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Primary bariatric surgery has been proven to be effective in weight loss and improvement of weight-related metabolic co-morbidities. However, a small proportion of patients after bariatric surgery either have persistent hyperglycemia or relapse after initial remission of their metabolic disease. Revisional bariatric surgery has been evaluated extensively for weight recidivism and postoperative complications. However, there has not been any high-level evidence validating the utility of revisional bariatric surgery on recurrent metabolic diseases, especially diabetes. In this review of 30 studies, we aimed to summarize the evidence and determine whether revisional surgery can have a positive impact on metabolic diseases that were not reversed by initial bariatric intervention. Overall, 14-38% of patients had residual diabetes at the time of revisional surgery. Depending on the index surgery and subsequent reconstruction, revisions induced 20-80% additional excess weight loss, or further decrease of body mass index by 10-30%. Improvement of diabetes was seen in 65-100% of patients. Specifically, conversion to Roux-en-Y gastric bypass (RYGB) yielded improvement of diabetes in 79%, 72%, and 62% of patients who previously had vertical banded gastroplasty (VBG), adjustable gastric banding (AGB), or sleeve gastrectomy (SG), respectively. Converting AGB to SG improved diabetes in 65% of patients, and SG to duodenal switch improved diabetes in 79% of patients. Revision of the gastric pouch or stoma in RYGB yielded improvement of diabetes in 79% of patients. Further clinical and mechanistic research is needed to better delineate the role of revisional bariatric surgery in patients with residual metabolic disease.

Super-obese patients can achieve adequate weight loss with long limb Roux-en-Y gastric bypass (RYGB). These patients, however, might need longer intestinal limbs to control co-morbidities such as type 2 diabetes, lipid disorders, hypertension, sleep apnea, and gastroesophageal reflux disorder.A total of 105 patients with a body mass index ofor =50 kg/m(2) were randomly divided into 2 similar groups regarding sex, age, and number of co-morbidities. All underwent laparoscopic Roux-en-Y gastric bypass. In group 1, the length of the biliary limb was 50 cm and the length of the Roux limb was 150 cm. In group 2, the length of the biliary limb was 100 cm and the length of the Roux limb was 250 cm.The follow-up for both group was 48 months. Diabetes was controlled in 58% of group 1 and in 93% of group 2 (P0.05). Lipid disorders improved in 57% of group 1 and in 70% of group 2 (P0.05). No statistical difference was found in the control or improvement of hypertension, sleep apnea, or gastroesophageal reflux disorder. The excess weight loss was faster in group 1 but was similar in both groups at 48 months (70% in group 1 and 74% in group 2), with no statistical difference.Patients with longer biliary and Roux limbs achieved greater type 2 diabetes control, greater lipid disorder improvement, and showed a trend toward faster excess weight loss.

Type 2 diabetes mellitus (T2 DM) is characterized by a decline in insulin secretion and increased hepatic and peripheral insulin resistance, resulting in poor glycemic control and several long-term complications [1]. C-peptide fulfills an important function in the synthesis of insulin. After cleavage of proinsulin in pancreatic β-cells, the 31-aminoacid protein C-peptide is secreted into the portal circulation in equimolar concentrations with insulin. C-peptide has been used as a surrogate marker for β-cell function in patients with type 1 and 2 diabetes mellitus [2]. Indeed, recent studies aimed at the development of new T2 DM treatment modalities have monitored the levels of C-peptide and other markers [3] with the goal of identifying severe β-cell dysfunction. In addition, fasting C-peptide levels have been used as a criterion for determining inclusion or exclusion in several T2 DM treatment protocols [4–6]. Several clinical trials have arbitrarily adopted a C-peptide level of 1 ng/dL as the threshold for protocol inclusion [6–9]. Levels below this threshold were predicted to lead to poor outcomes in patients selected for surgical treatment. In clinical practice, fasting C-peptide levels have been used as a marker of β-cell function before bariatric/metabolic procedures in T2 DM patients, and also as a prognostic factor for predicting success after metabolic surgery. Higher levels of C-peptide have been shown to indicate better outcomes, leading to the suggestion that the selection of surgical technique should be based on fasting C-peptide levels [8,10]. Unlike latent autoimmune diabetes of adulthood, in which the diabetes results from a cellular-mediated autoimmune