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1.  Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient—2013 Update: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery* 
Obesity (Silver Spring, Md.)  2013;21(0 1):S1-27.
The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
doi:10.1002/oby.20461
PMCID: PMC4142593  PMID: 23529939
Bariatric surgery; Obesity; Metabolic surgery; Diabetes surgery; Metabolic syndrome; Clinical practice guidelines; Best practice guidelines; Weight loss surgery
2.  CLINICAL PRACTICE GUIDELINES FOR THE PERIOPERATIVE NUTRITIONAL, METABOLIC, AND NONSURGICAL SUPPORT OF THE BARIATRIC SURGERY PATIENT—2013 UPDATE: COSPONSORED BY AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS, THE OBESITY SOCIETY, AND AMERICAN SOCIETY FOR METABOLIC & BARIATRIC SURGERY★ 
The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE- TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
doi:10.4158/EP12437.GL
PMCID: PMC4140628  PMID: 23529351
3.  Metabolic Effects of Bariatric Surgery in Patients With Moderate Obesity and Type 2 Diabetes 
Diabetes Care  2013;36(8):2175-2182.
OBJECTIVE
To evaluate the effects of two bariatric procedures versus intensive medical therapy (IMT) on β-cell function and body composition.
RESEARCH DESIGN AND METHODS
This was a prospective, randomized, controlled trial of 60 subjects with uncontrolled type 2 diabetes (HbA1c 9.7 ± 1%) and moderate obesity (BMI 36 ± 2 kg/m2) randomized to IMT alone, IMT plus Roux-en-Y gastric bypass, or IMT plus sleeve gastrectomy. Assessment of β-cell function (mixed-meal tolerance testing) and body composition was performed at baseline and 12 and 24 months.
RESULTS
Glycemic control improved in all three groups at 24 months (N = 54), with a mean HbA1c of 6.7 ± 1.2% for gastric bypass, 7.1 ± 0.8% for sleeve gastrectomy, and 8.4 ± 2.3% for IMT (P < 0.05 for each surgical group versus IMT). Reduction in body fat was similar for both surgery groups, with greater absolute reduction in truncal fat in gastric bypass versus sleeve gastrectomy (−16 vs. −10%; P = 0.04). Insulin sensitivity increased significantly from baseline in gastric bypass (2.7-fold; P = 0.004) and did not change in sleeve gastrectomy or IMT. β-Cell function (oral disposition index) increased 5.8-fold in gastric bypass from baseline, was markedly greater than IMT (P = 0.001), and was not different between sleeve gastrectomy versus IMT (P = 0.30). At 24 months, β-cell function inversely correlated with truncal fat and prandial free fatty acid levels.
CONCLUSIONS
Bariatric surgery provides durable glycemic control compared with intensive medical therapy at 2 years. Despite similar weight loss as sleeve gastrectomy, gastric bypass uniquely restores pancreatic β-cell function and reduces truncal fat, thus reversing the core defects in diabetes.
doi:10.2337/dc12-1596
PMCID: PMC3714483  PMID: 23439632
4.  Can Diabetes Be Surgically Cured? 
Annals of surgery  2013;258(4):628-637.
Objective
Evaluate the long-term effects of bariatric surgery on type 2 diabetes (T2DM) remission and metabolic risk factors.
Background
Although the impressive antidiabetic effects of bariatric surgery have been shown in short- and medium-term studies, the durability of these effects is uncertain. Specifically, long-term remission rates following bariatric surgery are largely unknown.
Methods
Clinical outcomes of 217 patients with T2DM who underwent bariatric surgery between 2004 and 2007 and had at least 5-year follow-up were assessed. Complete remission was defined as glycated hemoglobin (A1C) less than 6% and fasting blood glucose (FBG) less than 100 mg/dL off diabetic medications. Changes in other metabolic comorbidities, including hypertension, dyslipidemia, and diabetic nephropathy, were assessed.
Results
At a median follow-up of 6 years (range: 5–9) after surgery (Roux-en-Y gastric bypass, n = 162; gastric banding, n = 32; sleeve gastrectomy, n = 23), a mean excess weight loss (EWL) of 55% was associated with mean reductions in A1C from 7.5% ± 1.5% to 6.5% ± 1.2% (P < 0.001) and FBG from 155.9 ± 59.5 mg/dL to 114.8 ± 40.2 mg/dL (P < 0.001). Long-term complete and partial remission rates were 24% and 26%, respectively, whereas 34% improved (>1% decrease in A1C without remission) from baseline and 16% remained unchanged. Shorter duration of T2DM (P < 0.001) and higher long-term EWL (P = 0.006) predicted long-term remission. Recurrence of T2DM after initial remission occurred in 19% and was associated with longer duration of T2DM (P = 0.03), less EWL (P = 0.02), and weight regain (P = 0.015). Long-term control rates of low high-density lipoprotein, high low-density lipoprotein, high triglyceridemia, and hypertension were 73%, 72%, 80%, and 62%, respectively. Diabetic nephropathy regressed (53%) or stabilized (47%).
Conclusions
Bariatric surgery can induce a significant and sustainable remission and improvement of T2DM and other metabolic risk factors in severely obese patients. Surgical intervention within 5 years of diagnosis is associated with a high rate of long-term remission.
doi:10.1097/SLA.0b013e3182a5034b
PMCID: PMC4110959  PMID: 24018646
bariatric; diabetes; gastric banding; gastric bypass; LAGB; long term; metabolic; nephropathy; RYGB; sleeve gastrectomy
5.  Outcomes of a Third Bariatric Procedure for Inadequate Weight Loss 
Background and Objectives:
The robust volume of bariatric surgical procedures has led to significant numbers of patients requiring reoperative surgery because of undesirable results from primary operations. The aim of this study was to assess the feasibility, safety, and outcomes of the third bariatric procedure after previous attempts resulted in inadequate results.
Methods:
We retrospectively identified patients who underwent a third bariatric procedure for inadequate weight loss or significant weight regain after the second operation. Data were analyzed to establish patient demographic characteristics, perioperative parameters, and postoperative outcomes.
Results:
A total of 12 patients were identified. Before the first, second, and third procedures, patients had a mean body mass index of 67.1 ± 29.3 kg/m2, 60.9 ± 28.3 kg/m2, and 49.4 ± 19.8 kg/m2, respectively. The third operations (laparoscopic in 10 and open in 2) included Roux-en-Y gastric bypass (n = 5), revision of pouch and/or stoma of Roux-en-Y gastric bypass (n = 3), limb lengthening after Roux-en-Y gastric bypass (n = 3), and sleeve gastrectomy (n = 1). We encountered 5 early complications in 4 patients, and early reoperative intervention was needed in 2 patients. At 1-year follow-up, the excess weight loss of the cohort was 49.4% ± 33.8%. After a mean follow-up time of 43.0 ± 28.6 months, the body mass index of the cohort reached 39.9 ± 20.8 kg/m2, which corresponded to a mean excess weight loss of 54.4% ± 44.0% from the third operation. At the latest follow-up, 64% of patients had excess weight loss >50% and 45% had excess weight loss >80%.
Conclusion:
Reoperative bariatric surgery can be carried out successfully (often laparoscopically), even after 2 previous weight loss procedures.
doi:10.4293/JSLS.2014.00117
PMCID: PMC4208900  PMID: 25392664
Reoperative; Revision; Conversion; Weight regain; Bariatric surgery
6.  Reduced cardiovascular risk after bariatric surgery is linked to plasma ceramides, apolipoprotein-B100 and the ApoB100/A1 ratio 
Background
Obesity-associated hyperlipidemia and hyperlipoproteinemia are risk factors for cardiovascular disease (CVD). Recently, ceramide-derived sphingolipids were identified as a novel independent CVD risk factor. We hypothesized that the beneficial effect of RYGB on CVD risk is related to ceramide-mediated improvement in lipoprotein profile.
Methods
A prospective study of patients undergoing RYGB was conducted. Patients clinical data and biochemical markers related to cardiovascular risk were documented. Plasma ceramide subspecies (C14:0, C16:0, C18:0, C18:1, C20:0, C24:0, and C24:1), ApoB100 and ApoA-1 were quantified preoperatively, 3 and 6 months post-RYGB, as was Framingham risk score. Brachial artery reactivity testing (BART) was performed before and 6 months after RYGB.
Results
Ten patients (9 female; age 48 yrs; BMI, 48.5±5.8 kg/m2) were included in the study. At 6 months post-op, mean BMI decreased to 35.7±5.0 corresponding to 51.3±10.0 % excess weight loss. Fasting total cholesterol, triglycerides, LDL, free fatty acids, ApoB100, ApoB100/ApoA-1 ratio and insulin resistance estimated from HOMA-IR were significantly reduced compared to pre-surgery values. The ratio of ApoB100/ApoA-1 correlated with a reduction in ceramide subspecies (C18:0, C18:1, C20, C24:0 and C24:1) (p<0.05). ApoB100 and the ApoB100/ApoA-1 ratio also positively correlated with the reduction in TG, LDL and HOMA-IR (p<0.05). BART inversely correlated with ApoB100 and total ceramide (p=0.05). Furthermore, the change in BART correlated with the decrease in C16:0 (p<0.03).
Conclusion
Our data suggests that improvements in lipid profiles and CVD risk factors after gastric bypass surgery may be linked to changes in ceramide lipid. Mechanistic studies are needed to determine if this link is causative or purely correlative.
doi:10.1016/j.soard.2011.11.018
PMCID: PMC3337956  PMID: 22264909
RYGB; bariatric surgery; cardiovascular risk; ceramide; sphingolipids; apolipoproteins; ApoB100; Apo A-1; ApoB100/Apo A-1 ratio
7.  NOTES for the management of an intra-abdominal abscess: transcolonic peritonoscopy and abscess drainage in a canine model 
Canadian Journal of Surgery  2013;56(3):159-166.
Background
We studied natural orifice transcolonic drainage of intra-abdominal abscesses in a canine survival model to evaluate the difficulty of peritonoscopy and abscess drainage and the reliability of endoluminal colotomy closure.
Methods
We placed a 7 cm nonsterile saline-filled latex balloon intra-abdominally to mimic or induce an abscess or inflammatory mass. Seven days later, we advanced a single-channel endoscope transanally into the sigmoid colon of the animal, made a colotomy and then advanced the endoscope intraperitoneally. We evacuated the identified abscess and placed a drain transabdominally. We closed the colotomy endoluminally with a tissue approximation system using 2 polypropylene sutures attached to metal T-bars. Two weeks later, we evaluated the colotomy closure at laparotomy.
Results
We studied 12 dogs: 8 had subphrenic balloon implants and 4 had inter-bowel loop implants. Eleven survived and underwent transcolonic peritonoscopy; we identified the “abscess” in 9. The colotomy was successfully closed in 10 of 11 dogs. Although abscesses were easily identified, the overall difficulty of the peritonoscopy was moderate to severe. One dog required colotomy closure via laparotomy, while 9 had successful endoluminal closure. After colotomy closure, 8 animals survived for 2 weeks (study end point) without surgical complications, sepsis or localized abdominal infections. On postmortem examination, all closures were intact without any adjacent organ damage or procedure-related complications.
Conclusion
Natural orifice transluminal endoscopic surgery provides a novel alternative to treating intra-abdominal pathology. It is technically feasible to perform endoscopic transcolonic peritonoscopy and drainage of an intra-abdominal abscess with reliable closure of the colotomy in a canine experimental model.
doi:10.1503/cjs.037111
PMCID: PMC3672428  PMID: 23706846
8.  Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes 
The New England Journal of Medicine  2012;366(17):1567-1576.
BACKGROUND
Observational studies have shown improvement in patients with type 2 diabetes mellitus after bariatric surgery.
METHODS
In this randomized, nonblinded, single-center trial, we evaluated the efficacy of intensive medical therapy alone versus medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy in 150 obese patients with uncontrolled type 2 diabetes. The mean (±SD) age of the patients was 49 ± 8 years, and 66% were women. The average glycated hemoglobin level was 9.2 ± 1.5%. The primary end point was the proportion of patients with a glycated hemoglobin level of 6.0% or less 12 months after treatment.
RESULTS
Of the 150 patients, 93% completed 12 months of follow-up. The proportion of patients with the primary end point was 12% (5 of 41 patients) in the medical-therapy group versus 42% (21 of 50 patients) in the gastric-bypass group (P = 0.002) and 37% (18 of 49 patients) in the sleeve-gastrectomy group (P = 0.008). Glycemic control improved in all three groups, with a mean glycated hemoglobin level of 7.5 ± 1.8% in the medical-therapy group, 6.4 ± 0.9% in the gastric-bypass group (P<0.001), and 6.6 ± 1.0% in the sleeve-gastrectomy group (P = 0.003). Weight loss was greater in the gastric-bypass group and sleeve-gastrectomy group (−29.4 ± 9.0 kg and −25.1 ± 8.5 kg, respectively) than in the medical-therapy group (−5.4 ± 8.0 kg) (P<0.001 for both comparisons). The use of drugs to lower glucose, lipid, and blood-pressure levels decreased significantly after both surgical procedures but increased in patients receiving medical therapy only. The index for homeostasis model assessment of insulin resistance (HOMA-IR) improved significantly after bariatric surgery. Four patients underwent reoperation. There were no deaths or life-threatening complications.
CONCLUSIONS
In obese patients with uncontrolled type 2 diabetes, 12 months of medical therapy plus bariatric surgery achieved glycemic control in significantly more patients than medical therapy alone. Further study will be necessary to assess the durability of these results. (Funded by Ethicon Endo-Surgery and others; ClinicalTrials.gov number, NCT00432809.)
doi:10.1056/NEJMoa1200225
PMCID: PMC3372918  PMID: 22449319
9.  Bariatric surgery for type 2 diabetes: Weighing the impact for obese patients 
Obesity is a potent risk factor for the development and progression of type 2 diabetes, and weight loss is a key component of diabetes management. Bariatric surgery results in significant weight loss and remission of diabetes in most patients. After surgery, glycemic control is restored by a combination of enforced caloric restriction, enhanced insulin sensitivity, and increased insulin secretion.
doi:10.3949/ccjm.77a.09135
PMCID: PMC3102524  PMID: 20601620

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