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Background Limited studies have focused on diabetes relapse after metabolic surgery, especially among Asians. Objectives To identify the predictors of diabetes relapse following initial postoperative remission in Asia. Setting Four tertiary hospitals Methods We assessed 342 patients (age, 41.0±10.8 years; 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. Results 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 0.814, 0.793, and 0.795, while those of the DiaRem2 score were 0.823, 0.774, and 0.701, 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: 0.919). Conclusions 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.

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/mRoutine 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.

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.

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 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 P 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.

laifi@ Obesity is becoming an epidemic health problem and has been identified as an independent risk factor for the development of gastroesophageal reflux disease and Barrett's esophagus, which increases the incidence of esophageal cancer (EsC) [1]. Routine esophagogastroduodenoscopy (EGD) before bariatric/metabolic surgery has a high diagnostic yield and it can alter or delay the surgical management in 4.9– 9.4% of cases [2,3]. We report a case of early EsC in an obese diabetic patient treated with laparoscopic Roux-en-Y gastric bypass (LRYGB).

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.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.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/m2 (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/m2 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 groupsBy combining LAGB with gastric plication, LAGB-P can augment the weight loss of LAGB and is similar to LSG but may increase risk.

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.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.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.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.

Familial lipoprotein lipase deficiency (LPLD) is an autosomal recessive disorder characterized by severely elevated serum triglyceride (TG) levels with an associated risk of recurrent pancreatitis. The prevalence is approximately 1–2 in 1,000,000 [1]. LPLD usually presents in childhood with severe hypertriglyceridemia (HTG) and associated episodes of abdominal pain, recurrent pancreatitis, eruptive cutaneous xanthomata, and hepatosplenomegaly [1]. Metabolic surgery, defined as surgery resulting in anatomic and functional changes with the goal of treating metabolic disorders [2], has been proposed as an effective treatment for severe HTG. Gastric bypass, as a bariatric surgery, has been shown to be highly effective for reducing plasma lipid levels in patients with hyperlipidemia [3,4]. Therefore, gastric bypass should be a viable treatment option for recurrent pancreatitis secondary to LPLDinduced HTG. To the best of the authors’ knowledge, this is the first report of a patient with LPLD undergoing laparoscopic mini-gastric bypass (LMGB) as a metabolic surgery for the treatment of intractable HTG-related pancreatitis.

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/m 2 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.

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/m 2 (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.

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/m 2 ), 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/m 2 . 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.