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metabolic surgery: ADSS data
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Speech Abstracts / Diabetes Research and Clinical Practice 120S1 (2016) S1–S39
exercise, and leisure time physical activity among diabetic patients are still a difficult task, especially for optimal blood pressure, glucose and lipid level control. Evidence from clinical trial data, such as Steno-2 and Diabetes Complication Study, showed behavioral intervention as important tools for further cardiovascular risk prevention. Novel modalities, such as information technology and behavioral economics approaches, provide a new way for diabetes care through behavioral and lifestyle intervention. In addition, the approach through dietary modification of gut microbiota as a key organ involved in metabolism is considered a new way to control diabetes. In summary, Primary and secondary prevention of diabetes is still a big challenge; however, innovative modalities through evidence-based lifestyle and behavioral intervention programs will provide insightful strategy for diabetes control.
Update of Bariatric/Metabolic Surgery S02-1 Current status of bariatric/metabolic surgery: ADSS data Wei-Jei LEE1,2. 1Department of Surgery, Min-Sheng General Hospital, Taoyuan, 2Department of Surgery, National Taiwan University, Taipei, Taiwan Obesity and associated type 2 diabetes mellitus (T2DM) is becoming a serious medical issue worldwide. Bariatric surgery has been shown to be the most effective and durable therapy for the treatment of morbid obese patients. The advent of bariatric surgery to treat T2DM morbidly obese patients offers a new paradigm in T2DM therapy. Bariatric surgery has been shown to confer long-term weight loss and glycemic control in obese diabetics. “Metabolic surgery” has been proposed as a treatment for T2DM in view of the relatively high remission rates with bariatric surgery (range 36–93%) compared to medical therapy alone. Increasing data indicates bariatric surgery, played as metabolic surgery, is an effective and novel therapy for not well controlled obese T2DM patients. Because Asian people had a higher incidence of T2DM and tend to have an earlier onset T2DM than Caucasian, Asian surgeons had more experience in using metabolic surgery to treat T2DM in low BMI patients. Subjects are recruited as part of a multi-institutional ADSS group consisting of 11 centers in 6 countries, including Hong Kong, India, Japan, Korea, Singapore and Taiwan. There were a total of 4,380 subjects registered in this study between September 1997 and December 2015. This report was performed to examine the recent advancement of metabolic surgery in Asia can be classified into 4 major fields. (1) Improvement of safety: Recent advancement in laparoscopic surgery has made this minimal invasive surgery more than ten times safe than a decade ago. The safety profile of laparoscopic bariatric/metabolic surgery is compatible with laparoscopic cholecystectomy now. (2) New metabolic surgery: Laparoscopic sleeve gastrectomy (LSG) is becoming the leading bariatric surgery because of its simplexes and efficacy. Other new procedures, such as single anastomosis (mini) gastric bypass and Duodeno-jejunal bypass with sleeve gastrectomy have all been accepted as treatment modalities for the bariatric/metabolic surgery. (3) Mechanism of metabolic surgery: Restriction is the most important mechanism for bariatric surgery. Weight regain after bariatric surgery is usually associated with loss of restriction. Recent studies demonstrated that gut hormone, microbiota and bile acid change after bariatric surgery may play an important role in durable weight loss as well as in T2DM remission. However, weight loss is still the cornerstone of T2DM remission after metabolic surgery. (4) Patients selection: Patients who may benefit most from bariatric surgery was found to be patients with insulin resistance. For T2DM
treatment, the indication has been set to not well controlled (HbA1c >7.5%) with their BMI >27.5 Kg/m2 in Asian. A novel diabetes surgical score, ABCD score, is a simple system for predicting the success of surgical therapy for T2DM. S02-4 Management of residual diabetes and micronutrient deficiencies after bariatric surgery Keong CHONG1. 1Department of Internal Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan Bariatric surgery is regarded as “metabolic surgery” and “diabetic surgery” because of its noticeable effects on metabolic syndrome and type 2 diabetes. Although many studies show the effectiveness of bariatric surgery to treat diabetes, recent studies document that a growing number of patients with type 2 diabetes do not achieve “remission” of diabetes or are unable to sustain this effect long-term despite initial success with weight loss after bariatric surgery. Some possible factors associated with diabetes non-remission or re-emergence were noted, such as older age, lower preoperative BMI, longer diabetes duration, insulin use, inadequate weight loss and weight regain, surgery type and severity of preoperative beta-cell dysfunction. Currently, no clinical practice guideline is established for the patients with “residual” diabetes after bariatric surgery. According to the recommendation of ADA, metformin remains the first line agent for T2DM in that it improved insulin sensitivity. Thus the use of metformin for glycemic control after bariatric surgery is reasonable due to low risk of hypoglycemia and neutral/loss for weight gain. A report demonstrated accelerated absorption and bioavailability of metformin following gastric bypass and indicated that a reduce dose of metformin may be required for achieving glycemic control. In contrast, use of thiazolidinediones may hamper weight loss efforts despite increasing insulin sensitization and low risk of hypoglycemia. Sulfonylurea drugs should generally be avoided in the immediate postoperative period when insulin secretion may enhance and increase the risk of hypoglycemia. However, in patients with residual diabetes after bariatric surgery, who cannot achieve the treatment goal by use of metformin, the addition of sulfonylurea to metformin may restore glycemia control by targeting pancreatic beta-cell failure. Incretin analogue (i.e. DPP4 inhibitors and GLP-1 analogues) enhance glucose dependent insulin secretion and offer advantages for weight loss in obese type 2 diabetic patients but evidence for their use in bariatric surgery is lacking. For the favorable effects of SGLT2 inhibitors on glycemic control, weight loss and blood pressure, SGLT2 inhibitors maybe an attractive anti-diabetic agent to treat residual diabetes. However, the use of these drugs increases the risk of genital mycotic infection and dehydration. For those patients with residual diabetes, who cannot achieve the treatment goal by oral anti-diabetic agents and/or GLP-1 analogues, insulin therapy is indicated. Besides, all diabetic patients underwent bariatric surgery should keep a lifelong lifestyle modification. Deficiencies in micronutrients, which include trace elements, essential minerals, and water-soluble and fat-soluble vitamins, are common before bariatric surgery and often persist postoperatively, despite universal recommendations on multivitamin and mineral supplements. Recognition of the clinical presentations of micronutrient deficiencies is important, both to enable early intervention and to minimize longterm adverse effects. Anemia without evidence of blood loss warrants evaluation of nutritional deficiencies as well as age appropriate causes during the late postoperative period. Iron status should be monitored in all bariatric surgery patients. Treatment regimens include oral ferrous sulfate, fumarate, or gluconate to
Speech Abstracts / Diabetes Research and Clinical Practice 120S1 (2016) S1–S39
exercise, and leisure time physical activity among diabetic patients are still a difficult task, especially for optimal blood pressure, glucose and lipid level control. Evidence from clinical trial data, such as Steno-2 and Diabetes Complication Study, showed behavioral intervention as important tools for further cardiovascular risk prevention. Novel modalities, such as information technology and behavioral economics approaches, provide a new way for diabetes care through behavioral and lifestyle intervention. In addition, the approach through dietary modification of gut microbiota as a key organ involved in metabolism is considered a new way to control diabetes. In summary, Primary and secondary prevention of diabetes is still a big challenge; however, innovative modalities through evidence-based lifestyle and behavioral intervention programs will provide insightful strategy for diabetes control.
Update of Bariatric/Metabolic Surgery S02-1 Current status of bariatric/metabolic surgery: ADSS data Wei-Jei LEE1,2. 1Department of Surgery, Min-Sheng General Hospital, Taoyuan, 2Department of Surgery, National Taiwan University, Taipei, Taiwan Obesity and associated type 2 diabetes mellitus (T2DM) is becoming a serious medical issue worldwide. Bariatric surgery has been shown to be the most effective and durable therapy for the treatment of morbid obese patients. The advent of bariatric surgery to treat T2DM morbidly obese patients offers a new paradigm in T2DM therapy. Bariatric surgery has been shown to confer long-term weight loss and glycemic control in obese diabetics. “Metabolic surgery” has been proposed as a treatment for T2DM in view of the relatively high remission rates with bariatric surgery (range 36–93%) compared to medical therapy alone. Increasing data indicates bariatric surgery, played as metabolic surgery, is an effective and novel therapy for not well controlled obese T2DM patients. Because Asian people had a higher incidence of T2DM and tend to have an earlier onset T2DM than Caucasian, Asian surgeons had more experience in using metabolic surgery to treat T2DM in low BMI patients. Subjects are recruited as part of a multi-institutional ADSS group consisting of 11 centers in 6 countries, including Hong Kong, India, Japan, Korea, Singapore and Taiwan. There were a total of 4,380 subjects registered in this study between September 1997 and December 2015. This report was performed to examine the recent advancement of metabolic surgery in Asia can be classified into 4 major fields. (1) Improvement of safety: Recent advancement in laparoscopic surgery has made this minimal invasive surgery more than ten times safe than a decade ago. The safety profile of laparoscopic bariatric/metabolic surgery is compatible with laparoscopic cholecystectomy now. (2) New metabolic surgery: Laparoscopic sleeve gastrectomy (LSG) is becoming the leading bariatric surgery because of its simplexes and efficacy. Other new procedures, such as single anastomosis (mini) gastric bypass and Duodeno-jejunal bypass with sleeve gastrectomy have all been accepted as treatment modalities for the bariatric/metabolic surgery. (3) Mechanism of metabolic surgery: Restriction is the most important mechanism for bariatric surgery. Weight regain after bariatric surgery is usually associated with loss of restriction. Recent studies demonstrated that gut hormone, microbiota and bile acid change after bariatric surgery may play an important role in durable weight loss as well as in T2DM remission. However, weight loss is still the cornerstone of T2DM remission after metabolic surgery. (4) Patients selection: Patients who may benefit most from bariatric surgery was found to be patients with insulin resistance. For T2DM
treatment, the indication has been set to not well controlled (HbA1c >7.5%) with their BMI >27.5 Kg/m2 in Asian. A novel diabetes surgical score, ABCD score, is a simple system for predicting the success of surgical therapy for T2DM. S02-4 Management of residual diabetes and micronutrient deficiencies after bariatric surgery Keong CHONG1. 1Department of Internal Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan Bariatric surgery is regarded as “metabolic surgery” and “diabetic surgery” because of its noticeable effects on metabolic syndrome and type 2 diabetes. Although many studies show the effectiveness of bariatric surgery to treat diabetes, recent studies document that a growing number of patients with type 2 diabetes do not achieve “remission” of diabetes or are unable to sustain this effect long-term despite initial success with weight loss after bariatric surgery. Some possible factors associated with diabetes non-remission or re-emergence were noted, such as older age, lower preoperative BMI, longer diabetes duration, insulin use, inadequate weight loss and weight regain, surgery type and severity of preoperative beta-cell dysfunction. Currently, no clinical practice guideline is established for the patients with “residual” diabetes after bariatric surgery. According to the recommendation of ADA, metformin remains the first line agent for T2DM in that it improved insulin sensitivity. Thus the use of metformin for glycemic control after bariatric surgery is reasonable due to low risk of hypoglycemia and neutral/loss for weight gain. A report demonstrated accelerated absorption and bioavailability of metformin following gastric bypass and indicated that a reduce dose of metformin may be required for achieving glycemic control. In contrast, use of thiazolidinediones may hamper weight loss efforts despite increasing insulin sensitization and low risk of hypoglycemia. Sulfonylurea drugs should generally be avoided in the immediate postoperative period when insulin secretion may enhance and increase the risk of hypoglycemia. However, in patients with residual diabetes after bariatric surgery, who cannot achieve the treatment goal by use of metformin, the addition of sulfonylurea to metformin may restore glycemia control by targeting pancreatic beta-cell failure. Incretin analogue (i.e. DPP4 inhibitors and GLP-1 analogues) enhance glucose dependent insulin secretion and offer advantages for weight loss in obese type 2 diabetic patients but evidence for their use in bariatric surgery is lacking. For the favorable effects of SGLT2 inhibitors on glycemic control, weight loss and blood pressure, SGLT2 inhibitors maybe an attractive anti-diabetic agent to treat residual diabetes. However, the use of these drugs increases the risk of genital mycotic infection and dehydration. For those patients with residual diabetes, who cannot achieve the treatment goal by oral anti-diabetic agents and/or GLP-1 analogues, insulin therapy is indicated. Besides, all diabetic patients underwent bariatric surgery should keep a lifelong lifestyle modification. Deficiencies in micronutrients, which include trace elements, essential minerals, and water-soluble and fat-soluble vitamins, are common before bariatric surgery and often persist postoperatively, despite universal recommendations on multivitamin and mineral supplements. Recognition of the clinical presentations of micronutrient deficiencies is important, both to enable early intervention and to minimize longterm adverse effects. Anemia without evidence of blood loss warrants evaluation of nutritional deficiencies as well as age appropriate causes during the late postoperative period. Iron status should be monitored in all bariatric surgery patients. Treatment regimens include oral ferrous sulfate, fumarate, or gluconate to