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Angiopoietin-like protein 8 (ANGPTL8) is an important regulator of lipid metabolism. We aimed to investigate the difference of ANGPTL8 expression in different depots of adipose tissues between individuals with and without obesity, and its correlation with various metabolic parameters. Subcutaneous (SAT) and visceral adipose tissue (VAT) samples were collected from patients who underwent bariatric or intra-abdominal surgery. Expression levels of ANGPTL8, monoglyceride lipase (MGL) , monocyte chemoattractant protein-1 (MCP-1) , leptin and adiponectin (APM1) were determined using real-time quantitative polymerase chain reaction. The correlation of ANGPTL8 expression with various metabolic parameters and other gene expression levels was analyzed using Person's correlation analysis. Logistic regression was used to establish a prediction model of obesity. Totally 330 subjects (obese: 281, non-obese: 49) were recruited. ANGPTL8 expression in VAT was significantly higher in the obesity group than in the non-obesity group (P = 0.0096). ANGPTL8 expression in VAT was positively correlated with body mass index (BMI) (r = 0.1169, P < 0.05) and was independently associated with obesity (O.R., 1.246; 95 % C.I. 1.013–21.533, P = 0.038). We also found the gene expression of ANGPTL8 in SAT and VAT was negatively correlated with APM1 expression in respective SAT and VAT. ANGPTL8 expression levels in VAT were higher in subjects with obesity, and positively correlated with BMI. This suggests a role of ANGPTL8 in the pathophysiology of obesity and may pave the way for novel treatment target of obesity. [ABSTRACT FROM AUTHOR]

Sleeve gastrectomy (SG) is the most performed bariatric procedure now. Some patients would necessitate a revision to Roux-en-Y gastric bypass (RYGB) as a salvage procedure for intractable gastroesophageal reflux disease (GERD). However, outcome of the revision in Asians with co-existed obesity and those non-obese is not clear. We retrospectively reviewed the data of patients who underwent revisional laparoscopic RYGB after SG between 2007 and 2019 for intractable GERD with data of one year follow-up. Pre-operative clinical data, perioperative outcomes, GERD symptoms, weight loss and medication details were analyzed. Patients were classified into those with body mass index (BMI) ≥ 25 and < 25 kg/m2. Fifty-five patients (44 women, 11 men; mean age 42.5 years) were included. Mean interval from the initial SG to revision surgery was 51.2 months (range, 5–132). Mean body mass index before SG was 34.6 kg/m2, whereas that before revision surgery was 27.6 kg/m2. All the patients required continue proton pump inhibitor (PPI) to control the GERD symptoms before surgery. Among them, 36 (65.4%) patients in the obese group received long BP limb (>100 cm) RYGB for associated obesity but the common channel was assured to ≥ 400 cm or 70% of small bowel length, the other 19 (34.6%) patients in the non-obese group received standard BP limb (<100 cm) RYGB. There was no difference in basic characters between the two groups before revision surgery except a higher mean BMI (30.0 vs. 22.2 kg/m2, p < 0.001), blood pressure and triglyceride in obese group. One year after revision surgery, all the patients had improved GERD symptoms but only 33 (60%) can completely wave PPI, without difference between the 2 groups. Obese group with a long BP limb RYGB had a significant higher % total weight loss (TWL) than non-obese group (%TWL 9.1% vs. −3.1%, p = 0.005). Laparoscopic revision to RYGB is a safe and effective treatment for patients with intractable GERD after SG but some patients may still have residual GERD symptoms. Using a modified RYGB technique in revision surgery may help in weight reduction for obese Asian patients. [ABSTRACT FROM AUTHOR]

Taiwan is a leading country regarding bariatric surgery in Asia-Pacific. Since 2010, the Taiwan Society for Metabolic and Bariatric Surgery (TSMBS) has been accountable for the national evolution of bariatric surgery and inaugurated a national database accordingly. This study aimed to analyze the bariatric surgery trends and progress in Taiwan from 2010 to 2021. The TSMBS database was collected on the basis of structured inquiries filled out by bariatric surgeons in Taiwan. All patients involving bariatric surgery were included. The data were stratified with the following objectives, including the types of bariatric procedures, demographic characteristics, and perioperative variables. A nationwide database was comprehensively analyzed and evaluated to determine the trends in the applications of the procedure. Data of 30,026 patients were enrolled. A 2.5-fold increase was observed in bariatric procedures, from 1218 in 2010 to 3005 in 2021. Within 12 years, female accounts for 61.8 %. The revisional rate was 3.40 % during the exploration stage (2010–2013), 2.77 % during the maturity stage (2013–2018), and 5.10 % during the expansion stage (2019–2021). The top five of primary bariatric surgery is sleeve gastrectomy (SG, 63.05 %), gastric clipping surgery (GC, 11.17 %), Roux-en-Y gastric bypass (RYGB, 9.34 %), one anastomosis gastric bypass (OAGB, 8.80 %), and sleeve plus surgery (SG plus, 4.43 %). The trends and progress of Taiwan's bariatric surgery within recent decades are presented in this article. Taiwan's bariatric surgery case number has increased steadily from 2010 to 2021. Amongst all, SG has become the most dominant procedure since 2011 while OAGB takes up second place in 2020. • Taiwanis the pioneer of bariatric surgery in the Asia Pacific since the late 20th century. • To comprehensively demonstrate a panorama of Taiwan's bariatric surgery development. • Several factors influencing the ebb and flow of various bariatric surgery procedures in Taiwan are discussed. • The trends of Taiwan's bariatric surgery may provide an insight of the evolvement of bariatric surgery in Asian population. [ABSTRACT FROM AUTHOR]

Gall stone disease was known to increase after bariatric surgery. Ursodeoxycholic acid (UDCA) might reduce the gallstone formation rate after bariatric surgery. However, other option for gallstone prevention was unclear. We reported the result of a randomized trial comparing the gallstone prevention efficacy of probiotics and digestive enzyme versus UDCA. This prospective, randomized trial was held in an institute of Taiwan. Patients were eligible for inclusion if their body-mass index (BMI) was 32.5 kg/m2 or higher with the presence of comorbidity, or 27.5 kg/mw or higher with not-well controlled type 2 diabetes, and were aged 18–65 years. Participant were randomized assigned (1:1:1) to probiotic, digestive enzyme or UDCA. The primary endpoint was assessed in the incidence of gallstone disease at 6 months after surgery. This study is registered with ClinicalTrials.gov. number NCT03247101, and is now completed. From January 2016 to December 2018, of 186 patients screened for eligibility, 152 were randomly assigned to probiotic (52) or digestive enzyme (52) or UDCA (52). In the per-protocol population, mean age was 35.9 years (SD 10.6), mean BMI was 40.3 kg/m2 (SD 6.9), 57(58.2%) were female. After 6 months, the incidence of gall bladder diseased was 15.2%, in the probiotics group, 17.6% in UDCA group and 29.1% in digestive enzyme groups, confirming non-inferiority of probiotic (p = 0.38). Female gender was identified as a risk factor for gall bladder disease after bariatric surgery (odds ratio = 4.61, 95% confidence interval = 1.05, 20.3, p = 0.04). The poor drug compliance rate was 19.5%, 22.7% and 26.2% in probiotics, UDCA and digestive enzyme group respectively. UDCA group had a higher drug adverse effect than probiotic group (15.9% vs. 2.4%, p = 0.03). Probiotic is not inferior to UDCA regarding gall bladder disease prevention after bariatric surgery at 6 months. • 156 patients were randomly assigned to probiotic (52) or digestive enzyme (52) or UDCA (52) for prevention of gallbladder disease after bariatric surgery. • After 6 months, the incidence of gall bladder diseased was 15.2%, in the probiotics group, 17.6% in UDCA group and 29.1% in digestive enzyme groups (p = 0.38), confirming non-inferiority of probiotic to UDCA. • Female gender was identified as a risk factor for gall bladder disease after bariatric surgery (odds ratio = 4.61, 95% confidence interval = 1.05, 20.3, p = 0.04). • UDCA group had a higher drug adverse effect than probiotic group (15.9% vs. 2.4%, p = 0.03). [ABSTRACT FROM AUTHOR]

While clinical findings demonstrate a superior benefit of cardiovascular (CV) risk reduction in obese patients with type 2 diabetes mellitus (T2D) receiving bariatric surgery over non-T2D patients, the mechanism is unclear. This study aimed to investigate the changes in the CV risk score and five CV-associated biomarkers after gastric bypass surgery. We enrolled 80 obese subjects who underwent gastric bypass (40 T2D and 40 non-T2D). CV risks were assessed using the United Kingdom Prospective Diabetes Study (UKPDS) engine before and after surgery. Levels of five biomarkers —fasting serum fibroblast growth factor (FGF)-19, FGF-21, corin, oxidized low-density lipoprotein (ox-LDL), and soluble receptor for advanced glycation end-products (sRAGE)—were measured before surgery and one year after surgery. The T2D group was significantly older and had a higher CV risk score than the non-T2D group, but body mass index (BMI) was similar between the groups. Preoperative biomarker levels were similar in both the T2D and the non-T2D groups. One year after surgery, the percentage of total weight loss (%TWL) was similar between the two groups (32.2 ± 19.5% versus 34.1% ± 8.8%, p = 0.611). Complete T2D remission (hemoglobin A1c (HbA1c) < 6.0%) was achieved in 29 patients (72.5%). The 10-year CV risk scores by the UKPDS risk engine reduced significantly in both the T2D and the non-T2D groups, but more in the T2D group. Three of five biomarkers changed significantly after surgery: the FGF-19 increased from 195.6 ± 249.1 pg/mL to 283.2 ± 211.8 pg/mL, corin increased from 3.3 ± 2.3 ng/mL to 4.6 ± 3.7 ng/mL, and ox-LDL decreased from 148.5 ± 71.7–107.9 U/L; the P values were 0.002, 0.002 and < 0.001, respectively. The T2D group showed a significantly different change in FGF-19 increase and FGF-21 decrease compared to the non-T2D group. The changes in corin and ox-LDL levels were not different between the T2D and non-T2D groups. Gastric bypass surgery resulted in a higher UKPDS CV risk score reduction in obese T2D Asians than in those without. FGF-19 and FGF-21 may be associated with the underlying mechanism of this difference. • We tested 5 CV biomarkers in obese T2D and non-T2D Asian patients. T2D patients had a higher UKPDS CV risk score than non-T2D patients at baseline. • One year after surgery, both groups had similar weight loss, but T2D patients had a higher CV risk reduction than non-T2D patients. • T2D patients showed a significantly different change in FGF-19 increase and FGF-21 decrease compared to non-T2D patients. • Although corin and ox-LDL levels changed significantly after surgery, there was no difference between T2D and non-T2D Asian patients. [ABSTRACT FROM AUTHOR]

Limited studies have focused on diabetes relapse after metabolic surgery, especially among Asians. To identify the predictors of diabetes relapse following initial postoperative remission in Asia. Four tertiary hospitals We assessed 342 patients (age, 41.0 ± 10.8 yr; body mass index [BMI], 39.6 ± 7.3 kg/m2) with complete diabetes data before and 1 and 3 years after metabolic surgery. A total of 290 (84.8%) and 277 (81.0%) patients had diabetes remission at 1 and 3 years after surgery. Logistic regressions were performed to identify the independent predictors of diabetes relapse. Two published predictive models for diabetes remission were also tested for relapse. Of the 290 patients with 1-year diabetes remission, 29 (10%) experienced a relapse at 3 years after surgery. The area under the receiver operating characteristic curve of the ABCD score in predicting 1-year remission, 3-year remission, and 3-year relapse were.814,.793, and.795, while those of the DiaRem2 score were.823,.774, and.701, respectively. The baseline age, BMI, and insulin use were independent predictors for relapse. The most powerful predictive model for relapse was composed of preoperative insulin use, 1-year A1C, and a change in BMI between the first and third year (C-statistic:.919). The ABCD score predicted both mid-term postoperative diabetes remission and relapse in Asians. Initial older age, lower BMI, insulin use, higher 1-year A1C, and weight regain were independent predictors of relapse. Personalized strategies should be proposed for those at risk of relapse to optimize diabetes outcomes after surgery. • In total, 10% people had diabetes relapse 3 years after metabolic surgery. • Age, BMI, insulin use, 1-year A1c, and weight regain predicted diabetes relapse. • The ABCD score predicted both diabetes remission and relapse in Asians. [ABSTRACT FROM AUTHOR]

Background: Very few studies have explored the changes of serum pepsinogen after bariatric surgery and no research has evaluated the feasibility of ABC classification to predict gastric cancer risk after bariatric surgery.Methods: We enrolled 94 obese subjects that received bariatric surgery, including 41 sleeve gastrectomy (SG) and 53 Roux-en-Y gastric bypass (RYGB). The serum pepsinogen I (PGI), pepsinogen II (PGII), PGI/II ratio and seropositivity of Helicobacter pylori ( H. pylori ) were measured before and one year after surgery. Patients were classified according to ABC classification and post-operative change was evaluated.Results: Preoperatively, four (4.2%) patients were classified into high risk group (classification C and D) for gastric cancer. Significant reduction of PGI, PGII and decrease of PGI/II ratio were noted after bariatric surgery. H. pylori seropositive patients had a greater postoperative change of PGI (-38.6μg/L vs -22.1μg/L, p=0.003) and PGII (-8.0μg/L vs -2.5μg/L, p <0.001) but a less postoperative change of PGI/II ratio (-0.6 vs -2.1, p =0.04) than H. pylori seronegative patients. One year after surgery, the portion of high risk group of ABC classification for gastric cancer increased markedly from 4.2% to 23.7%.Conclusion: Both of SG and RYGB resulted in significant reduction of serum PGI and PGII after bariatric surgery, and significantly influenced the ABC classification. The application of ABC classification for gastric cancer screening was limited after bariatric surgery. [ABSTRACT FROM AUTHOR]

Laparoscopic 1- (single-) anastomosis gastric bypass (OAGB) was developed as a simplified technique of Roux-en-Y gastric bypass (RYGB), but super long-term data are lacking. To evaluate the risks and long-term results of OAGB over a period of 20 years. Tertiary teaching hospital. A total of 2223 patients underwent OAGB from 2001 to 2020; the mean age was 35.3 ± 11.4 years (range, 14–71 yr), 70.2% were female, and the mean body mass index was 40.2 ± 11.9 kg/m2. All data were kept in a prospective bariatric database. Patients were divided into 4 groups, based on the 5-year period in which their surgery was performed, and a retrospective analysis was conducted. The means for operating time, intraoperative blood loss, and length of hospital stay after OAGB were 131.9 ± 40.1 minutes, 38.5 ± 30.7 mL, and 4.5 ± 4.0 days, respectively. There were 27 patients (1.2%) with 30-day postoperative major complications overall, but the group rate decreased to.4% in the last 5-year period. At postoperative years 5, 10, and 15, the percentages of total weight loss were 31.9%, 29.6%, and 29.5%, respectively, and the percentages of excess weight loss were 77.2%, 68.4%, and 65.5%, respectively. Among 739 patients (33.2%) with type 2 diabetes (T2D), the rates of complete remission (glycated hemoglobin < 60%) at 5, 10, and 15 years were 67.3%, 73.8%, and 66.7%, respectively. The weight loss and antimetabolic effects were similar in each 5-year period, but a significant malnutrition effect was observed. A total of 113 (5.1%) patients needed revision surgery at follow-up, due to malnutrition (n = 51), weight regain (n = 24), acid or bile reflux (n = 22), marginal ulcer (n = 8), ileus (n = 3), and other causes (n = 5). At 15 years, the overall revision rate was 11.9% (27/226), and 80% of the patients were very satisfied with their procedures. Our results showed that OAGB is a safe and durable primary bariatric procedure, with sustained weight loss and a high resolution of T2D up to 20 years post surgery in Taiwan, although malnutrition is a major side effect. 1. OAGB is a very safe bariatric/metabolic surgery with a 0.4% major complication rate at recent 5 years. 2. OAGB has a durable weight loss with %TWL of 31.9% at 5 years, 29.64% at 10 years and 39.4% at 15 years after surgery. 3. OAGB is highly effective for T2D treatment, with a 67.2% 5-y, 73.8% 10-y and 66.7% 15-y T2D complete remission rate. 4. Overall revision rate was 5.1% and accumulated revision rate at 15 years was 12.5%. 5. Malnutrition (45.1%) was the first indication for revision, followed by weight regain (21.2%) and reflux disease (10.0%). [ABSTRACT FROM AUTHOR]

Laparoscopic one (single)-anastomosis gastric bypass (OAGB) is an effective and durable treatment for morbidly obese patients. However, the ideal length of the small bowel bypass remains controversial. The study aimed to report the clinical results of using a tailored bypass based on the total length of the small bowel. Academic medical center. Since 2005, we have performed OAGB with tailored limb according to preoperative body mass index. From July 2014, we modified our technique, measuring the whole small bowel length to keep the common channel at least 400-cm long. Data from 470 patients treated with the new technique (Group II) were compared with those of a matched group treated with tailored bypass only (Group I). The preoperative clinical data and outcomes were analyzed. All clinical data were prospectively collected and stored. Both groups had similar clinical profiles at baseline. All procedures were completed laparoscopically. Group II had a significant longer operation time (161.9 versus 122.6 min; P <.001), but shorter hospital stay (2.9 versus 5.3 d; P <.001) and lower complication rate (.2% versus 1.5%; P =.002) than Group I. One year after surgery, the mean body mass index (27.4 versus 26.8 kg/m2; P =.244), percent total weight loss (32.0% versus 34.0%; P =.877), and diabetes remission rate (84.7% versus 84.1%; P =.876) were comparable between the 2 groups. However, Group II patients had a significantly lower incidence of anemia (5.9% versus 11.1%; P <.001), secondary hyperparathyroidism (21.7% versus 33.8%; P <.001) and hypoalbuminemia (1.5% versus 2.8%; P <.001) than did Group I. Routine measurement of the whole bowel length to keep the common channel at least 400-cm long may reduce the incidence of malnutrition after OAGB with tailored limb bypass, without compromising efficacy in weight loss and diabetes resolution. 1) The small bowel length varied widely in bariatric patients. 2) To keep the common channel > 400cm by measuring the whole small bowel length, the incidence of malnutrition was significantly reduced comparing to those without control. 3) The weight loss and T2D remission rate were similar between those with measuring the small bowel length and those without. 4) When we try to maximize the anti-metabolic efficacy of bariatric surgery by extended the BP limb, we need to control the common channel by counting the whole length of small bowel. [ABSTRACT FROM AUTHOR]

• Common limb length less than 400 cm correlates with a high risk of PD. • Common limb length should be evaluated during revision surgery for intractable PD. • Whole bowel length should be measured, if possible, during gastric bypass surgery. • Conversion to SG is an option for treatment of intractable PD. Bariatric surgery, especially the gastric bypass procedure, is an effective therapy for morbid obesity, but may reduce protein absorption and induce protein deficiency (PD). A recent study reported an issue about common limb length for PD. This study aimed to examine the prevalence of PD after gastric bypass surgery and investigate the role of common limb length in PD-related revision surgery. Hospital-based bariatric center. From 2001 to 2016, 2397 patients with morbid obesity who underwent bariatric/metabolic surgery with 1-year follow-up were recruited. Serum albumin and total protein were measured before and 1 year after surgery. Medical records of patients who underwent revision surgery due to PD were reviewed. The overall prevalence of PD was.5% preoperatively. The prevalence of PD increased to 2.0% at 1 year after surgery. The incidence was highest in one-anastomosis gastric bypass (2.8%) followed by Roux-en-Y gastric bypass (1.8%). Until the end of follow-up, all 19 patients who underwent revision surgery for intractable PD had a relatively short common limb length of <400 cm. After elongation of the common limb length to >400 cm in revision surgery, PD improved in all patients. A subset of patients can develop PD after gastric bypass surgery when the common limb length is <400 cm. In patients with intractable PD after gastric bypass surgery, revision surgery for elongation of common limb length to >400 cm is mandatory to avoid PD-related complications. [ABSTRACT FROM AUTHOR]

Highlight • The current study reported the 5-y outcomes of a novel bariatric/metabolic procedure: SADJB-SG. • SADJB-SG can be adopted as an effective bariatric/metabolic surgery, replaces gastric bypass in area where gastric cancer from the excluded stomach is a concern. • SADJB-SG is a durable primary bariatric procedure with sustained weight loss and a high resolution of T2D at 5 year. • The disadvantages of SADJB-SG are technical difficulty and de-novo GERD from the SG. Abstract Background Single-anastomosis duodeno-jejunal bypass with sleeve gastrectomy (SADJB-SG) was developed as a simplified technique of DJB-SG, but long-term data are lacking. Objective To report the long-term data of SADJB-SG. Setting Tertiary Teaching Hospital. Methods A total of 148 SADJB-SG was performed from 2011 to 2016 with mean age of 42.0 ± 10.9-years old (14–71), female 64.9%, and mean body mass index 34.2 ± 5.9 kg/m2. All patients were evaluated and managed under a strict multidisciplinary team approach. A retrospective analysis of a prospective bariatric database and telephone interview of patients who defaulted clinic follow-up at 5-year was conducted. Results The mean operating time, intraoperative blood loss, and hospital stay of SADJB-SG were 189.6 ± 32.1 minutes, 43.5 ± 17.9 mL, and 5.0 ± 5.1 days, respectively. The 30-days postoperative major complication occurred in 7(4.7%) patients, all in patients with type 2 diabetes (T2D). At postoperative 1, 2, and 5 years, the mean percentage of total weight loss and excess weight loss of SADJB-SG patients were 25.5%, 22.8%, 22.5%, and 83.9%, 76.1%, 58.6%, respectively. Among 118 patients with T2D, 62 (52.5%) achieved complete remission (hemoglobin A1C <60%) at 1 year and 36.5% at 5 years after surgery. A total of 15 patients needed reoperation at follow-up, due to reflux disease (n = 11), weight regain, and recurrent of T2D (n = 2), ileus (n = 1), and peritonitis (n = 1). Among them, 8 were converted to RYGB and the others remained in same anatomy. At 5 years, the overall revision rate was 12.9% (8/62) and 24.5% (14/57) of the remaining required proton pump inhibitor for reflux symptoms. Conclusion Our results show that primary SADJB-SG is a durable primary bariatric procedure with sustained weight loss and a high resolution of T2D at 5 years, but de novo GERD is the major side effect. [ABSTRACT FROM AUTHOR]

Summary Background Strong evidence has shown that metabolic surgery is more effective than medical treatment in the treatment of type 2 diabetic patients. However, no study demonstrated a survival benefit and reduction of diabetes-related end-organ damage. Here, we describe the study design of a large prospective cohort study, the Taiwan Diabesity Study (TDS) which would compare the long-term survival rate and end-organ damage between overweight/obese type 2 diabetic patients receiving metabolic surgery and medical treatment. Methods Eligibility criteria include type 2 diabetic patients with duration > 6 months, body mass index (BMI) over 25 kg/m2 and age between 20 and 67 years. Exclusion criteria are serum creatinine over 2.0 mg/dL, C-peptide below 1.0 ng/ml, recent history of cancer, and major diabetic complications. Eligible participants were recruited from six medical centers in Taiwan. The survival rate and diabetes-related end organ damage will be compared between the metabolic surgery group and medical group after follow-up for 10 years. Results In 3 years, 1016 participants were identified from 38,751 patients. The average BMI of patients was 30.6 (±2.6) kg/m2 and the average hemoglobin A1c was 8.2% (±1.5%) with 18% of them receiving insulin treatment. Among them, 126 patients received metabolic surgery and 890 patients received conventional medical treatment. The metabolic surgery group are younger, have a higher proportion of females, higher BMI and blood lipids as compared to the medical group. Conclusion The TDS recruited 1016 overweight/obese type 2 diabetic patients including 126 patients receiving metabolic surgery and 890 patients receiving medical treatment. [ABSTRACT FROM AUTHOR]

Summary Background Nonalcoholic steatohepatitis (NASH) is closely associated with obesity and is one of the important etiologies of hepatocellular carcinoma (HCC and liver failure. Bariatric surgery is proven to be effective in causing weight loss and improvement of NASH) but there is limited long term data. Objectives To identify the predictors of NASH in morbidly obese patients and evaluate long term data of bariatric surgery effects on NASH. Methods 308 bariatric patients (mean age 30.2 years old, body mass index (BMI) 45.0 kg/m2) with concurrent liver biopsy form 2003 to 2008 were included. We compared the clinical data between the NASH and non-NASH group and identify predictors of NASH in this cohort of patients. Remission of NASH was evaluated using the predictor of NASH. Results Prevalence of NASH was 43.8%. At baseline, the NASH and non-NASH groups both had similar age, BMI and sex ratio but the NASH group had significantly worse glycemic control, liver enzymes, triglycerides and uric acid. Highly sensitive-C Reactive Protein (HSCRP) level was identified as the only independent predictor of NASH. Ten years follow up (60.4% loss to follow up) showed good weight loss, resolution of co-morbidities and reduction of HSCRP. Patients with bypass surgery had better weight loss and lower levels of HSCRP. (HSCRP 0.2 ± 0.1 mg/dL vs. 0.8 ± 0.7 mg/dL, p = 0.009). than non-bypass group. Conclusion NASH is common in bariatric patients. HSCRP is the only independent predictor of NASH and can be used as a surrogate marker in predicting long term effect of Bariatric Surgery on resolution of non-alcoholic steatohepatitis Bypass procedure was better in resolution of NASH than non-bypass procedure. [ABSTRACT FROM AUTHOR]

Highlights • The current study confirms the significant reduction of the CVD risk of up to 50% after one year of surgery. • Metabolic surgery confirms the well remission of type 2 diabetes mellitus after one year of surgery. • The sleeve gastrectomy before surgery was the independent predictor of CVD risk reduction after MS. • Gastric bypass surgery carries a higher power on CVD risk reduction than SG. Abstract Background In recent years, bariatric surgery was found to have therapeutic potential for the treatment of type 2 diabetes (T2D) in severely obese patients (body mass index [BMI] ≥35 kg/m2) and to reduce cardiovascular disease (CVD) risk and mortality. However, the benefit of CVD risk reduction after metabolic surgery in nonseverely obese T2D patients (BMI <35 kg/m2) remained to be proven. Objective To evaluate the CVD risk after metabolic surgery in T2D patients using The UK Prospective Diabetes Study score. Setting Tertiary referral general hospital, Taiwan, Republic of China. Methods Outcomes of 392 patients (235 women and 147 men) who had undergone sleeve gastrectomy (87) or gastric bypass (305) for treatment of T2D with 1-year follow-up were assessed. Data were prospectively collected for study, and cerebral and coronary heart disease risk was calculated by using The UK Prospective Diabetes Study risk engine. Outcomes of patients who had undergone different surgical procedures were assessed. Results One year after surgery, weight and glycemic control with complete and partial remission of T2D were significant in most of the patients. The 10-year coronary heart disease risk and fatal coronary heart disease risk were also reduced from 8.8% to 4.6% and from 4.6% to 2.1%, respectively (both P <.001). Similar CVD risk reduction was seen in both patients with BMI ≥35 and BMI <35. Multivariable analysis confirmed that surgical procedure of sleeve gastrectomy was a negative independent predictor of CVD risk reduction after metabolic surgery. Conclusion The present study confirms the efficacy of metabolic surgery for the T2D treatment and reduction of CVD risk up to 50% 1 year after surgery. Gastric bypass surgery has more power on CVD risk reduction than sleeve gastrectomy. [ABSTRACT FROM AUTHOR]

Highlights • To validate a scoring system for predicting NASH in morbidly obese patients and using it to evaluate the long term effect of bariatric surgery on NASH. • At baseline, the NASH group had significantly worse fasting glucose levels, triglycerides, uric acid, AST, ALT, GGT and HbA1c. • The diagnostic sensitivity of the scoring system for NASH was 84.4% and the accuracy was 68.4%. • Among 5741 bariatric patients, the NASH prevalence using the scoring system was 40.9%. • Patients with gastric banding had less weight loss, higher mean level of NASH score and incidence of persistent NASH compared to other procedures at follow-up. • Bariatric surgery is effective and durable in causing remission of NASH. Abstract Background Nonalcoholic steatohepatitis (NASH) is an important etiology of end-stage liver disease. Long-term effect of bariatric surgery in improvement of NASH is not clear. Objectives To validate a scoring system for predicting NASH in morbidly obese patients and using it to evaluate the long-term effect of bariatric surgery on NASH. Setting Tertiary referral hospital, Taiwan. Methods A new 5-point clinical NASH (C-NASH) score incorporating body mass index, alanine aminotransferase, and triglyceride was validated in a group of 307 bariatric patients (mean age 30.2 years, incorporating body mass index 45.0 kg/m2) with concurrent liver biopsy from 2003 to 2008. Remission of NASH in 5741 obese patients undergoing bariatric/metabolic surgery with long-term follow-up was then evaluated using the C-NASH score. Results Among 307 patients with liver biopsy, the prevalence of NASH was 44.0%. At baseline, the NASH group had significantly worse fasting glucose levels, triglycerides, uric acid, aspartate aminotransferase, alanine aminotransferase, gamma glutamyl transferase, and glycated hemoglobin. The diagnostic sensitivity of C-NASH score was 84.4%, and the accuracy was 68.4%. Among 5741 bariatric patients, the prevalence of high risk for NASH evaluated by C-NASH score was 40.9%. Postoperative follow-up showed good weight loss and almost complete remission of high risk for NASH up to 10 years. Patients with gastric banding had less weight loss, higher mean level of C-NASH score, and a higher incidence of high risk for NASH compared with other procedures at follow-up. Conclusion This study demonstrated that improvement in C-NASH score suggesting remission of NASH is durable up to 10 years in all kinds of bariatric procedures. [ABSTRACT FROM AUTHOR]

Gastrointestinal stromal tumors (GISTs) treatment has improved remarkably in recent years. However, giant and unresectable lesions could still be challenging, especially from the surgical aspect. We reported a case of a 44-year-old male patient who complained about abdominal pain and distention. Computed tomography scans, upper GI endoscopy, and tissue biopsy proved the diagnosis of a giant GIST which was considered unresectable. With the aid of neoadjuvant imatinib therapy, the tumor shrank tremendously, and we successfully performed en bloc resection with clean margins. Therefore, we suggested combining imatinib therapy and surgery in managing giant and unresectable GIST lesions. [ABSTRACT FROM AUTHOR]

Background Metabolic surgery has become increasingly accepted for the treatment of type 2 diabetes (T2D). However, there is limited evidence regarding the optimal candidate and surgical procedure. Although a new individualized metabolic surgery (IMS) score was recently proposed for procedure selection, it has yet to be validated. Objective To validate the IMS score with regard to remission of T2D after metabolic surgery and compare it with the age, body mass index, C-peptide level, and duration of T2D (ABCD) score. Setting Hospital-based bariatric center. Methods A total of 310 T2D patients who underwent gastric bypass and sleeve gastrectomy at an academic center in Taiwan and had a minimum 5-year follow-up (2004–2012) were examined for the predictive power of complete remission using the IMS and the ABCD scoring systems. Results At the 5-year follow-up, weight loss was 27.5%, with mean body mass index decreasing from 37.8 to 27.9 kg/m 2 , mean glycated hemoglobin decreased from 8.6% to 6.1%, and prolonged remission of T2D achieved in 224 (72.3%) T2D patients. Remission rates were higher in patients who underwent gastric bypass than in those who underwent sleeve gastrectomy (73.6% versus 66.1%; P = .04), regardless of T2D severity, and were 96%, 68%, and 16% in patients with IMS mild, moderate, and severe scores, respectively. Although both scores predicted the success of surgery, the ABCD was better in patients with IMS moderate scores. Conclusion Metabolic surgery is an option for T2D patients with obesity. The ABCD score may be better at predicting T2D remission after metabolic surgery compared with the IMS score. [ABSTRACT FROM AUTHOR]

Background In recent years, gastric bypass surgery has been found to have therapeutic potential for the treatment of type 2 diabetes (T2D). However, the difference between 2 bypass procedures, Roux-en-Y gastric bypass (RYGB) and another single anastomosis gastric bypass (SAGB), is not clear. Objective To evaluate the differences between SAGB and RYGB in the efficacy of T2D remission in obese patients. Setting Tertiary teaching hospital. Methods Outcomes of 406 (259 women and 147 male) patients who had undergone RYGB (157) or SAGB (249) for the treatment of T2D with 1-year follow-up were assessed. The remission of T2D after surgery was evaluated in matched groups, including body mass index (BMI) and the ABCD scoring system, which comprises patient age, BMI, C-peptide levels, and duration of T2D (yr). Results The weight loss of the SAGB patients at 1 year after surgery was better than the RYGB patients (24.1% [8.4%] versus 30.7% [8.7%]; P <.001). The mean BMI decreased from 39.9 (8.0) to 27.4 (4.6) kg/m 2 in SAGB patients at 1 year after surgery and decreased from 34.5 (6.6) to 26.2 (4.2) kg/m 2 in the RYGB patients. The mean glycated hemoglobin A1C (HbA1C) decreased from 8.6% to 6.2% of the RYGB group and from 8.6% to 5.5% of the SAGB group. Eighty-seven (55.4%) patients of the RYGB group and 204 (81.9%) of the SAGB group achieved complete remission of T2D (HbA1C<6.0%) at 1 year after surgery ( P <.001). SAGB exhibited significantly better glycemic control than RYGB surgery in selected groups stratified by different BMI and ABCD score. At 5 years after surgery, SAGB still had a better remission of T2D than RYGB (70.5% versus 39.4%; P = .002). Multivariate analysis confirms that both SAGB and ABCD score are independent predictors of T2D remission after bypass surgery. Conclusions Both RYGB and SAGB are effective metabolic surgery. SAGB carries a higher power on T2D remission than RYGB in a small group of patients. ABCD score is useful in T2D patient classification and selection for different procedures. [ABSTRACT FROM AUTHOR]

Summary Background Bariatric surgery (BS) is totally different from diabetes surgery (DS) in the patient characters, goals of surgery, and management although similar in surgical procedure. Comparison of BS and DS with long-term data is lacking. Materials and methods A retrospective review of patients who received BS and patients who received DS at Min-Sheng General Hospital from 2007 to 2013 was designed. All inpatient and outpatient follow-up data were analyzed. Patients undergoing BS for the treatment of morbid obesity were compared with patients undergoing metabolic surgery for the treatment of type 2 diabetes mellitus (T2DM). Patients who received revision surgeries were excluded. The main outcome measures were: (1) operation risk; (2) weight loss; and (3) diabetes remission. Results Between 2007 and 2013, 2073 patients who received BS and 741 patients who received DS were recruited from both centers. DS patients were older (41.1 ± 10.9 years vs. 33.1 ± 9.3 years, p < 0.05) and were more likely to be male (40.2% vs. 28.2%, p < 0.05) and to have diabetes (100% vs. 6.0%, p < 0.05), however, they had similar body mass index (BMI) (37.9 ± 8.0 vs. 38.5 ± 9.7, p = 0.78) compared to the BS patients. Surgical procedures are significantly different between the two groups (73.3% of the DS surgeries were gastric bypass procedure, whereas this procedure made up only 47.1% of BS surgeries). Although the major complication rates were similar (2.0% vs. 2.4%), the DS program had a significant higher mortality rate than the BS program (0.54% vs. 0.1%; p < 0.05). At the 5-year follow-up time point, 58.0% of the BS patients had achieved successful results (weight loss > 30%) and 80% of the DS patients had complete remission of their diabetes [hemoglobin A1c (HbA1c) < 6.0%]. Both the DS and the BS group had good results in up to 85% of the patients at the 5-year follow-up time point. Conclusion The clinical profiles were very different between the BS and the DS programs. Both programs achieved the desired outcomes equally well, however, the DS program had a higher risk than the BS program. [ABSTRACT FROM AUTHOR]

Laparoscopic Roux-en-Y gastric bypass (RYGB) achieves a higher remission of type 2 diabetes mellitus (T2DM) than laparoscopic sleeve gastrectomy (SG) in non-morbidly obese patients. However, the mechanisms of the higher remission are unknown. To compare glucagon-provoked acute insulin responses, as well as changes of gut and pancreatic hormones and adipokines between patients with T2DM after RYGB and SG at one year post-operatively, a total of 14 RYGB and 13 SG patients were followed-up and evaluated for glucose metabolism, gut and pancreatic hormones, and adipokines. One year after surgery, 1-mg intravenous glucagon tests were performed. The differences in each hormone at different time points and the area under the curve (AUC) were compared between the two groups. Glucagon-stimulated acute insulin responses were not different between the RYGB and SG groups, nor were they different between the remitters and non-remitters at one year after the metabolic surgery. Plasma des-acyl ghrelin and nesfatin-1 levels significantly decreased at 6 min after glucagon stimulation in the RYGB and SG groups, as well as in the remitters and non-remitters. The glucagon test did not affect intestinal hormones. Plasma resistin was suppressed after intravenous glucagon stimulation in both RYGB and SG groups. In conclusion, intravenous glucagon inhibited plasma levels of des-acyl ghrelin, nesfatin-1, and resistin in T2DM patients at one year after both RYGB and SG, whereas post-glucagon suppression of plasma obestatin and resistin was shown in the remitters but not in the non-remitters. [ABSTRACT FROM AUTHOR]

Background Gastric bypass surgery is the recommended treatment for severely obese patients. However, postoperative symptomatic gastrointestinal (GI) episodes are common complaints. Objectives To determine if administration of probiotics improves symptomatic GI episodes after gastric bypass surgery. Setting Hospital-based bariatric center. Methods This double-blind, randomized trial was conducted between March 2010 and September 2010 with 60 patients who underwent gastric bypass for severe obesity and experienced postoperative symptomatic GI episodes. Patients were randomly assigned to the probiotics group A (n = 20; 1 g Clostridium butyricum MIYAIRI twice daily); probiotics group B (n = 20; Bifidobacterium longum BB536 twice daily); or digestive enzymes group (n = 20; Aczym, containing 100 mg takadiastase N, 20 mg cellulase AP, 50 mg lipase MY, and 100 mg pancreatin, twice daily). Quality of life was measured using the modified Gastrointestinal Quality of Life Index (mGIQLI) before and after the 2-week intervention. Results Preintervention patient characteristics and mGIQLI scores were similar among the 3 groups. After the 2-week intervention, the mean mGIQLI score improved from 57.4 to 63.9 points in the entire sample and also within each group for 7 items specifically for 7: excessive passage of gas, foul smell of flatulence, belching, heartburn, abdominal noises, abdominal bloating, and abdominal pain. Conclusions Administration of probiotics or digestive enzymes may improve symptomatic GI episodes after gastric bypass surgeries and improve quality of life, at least initially. [ABSTRACT FROM AUTHOR]

Summary Background Laparoscopic sleeve gastrectomy (LSG) is a popular stand-alone bariatric surgery, despite a paucity of long-term data. Hence, this study is to report the long-term outcome of LSG as primary bariatric procedure and the result of revisional surgery. Methods With retrospective analysis of a prospective bariatric database, participants who defaulted clinic follow-up were interviewed by telephone. A total of 667 LSG was performed as primary bariatric procedure (2006–2012) with mean age of 34.5 ± 9.7 years old, female 74.7%, mean body mass index (BMI) 37.3 ± 8.1 kg/m 2 . A 36-F bougie was used for all cases. Results There were 61 patients available with long-term data. The weight loss outcome at 1 year, 2 years, 3 years, 4 years, and 5 years showed a mean BMI 26.3, 25.2, 25.3, 27.1, and 26.2 with mean excess weight loss (EWL) 76.0%, 79.6%, 77.3%, 73.4%, and 72.6% respectively. However, 17% patients developed de novo gastro-esophageal reflux disease (GERD). Eighteen patients (2.2%) needed surgical revisions due to weight regain ( n = 6), persistent type 2 diabetes mellitus (T2DM; n = 2), stricture ( n = 2), and GERD ( n = 8). The revision resulted in an additional mean excess weight loss of 23.8% with mean BMI 24.9 kg/m 2 at 6 months postoperatively. There was a 23.7% mean reduction of HbA1c with one patient who was in complete diabetic remission at 1 year. Conclusion Our results showed LSG is a durable bariatric procedure with > 70% EWL at 5 years despite a high incidence of GERD. The need for revision of LSG is low and mainly for GERD. [ABSTRACT FROM AUTHOR]

Background Laparoscopic sleeve gastrectomy (LSG) is becoming a primary bariatric surgery for obesity and related diseases. This study presents the outcome of LSG with regard to the remission of type 2 diabetes mellitus (T2 DM) and the usefulness of a grading system to categorize and predict outcome of T2 DM remission. Methods A total of 157 patients with T2 DM (82 women and 75 men) with morbid obesity (mean body mass index 39.0±7.4 kg/m 2 ) who underwent LSG from 2006 to 2013 were selected for the present study. The ABCD score is composed of the patient’s age, body mass index, C-peptide level, and duration of T2 DM (yr). The remission of T2 DM after LSG was evaluated using the ABCD score. Results At 12 months after surgery, 85 of the patients had complete follow-up data. The weight loss was 26.5% and the mean HbA 1c decreased from 8.1% to 6.1%. A significant number of patients had improvement in their glycemic control, including 45 (52.9%) patients who had complete remission (HbA 1c <6.0%), another 18 (21.2%) who had partial remission (HbA 1c <6.5%), and 9 (10.6%) who improved (HbA 1c <7%). Patients who had T2 DM remission after surgery had a higher ABCD score than those who did not (7.3±1.7 versus 5.2±2.1, P <.05). Patients with a higher ABCD score were also at a higher rate of success in T2 DM remission (from 0% in score 0 to 100% in score 10). Conclusion LSG is an effective and well-tolerated procedure for achieving weight loss and T2 DM remission. The ABCD score, a simple multidimensional grading system, can predict the success of T2 DM treatment by LSG. [ABSTRACT FROM AUTHOR]

Background Laparoscopic sleeve gastrectomy (SG) has become accepted as a stand-alone procedure as a less complex operation than laparoscopic duodenojejunal bypass with sleeve gastrectomy (DJB-SG). Objectives The aim of this study was to compare one-year results between DJB-SG and SG. Setting University hospital. Methods A total of 89 patients who received a DJB-SG surgery were matched with a group of SG that were equal in age, sex, and body mass index (BMI). Complication rates, weight loss, and remission of co-morbidities were evaluated after 12 months. Results The mean preoperative patient BMI in the DJB-SG and SG groups was similar. There were more patients with type 2 diabetes mellitus (T2DM) in the DJB-SG group than in the SG group. The mean operative time and length of hospital stay (LOS) were significantly longer in the DJB-SG group than in the SG group. At 12 months after surgery, the BMI was lower and excess weight loss higher in DJB-SG than SG. Remission of T2DM was greater in the DJB-SG group. Low-density lipoprotein, total cholesterol, and metabolic syndrome (MS) improved after operation in both groups. Conclusions In this study DJB-SG was superior to SG in T2DM remission, triglyceride improvement, excess weight loss, and lower BMI at 1 year after surgery. Adding duodenal switch to sleeve gastrectomy increases the effect of diabetic control and MS resolution. [ABSTRACT FROM AUTHOR]

Summary Background It is well established that severe hypertriglyceridemia can lead to pancreatitis. At present, medical treatment for patients with severe hypertriglyceridemia and repeat pancreatitis attacks is not adequate. The aim of this study was to assess the effectiveness of laparoscopic bariatric surgery in these patients. Methods A review of 20 morbidly obese patients with severe hypertriglyceridemia (a triglyceride level of >1000 mg/dL) who received laparoscopic bariatric surgery was performed. The study population comprised 14 males and six females, with an average age of 35.0 years (range 24–52 years), and the mean body mass index was 38.2 kg/m 2 (range 25–53 kg/m 2 ). The preoperative mean plasma triglyceride level was 1782.7 mg/dL (range 1043–3884 mg/dL). Four patients had a history of hypertriglyceridemic pancreatitis and 13 patients had associated diabetes. Results Of the 20 patients, 17 (85%) received gastric bypass, whereas three (15%) received restrictive-type surgery. Laparoscopic access was used in all of the patients. Hypertriglyceridemia in morbidly obese patients was more commonly associated with male sex and a poorly controlled diabetic state. The mean weight reduction was 25.5% 1 year after surgery, with a marked improvement in diabetes management. As early as 1 month following surgery, the plasma mean triglyceride levels had decreased to 254 mg/dL (range 153–519 mg/dL), and this was further reduced to mean levels of 192 mg/dL (range 73–385 mg/dL) 1 year after surgery. One patient developed acute pancreatitis during the perioperative period, but none of the patients suffered an episode of pancreatitis in the follow-up period (from 6 months to 13 years). Conclusion Bariatric surgery can be successfully used as a metabolic surgery in severe hypertriglyceridemia patients at risk of acute pancreatitis. However, control of triglyceride levels prior to bariatric surgery is indicated. [ABSTRACT FROM AUTHOR]

Background Laparoscopic adjustable gastric banding (LAGB) is the safest type of bariatric surgery but is less effective than other bariatric surgeries. Combining LAGB with gastric plication (LAGB-P) may increase weight loss compared to LAGB alone. Methods In this study, we report our short-term experience with this novel technique and compare the data for the first 42 consecutive patients with the data for LAGB alone and LSG. Forty-two morbidly obese patients underwent LAGB-P and were followed for 12 months. Operative complications, weight loss, and late complications were followed and compared with matched groups of LAGB alone and laparoscopic sleeve gastrectomy (LSG). The setting was a university hospital in Taiwan. Results The study consisted of 42 patients, specifically 21 males and 21 females with an average age of 32.6 ± 9.7 years (range 18 to 58) and a mean body mass index of 40.7 ± 6.1 kg/m 2 (range 31.5 to 56.4). The mean operation time was 141.9 ± 24.8 minutes (range 105 to 190), and the mean hospital stay was 2.3 ± 1.9 days. Two (4.8%) major complications were encountered and resolved by laparoscopic revision surgery. There was 1 (2.4%) major complication in the LSG group and none in the LAGB group. The operation time for LAGB-P was longer than for LAGB and LSG (75.6 ± 17.9 and 110.5 ± 22.3 minutes; P <.001). The mean body mass index of the LAGB-P group decreased from 40.7 to 29.4 kg/m 2 at 1 year after surgery, with an excess weight loss of 62.6%. This result is similar to the 67.2% excess weight loss in the LSG group, but is higher than the 31.7% excess weight loss of the LAGB group. At follow-up, revision surgery was required in 2 (4.8%) patients in the LAGBP group, none (0%) in the LAGB group, and 1 (2.4%) in the LSG group. More patients in the LSG group still required proton pump inhibitor treatment at 1 year after surgery than the other 2 groups Conclusion By combining LAGB with gastric plication, LAGB-P can augment the weight loss of LAGB and is similar to LSG but may increase risk. [ABSTRACT FROM AUTHOR]

Background Recent studies have shown serum lipopolysaccharide binding protein (LBP) is associated with obesity and related metabolic disorder. Bariatric surgery can significantly reduce weight, but reports about the change of LBP after bariatric surgery are limited. We investigated LBP concentration and its associations with clinical variables. Methods We enrolled 178 obese patients receiving different bariatric surgeries and 38 normal weight individuals. Fasting blood samples were collected at baseline in all and 1 year after surgery in obese individuals. The serum LBP concentration was measured. Results The percentage of excess weight loss of mini-gastric bypass, Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric band were 72.0±20.0%, 65.5±23.0%, 67.2±18.4%, and 16.1±14.3%, respectively. Serum LBP levels were higher in the obese participants than in the normal weight participants (49.9±15.7 versus 25.2±7.5 μg/mL; P <.001) at baseline and significantly decreased to 35.1±22.6 μg/mL after bariatric surgery ( P <.001) in the obese group. In the bariatric participants, after multivariate analyses, preoperative LBP and the change of LBP with surgery were independently associated only with high sensitive C-reactive protein (hs-CRP) ( P <.001) and the change of hs-CRP ( P = .012), respectively, while none of the postoperative variables was independently associated with LBP. Conclusion LBP is associated with body mass index and hs-CRP. Bariatric surgery significantly decreased the serum level of LBP. The relationship between LBP and hs-CRP disappeared after bariatric surgery. (Surg Obes Relat Dis 2014;0:000–000.) © 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved. [ABSTRACT FROM AUTHOR]

Summary: Background: Single-incision laparoscopic surgery (SILS) has emerged recently, and this procedure minimizes surgical trauma. Laparoscopic Roux-en-Y gastric bypass is one of the most effective bariatric surgeries. From five to seven small skin incisions are usually required to perform this procedure. In regard to the single-incision laparoscopic surgery procedure, we developed a modified single-laparoscopic technique (2-site incision technique) to perform a Roux-en-Y gastric bypass. Our method and the associated learning curve will be presented here. Methods: Three hundred consecutive patients with a mean age of 31.7 years (range, 19–52 years) underwent a two-site incision laparoscopic Roux-en-Y gastric bypass (TILRYGB) between February 2009 and December 2010. The mean body mass index of the patients was 40.5 kg/m2 (range, 30.1–59.9 kg/m2) preoperatively. The same perioperative protocol and surgical technique were used in all patients. These 300 patients were equally divided into three groups in sequence. The pre- and postoperative data were collected and compared. Results: The TILRYGB procedure was performed successfully in all patients. The mean operative time of the groups in sequence was 170.9 minutes, 157.3 minutes, and 149.0 minutes. No perioperative major complications occurred. Minor complications occurred in these three groups in five, three, and zero cases. These minor complications included gastrointestinal bleeding and ileus, all of which resolved with conservative treatment. The mean hospital stay in sequence was 4.1 days, 3.8 days, and 3.5 days. Conclusion: TILRYGB is a safe, feasible, and reproducible bariatric procedure; once the learning curve is overcome, it can provide better postoperative results than other surgical procedures. [Copyright &y& Elsevier]

Abstract: Background: Hyperuricemia is associated with obesity. Few studies have reported the effects of different types of bariatric surgery on uric acid metabolism. The aim of our study was to determine the relationships between serum uric acid reduction and estrogen receptor-α (ESR1) gene polymorphism, as well as the type of bariatric surgery received. The potential physiological pathways involved in postsurgery serum uric acid reduction were also discussed. Methods: A total of 508 severely obese Han Chinese patients, aged 20 to 50 years, with a body mass index (BMI)≥35 kg/m2 were selected. Patients received either laparoscopic adjustable gastric banding (LAGB; n = 164) or laparoscopic mini-gastric bypass (LMGB; n = 344). A 12-month follow-up was performed to explore the effects of the type of bariatric surgery and ESR1 polymorphism on serum uric acid reduction. Results: The rs712221 polymorphism of ESR1 affects serum uric acid reduction after bariatric surgery. The LMGB group exhibited a greater reduction in serum uric acid level compared with the LAGB counterpart after adjusting for sex, age, and metabolic confounders (−2.3±2.1 mg/dL versus−1.2±1.1 mg/dL; P = .002). Patients with the rs712221 genotype exhibited better glycemic control and a greater serum uric acid reduction at 12 months after surgery. The effects of the rs712221 polymorphism in LMGB patients resulted in the greatest serum uric acid reduction (−2.7±1.4 mg/dL). Conclusions: For severely obese Han Chinese patients, bariatric surgery appears to reduce serum uric acid levels, potentially mediated by synergic effects of surgery type, BMI reduction, rs712221 locus, insulin sensitivity, and changed dietary factors via an unknown mechanism. [Copyright &y& Elsevier]

Abstract: Background: Surgery is the most effective treatment of morbid obesity and leads to dramatic improvements in type 2 diabetes mellitus (T2DM). Gastrointestinal metabolic surgery has been proposed as a treatment option for T2DM. However, a grading system to categorize and predict the outcome of metabolic surgery is lacking. The study setting was a tertiary referral hospital (Taoyuan City, Taoyuan County, Taiwan). Methods: We first evaluated 63 patients and identified 4 factors that predicted the success of T2DM remission after bariatric surgery in this cohort: body mass index, C-peptide level, T2DM duration, and patient age. We used these variables to construct the Diabetes Surgery Score, a multidimensional 10-point scale along which greater scores indicate a better chance of T2DM remission. We then validated the index in a prospective collected cohort of 176 patients, using remission of T2DM at 1 year after surgery as the outcome variable. Results: A total of 48 T2DM remissions occurred among the 63 patients and 115 remissions (65.3%) in the validation cohort. Patients with T2DM remission after surgery had a greater Diabetes Surgery Score than those without (8 ± 4 versus 4 ± 4, P < .05). Patients with a greater Diabetes Surgery Score also had a greater rate of success with T2DM remission (from 33% at score 0 to 100% at score 10); A 1-point increase in the Diabetes Surgery Score translated to an absolute 6.7% in the success rate. Conclusion: The Diabetes Surgery Score is a simple multidimensional grading system that can predict the success of T2DM treatment using bariatric surgery among patients with inadequately controlled T2DM. [Copyright &y& Elsevier]

Abstract: Background: Obesity is a risk factor for developing chronic kidney disease (CKD) that may be improved with bariatric surgical weight reduction. The objective of this study was to investigate changes in the glomerular filtration rate (GFR) in severely obese patients 1 year after bariatric surgery. Methods: GFR was measured in 233 severely obese patients before and more than 12 months after bariatric surgery. Patients were separated by baseline GFR: hyperfiltration (GFR>125 mL/min), normal (GFR 125–90 mL/min), CKD stage 2 (GFR 89–60 mL/min), and CKD stage 3 (59–30 mL/min). The groups were reanalyzed 12 months after bariatric surgery. Results: Of the 233 patients, 61 (26.2%) had hyperfiltration, 127 (54.5%) were normal, 39 (16.7%) had CKD stage 2, and 6 (2.6%) had CKD stage 3. The mean GFR was 146.4±17.1 mL/min in the hyperfiltration group, 105.7±9.6 mL/min in the normal group, 76.8±16.7 mL/min in the CKD stage 2 group, and 49.5±6.6 mL/min in the CKD stage 3 group. The mean GFR 1 year after weight loss surgery decreased to 133.9±25.7 mL/min in the hyperfiltration group, increased to 114.2±22.2 mL/min in the normal group, increased to 93.3±20.4 mL/min in the CKD stage 2 group, and increased to 66.8±19.3 mL/min in the CKD stage 3 group. Conclusions: Abnormal renal function was common in severely obese patients. Bariatric surgery-induced weight loss had positive effects on renal function at 1 year after surgery. [Copyright &y& Elsevier]

Summary: Hypertriglyceridemia can induce repeated pancreatitis, which may lead to life-threatening complications that are very difficult to cure. The exact mechanism is unclear, but it is believed to involve increased concentrations of chylomicrons in the blood. We report the case of a man aged 26 years with recurrent pancreatitis related to hypertriglyceridemia. The cause of his hypertriglyceridemia was diagnosed as familial. He had experienced repeated pancreatitis since he was 18 years old, and the attack frequency in the previous 2 years had increased from once per 3 months to once per 1.5 months. He had received diet modification, medication, and even apheresis, but the effects were not satisfactory. He finally underwent laparoscopic mini-gastric bypass surgery as a mode of metabolic surgery on August 1, 2011. His triglyceride level decreased rapidly after the surgery. This result indicates that gastric bypass surgery may be applied not only to bariatric surgery but may also be used as a treatment option for patients with intractable hypertriglyceridemia-related pancreatitis. [Copyright &y& Elsevier]

Summary: Background: Obesity and type II diabetes mellitus (T2DM) are closely related and difficult to control by current medical treatment. Bariatric surgery has been proposed for inadequately controlled T2DM in association with obesity. However, prediction of successful T2DM remission after surgery has not been clearly studied in Asian patients. This information might be helpful for applying gastrointestinal surgery as metabolic surgery for T2DM. Methods: This was a retrospective clinical study. From January 2002 to December 2008, 88 consecutive patients with morbid obesity, who were enrolled into a surgically supervised weight loss program, and who had T2DM before surgery with at least 1 year complete follow-up data were included. Sixty-eight (77.2%) patients received gastric bypass procedures, and the remaining 20 (22.8%) received restrictive procedures. We analyzed the available information during the initial evaluation of patients who were referred for bariatric surgery, by logistic regression analysis and data mining methods for predictors of successful diabetes remission after surgery. Results: Overall, 68 (77.2%) of the 88 patients had remission of their T2DM 1 year after surgery. Patients in the bypass group had a higher remission rate than those in the restrictive group [59/68 (86.7%) vs. 9/20 (45.0%), p =0.000]. In univariate analysis, patients who had T2DM remission after surgery were younger, heavier, had a wider waist, less severe disease, shorter duration, and higher C-peptide levels than those without remission. Type of operation and T2DM duration remained independent predictors of success after multivariate logistical regression analysis (p <0.000). Data mining analysis confirmed that T2DM duration was the most important predictor. Conclusions: Bariatric surgery is a treatment option for T2DM. Duration of diabetes is the most predictor of success after surgery. [ABSTRACT FROM AUTHOR]

Abstract: Background: Single-site or single-incision laparosopic surgery has recently been developed, but it is difficult to use in more complicated gastric bypass surgery. We have introduced a 2-site modified single-incision laparosopic surgery technique for laparoscopic Roux-en-Y gastric bypass (LRYGB). Methods: We used the umbilical site incision to place 2 ports (12 and 10 mm) to serve as the video port and working port for the stapler. Another small skin incision was placed at a left lateral abdominal site for the 5-mm working port. Through these working channels, we could use conventional laparoscopic instruments to perform LRYGB. The data from 100 consecutive 2-site LRYGB procedures (February 2009 to September 2009) were compared with the data from 100 traditional LRYGB procedures (September 2008 to January 2009). Results: The mean body mass index for the study group was 43 kg/m2 (range 32–61), and mean age was 34 years (range 18–55). The procedures were successfully performed in all but 18 patients. These 18 patients had required an extra skin incision for a 5-mm port to complete the procedures. The mean operating time was 144 minutes (range 95–160), and blood loss was 56 mL (range 20–150). A total of 3 perioperative major complications (3%) occurred, and 6 patients (6%) had minor complications. The 2-site LRYGB group had a significantly longer operating time and more blood loss than the traditional LRYGB group but less pain and better cosmesis. Conclusion: Two-site LRYGB generated minimal somatic pain and achieved excellent cosmetic results. We believe it can be applied as routine LRYGB surgery. [Copyright &y& Elsevier]

Abstract: Background: Laparoscopic gastric bypass (GB) is reportedly more effective than laparoscopic sleeve gastrectomy (SG) in the treatment of patients with a low body mass index and type 2 diabetes mellitus. However, the mechanism remains speculative. We compared the postprandial gut hormone patterns between patients undergoing laparoscopic GB and laparoscopic SG at 2 years after surgery in a hospital-based, prospective study. Methods: A total of 16 laparoscopic GB and 16 laparoscopic SG patients were followed up and appraised for glucose homeostasis. Two years after surgery, the mixed meal test and gut hormones were evaluated in 13 laparoscopic GB and 13 laparoscopic SG patients who had been included in the previous randomized trial. Results: The preoperative characteristics, such as body mass index, body weight, waist circumference, and duration of T2DM were comparable between the 2 groups. T2DM remission was achieved in 13 (81%) laparoscopic GB and 3 (19%) laparoscopic SG patients (P < .05) 2 years after surgery. The laparoscopic GB patients had lost more weight and had a smaller waist circumference and lower levels of glucose and hemoglobin A1c, and lower insulin resistance than the SG patients. Significant differences were found in acyl ghrelin, des-acyl ghrelin, cholecystokinin, and resistin between the 2 groups, but none in obestatin, gastric inhibitory peptide, glucagon-like peptide-1, and leptin. Conclusions: Both laparoscopic GB and laparoscopic SG have strong hindgut effects after surgery, but GB has a significant duodenal exclusion effect on cholecystokinin. The laparoscopic SG group had lower acyl ghrelin and des-acyl ghrelin levels but greater concentrations of resistin than the laparoscopic GB group. [Copyright &y& Elsevier]

Abstract: Background: Laparoscopic minigastric bypass (LMGB), a sleeved gastric tube with Billroth II anastomosis, has been proposed as an alternative to laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity. However, the data regarding revision surgery after LMGB during long-term follow-up is not clear. Methods: From January 2001 to December 2009, 1322 patients (996 women and 326 men, mean age 31.6 ± 9.1 years, mean body mass index 40.2 ± 7.4 kg/m2), who were enrolled in a surgically supervised weight loss program and had undergone LMGB were included. All the patients received regular yearly follow-up, and all the clinical data were prospectively collected and stored. The reasons and type of surgery for revision surgery were identified and analyzed. Results: The excess weight loss and mean body mass index at 5 years after LMGB was 72.1% and 27.1 ± 4.6 kg/m2. Of the 1322 patients, 23 (1.7%) had undergone revision surgery during a follow-up of 9 years. The estimated accumulated revision rate of 9 years was 2.69% for LMGB. The most common cause of revision was malnutrition in 9 (39.1%), followed by inadequate weight loss in 8 (34.7%), and intractable bile reflux and dissatisfaction each in 3 (13.0%). The type of revision surgery was LRYGB in 11 (47.8%), sleeve gastrectomy in 10 (43.5%), and conversion to a normal anatomic state in 2 (8.6%). All the revision procedures were performed using a laparoscopic approach, without major complications. Two patients underwent repeat second revision surgery to duodenal switch and biliopancreatic diversion each in 1 patient. All patients had satisfactory results after revision surgery. No patients had undergone revision surgery for internal hernia or ileus during the follow-up period. Conclusion: LMGB resulted in significant and sustained weight loss with an acceptably low revision rate at long-term follow-up. Revision surgery after LMGB can be performed using a laparoscopic approach with a low risk. [Copyright &y& Elsevier]

Background: Sleeve gastrectomy is a new bariatric surgery, and many reports have showed that patients who have undergone sleeve gastrectomy have experienced rapid resolution of type 2 diabetes. The mechanisms accounting for the beneficial effects of sleeve gastrectomy on glucose homeostasis are not well understood and remain speculative. This trial assessed prospectively the effect of sleeve gastrectomy on type 2 diabetes and the serial changes of insulin secretion to oral glucose loads. Methods: Prospective study on the response of insulin secretion to oral glucose loads in 20 severe diabetic patients (body mass index [BMI] >25 and <35, HbA1C >7.5%) before and at 1, 4, 12, 26, and 52 weeks after sleeve gastrectomy. The insulin secretion was measured by insulinogenic index and area under the curve (AUC) during a standard oral glucose tolerance test (OGTT). Remission of type 2 diabetes was defined as fasting glucose level <126 mg/dL and HbA1C <6.5% without any glycemic therapy. Results: Of the 20 patients enrolled, the mean age was 46.3 ± 8.0 years, mean BMI was 31.0 ± 2.9 kg/m2, and mean HbA1C was 10.1 ± 2.2. The mean BMI and excess body weight loss at 1, 4, 12, 26, and 52 weeks after operation were 28.9 (22.1%), 27.4 (43.0%), 25.7 (55.1%), 24.9 (71.9%), and 24.6 (69.1%), respectively. The mean HbA1C at 1, 4, 12, 26, and 52 weeks after operation were 9.2, 8.4, 7.7, 7.3, and 7.1, respectively. Resolution of type 2 diabetes was achieved in 2 (20%) patients at 4 weeks, 6 (30%) at 12 weeks, 8 (40%) at 26 weeks, and 10 (50%) at 52 weeks after sleeve gastrectomy. Before operation, the mean fasting plasma glucose and insulin levels were 240.1 + 80.9 mg/dL and 16.8 ± 15.4 uIU/mL, respectively. The OGTT test showed a blunted insulin secretion pattern with an AUC of 3,135 uIU.min/mL. At 1 week after operation, the fasting plasma glucose and insulin levels significantly decreased to 158 ± 52 mg/dL and 5.6 ± 3.2 uIU/mL, respectively. The AUC decreased to 2,988.7 uIU.min/mL. The AUC at 4, 12, 26, and 52 weeks after operation was 2,211, 1,584, 3,621, and 3,351 uIU.min/mL, respectively. The diabetes resolution rates for those with pre-operative C-peptide <3, 3–6, and >6 ng/mL were 1/7 (14.3%), 7/11 (63.6%), and 2/2 (100%), respectively (P < .05). Conclusion: Laparosopic gastric sleeve gastrectomy resulted in remission of poorly controlled nonmorbidly obese T2DM patients up to 50% at 1 year after operation. The effect is related more to the decreasing of insulin resistance because of calorie restriction and weight loss rather than to the increasing of insulin secretion. C-peptide >3 ng/mL is the most important predictor for a successful treatment. [Copyright &y& Elsevier]

Abstract: Visfatin/pre–B-cell colony-enhancing factor (PBEF)/nicotinamide phosphoribosyltransferase (Nampt) has been proposed as an insulin-mimicking adipocytokine predominantly secreted from visceral adipose tissue (VAT) and correlated with obesity. However, recent evidence challenged this proposal and instead suggested visfatin/PBEF/Nampt as a proinflammatory cytokine. The study aimed to examine whether visfatin/PBEF/Nampt was predominantly expressed in VAT and was correlated with obesity. The relationship of visfatin/PBEF/Nampt gene expression in adipose tissues with proinflammatory gene expression and metabolic phenotypes was also examined. The relative messenger RNA (mRNA) levels of visfatin/PBEF/Nampt, macrophage-specific marker CD68, and proinflammatory genes were measured in paired abdominal VAT and subcutaneous adipose tissues (SAT) and from 53 nondiabetic adults using quantitative real-time polymerase chain reaction. Fasting glucose, insulin, triglyceride, cholesterol, and uric acid levels were measured; and systemic insulin sensitivity was quantified with modified insulin suppression tests. There was no difference in visfatin/PBEF/Nampt mRNA levels between VAT and SAT, and neither was associated with measures of obesity. Visfatin/PBEF/Nampt mRNA levels were strongly correlated with proinflammatory gene expression including CD68 and tumor necrosis factor–α gene in both VAT and SAT. The VAT and SAT visfatin/PBEF/Nampt mRNA expressions were positively correlated with steady-state plasma glucose concentrations measured with modified insulin suppression tests, a direct measurement of systemic insulin resistance (r = 0.42, P = .03 and r = 0.44, P = .03, respectively). The VAT visfatin/PBEF/Nampt mRNA expression was also positively correlated with fasting triglyceride (r = 0.42, P = .002) and total cholesterol levels (r = 0.37, P = .009). Visfatin/PBEF/Nampt is not predominantly secreted from VAT and is not correlated with obesity. Our findings suggest that visfatin/PBEF/Nampt is a proinflammatory marker of adipose tissue associated with systemic insulin resistance and hyperlipidemia. [Copyright &y& Elsevier]

Abstract: Phosphoenolpyruvate carboxykinase (PEPCK) is a key enzyme for glyceroneogenesis in adipose tissues. Dysregulated glyceroneogenesis is associated with abnormal fatty acid homeostasis, obesity, and insulin resistance in both animal and cellular studies. However, the role of PEPCK expression in human adipose tissues on metabolic phenotypes has not been explored. This study aimed to analyze the correlation between PEPCK messenger RNA (mRNA) expressions in the subcutaneous adipose tissues with obesity-related metabolic phenotypes. We obtained the demographic data, biochemical variables, and abdominal subcutaneous adipose tissue from 75 nondiabetic nonmenopausal women. The relative PEPCK mRNA levels were quantified by real-time polymerase chain reaction normalized with β-actin as a control. The PEPCK mRNA levels of subcutaneous tissue were positively correlated with body mass index (BMI) using either univariate (r = 0.413, P < .001) or multivariate linear regression analysis (β = .978 ± .239, P < .001). The mRNA expression of PEPCK was also positively correlated with body fat percentage (r = 0.436, P < .001), plasma triacylglycerol, and total cholesterol levels (both P values < .001). However, the significant correlation between lipid profile and PEPCK expression in subcutaneous tissue was abolished after adjusting for BMI. The relative subcutaneous PEPCK mRNA level was not correlated with fasting plasma glucose and insulin, and with an insulin resistance index measured with homeostasis model assessment. In conclusion, we showed that PEPCK mRNA expression in the subcutaneous adipose tissues was associated with BMI and plasma triacylglycerol and total cholesterol levels, but was not correlated with insulin resistance index. [Copyright &y& Elsevier]