissue inflammation was examined histologically preoperatively and 24months after RGYB in subcutaneous adipose tissue. Insulin-resistance, leptin, oxidative stress as well as adipose tissue inflammation decreased significantly after RYGB. Similarly, systemic inflammation was reduced and peripheral blood mononuclear cells (PBMCs) were reprogrammed towards an M2-type inflammation. Loss of BMI correlated with leptin levels (r=0.891, p<0.0001), insulin resistance (r=0.527, p=0.003), and oxidative stress (r=0.592, p=0.016). Leptin correlated with improved insulin resistance (r=0.449, p=0.032) while reduced leptin showed a strong association with improved oxidative stress (r=0.809, p=0.001). Lastly, reduced oxidative stress correlated strongly with improved insulin-resistance (r=0.776, p=0.001). RYGB improves adipose tissue function and inflammation. Leptin as marker for adipose tissue dysfunction may be the mediating factor between insulin resistance and oxidative stress and thereby likely improving T2DM.

Single-unit muscle sympathetic nerve activity (MSNA) is more powerful predictor of sleep apnea syndrome patient’s severity than multiunit MSNA

syndrome (OSAS) has been reported in severely obese patients with nonalcoholic fatty liver disease (NAFLD), associated with obesity and metabolic syndrome. Aim of the study is to assess the prevalence of OSAS in patients with NAFLD without severe obesity. Methods. Thirty-five patients with histological NAFLD and body mass index (BMI) b35 kg/m2 underwent a complete polysomnographic (PSG) study, analyzed by a sleep expert according to the American Academy Sleep Medicine criteria. Results. PSG analysis showed that out of the 35 patients (28 males, mean age 53 ± 13.7 years, BMI 28 ± 3.3 kg/m2, neck circumference 40.6 ± 3.3 cm, waist-to-hip ratio 0.94). 23 patients (66%) had a sleep study positive for OSAS, as detected by an apnea-hypopnea index (AHI) N 5. Out of these, 13 (37%) had mild OSAS (AHI 5-15), 8 (23%) moderate OSAS (AHI 1530) and 2 (6%) severe OSAS (AHI N 30). Lowest oxygen saturation in patients without OSAS was 84 ± 8%, 82 ± 7% in those with mild OSAS, 80 ± 7% and 73 ± 9.9% respectively in thosewithmoderate and severe disease. Conclusions. In non-severely obese patients with NAFLD high risk of OSAS with sleepiness, as detected by BQ and ESS positivity, is independently associated with more severe liver damage; furthermore, a high prevalence of OSAS has been confirmed by PSG.

Gastric bypass improves glycemic control and reduces systemic inflammation in non-severely obese patients (BMI &lt; 35 kg/m2) with type 2 diabetes mellitus

Gastric bypass improves glycemic control and reduces systemic inflammation in non-severely obese patients (BMI &lt; 35 kg/m2) with type 2 diabetes mellitus

Gastric bypass improves subclinical nephropathy in non-severely obese patients (BMI &lt; 35 kg/m2) with type 2 diabetes mellitus

Introduction: Bariatric surgery results in high remission rates of type 2 diabetes mellitus (T2DM) in obese patients. We have previously shown that Roux-en-Y gastric bypass (RYGB) improves diabetic neuropathy, likely due to a reduction in nitrosative stress. The purpose of this study was to investigate whether RYGB is also able to improve diabetic nephropathy.

Surgical versus medical treatment of type 2 diabetes mellitus in nonseverely obese patients: a systematic review and meta-analysis.

To compare surgical versus medical treatment of type 2 diabetes mellitus (T2DM) remission and comorbidities in patients with a body mass index (BMI) less than 35 kg/m2. Obesity surgery can achieve remission of T2DM and its comorbidities. Metabolic surgery has been proposed as a treatment option for diabetic patients with BMI less than 35 kg/m2 but the efficacy of metabolic surgery has not been conclusively determined. A systematic literature search identified randomized (RCT) and nonrandomized comparative observational clinical studies (OCS) evaluating surgical versus medical T2DM treatment in patients with BMI less than 35 kg/m2. The primary outcome was T2DM remission. Additional analyses comprised glycemic control, BMI, HbA1c level, remission of comorbidities, and safety. Random effects meta-analyses were calculated and presented as weighted odds ratio (OR) or mean difference (MD) with 95% confidence intervals (95% CI). Five RCTs and 6 OCSs (706 total T2DM patients) were included. Follow-up ranged from 12 to 36 months. Metabolic surgery was associated with a higher T2DM remission rate (OR: 14.1, 95% CI: 6.7-29.9, P < 0.001), higher rate of glycemic control (OR: 8.0, 95% CI: 4.2-15.2, P < 0.001) and lower HbA1c level (MD: -1.4%, 95% CI -1.9% to -0.9%, P < 0.001) than medical treatment. -5.5 kg/m2, 95% CI: -6.7 to -4.3 kg/m2, P < 0.001), rate of arterial hypertension (OR: 0.25, 95% CI: 0.12-0.50, P < 0.001) and dyslipidemia (OR: 0.21, 95% CI: 0.10-0.44, P < 0.001) were lower after surgery. Metabolic surgery is superior to medical treatment for short-term remission of T2DM and comorbidities. Further RCTs should address the long-term effects on T2DM complications and mortality.

Amelioration of glycemic control by sleeve gastrectomy and gastric bypass in a lean animal model of type 2 diabetes: restoration of gut hormone profile.

In obese diabetic patients, bariatric surgery has been shown to induce remission of type 2 diabetes. Along with weight loss itself, changes in gut hormone profiles after surgery play an important role in the amelioration of glycemic control. However, the potential of gastrointestinal surgery regarding diabetes remission in non-severely obese diabetic patients has yet to be defined. In the present experimental study, we explored the effect of established bariatric procedures with and without duodenal exclusion on glycemic control and gut hormone profile in a lean animal model of type 2 diabetes. Forty 12- to 14-week-old non-obese diabetic Goto-Kakizaki (GK) rats were randomly assigned to four groups: control group (GKC), sham surgery (GKSS), sleeve gastrectomy (GKSG), and gastric bypass (GKGB). Age-matched Wistar rats served as a non-diabetic control group (WIC). Glycemic control and plasma lipids were assessed at the beginning of the observation period and 4 weeks after surgery. Fasting and mixed meal-induced plasma levels of ghrelin, glucagon-like peptide-17-36 (GLP-1), and peptide tyrosine-tyrosine (PYY) were measured. In GK rats, glycemic control improved after sleeve gastrectomy (SG) and gastric bypass (GB). Mixed meal-induced gut hormone profiles in Wistar rats (WIC) were significantly different from those of sham-operated or control group GK rats. After SG and GB, GK rats showed a similar postprandial decrease in ghrelin as observed in non-diabetic WIC. Following both surgical procedures, a significant meal-induced increase in PYY and GLP-1 could be demonstrated. SG and GB induce a similar improvement in overall glycemic control in lean diabetic rodents. Meal-induced profiles of ghrelin, GLP-1, and PYY in GK rats are significantly modified by SG and GB and become similar to those of non-diabetic Wistar rats. Our data do not support the hypothesis that duodenal exclusion and early contact of food with the ileal mucosa alone explain changes in gut hormone profile in GK rats after gastrointestinal surgery.

Metabolic Surgery: Roux-en-Y Gastric Bypass and Variables Associated with Diabetes Remission in Patients with BMI &lt;35

Metabolic results of bariatric surgery have determined an expansion of its traditional indications, being increasingly performed in non-severely obese patients, especially in type 2 diabetes mellitus (T2DM). Our aim is to determine the effectiveness of laparoscopic Roux-en-Y gastric bypass (LRYGB) in T2DM remission in patients with body mass index (BMI) below 35kg/m(2) and the variables associated with T2DM remission after surgery. Retrospective analysis of diabetic patients with BMI <35kg/m(2) who underwent LRYGB in our center between 2002 and 2010 was done. We analyzed patient's demographics, comorbidities, BMI, excess weight loss percentage (EWLp), complications, and metabolic results at 3years. Univariate and multivariate analyses were performed to determine variables associated with T2DM remission. One hundred patients were included. Sixty patients (60%) were women; median age was 48years old (interquartile range (IQR) 42-54), and median preoperative BMI was 32.7kg/m(2) (IQR 31.6-34.1). Median preoperative duration of T2DM was 4years (IQR 2-7), with 49, 30, 2, and 18% on treatment with one, two, and three hypoglycemic agents and insulin, respectively. Ninety-four percent achieved 36-month follow-up, and at this time, median EWLp was 93% (IQR 67-121). A total of 53.2, 9.6, 25.5, and 11.7% achieved a T2DM complete remission, partial remission, improvement, and no improvement, respectively. T2DM remission only was associated with non-insulin use in multivariate analysis, with an OR = 15.1 (2.8-81.2) and p = 0.002. LRYGB is a reliable and effective treatment in diabetic patients with a BMI <35kg/m(2) at 3years. T2DM remission's best results are observed in non-insulin diabetic patients.

Obstructive sleep apnea syndrome in non-severely obese patients with NAFLD

Introduction: We previously showed that a third of non-severely obese patients with nonalcoholic fatty liver disease (NAFLD) are at risk of obstructive sleep apnea syndrome (OSAS), that in the presence of daytime somnolence was independently associated with non-alcoholic steatohepatitis (NASH) and fibrosis severity.

Gastric Bypass Leads to Improvement of Diabetic Neuropathy Independent of Glucose Normalization—Results of a Prospective Cohort Study (DiaSurg 1 Study)

Surprisingly, 40% to 95% of patients with type 2 diabetes mellitus (T2DM) show early remission of hyperglycemia after obesity surgery. It is unknown to what extent other diabetes-associated comorbidities such as distal peripheral neuropathy (DPN) might be influenced by obesity surgery. This pilot study aimed at providing further evidence for the impact of Roux-en-Y gastric bypass (RYGB) on both glycemic control and DPN in non-severely obese patients with insulin-dependent T2DM. In the present prospective cohort study, 20 patients with long-standing, insulin-dependent T2DM and a body mass index (BMI) between 25 and 35 kg/m underwent laparoscopic RYGB. Body mass index, glycosylated hemoglobin (HbA1c), and DPN [quantified by the Neuropathy Symptom Score (NSS) and the Neuropathy Deficit Score (NDS)] were investigated. Six months after surgery, the preoperative BMI of 32.8 ± 2.1 kg/m (mean ± standard deviation) dropped to 25.6 ± 2.5 kg/m (P < 0.001). Preoperative HbA1c levels decreased from 8.5 ± 1.2% to 7.1 ± 1.2% (P < 0.001), with 15% of patients having a normalized HbA1c level lower than 6.2%. Of 12 patients with documented DPN, the median NSS was 8 (range, 0-10) preoperatively and 0 (range, 0-9) postoperatively (P = 0.004), with 8 patients scoring an NSS of 0. The median NDS was 6 (range, 2-8) preoperatively and 4 (range, 0-8) postoperatively (P = 0.027), with 1 patient scoring an NDS of 0. All patients had an improvement or normalization in either 1 or both scores. As expected, BMI and HbA1c levels improved significantly after RYGB. More interestingly, neuropathy scores, such as NSS and NDS, improved significantly early after surgery. Symptomatic neuropathy was completely reversible in 67% of the patients. These findings add further evidence to the fact that RYGB might be a valuable treatment option not only for improving glycemic control but also for reducing diabetes-associated comorbidities, such as DPN. This points to a complex metabolic effect of RYGB that exceeds glucose normalization. However, the results still need to be confirmed in controlled trials.

DiaSurg 2 trial - surgical vs. medical treatment of insulin-dependent type 2 diabetes mellitus in patients with a body mass index between 26 and 35 kg/m2: study protocol of a randomized controlled multicenter trial - DRKS00004550

BackgroundType 2 diabetes mellitus (T2DM) is a disease with high prevalence, associated with severe co-morbidities as well as being a huge burden on public health. It is known that glycemic control decreases long-term morbidity and mortality. The current standard therapy for T2DM is medical treatment. Several randomized controlled trials (RCTs) performed in obese patients showed remission of T2DM after bariatric surgery. Recent RCTs have shown bariatric procedures to produce a similar effect in non-morbidly and non-severely obese, insulin-dependent T2DM patients suggesting procedures currently used in bariatric surgery as new therapeutical approach in patients with T2DM. This study aims at investigating whether Roux-en-Y gastric bypass (RYGB) is an efficient treatment for non-severely obese T2DM patients in terms of preventing long-term complications and mortality.MethodsThe DiaSurg 2 trial is a multicenter, open randomized controlled trial comparing RYGB including standardized medical treatment if needed to exclusive standardized medical treatment of T2DM (control group). The primary endpoint is a composite time-to-event endpoint (cardiovascular death, myocardial infarction, coronary bypass, percutaneous coronary intervention, non-fatal stroke, amputation, surgery for peripheral atherosclerotic artery disease), with a follow-up period of 8 years. Insulin-dependent T2DM patients aged between 30 and 65 years will be included and randomly assigned to one of the two groups. The experimental group will receive RYGB and, if needed, standardized medical care, whereas the control group will receive exclusive standardized medical care, both according to the national treatment guidelines for T2DM. Statistical analysis is based on Cox proportional hazards regression for the intention-to-treat population. Assuming a loss to follow-up rate of 20%, 200 patients will be randomly allocated to the comparison groups. A total sample size of n = 400 is sufficient to ensure 80% power in a two-tailed significance test at alpha = 5%.DiscussionThe DiaSurg2 trial will yield long-term data (8 years) on diabetes-associated morbidity and mortality in patients with insulin-dependent T2DM receiving either RYGB or standardized medical care.Trial registrationThe trial protocol has been registered in the German Clinical Trials Register DRKS00004550.

Safety and Efficacy of Roux-en-Y Gastric Bypass to Treat Type 2 Diabetes Mellitus in Non-severely Obese Patients

The efficacy of Roux-en-Y gastric bypass (RYGB) to control type 2 diabetes mellitus (T2DM) has been demonstrated in morbidly obese patients. Surgical procedures primarily focused on T2DM control in patients with body mass index (BMI) < 35 kg/m(2) have shown to effectively induce remission of T2DM. However, only few reports have evaluated the safety and efficacy of RYGB in this group of patients. The aim of this study is to assess the safety and efficacy of RYGB in TD2M patients with BMI < 35 kg/m(2). All T2DM patients with BMI < 35 kg/m(2) and at least 12 months of follow-up who underwent laparoscopic RYGB were included. Safety of the procedure was evaluated according to mortality, need of reoperation/conversion, and complication rates. Metabolic parameters were evaluated at baseline and 6, 12, and 24 months after surgery. Thirty patients were included. Seventeen (56.6%) were women. Age, BMI, and duration of diabetes were 48 ± 9 years, 33.7 ± 1.2 kg/m(2), 4 ± 2.9 years, respectively. No mortality was observed. No conversion/reoperation was needed. Average length of stay was 3.2 ± 0.9 days. Early and late postoperative complications were observed in five (16.6%) and five (16.6%) patients, respectively. Twelve months after surgery, remission was observed in 25 of 30 patients (83.3%). After 2 years, remission was achieved in 13 of 20 patients (65%), and hemoglobin A1c decreased from 8.1 ± 1.8% to 5.9 ± 1.1% and homeostasis model assessment of insulin resistance from 5.7 ± 3.2 to 1.9 ± 0.8 after 12 months. RYGB is a safe and effective procedure to induce T2DM remission in otherwise not eligible patients for bariatric surgery. Evidence from prospective studies is needed to validate this approach.

Surgical treatment of nonseverely obese patients with type 2 diabetes mellitus: sleeve gastrectomy with ileal transposition (SGIT) is the same as the neuroendocrine brake (NEB) procedure or ileal interposition associated with sleeve gastrectomy (II-SG), but ileal interposition with diverted sleeve gastrectomy (II-DSG) is the same as duodenal switch

Surgical treatment of nonseverely obese patients with type 2 diabetes mellitus: sleeve gastrectomy with ileal transposition (SGIT) is the same as the neuroendocrine brake (NEB) procedure or ileal interposition associated with sleeve gastrectomy (II-SG), but ileal interposition with diverted sleeve gastrectomy (II-DSG) is the same as duodenal switch