Table 5 - uploaded by Laurent Biertho
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Background:
Sleeve gastrectomy (SG) was originally performed as the restrictive and acid-reducing part of a biliopancreatic diversion with duodenal switch (BPD-DS). It is now recognized as a stand-alone procedure, but direct comparison between the two procedures is still lacking. The goal of this study is to compare the outcomes of the two procedu...
Citations
... Studies have shown that patients living with T2DM undergoing BDP-DS tend to lose between 36% and 55% of their initial body weight after 10 and 3 years, respectively [28,29], compared to 28% with RYBG [30] and 22% with sleeve gastrectomy after 10 years [30]. Similarly, BPD-DS is the procedure conferring the highest rate of long-term (2-5 years) diabetes remission, ranging from 90 to 100% [27,31] compared to 50-84% [29,32] for RYGB and 14-86% for sleeve gastrectomy [33][34][35]. The longer duration of diabetes and the type of antidiabetic therapy used before surgery could influence postsurgical glycemic outcomes, thus explaining the heterogeneity in diabetes remission following bariatric surgery [36][37][38]. ...
Excess adiposity can contribute to metabolic complications, such as type 2 diabetes mellitus (T2DM), which poses a significant global health burden. Traditionally viewed as a chronic and irreversible condition, T2DM management has evolved and new approaches emphasizing reversal and remission are emerging. Bariatric surgery demonstrates significant improvements in body weight and glucose homeostasis. However, its complexity limits widespread implementation as a population-wide intervention. The identification of glucagon-like peptide 1 (GLP-1) and the development of GLP-1 receptor agonists (GLP-1RAs) have improved T2DM management and offer promising outcomes in terms of weight loss. Innovative treatment approaches combining GLP-1RA with other gut and pancreatic-derived hormone receptor agonists, such as glucose-dependant insulinotropic peptide (GIP) and glucagon (GCG) receptor agonists, or coadministered with amylin analogues, are demonstrating enhanced efficacy in both weight loss and glycemic control. This review aims to explore the benefits of bariatric surgery and emerging pharmacological therapies such as GLP-1RAs, and dual and triple agonists in managing obesity and T2DM while highlighting the caveats and evolving landscape of treatment options.
... It is a restrictive bariatric operation consisting of the resection of two-thirds of the greater curvature of the stomach while preserving the pylorus (5). SG leads to weight loss and comorbidities remission, but weight regain and T2D relapse is observed in some patients (6). Roux-en-Y gastric bypass (RYGB) is the second most frequently performed bariatric surgery worldwide (4). ...
... This surgery includes a SG and a significant hypoabsorptive component, with a common limb of only 100 cm (5). BPD-DS leads to important and sustained weight loss with 80-90% T2D remission in the long term (6,9). However, BPD-DS represented only 1.3% of the weight loss surgeries performed in 2021, mostly due to the perceived risk of long-term complications and technical complexity associated with the procedure (4,10). ...
Background
Among commonly performed bariatric surgeries, biliopancreatic diversion with duodenal switch (BPD-DS) provides greater weight loss than Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG), with sustained metabolic improvements. However, the risk of long-term nutritional deficiencies due to the hypoabsorptive component of BPD-DS hinders its widespread use.
Objective
The aim of the study was to examine nutritional status over 2 years after BPD-DS, RYGB or SG.
Methods
Patients were recruited in the REMISSION trial (NCT02390973), a single-center, prospective study. Out of 215 patients, 73, 48 and 94, respectively, underwent BPD-DS, RYGB or SG. Weight loss, micronutrient serum levels (including iron, calcium, parathormone, vitamins A, B12 and D), and nutritional supplementation were assessed over 2 years. Patients were supplemented according to the type of surgery and individual micronutrient level evolution.
Results
At baseline, BPD-DS patients were younger than SG patients (p = 0.0051) and RYGB patients had lower body mass index (p < 0.001). Groups had similar micronutrient levels before surgery, with vitamin D insufficiency as the most prevalent nutritional problem (SG: 38.3%, RYGB: 39.9%, BPD-DS: 54.8%, p = 0.08). BPD-DS patients showed lower levels of iron, calcium and vitamin A than SG patients at 24 months. Groups had similar levels of vitamin D at 24 months. Prevalence of vitamin D, calcium, iron, vitamin A and vitamin B12 deficiency was similar among groups at 24 months. Rates of vitamin D insufficiency and iron deficiency were lower at 24 months than at baseline. Micronutrient intake was consistent with recommendations in groups post-surgery, but most BPD-DS patients took vitamin A and vitamin D supplement doses above initial recommendations.
Conclusion
With appropriate medical and nutritional management, all surgeries led to similar rates of vitamin D, calcium, iron, vitamin A and vitamin B12 deficiencies at 24 months. However, initial vitamin A and vitamin D supplementation recommendations for BPD-DS patients should be revised upwards.
... Thirty-six studies (41.4%) reported ≥ 3 MBS procedures, 15 (17.2%) undertook only RYGB, 14 (16.1%) included both RYGB and SG, seven (8.0%) undertook strictly SG, four [27,33,89], and two studies (2.3%) did not report their included procedures [10,16]. ...
Systematic review/meta-analysis of cumulative incidences of venous thromboembolic events (VTE) after metabolic and bariatric surgery (MBS). Electronic databases were searched for original studies. Proportional meta-analysis assessed cumulative VTE incidences. (PROSPERO ID:CRD42020184529). A total of 3066 records, and 87 studies were included (N patients = 4,991,683). Pooled in-hospital VTE of mainly laparoscopic studies = 0.15% (95% CI = 0.13–0.18%); pooled cumulative incidence increased to 0.50% (95% CI = 0.33–0.70%); 0.51% (95% CI = 0.38–0.65%); 0.72% (95% CI = 0.13–1.52%); 0.78% (95% CI = 0–3.49%) at 30 days and 3, 6, and 12 months, respectively. Studies using predominantly open approach exhibited higher incidence than laparoscopic studies. Within the first month, 60% of VTE occurred after discharge. North American and earlier studies had higher incidence than non-North American and more recent studies. This study is the first to generate detailed estimates of the incidence and patterns of VTE after MBS over time. The incidence of VTE after MBS is low. Improved estimates and time variations of VTE require longer-term designs, non-aggregated reporting of characteristics, and must consider many factors and the use of data registries. Extended surveillance of VTE after MBS is required.
Graphical Abstract
... The DS cohort displayed significantly higher %TWL at 24 months when compared to SG and RYGB. Several studies on patients with BMIs ranging from 50 to 60 kg/ m 2 have demonstrated the effectiveness of DS when compared to RYGB and SG on the short-and mediumterm [15,16]. Similarly, our findings indicate that DS may be the optimal procedure for weight loss in the BMI 70 kg/m 2 cohort. ...
... Our data show that the serum cortisol level is an independent predictor of weight loss after LSG in severely obese Japanese men. Such a predictor may be helpful for the choice of surgical procedure, such as LSG or other surgical methods which can be expected to achieve greater weight loss than LSG [38,39]. Further studies are warranted to clarify the mechanism by which serum cortisol limits the effectiveness of LSG as well as validate the usefulness of cortisol level as a marker for effective weight loss in clinical settings in male patients with severe obesity. ...
Background
Bariatric surgery is an effective treatment for severe obesity and its associated medical problems. Preoperative factors that predict postoperative weight loss remain to be fully characterized, however.
Methods
Anthropometric and laboratory data were collected retrospectively for severely obese patients who underwent laparoscopic sleeve gastrectomy (LSG) between April 2016 and July 2019 at our hospital. Preoperative factors that predicted weight loss at 1 year after LSG were investigated.
Results
A total of 122 subjects (45 men and 77 women) underwent LSG. The mean ± SD age and body mass index at surgery were 44.4 ± 10.4 years and 40.7 ± 6.7 kg/m². The percent total weight loss (%TWL) was 27.0 ± 8.6 among all subjects, 26.4 ± 8.0 among men, and 27.4 ± 8.9 among women, with no significant difference between the sexes. The %TWL showed a significant inverse correlation with serum cortisol level in men and with age and the visceral/subcutaneous fat area ratio in women. Multivariable regression analysis revealed the presence of type 2 diabetes and the serum cortisol concentration to be negatively associated with %TWL among all subjects and men, respectively. Receiver operating characteristic curve analysis identified an optimal cutoff of 10 µg/dL for prediction of a %TWL of ≥ 25 in men by serum cortisol level.
Conclusions
Serum cortisol concentration was identified as a predictor for postoperative weight loss in men. Our results may thus help inform the decision to perform LSG or more effective surgical procedures in men with severe obesity.
Graphical Abstract
... Only 1 study 33 was identified with 5-year follow-up, while most others 18,19,[34][35][36][37][38][39] stopped at 2 to 3 years, which, from inspection of the global summary data, is around the time of maximum weight loss or the beginnings of weight regain (Figure 1). More long-term data regarding outcomes are required, as these patients may continue to engage with health care services beyond this time. ...
Importance
Information on the associations between barriers to delivery of bariatric surgery and poor weight trajectory afterward is lacking. Estimates are needed to inform decisions by administrators and clinicians to improve care.
Objective
To estimate the difference in patient-years of treatment for diabetes, hypertension, and dyslipidemia and public-payer cost between the Canadian standard and an improved bariatric surgery care pathway.
Design, Setting, and Participants
Economic evaluation of a decision analytic model comparing the outcomes of the standard care in Canada with an improved bariatric care pathway with earlier sleeve gastrectomy delivery and better postsurgical weight trajectory. The model was informed by published clinical data (101 studies) and meta-analyses (11 studies) between January and May 2019. Participants were a hypothetical 100-patient cohort with demographic characteristics derived from a Canadian study.
Interventions
Reduction of Canadian mean bariatric surgery wait time by 2.5 years following referral and improvement of patient postsurgery weight trajectory to levels observed in other countries.
Main Outcomes and Measures
Modeling weight trajectory after sleeve gastrectomy and resolution rates for comorbidities in Canada in comparison with an improved care pathway to estimate differences in patient-years of comorbidity treatment over 10 years following referral and the associated costs.
Results
For the 100-patient cohort (mean [SD] 88.2% [1.4%] female; mean [SD] age, 43.6 [9.2] years; mean [SD] body mass index, 49.4 [8.2]; and mean [SD] comorbidity prevalence of 50.0% [4.1%], 66.0% [3.9%], and 59.3% [4.0%] for diabetes, hypertension, and dyslipidemia, respectively) over 10 years following referral, the improved vs standard care pathway was associated with median reduction in patient-years of treatment of 324 (95% credibility interval [CrI], 249-396) for diabetes, 245 (95% CrI, 163-356) for hypertension, and 255 (95% CrI, 169-352) for dyslipidemia, corresponding to total savings of $900 000 (95% CrI, $630 000 to $1.2 million) for public payers in the base case. Relative to standard of care, the associated reduction in costs was approximately 29% (95% CrI, 20%-42%) in the improved pathway. Sensitivity analyses demonstrated independent associations of earlier surgical delivery and various levels of postsurgical weight trajectory improvements with overall savings.
Conclusions and Relevance
This study suggests that health care burden may be decreased through improvements to delivery and management of patients undergoing sleeve gastrectomy. More data are needed on long-term patient experience with bariatric surgery in Canada to inform better estimates.
... Surgical procedures performed included mainly biliopancreatic diversion with duodenal switch (BPD-DS) with the progressive introduction of laparoscopic techniques and sleeve gastrectomy (SG) in the 2000s. 14 We identified patients with a detailed history of CAD defined as a history of coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), previous myocardial infarction (MI), coronary angiography showing ≥1 coronary stenosis ≥50% or a positive stress imaging technique. After identification of the CAD cohort and confirmation of CAD diagnosis in these patients, a oneto-one control population devoid of CAD was extracted from this same database using a propensity score. ...
There is little data regarding the risks and benefits of bariatric surgery in patients with coronary artery disease (CAD). We aimed to assess the short- and long-term cardiovascular outcomes of patients with CAD undergoing bariatric surgery. Patients with a history of CAD were identified from a dedicated database with prospectively collected outcomes, comprising all 6795 patients who underwent bariatric surgery between January 1992 and October 2017. Patients were matched with patients who did not have CAD before the bariatric surgery procedure. The primary endpoints were mortality (cardiac and noncardiac) and major adverse cardiocerebral events (MACCE), including all-cause death, myocardial infarction, stroke, and myocardial revascularization at 30 days after bariatric surgery and throughout follow-up. After propensity score matching, 249 patients with chronic CAD were matched with 249 patients without CAD. Throughout follow-up (7.4 years; interquartile range 4.1 to 11.5, maximum 22 years), mortality (mainly cardiac mortality) remained significantly higher in the CAD compared with the non-CAD group (18% vs 10%, hazard ratio [HR] 1.70, 95% confidence interval [CI]: 1.03 to 2.79, p = 0.037). At 30 days, MACCE rate was significantly higher in the CAD compared with the non-CAD group (3.6% vs 0.4%, p = 0.011), essentially driven by non-ST elevation myocardial infarctions. After 30 days, MACCE rates remained significantly higher in the CAD group (30% vs 14%, HR 2.18, 95% CI: 1.45-3.28, p = 0.0002). In conclusion, patients with severe obesity and CAD referred to bariatric surgery were at a higher risk of early and late MACCE compared with non-CAD severely obese patients. Further study is required to define how this cardiovascular risk compares with nonoperated patients.
... associated with malnutrition [3]. BPD/DS is however the most efficacious surgery to reduce excess fat loss and to alleviate T2D [4]. It is a two-stage procedure including a SG and a biliopancreatic derivation component (duodenal switch (DS)). ...
... One primary goal of the present study was to examine the effects of the BPD/DS on the gut microbiota in rats, in which BPD/DS largely replicates the beneficial metabolic effects seen in humans [3,4,17]. We found that the fecal microbiota of BPD/DS rats significantly differs from that of SHAM animals. ...
... Furthermore, analysis of the microbial profile demonstrated a major shift from a microbiota dominated by Clostridiales prior to the surgery (or in SHAM rats) to a microbiota highly concentrated in Bifidobacteriales soon post-surgery. Since BPD/DS includes two surgical components, namely the SG and the DS, which distinctly influence energy homeostasis and metabolism [4,6], we also aimed at dissecting the respective contribution of those components on the effect on gut microbiota. We found that DS, similar to BPD/DS, caused marked alterations in the fecal microbiota compared with SHAM or SG surgery. ...
Background:
The biliopancreatic diversion with duodenal switch (BPD/DS) represents the most effective surgical procedure for the treatment of severe obesity and associated type 2 diabetes. The mechanisms whereby BPD/DS exerts its positive metabolic effects have however yet to be fully delineated. The objective of this study was to distinguish the effects of the two components of BPD/DS, namely the sleeve gastrectomy (SG) and the DS derivation, on gut microbiota, and to appraise whether changes in microbial composition are linked with surgery-induced metabolic benefits.
Methods:
BPD/DS, DS, and SG were performed in Wistar rats fed a standard chow diet. Body weight and energy intake were measured daily during 8 weeks post-surgery, at which time glucagon-like peptide 1 (GLP-1), peptide tyrosine tyrosine (PYY), insulin, and glucose were measured. Fecal samples were collected prior to surgery and at 2 and 8 weeks post-surgery. Intraluminal contents of the alimentary, biliopancreatic, and common limbs (resulting from BPD/DS) were taken from the proximal portion of each limb. Fecal and small intestinal limb samples were analyzed by 16S ribosomal RNA gene sequencing.
Results:
BPD/DS and DS led to lower digestible energy intake (P = 0.0007 and P = 0.0002, respectively), reduced weight gain (P < 0.0001) and body fat mass (P < 0.0001), improved glucose metabolism, and increased GLP-1 (P = 0.0437, SHAM versus DS) and PYY levels (P < 0.0001). These effects were associated with major alterations of both the fecal and small intestinal microbiota, as revealed by significant decrease in bacterial richness and diversity at 2 (P < 0.0001, Chao1 index; P < 0.0001, Shannon index) and 8 weeks (P = 0.0159, SHAM versus DS, Chao1 index; P = 0.0219, SHAM versus DS, P = 0.0472, SHAM versus BPD/DS, Shannon index) post-surgery in BPD/DS and DS, and increased proportions of Bifidobacteriales (a 60% increase in both groups) but reduced Clostridiales (a 50% decrease and a 90% decrease respectively), which were mostly accounted at the genus level by higher relative abundance of Bifidobacterium in both the fecal and intestinal limb samples, as well as reduced abundance of Peptostreptococcaceae and Clostridiaceae in the small intestine. Those effects were not seen in SG rats.
Conclusion:
The metabolic benefits following BPD/DS are seemingly due to the DS component of the surgery. Furthermore, BPD/DS causes marked alterations in fecal and small intestinal microbiota resulting in reduced bacterial diversity and richness. Our data further suggest that increased abundance of Bifidobacterium and reduced level of two Clostridiales species in the gut microbiota might contribute to the positive metabolic outcomes of BPD/DS.
... 9 It appears that excluding or altering the presentation of nutrients to the duodenum contributes to the immediate improvements in glycaemic regulation after bariatric surgery, which do not appear to be due to malabsorption or the substantial weight loss often observed later post surgery. [10][11][12] Studies suggest a critical physiological and pathophysiological role of the small bowel in metabolic homeostasis. The easy endoscopic accessibility of the duodenum makes it a potential target for disease-modifying intervention. ...
Background
The duodenum has become a metabolic treatment target through bariatric surgery learnings and the specific observation that bypassing, excluding or altering duodenal nutrient exposure elicits favourable metabolic changes. Duodenal mucosal resurfacing (DMR) is a novel endoscopic procedure that has been shown to improve glycaemic control in people with type 2 diabetes mellitus (T2D) irrespective of body mass index (BMI) changes. DMR involves catheter-based circumferential mucosal lifting followed by hydrothermal ablation of duodenal mucosa. This multicentre study evaluates safety and feasibility of DMR and its effect on glycaemia at 24 weeks and 12 months.
Methods
International multicentre, open-label study. Patients (BMI 24–40) with T2D (HbA1c 59–86 mmol/mol (7.5%–10.0%)) on stable oral glucose-lowering medication underwent DMR. Glucose-lowering medication was kept stable for at least 24 weeks post DMR. During follow-up, HbA1c, fasting plasma glucose (FPG), weight, hepatic transaminases, Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), adverse events (AEs) and treatment satisfaction were determined and analysed using repeated measures analysis of variance with Bonferroni correction.
Results
Forty-six patients were included of whom 37 (80%) underwent complete DMR and 36 were finally analysed; in remaining patients, mainly technical issues were observed. Twenty-four patients had at least one AE (52%) related to DMR. Of these, 81% were mild. One SAE and no unanticipated AEs were reported. Twenty-four weeks post DMR (n=36), HbA1c (−10±2 mmol/mol (−0.9%±0.2%), p<0.001), FPG (−1.7±0.5 mmol/L, p<0.001) and HOMA-IR improved (−2.9±1.1, p<0.001), weight was modestly reduced (−2.5±0.6 kg, p<0.001) and hepatic transaminase levels decreased. Effects were sustained at 12 months. Change in HbA1c did not correlate with modest weight loss. Diabetes treatment satisfaction scores improved significantly.
Conclusions
In this multicentre study, DMR was found to be a feasible and safe endoscopic procedure that elicited durable glycaemic improvement in suboptimally controlled T2D patients using oral glucose-lowering medication irrespective of weight loss. Effects on the liver are examined further.
Trial registration number
NCT02413567
... The technique of BPD-DS consisting of a a pylorus-preserving gastric sleeve resection with a duodenal switch has been shown to have the best results of any metabolic procedure, including Roux en Y Gastric Bypass, (14) in terms of efficiency and duration of weight loss (3) (Fig. 1). The resolution of T2DM has been demonstrated in90-100% of the cases (9,(15)(16)(17)(18).However, the procedure is a complex one associating high peri-operative morbidity, especially in the super-super obese (SSO) patients. Michel Gagner performed the first laparoscopic duodenal switch (LBPD-DS) in 1999 (7) and demonstrated the advantages of the minimal invasive surgery in decreasing of the surgical complications, especially the pulmonary embolism. ...
Background: Morbid obesity and type 2 diabetes are rapidly increasing worldwide. The conservative treatment is providing a limited control while the more efficient metabolic surgery is more recommended. Biliopancreatic diversion with duodenal switch (BPD-DS) is the operation which provides one of the most stable weight losses and T2DM remission of any bariatric procedure. The aim is to describe the technique of laparoscopic BPD-DS. Methods: The detailed technical aspects of LBPD-DS are presented. Fiftysix consecutive patients underwent laparoscopic BPD-DS in our Bariatric Surgery Program, meaning 0.7% of the authors' bariatric surgery activity (2002-2018). Thirteen of them had BPD-DS as a primary option and the rest (42 patients, 75%) had the procedure in 2 stages. 48 patients had poorly controlled T2DM. Median hospital length of stay was 6 days (range 3-21 days). There 30-day mortality was nil. Major morbidities occurred in 4 patients (7.1%), including 1 anastomotic leak (1.7%), 3 staple-line hemorrhages (5.3%) 12 BPD-DS patients were lost in the follow-up program and the mean follow up rate for the rest was 62 months (12-156 mo.). The %excess BMI loss was 82 ÃÂ+- 13% while the T2DM remission rate was 92% (44 pts) Conclusion: Current evidence suggests that BPD-DS is the most effective metabolic procedure on obesity-related comorbidities, especially on T2DM, with an acceptable morbidity. However, due to its technical complexity and concerns regarding severe metabolic disturbances and malnutrition the utilization of this bariatric surgical procedure is limited compared to other surgical options.
