| Chapter 1 Metabolic effects and safety of Roux‐en‐Y gastric bypass surgery vs.conventional medication in obese patients with type 2 diabetesAim:To assess metabolic effects and safety of Roux‐en‐Y gastric bypass(RYGB)versus conventional medication(CM)in obese patients with type2 diabetes(T2DM)after 1 year follow-up.Methods:This retrospective cohort study included 40 patients who underwent RYGB in the department of general surgery,and matched 36patients who were treated with medication in the department of endocrinology,at Drum Tower Hospital,affiliated with Nanjing University Medical School,China.The baseline and 1-year follow-up data of patients in the two groups were collected,including general situation,body weight,body mass index(BMI),blood glucose,blood lipid,medication usage,complications,and adverse events,to evaluate the efficacy and safety of the two treatments.Results:Forty subjects(19 men and 21 women)aged 44.1 years with a mean T2DM duration of 8.3 years were given RYGB.In CM group,36 participants(23 men and 13 women)aged 49.4 years and T2DM duration was 8.3 years.Baseline clinical characteristics between above two groups,including age,T2DM duration,blood pressure,body weight,blood glucose,and blood lipid were similar.After 1‐year follow‐up,35%of patients in the RYGB group achieved the triple endpoint(including haemoglobin A1C[Hb A1c]<7.0%,low‐density lipoprotein cholesterol[LDL-C]<2.6 mmol/L,and systolic blood pressure[SBP]<130 mm Hg),and the rate of reaching the triple endpoint was significantly higher than that in the CM group(8%)(P=0.005).We analyzed the factors of the triple endpoint respectively and found that98%of patients in the RYGB group had Hb A1c<7.0%,which was significantly higher than that in the CM group(42%)(P<0.001),also more patients in the RYGB group had LDL-C<2.6 mmol/l than those in the CM group(88%vs.67%)(P=0.030),but there was no significant difference in patients with SBP<130 mm Hg between the two groups.More patients in the RYGB group achieved complete(48%vs 3%)(P<0.001)or partial(23%vs 0%)(P=0.007)remission of diabetes,and there was higher proportion of complete remission of hypertension in RYGB group than that in CM group(58%vs 24%)(P=0.019).Factors related to achieving complete remission of diabetes were determined using a stepwise binary logistic model,which including age,sex,duration of diabetes,baseline BMI,baseline Hb A1c,LDL‐C,SBP,and△BMI.The results indicated that baseline Hb A1c levels(OR 0.32;95%confidence interval[CI],0.14‐0.72;P=0.006)and△BMI(OR 1.82;95%CI,1.22‐2.74;P=0.004)strongly predicted complete remission of T2DM.Patients in the RYGB group had greater weight loss and decrease in BMI,waist circumference,fasting and postprandial of blood glucose and insulin levels,Hb A1c,blood pressure,triglycerides,and increased high‐density cholesterol.Fewer patients in the RYGB group received antidiabetics,antihypertensives,or antilipemic treatments,and had non‐alcoholic fatty liver disease(NAFLD)than those in the CM group during follow‐up.The risk analysis suggested that RYGB was benefited for patients to achieve the triple endpoint(OR1.41;95%CI,1.10‐1.8),complete remission of diabetes(OR 1.85;95%CI,1.37‐2.50),complete remission of hypertension(OR 1.83;95%CI,1.08‐3.11),complete remission of NAFLD(OR 19.5;95%CI,2.81‐135.12),and BMI<24 kg/m~2(OR 1.60;95%CI,1.26‐2.03).In addition,the risk analysis indicated that fewer patients in the RYGB group using medications to control glycaemia(OR 0.02;95%CI,0.04‐0.10),hypertension(OR 0.17;95%CI,0.05‐0.60),and dyslipidemia(OR 0.21;95%CI,0.07‐0.67),compared with the CM group.96%of the patients in RYGB group had complete remission of NAFLD at 12 months,while only 25%of the patients in CM group had.The prevalence rate of NAFLD was significantly lower than that in CM group(OR 0.01;95%CI,0.00‐0.11).Four patients in CM group developed NAFLD at 12‐months follow‐up,and no new cases were found in RYGB group.Patients with diabetic retinopathy and neuropathy in the RYGB group was trending downward,while no change in the CM group.Patients with carotid atherosclerosis showed an increasing trend in the CM group,and maintained stable following RYGB intervention.A total of 14 patients had 16 adverse events after RYGB,as follows:gastric stump inflammation(N=1),dumping syndrome(N=1),cholelithiasis(N=3),iron‐deficiency anaemia(N=3),low ferritin(N=4),osteopenia(N=2),and osteoporosis(N=2).One patient had cholelithiasis and four patients had osteopenia after CM intervention.Conclusions:For obese patients with T2DM,RYGB significantly improved the attainment of the triple endpoint,including blood lipid and glucose levels and blood pressure,and also complete remission of NAFLD,diabetes,and hypertension,greater weight loss,lower usage of medication.However,RYGB was associated with more nutrient deficiency contrast to CM.Chapter 2 Glycemic variability after Roux‐en‐Y gastric bypass surgery in obese patients with type 2 diabetesAim: To evaluate glycemic variability after Roux‐en‐Y gastric bypass surgery(RYGB)in obese patients with type 2 diabetes(T2DM).Methods: This retrospective cohort study assessed the glycemic variability three and twelve months following RYGB in 22 obese patients with T2 DM.Results: Twenty-two obese patients with T2DM(7 males and 15 females)average aged 37.1 years received RYGB.The peak value of blood glucose 3 months and 12 months following RYGB were significantly lower than those at baseline.The indexes of glycemic variability 3 and 12 months after RYGB,including mean blood glucose level(MBG),continuous overlapping net glycemic action(CONGA),hyperglycemic index(HBMI),and absolute mean of daily differences(MODD)were decreased compared with the baseline(All P < 0.05),and there was no significant difference between 12 months and 3 months after RYGB.The highest blood glucose value,the lowest blood glucose value and the percentage of the time that the blood glucose value(TBG)was ≥ 10.0mmol/L reduced 3 and 12 months following RYGB(All P < 0.05).TBG between 3.9 mmol/L and 10.0 mmol/L was increased(All P < 0.05),and TBG ≤ 3.9mmol/L remained stable 3 and 12 months after RYGB intervention.The glucose tolerance improved 3 and 12 months following RYGB,and fasting blood glucose,fasting insulin,120 min glucose,and 120 min insulin at 12 months were further improved compared with 3 months post-operation(All P < 0.05).Insulin sensitivity and β cell function improved 3 months after RYGB,and took a turn for better 12 months following RYGB(All P < 0.05).The patient’s body weight,body mass index,waist-to-hip ratio,alanine aminotransferase,aspartate aminotransferase,uric acid,triglyceride,total cholesterol,high-density lipoprotein cholesterol,and low-density lipoprotein cholesterol were significantly decreased after RYGB(All P < 0.05).Conclusions: For obese patients with T2 DM,hyperglycemia and glycemic variability were significantly ameliorated in case of discontinuation of the hypoglycemic agents three months post-operation and maintained twelve months after RYGB.The insulin resistance,insulin sensitivity,β cell function,hepatic function,and serum lipid levels were significantly improved three and twelve months after RYGB. |
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