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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/mThe 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 hemoglobin60%) 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.

Small bowel length is drawing attention in the development of gastrointestinal bariatric/metabolic surgery, but the importance of the length of the small bowel in bariatric/metabolic is not clear. The present study was conducted to investigate variations in small bowel length and their clinical significance in patients undergoing laparoscopic sleeve gastrectomy (LSG). Small bowel length was measured in 620 patients diagnosed with obesity who underwent LSG between March 2014 and August 2018. Prospectively obtained demographic and clinical data were investigated, focusing on the association between small bowel length and weight loss. Small bowel length varied widely among patients (mean 739.8 + 115.7 cm, range 380–1050 cm). Linear regression analysis revealed a significant association between small bowel length and body height, body weight, waist circumference, and serum levels of low-density lipoprotein cholesterol, hemoglobin, C-peptide, glycated hemoglobin (A1C), and gamma-glutamyl transferase (r-GT). Multivariate analysis confirmed that body height and serum A1C% levels independently predicted small bowel length in bariatric patients, strongly with body height (p

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.

The YOMEGA study (Y-study) was a randomized trial comparing one anastomosis gastric bypass (OAGB) and Roux-en-Y gastric bypass (RYGB). Here, we aim to compare the Y-study and our pioneer trial from Taiwan (T-study). Data from the Y-study and the T-study were collected and compared. The Y-study recruited 234 patients with a mean body mass index (BMI) of 43.9 and age of 43.5 years. The T-study recruited 80 patients with a similar mean BMI of 44.3 and mean age of 31.4 years. The studies had similar findings including (1) OAGB is easier and possibly safer procedure than RYGB. Both studies showed that OAGB had a shorter operation time than RYGB, but a lower surgical complication rate was only demonstrated in T-study. (2) Both procedures have similar weight loss but OAGB features better glycemic control than RYGB. Weight loss at 2 years after surgery was similar between two procedures, but OAGB reduced HbA1c to a greater degree than RYGB at 2 years in Y-study (− 2.3% vs. − 1.3%; p = 0.025). The resolution of the metabolic syndrome was 100% for both groups in the T-study. (3) OAGB carried a higher risk of malnutrition. OAGB had more malabsorptive problems with a lower hemoglobin level than RYGB at 2 years after surgery. Adverse malnutrition events occurred in nine (7.8%) OAGB patients in the Y-study. Four (3.4%) patients of OAGB received revision surgery in Y-study but none in T-study. (4) Bile reflux was noted in OAGB patients but did not influence quality of life or revision rate. Y-study found that bile in the gastric pouch was present in 16% of patients in the OAGB group versus none in the RYGB, but no inter-group difference in quality of life was detected. There was a trend for RYGB patients to experience more abdominal pain than OAGB. Both studies showed that OAGB is a technically easier procedure and features better glycemic control than RYGB, but has a mal-absorptive effect. However, the bile reflux and abdominal pain controversies persisted.

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 of400 cm. After elongation of the common limb length to400 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 is400 cm. In patients with intractable PD after gastric bypass surgery, revision surgery for elongation of common limb length to400 cm is mandatory to avoid PD-related complications.

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.To report the long-term data of SADJB-SG.Tertiary Teaching Hospital.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/mThe 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 A1C60%) 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.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.

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. Keywords: Bariatric surgery, NAFLD, NASH, Nonalcoholic fatty liver disease, Steatohepatitis

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. Keywords: Type 2 diabetes mellitus, Obesity, Diabesity, Metabolic surgery, Bariatric surgery, Recruitment

Background Bariatric surgery has been shown to improve glycemic control in patients with type 2 diabetes. However, less is known whether it can also reduce diabetic renal, neurological, and ophthalmic complications. Methods This prospective multicenter cohort study compared renal, ophthalmic, and neurological complications between 49 patients with obesity/overweight receiving bariatric surgery and 338 patients receiving standard medical treatment after follow-up for 2 years. Patients received neurological examinations including toe tuning fork vibration test, ankle tendon reflex test, 10-g monofilament test, and ophthalmic examinations including visual acuity measurement and fundus examinations. Multiple regressions, propensity score weighting, and matching were employed to adjust for baseline differences. Results After 2 years of follow-up, patients with type 2 diabetes receiving bariatric surgery had greater reduction in BMI, HbA1c, and urine albumin–creatinine ratio, greater improvement in estimated glomerular filtration rate, and greater increase in tuning fork test score of right and left toes compared with the medical group. However, there is no improvement in 10 g-monofilament test, visual acuity, diabetic non-proliferative retinopathy, and proliferative retinopathy. Similar results were obtained using multiple regression adjustment, propensity-score weighting, or comparing age-, sex-, and BMI-matched subjects. Conclusions After 2-year follow-up, patients with obesity/overweight and type 2 diabetes receiving bariatric surgery have increased glomerular filtration rate, reduced albuminuria, and improved tuning folk vibration sensation.

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.

Ten to 50% of patients who received restrictive bariatric operations may require reoperation for unsatisfactory weight loss or weight regain. Failed restrictive procedures are usually managed with conversion to another bariatric procedure with a favor of conversion to laparoscopic gastric bypass. Our aim is to evaluate two different bypass techniques, laparoscopic RY gastric bypass (RYGB) versus single-anastomosis (mini-) gastric bypass (SAGB) as a revision option (R-RYGB and R-SAGB) for failed restrictive bariatric operations. From May 2001 to December 2015, a total of 116 patients with failed restrictive bariatric operations underwent laparoscopic revisional bypass surgery (81 R-SAGB and 35 R-RYGB). Among them, 81 were failed after vertical banded gastroplasty (VBG) and 35 were after adjustable gastric band (AGB). The demographic data, surgical parameters, and outcomes were studied. The average age at revision surgery was 35.7 years (range 22–56), and the average body mass index (BMI) before reoperation was 37.2 kg/m2 (29.0–51.8). Revision surgery was performed after 58.8 months from the primary surgery on average (14–180 months). The main reasons for the revisions were weight regain (50.9%), inadequate weight loss (31%), and intolerance (18.1%). All of the procedures were completed laparoscopically as one-stage procedure. R-RYGB had significantly longer operative times than R-SAGB. Major complication occurred in 12 (10%) patients without significant difference between R-SAGB group and R-RYGB group. At 1 year follow-up, weight loss was better in R-SAGB than R-RYGB (76.8 vs. 32.9% EWL; p = 0.001). At 5 year follow-up, a significantly lower hemoglobin level was found in R-SAGB group (p = 0.03). Both SAGB and RYGB are acceptable options for revising a restrictive type of bariatric procedures with equal safety profile. R-SAGB was shown to be a simpler procedure with better weight reduction than R-RYGB but anemia is a considerable complication at long-term follow-up.

Bariatric surgery is an effective therapy for morbid obesity but may reduce calcium absorption and significantly decrease the bone mineral density. This study examined the prevalence of secondary hyperparathyroidism (SHPT) in obese subjects during follow-up after different bariatric surgeries. We investigated predictors of SHPT. We enrolled 1470 obese subjects undergoing bariatric/metabolic surgery with at least 1-year follow-up, including 322 patients undergoing Roux-en-Y gastric bypass (RYGB), 695 undergoing single anastomosis (mini-) gastric bypass (SAGB), 93 undergoing laparoscopic adjustable gastric banding (LAGB), and 360 undergoing sleeve gastrectomy (SG). Five years of data were available for 215 patients. Patients were instructed to supplement their diet according to the guideline. Calcium, parathyroid hormone (PTH), and vitamin D levels were measured before surgery and at 1 and 5 years after surgery. SHPT was defined as PTH > 69 pg/mL. The overall prevalence of SHPT was high, 21.0% before surgery and was not different between patients with different bariatric procedures. Pre-operative PTH correlated with age, BMI, and vitamin D levels. Multi-variate analysis confirmed that vitamin D level was the only independent predictor of SHPT before surgery. The prevalence of SHPT increased to 35.4% at 1 year after surgery and 63.3% at 5 years after surgery. SAGB had the highest prevalence of SHPT (50.6%) followed by RYGB (33.2%), LAGB (25.8%), and SG (17.8%) at 1 year after surgery. At 5 years after surgery, SAGB still had the highest prevalence of SHPT (73.6%), followed by RYGB (56.6%), LAGB (38.5%), and SG (41.7%). Serum PTH at 1 year after surgery correlated with decreased BMI and weight loss. Multi-variate analysis confirmed that age, sex, calcium level, and bypass procedure were independent predictor of SHPT after surgery. The prevalence of SHPT is high in morbidly obese patients before bariatric surgery which is related to vitamin D deficiency. The prevalence of SHPT increased continually along with the time after bariatric surgery, especially in patients receiving SAGB, followed by RYGB. The supplementation of vitamin D and calcium have to be higher in bypass procedure, especially in malabsorptive procedure.

The number of people undergoing bariatric surgery is increasing every year, and their expectations for surgery often differ greatly. The purpose of this study was to develop a patient-centered decision-making aid to help people define their weight loss goals and assist them in discussing their surgical treatment with surgeons. Before the operation, the patients were asked to read the shared decision-making text and conduct a self-assessment. After the operation, we evaluated the program using survey questionnaires. A total of 103 patients were formally included in this study. The results show that patients were very satisfied with the use of patient decision aids (PDAs), with a score of 4.3 points (&plusmn, 0.6), and the postoperative decision-making satisfaction was also very high, at 4.4 points (&plusmn, 0.5), while the postoperative regret score was low, at 1.6 points (&plusmn, 0.6). Their satisfaction with surgical decision making and decision regret were statistically significantly negatively correlated (r = &minus, 0.711, p &lt, 0.001). The experience of using PDAs was statistically significantly negatively correlated with decision regret (r = &minus, 0.451, p &lt, 0.001), the experience of PDA use was statistically positively correlated with decision satisfaction (r = 0.522, p &lt, 0.001). Patient decision aids are a means of helping patients make informed choices before they seek to undergo bariatric surgery.

Functional studies of how duodenal–jejunal exclusion (DJE) brings a superior glycemic control when added to sleeve gastrectomy in duodenal–jejunal bypass with sleeve gastrectomy (DJB-SG) patients, are lacking. To study this, we compared the appetite sensations and the β-cell response following a standard mixed meal in patients with DJB-SG, versus those with sleeve gastrectomy (SG) alone. Twenty one patients who underwent DJB-SG and 25 with SG, who participated in mixed-meal tests (MMTT) preoperatively and at 1 year, with complete data were included and compared. Blood glucose, C-peptide, and insulin levels were estimated, along with the visual analogue scale (VAS) scoring of the six appetite sensations, as a part of the MMTT. At 1 year following surgery, compared to SG group, DJB-SG group had greater complete remission rates (HbA1C

Hepatitis C virus (HCV) is an important cause of liver cirrhosis and its complications. The safety and efficacy of bariatric surgery in patients with HCV infection is not clear.Charts were reviewed to identify patients with HCV infection before bariatric surgery. Bariatric surgical patients with non-alcoholic steatohepatitis (NASH) and without NASH (non-NASH) were recruited as comparative groups. Demographic variables, perioperative data, follow-up, and HCV-related parameters were extracted and compared.Forty-seven bariatric patients between 2000 and 2016 that suffered from HCV infection were identified. The mean age and body mass index (BMI) at baseline were 34.5 ± 9.9 years and 40.4 ± 7.7 kg/mCo-existence of HCV infection does not influence the outcome of bariatric surgery but continued monitoring of the liver function is indicated.

Laparoscopic sleeve gastrectomy (LSG) has been validated as a safe and effective treatment for morbid obesity. However, data of the long-term outcome remains lacking. A total of 1759 LSG was performed as primary bariatric procedure from 2005 to 2017 with mean age of 35.2 ± 10.3 years old (14–71), female 69.7%, mean body mass index (BMI) 37.9 ± 7.7 kg/m2, and mean waist width 113.7 ± 17.9 cm. 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 10 years was conducted. The mean operating time, intraoperative blood, and hospital stay of LSG were 121.5 ± 36.5 min, 40.8 ± 69.7 ml, and 2.8 ± 2.7 days, respectively. The 30-day postoperative major complication occurred in 25 (1.4%) patients. The major complication rate was 15% at first year and 0% at the last year. The follow-up rate at 1, 5 and 10 years were 89.3%, 52.1 and 64.4%. At postoperative 1, 5, and 10 years, the mean percentage of total weight loss (%TWL) and excess weight loss (EWL%) of LSG patients were 33.4, 28.3, and 26.6% and 92.2, 80.1, and 70.5%, respectively. The mean BMI became 27, 26.2, and 27.1 kg/m2 at postoperative 1, 5, and 10 years. At follow-up, a total 69 patients needed surgical revision due to reflux disease (n = 45), weight regain (n = 19), persistent diabetes (n = 2), and chronic fistula (n = 3). The type of revision procedures were hiatal repair and gastropexy (n = 29), Roux-en Y gastric bypass (RYGB) (n = 23), and single anastomosis bypass (n = 17) with median time to revision 33 months (range 3–62). At 10 years, the overall revision rate was 21.5% (14/65) and 11(16.9%) of 65 patients were converted to RYGB. The other 54 patients remained at LSG anatomy, but 45% of them required proton pump inhibitor for reflux symptoms. Our results showed that primary LSG is a durable primary bariatric procedure with sustained weight loss and a high resolution of comorbidities at 10 years, but about half the patients had de novo GERD. The need for conversion to RYGB was 16.9% at 10 years.

Laparoscopic gastric bypass is a commonly performed bariatric surgery for the treatment of morbid obesity. Revision surgery for patients who have gastric bypass complications is a challenge for bariatric surgeon. Our aim is to present the early results of the conversions of gastric bypass complications to sleeve gastrectomies. From January 2001 to April 2015, 49 of 2382 gastric bypasses underwent revisional surgery to convert gastric bypasses to sleeve gastrectomies. The demographic data, surgical parameters, and outcomes were studied. The mean age of the study group was 35.0 years (range 20 to 55), and the average body mass index (BMI) prior to the reoperation was 25.3 kg/m2. Seven patients had previous laparoscopic Roux-en-Y gastric bypasses (LRYGBs), and 42 had laparoscopic single anastomosis (mini-) gastric bypasses (LSAGBs). The main reasons for the revisions were malnutrition (58 %), weight regain (10 %), intolerance (18 %), and others (14 %). The revisional surgeries had longer operative times, greater blood loss, and longer flatus passage times than the primary gastric bypass surgeries. Four patients (8.1 %) developed major complications during revisional surgery, including three (6.1 %) cases of leakage and one (2.0 %) case of internal bleeding. No mortality was noted. After conversion to sleeve gastrectomy, the body weights of the patients remained stable, and all patients improved in terms of malnutrition, including anemia, hypoalbuminemia, and secondary hyperparathyroidism. Conversion to sleeve gastrectomy is an effective and safe option for patients with gastric bypass complications. The conversions to sleeve gastrectomy resulted in significant improvements in malnutrition and maintained weight loss at the early follow-ups.

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.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.At 12 months after surgery, 85 of the patients had complete follow-up data. The weight loss was 26.5% and the mean HbA1c 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 (HbA1c6.0%), another 18 (21.2%) who had partial remission (HbA1c6.5%), and 9 (10.6%) who improved (HbA1c7%). 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).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.

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.

Bariatric/metabolic surgery has been proposed for the treatment of inadequately controlled type 2 diabetes mellitus (T2DM) in obese patients. However, prediction on successful long-term remission of T2DM after metabolic surgery has not been clearly studied. Our objectives were to evaluate rates of long-term remission of T2DM after metabolic surgery and determine the independent predictors of remission. Outcomes of 157 patients who underwent metabolic surgery between 2006 and 2009 and who had complete 5-year follow-up data were assessed. Prolonged complete remission was defined as glycated hemoglobin (HbA1c) less than 6 % without diabetes medication up to 5 years. Predictors of prolonged remission studies included patient characteristics such as glucose level, HbA1c, body weight, waist circumference, blood pressure, total cholesterol, LDL, triglyceride, uric acid, AST, alanine transaminase (ALT), albumin, insulin, C-peptide, iron, calcium, complete blood cell count, the ABCD score (a multidimensional grading system composed of age, body mass index (BMI), C-peptide levels, and duration of T2DM), and postoperative weight loss. At 5 years after surgery, the weight loss was 27.1 % and the mean BMI decreased from 39.8 to 28.8 kg/m2. The mean HbA1c decreased from 8.3 to 6.0 %. A significant number of patients had improvement in their glycemic control, including 97 (71.3 %) patients who had complete remission (HbA1c

Emerging evidence has shown that bariatric/metabolic surgery ameliorates type 2 diabetes (T2DM) in mildly obese patients (BMI 35 kg/m(2)) but long-term data is inadequate. We investigated the change of the quality of life after metabolic surgery in not well-controlled T2DM patients with BMI 35 kg/m(2).The quality of life was measured by the gastrointestinal quality of life index (GIQLI), a 36-item questionnaire divided into three domains of general health and one domain of specific gastro-intestinal symptoms, administered before operation, at 3, 6, and 12 months after surgery. A control group matched in age, gender, and BMI was recruited for comparison.A total of 86 patients were enrolled, and the preoperative BMI and HbA1C (mean ± SD) were 30.7 ± 2.8 kg/m(2) and 9.3 ± 2.1 %, respectively. At 1 year after surgery, the BMI and HbA1C were 24.3 ± 2.3 kg/m(2) and 6.2 ± 1.1 %, respectively. There was a significantly improvement in all of the measures of glucose metabolism. Complete remission (HbA1C 6.0 %) was achieved in 56 subjects (65 %) at 12 months. The GIQLI score was significantly impaired in T2DM patients before surgery compared with the control group. The GIQLI score significantly increased from 109.2 ± 20.0 to 116.1 ± 14.2 points 1 year after surgery. The patients had improvement in the three domains of general health (social, physical, and emotional function) without a difference with the normal control but deteriorated in the domain of specific symptoms. Most of the patients experienced symptoms including abdominal pain, bloating, flatulence, belching, abdominal noise, regurgitation, dysphagia, slow eating speed, nausea, bowel urgency, and incontinence after metabolic syndrome.Health-related QOL improved dramatically after metabolic surgery for not well-controlled T2DM patients with BMI 35 kg/m(2), but patients might develop specific gastro-intestinal symptoms after surgery.

Laparoscopic sleeve gastrectomy (LSG) is considered a primary bariatric surgery and is increasingly being performed worldwide; however, long-term data regarding the durability of this procedure are inadequate. Here, we report the long-term results of LSGs in comparison to those of gastric bypass surgeries. A prospectively collected bariatric database from Ming-Shen General Hospital was retrospectively studied. Five hundred nineteen morbidly obese patients (mean age 36.0 ± 9.1 years old (14–71), 74.6 % female, mean body mass index (BMI) 37.5 ± 6.1 kg/m2) underwent LSG as a primary bariatric procedure from 2006 to 2012 at our institute. The operative parameters, weight loss, laboratory data, and quality of life were followed. Another two matched groups of laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic single anastomosis (mini-) gastric bypass (SAGB) patients who were matched in terms of age, sex, and BMI were recruited for comparisons. The mean surgical time for LSG was 113.5 ± 31.3 min, and the mean blood loss was 49.1 + 100.9 ml. The rate of major complications was 1.6 %, and the average length of the postoperative stay was 3.0 ± 1.7 days. The operation times of the RYGB patients were longer than those of both the LSG and SAGB patients. The RYGB and SAGB patients experienced higher major complication rate than the LSG patients. The weight loss of the LSG patient at 5 years was 28.3 + 8.9 %, and the mean BMI was 27.1 + 4.3. The RYGB patients exhibited a 5-year weight loss similar to the LSG patients, and the SAGB patients exhibited greater weight loss than both of the other groups. Both the RYGB and SAGB patients exhibited significantly better glycemic control and lower blood lipids than the LSG patients, but the LSG patients exhibited a lesser micronutrient deficiency than the RYGB and SAGB groups. All three of the groups exhibited improved quality of life at 5 years after surgery, and there was no significant between-group difference in this measure. LSG appears to be an ideal bariatric surgery, and the efficacy of this surgery is not inferior to that of gastric bypass.

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.

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).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.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.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.

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 30%) and 80% of the DS patients had complete remission of their diabetes [hemoglobin A1c (HbA1c)

Gastric bypass surgery has been well accepted as a novel treatment modality for type 2 diabetes mellitus (T2DM) in obese patients. Some scoring systems have been proposed for the selection of T2DM patients who are eligible for gastric bypass surgery. This study compares two scoring systems with regard to remission of T2DM after gastric bypass surgery. This retrospective cohort study included 245 patients (150 females and 95 males) who had undergone gastric bypass surgery for the treatment of T2DM with 1 year follow-up. We examined the predictive power of complete remission of two scoring systems, the DiaRem score, and the ABCD score. The DiaRem score includes the factors of age, HbA1c, medication, and insulin usage. The ABCD score includes the factors of age, BMI, C-peptide level, and duration of T2DM. The rate of remission of T2DM after gastric bypass surgery was evaluated using both scoring systems. At 1 year after surgery, the percent weight loss was 26.5 % and the mean BMI decreased from 35.7 to 26.2 kg/m2. The mean HbA1c decreased from 8.8 to 6.2 %. A significant number of patients showed improvement in glycemic control, including 130 (53.1 %) patients with complete remission (HbA1c

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the gold standard for the treatment of morbid obesity but is technically challenging and results in significant perioperative complications. While laparoscopic mini-gastric bypass (LMGB) has been reported to be a simple and effective treatment for morbid obesity, controversy exists. Long-term follow-up data from a large number of patients comparing LMGB to LRYGB are lacking. Between October 2001 and September 2010, 1,657 patients who received gastric bypass surgery (1,163 for LMGB and 494 for LRYGB) for their morbid obesity were recruited from our comprehensive obesity surgery center. Patients who received revision surgeries were excluded. Minimum follow-up was 1 year (mean 5.6 years, from 1 to 10 years). The operative time, estimated blood loss, length of hospital stay, and operative complications were assessed. Late complication, changes in body weight loss, BMI, quality of life, and comorbidities were determined at follow-up. Changes in quality of life were assessed using the Gastrointestinal Quality of Life Index. There was no difference in preoperative clinical parameters between the two groups. Surgical time was significantly longer for LRYGB (159.2 vs. 115.3 min for LMGB, p

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

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.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.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.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.

BACKGROUND/AIMS: The effectiveness of laparoscopic sleeve gastrectomy (LSG) in measuring the quality of life (QOL) and personality in obese patients has not been previously investigated. This study aims to investigate different clinical outcome variables, the relationships between quality of life and different personality one-year after LSG in obese patients. METHODOLOGY: Sixty-one consecutive obese patients (49 females) who underwent LSG were evaluated for clinical characteristics after weight reduction. Chinese Personality Assessment Inventory and Gastrointestinal Quality-of-Life Index (GIQLI) were analyzed. RESULTS: One year after LSG, mean body weight (BW), mean body mass index (BMI) and excess weight loss (EWL) were 66.5±13.6kg, 24.4±4.4kg/m2 and 88.1±32.5%, respectively. Metabolic syndrome decreased from 45.1% to 9.8%. The significant variables were systolic blood pressure, fasting glucose, triglyceride, uric acid, aspartate aminotransferase, alanine aminotransferase, insulin, high sensitivity C-reactive protein, HbA1c, C-peptide and HOMA. All patients demonstrated improvement in two domains of the questionnaire (physical status and emotion status), but not in gastrointestinal symptoms. Although the 'Agreeableness' dimension of Chinese personality had a lower presenting BMI (23.9kg/m2) and better excess weight loss (88.0%), this group showed less improvement in gastrointestinal symptoms and had poorer physical status. CONCLUSIONS: LSG provided meaningful weight loss and improvement in quality of life. Chinese personality was the predictor of weight loss and GIQLI.

Significant variability in weight loss and glycemic control has been observed in obese patients receiving bariatric surgery. Genetic factors may play a role in the different outcomes. Five hundred and twenty severely obese patients with body mass index (BMI) ≥35 were recruited. Among them, 149 and 371 subjects received laparoscopic adjustable gastric banding (LAGB) and laparoscopic mini-gastric bypass (LMGB), respectively. All individuals were genotyped for five obesity-related single nucleotide polymorphisms on ESR1, FTO, PPARγ, and UCP2 genes to explore how these genes affect weight loss and glycemic control after bariatric surgery at the 6th month. Obese patients with risk genotypes on rs660339-UCP2 had greater decrease in BMI after LAGB compared to patients with non-risk genotypes (−7.5 vs. −6 U, p = 0.02). In contrast, after LMGB, obese patients with risk genotypes on either rs712221-ESR1 or rs9939609-FTO had significant decreases in BMI (risk vs. non-risk genotype, −12.5 vs. −10.0 U on rs712221, p = 0.02 and −12.1 vs. −10.6 U on rs9939609, p = 0.04) and a significant amelioration in HbA1c levels (p = 0.038 for rs712221 and p

Most morbidly obese patients who undergo gastric bypass experience rapid remission of type 2 diabetes mellitus (T2DM) but the response in non-morbidly obese patients is not clear. This trial prospectively assessed the effect of diabetes remission, glucose metabolism, and the serial changes of insulin secretion after gastric bypass in inadequately controlled T2DM patients with a BMI of 23-35 kg/m(2).A total of 62 consecutive patients with T2DM and a BMI of 23-35 kg/m(2) underwent gastric bypass. Data were prospectively collected before surgery and 1, 4, 12, 26, and 52 weeks and 2 years after surgery. 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 level110 mg/dl and HbA1c6.0% without any glycemic therapy.Of the 62 patients, 24 were men and 38 were women (age 43.1 ± 10.8 years). Their preoperative characteristics were as follows: BMI 30.1 ± 3.3 kg/m(2), waist circumference 99.6 ± 9.6 cm, C-peptide 3.1 ± 1.4 ng/ml, and duration of T2DM 5.4 ± 5.1 years. The mean BMI decreased postoperatively to 22.6 ± 2.3 kg/m(2) in 1 year and 23.0 ± 2.7 kg/m(2) in 2 years. The mean HbA1c decreased from 9.7 ± 1.9% to 5.8 ± 0.5% in 1 year and 5.9 ± 0.5% in 2 years. Complete remission of T2DM was achieved in 57% in 1 year and 55% in 2 years after surgery. Before surgery, the OGTT test showed a blunted insulin secretion pattern with an insulinogenic index of 0.1 ± 0.2 and AUC of 2,324 ± 1,015 μIU min/ml. In 1 week after surgery, the insulinogenic index increased to 0.16 and AUC decreased to 1,366 μIU min/ml along with a rapid drop of insulin resistance. The insulinogenic index and AUC gradually increased to 0.27 and 3,220, respectively, 1 year after surgery and remained stable up to 2 years with a very low insulin resistance.Laparoscopic gastric bypass facilitates immediate improvement in the glucose metabolism of inadequately controlled non-severe obese T2DM patients, and the benefit is sustained up to 2 years after surgery. The benefit is regulated by the decrease in insulin resistance, increase in early insulin response, and total insulin secretion to glucose load.

Objective: Obesity surgery is the most effective treatment for morbid obesity and leads to dramatic improvement in related co-morbidities. The aim of this study was to present the long-term results of a prospective trial studying the efficacy of laparoscopic obesity surgery in a group of oriental patients. Method: From April 1998 to March 2009, 2385 patients who underwent obesity surgery in a single bariatric center in Asia were recruited. Various procedures have been adopted so far, including laparoscopic vertical banded gastric partition in 652 patients (27.3%), laparoscopic gastric bypass (LGB) in 1228 patients (51.5%), laparoscopic adjustable gastric banding in 226 patients (9.5%), laparoscopic sleeve gastrectomy in 128 patients (5.4%), gastric balloon in 68 patients (2.8%) and laparoscopic revision surgery in 83 patients (3.5%). We evaluated the clinical data and effect of obesity surgery on different procedures. Results: Overall, the major complication rate and mortality were 1.5% and 0.12%. There was an increase of surgical risk in laparoscopic sleeve gastrectomy and laparoscopic revision surgery patients. The mean total weight loss for the population was 28.1%, 33.9%, 21.3% 18.7% and 17.4% at 1, 3, 5, 7 and 9 years after surgery, respectively. LGB had a better weight loss (30.1%) than that of the restrictive-type procedures (20.9%) at 5 years after surgery. After surgery, most of the obesity-associated co-morbidities were resolved or improved in these patients. Conclusion: Laparoscopic obesity surgery resulted in significant and sustained weight loss in morbidly obese Asian patients with resolution of associated co-morbidities. LGB had a better result in weight reduction than other restrictive procedures.

Obesity is a major risk factor for the development of type 2 diabetes mellitus (T2DM). Surgery is the most effective treatment for morbid obesity, and it has been shown to lead to dramatic improvement in type T2DM. However, data concerning obese Asian patients have not been reported, and the mechanism of improving T2DM after bariatric surgery in this population remains speculative. From April 1997 to March 2006, 1,375 patients undergoing obesity surgery were recruited for our study of the effects of weight loss surgery on type 2 diabetes mellitus (T2DM). Laparoscopic vertical banded gastric partition (LVBG) was performed in 552 patients (40.1%), laparoscopic gastric bypass in 660 patients (48.0%), and laparoscopic adjustable gastric banding (LAGB) in 140 patients (10.2%). Another 23 patients (1.7%) received open or revision surgery. We evaluated the clinical data and effect of obesity surgery on T2DM, impaired fasting glucose (IFG) and compared the changes with those with normal fasting glucose. Among all the patients, 166 (12.1%) had impaired fasting glucose (IFG) and 247 (18.0%) had T2DM. Patients with IFG or DM were significantly older, more central obese, and they had higher insulin resistance and a higher HbA1C level than those with normal fasting glucose. The mean total weight loss for the population was 28.6%, 29.1%, 28.5%, 23.8%, and 24.4% (at 1, 2, 3, 5, and 7 years after surgery). There was no increase of surgical risk in T2DM or IFG patients. One year after operation, fasting plasma glucose returned to normal in 78.5% of T2DM patients and 94.7% of IFG patients. The HbA1C level returned to under 7.0 in 81.5% of T2DM and in 100% of IFG patients. Laparoscopic gastric bypass patients had a greater weight loss and a higher rate of glucose normalization (93.1%) than the LVBG patients (85.3%) and LAGB patients (73.9%), but no difference in HbA1C normalization. Obesity surgery resulted in significant and sustained weight loss with a cure rate of T2DM up to 80% in morbidly obese Asian patients. Gastric bypass surgery had a better result in T2DM cure rate than LVBG and LAGB because of better weight reduction.

Obesity has been widely recognized as a chronic inflammatory condition and associated with elevated inflammatory indicators including C-reactive protein (CRP) and white blood cell count (WBC). Recent studies have shown elevated CRP or WBC is a significant risk factor for cardiac events and stroke but the clinical significance of CRP and WBC has not been clearly studied in morbidly obese patients. This study is aimed at the clinical significance of WBC and CRP in morbidly obese patients and the change after bariatric surgery.The study was a prospectively controlled clinical study. From December 1, 2001 to January 31, 2006, of 640 (442 females and 198 males) consecutive morbid obese patients enrolled in a surgically supervised weight loss program with at least 1 year's follow-up were examined.Of the patients, 476 (74.4%) had elevated CRP and 100 (15.6%) had elevated WBC at preoperative study. CRP and WBC were significantly related and both increased with increasing body mass index (BMI). CRP is also increased with increasing waist, glucose level, hemoglobin, albumin, Ca, insulin, C-peptide, and metabolic syndrome while WBC is increased with metabolic syndrome but decreased with increasing age. Multivariate analysis confirmed fasting glucose level and hemoglobin are independent predictors of the elevation of CRP while age is the only independent predictor for elevated WBC. Both WBC and CRP levels decreased rapidly after obesity surgery. These improvements resulted in a 69.8% reduction of CRP and 26.4% reduction of WBC 1 year after surgery. Although individuals who underwent laparoscopic gastric bypass lost significantly more weight (36.8 +/- 11.7 kg vs. 17.3 +/- 10.8 kg; p = 0.000) and achieved a lower BMI (27.8 +/- 4.6 vs. 35.0 +/- 5.5; p = 0.000) than individuals who underwent laparoscopic gastric banding, there was no difference in the resolution of elevated CRP 1 year after surgery (95.9% vs. 84.5%; p = 0.169) and WBC (99.4% vs. 98.3%; p = 0.323).Both baseline WBC and CRP are elevated in morbid obese patients but CRP has a better clinical significance. Significant weight reduction 1 year after surgery markedly reduced CRP and WBC with a resolution rate of 93.9% and 98.2% separately. Obesity surgery performed by laparoscopic surgery is recommended for obese patients with elevated CRP or WBC.

Nonalcoholic steatohepatitis (NASH) and gallbladder disease (GD) are members of metabolic syndrome in morbidly obesity. Insulin resistance is a risk factor for NASH and GD. The aim of the present study was to investigate the relationship between insulin resistance (HOMA-IR), liver fibrosis, NASH and GD in morbidly obese patients who presented with fatty liver during preoperative abdominal ultrasonography examination.We studied 152 morbid obese patients with fatty liver disease including 54 with NASH, 11 with GD and two with concurrent NASH and GD that were undergoing laparoscopic bariatric surgery. Clinical data (gender, age, body mass index [BMI], and associated diseases), laboratory evaluation, and histopathology were obtained from the patient databases. We analyzed the relationship between clinical characteristics, histological parameters, HOMA-IR, and fibrosis stage associated with NASH and GD in morbid obese patients.Among the 152 patients with fatty liver disease, 93 were females and 59 were males. The mean age was 30.3 +/- 8.9 years and the mean BMI was 44.9 +/- 5.4 kg/m(2). Fifty-four patients (54/152, 35.5%) were diagnosed as NASH and 11 patients (11/152, 7.2%) received concomitant laparoscopic cholecystectomy because of gallbladder disease (GD). Morbidly obese patients with fatty liver disease and GD were significantly older (P = 0.020), had higher serum levels of cholesterol (P = 0.020) and low-density lipoprotein (LDL)-cholesterol (P = 0.044), and had lower serum levels of total bilirubin (P = 0.044), C-peptide (P = 0.023), and insulin (P = 0.039) than the NASH group. Histopathology factors of hepatic steatosis (P = 0.012), ballooning degeneration (P = 0.001), lobular inflammation (P = 0.019), fibrosis (P = 0.026), and glycogenated nuclei (P = 0.028) were significantly different between NASH and GD groups. However, further multivariate analysis failed to demonstrate any independent clinicopathological factor. The prevalence of chronic hepatitis B and NASH was the same (18%) in all 11 GD patients. Besides, when we compared NASH patients (n = 54) with concurrent NASH-GD patients (n = 2), we found that waist (P = 0.016), waist/hip (P = 0.039), and HOMA-IR (P = 0.040) were independent associated factors. We further assessed the HOMA-IR distribution and the relationship between fibrosis stage in patients with NASH and GD. In the NASH group, HOMA-IR distribution progressively decreased when the severity of fibrosis was plotted as a function of insulin resistance.The prevalence of NASH in gallbladder disease was 18% in morbid obese population. We concluded that age, serum cholesterol, and low-density lipoprotein cholesterol levels were risk factors associated with gallbladder disease and fatty liver disease. Insulin resistance was more common in concurrent NASH and gallbladder disease. The mechanism between insulin resistance, fibrosis stage, NASH, and gallbladder disease is unknown.

Obesity is a major risk factor for the development of type 2 diabetes mellitus (T2DM). Insulin resistance (IR) is considered the pathologic link between T2DM and obesity. The mechanism in improving T2DM after bariatric surgery remains speculative. This trial assessed the effect of duodenal jejunal exclusion on the resolution of IR in gastric banding and gastric bypass procedures.660 patients with complete biochemical and clinical data at baseline and at 3 years were selected for analysis. There were 197 males and 463 females. The mean age was 31.5 years (18-64) and mean BMI was 41.4 (32-77). There were 544 patients who received laparoscopic gastric bypass, and 116 patients received laparoscopic gastric banding. IR was measured by homeostatic model assessment (HOMA) index (HI), that can be calculated as HI = plasma glucose (mmol/l) x insulin (UI/ml)/22.5. HI was measured before surgery and 1, 3, 6, 12, 24, and 36 months after surgery.Of the 660 individuals, 517 (78.4%) had IR. The mean HI was 7.62 +/- 13.13. The HI was correlated with BMI, waist circumference, insulin resistance, hyperlipidemia, inflammatory indicators, and abnormal liver enzymes. Before surgery, the HI was 7.92 +/- 14.18 for the bypass group and 6.27 +/- 6.47 for the banding group. After surgery, the HI began to lower in both groups, and this reduction was maintained during follow-up. At 36 months after surgery, mean percentage of excess weight loss (%EWL) was 70.5% for the bypass group and 41.9% for the banding group. The HI was 1.00 +/- 0.79 for bypass and 1.51 +/- 1.25 for banding. The bypass patients had a better and faster weight reduction, but the HI was similar between the two groups at the same weight reduction percentage.IR is common in morbidly obese patients. Both gastric banding and gastric bypass are effective for the reverse of IR in these patients. It seems that the effect is related to the absolute weight loss rather than different surgical procedures. There is no duodenal jejunal exclusion effect on IR resolution was observed in this study.

Non-alcoholic fatty liver disease is prevalent in obese patients. Liver biopsy remains the best diagnostic tool for confirmation. We evaluated the effectiveness of macroscopic parameters of laparoscopy in diagnosis of liver diseases. Moreover, correlations of laparoscopy with histology and laboratory data were also studied.From December 2004 to April 2006, 126 morbidly obese patients submitted to laparoscopic bariatric surgery at the En-Chu-Kong Hospital were prospectively studied.There were correlations of histologic steatosis with liver surface fat spot density, liver margin shape, and liver size. Histologic inflammation was related to liver color, vascularity beneath hepatic capsule, liver margin shape, liver size, and liver surface nodularity. Histologic fibrosis had relations to liver color, liver surface nodularity, liver size, varices of ligamentum teres. Spleen size was related to liver surface nodularity and spleen congestion. Relationships of laboratory data with laparoscopic findings included: aspartate transaminase (AST) level with liver size, alanine transaminase (ALT) level with liver color and liver size, albumin level with liver margin shape and liver surface fibrosis and liver size, total protein level with liver size, alkaline phosphatase (ALP) level with liver surface fibrosis, blood glucose level with liver surface nodularity and spleen size, C-peptide with liver size. Besides, there were relations of gamma-GT level with liver color, liver margin shape, liver and spleen size.Besides histology and laboratory studies, laparoscopic inspection of the abdominal cavity provides important and additional information, which contributed to the final diagnosis of chronic liver diseases and detection of possible pathology in patients.

Background Obesity is a risk factor for gallbladder disease. The authors retrospectively analyse the prevalence and risk factors of gallbladder disease using logistic regression and artificial neural networks among obese patients in Taiwan. Methods Artificial neural networks is a popular technique, which can detect complex patterns within data. They have not been applied to risk of gallbladder disease in obese population. We studied the risk factors associated with gallstones in 117 obese patients who were undergoing bariatric surgery between February 1999 and October 2005. Artificial neural networks, constructed with three-layered back-propagation algorithm, were trained to predict the risk of gallbladder disease. Thirty input variables including clinical data (gender, age, body mass index and associated diseases), laboratory evaluation and histopathologic findings of gallbladder were obtained from the patient records. The result was compared with a logistic regression model developed from the same database. Results Artificial neural networks demonstrated better average classification rate and lower Type II errors than those of logistic regression. The risk factors from both data mining techniques were diastolic blood pressure, inflammatory condition, abnormal glucose metabolism and cholesterolosis. The biological significance of inflammatory condition in obese population requires further investigation. Conclusion Artificial neural networks might be a useful tool to predict the risk factors and prevalence of gallbladder disease and gallstone development in obese patients on the basis of multiple variables related to laboratory and pathological features. The performance of artificial neural networks was better than traditional modeling techniques.

Background: Obesity is a risk factor for gallbladder disease. The authors analyze the prevalence and clinicopathology of gallbladder disease among obese patients in Taiwan. Methods: Prevalence and various clinical factors associated with cholelithiasis were studied in 199 patients who were undergoing bariatric surgery for obesity. Clinical data (gender, age, BMI and associated diseases), laboratory evaluation and immunoglobulin G antibodies against Helicobacter pylori were obtained from the patient records. The histopathologic findings of the gallbladder were also examined retrospectively. The degree of acute inflammation, chronic inflammation, cholesterolosis, cholesterol polyp and gastric metaplasia was determined and scored. Results: Of the patients, 91% (n=181) were females and 9% (n=18) were males, age 34.26 ± 8.41 years, with mean BMI 35.28 ± 6.11 kg/m 2 . The prevalence of cholelithiasis was 10.1%. Increased diastolic blood pressure and HBsAg carrier were the only significant factors associated with cholelithiasis. All obese patients in our study presented with variable degrees of chronic mononuclear cell infiltration in the gallbladder mucosa. Cholesterolosis was present in 100 patients (50.3%), followed by gastric metaplasia (27.1%), cholesterol polyp (16.1%) and acute inflammation (9.5%). Multivariate analysis showed an association between cholelithiasis and acute and chronic inflammation. The predictors of cholesterolosis were BMI, waist circumference and high-sensitivity C-reactive protein. The seroprevalence of H. pylori was 42.2%. Older age, abnormal liver function tests, calcium and HBsAg carrier were significantly different between H. pylori-seropositive and H. pylori-seronegative obese patients. However, we could rarely find H. pylori within the gallbladder mucosa. Conclusion: Cholelithiasis in Asian obese patients is significantly associated with increased diastolic blood pressure and hepatitis B surface antigen carriers. Because chronic liver disease seems to be a risk factor for cholelithiasis in both non-obese and obese populations, prophylactic cholecystectomy can be considered in obese patients with HBsAg positivity. We did not find evidence that H. pylori has a role in the pathogenesis of gallbladder disease and gallstone by histologic and serologic examinations. Furthermore, mucosal abnormalities of acute and chronic inflammatory cell infiltration are common in obese patients, which related to cholelithiasis.

Metabolic surgery is a novel therapy for mild obesity (BMI 30-35 Kg/m(2)) in type 2 diabetes mellitus (T2DM) patients. The ABCD score, which comprise age, BMI, C-peptide level, and duration of T2DM (years), was reported as useful in predicting the success of T2DM treatment using metabolic surgery. This study examines gastric bypass and sleeve gastrectomy as a salvage treatment for non-obese (BMI 30 kg/m(2)) T2DM patients and evaluates the role of ABCD scores.From January 2007 to July 2013, 512 (71.2%) of 711 T2DM patients enrolled in a metabolic surgical program had at least 1-year follow-up were recruited. Clinical data and outcomes of 80 (15.6%) patients with BMI 30 Kg/m(2) were compared with those of the other 432 (84.4%) patients with BMI ≥ 30 Kg/m(2). Complete remission was defined as HbA1c ≤ 6%, and partial remission was defined as HbA1c 6.5%. A binary logistic regression was used to identify predictors of T2DM remission.Mean age of the 80 non-obese T2DM patients was 47.7 ± 9.1 years, and mean HbA1c and disease duration were 9.1 ± 1.8% and 6.5 ± 5.1 years, respectively. Mean total body weight loss was 17.1 ± 7.4% at 1 year, and mean BMI decreased from 26.9 ± 2.2 to 22.7 ± 2.5 kg/m(2) at 1 year. Complete remission of T2DM was achieved in 25.0% of patients, and partial remission was achieved in 23.8%. The complete remission rate was significantly lower than the 49.5% found in patients with BMI 30-35 and 79.0% of patients with BMI 35 Kg/m(2). In univariate analysis, non-obese patients who had T2DM remission after surgery were heavier and had a wider waist, higher C-peptide levels, shorter disease duration, more weight loss, and higher ABCD score than those without remission. The ABCD score remained the only independent predictor of success after multivariate logistical regression analyses (P = 0.003).Metabolic surgery may be useful in achieving glycemic control of selected non-obese T2DM patients. The ABCD score is a simple multidimensional grading system that can predict the success of T2DM treatment.

Background: Helicobacter pylori is a major pathogen of stomach. Ghrelin is secreted from the stomach, and it plays a role in the coordination of eating behavior, and facilitates fat storage and weight regulation. The effects of H. pylori infection on gastric ghrelin production are still not well known. Recent exciting studies linked H. pylori infection to ghrelin, then to obesity. The aim of the present study is to investigate gastric ghrelin immunoreactivity associated with H. pylori infection, chronic gastritis and the clinical correlation in obese patients. Methods: The histologic findings of stomach were examined in 156 patients who were undergoing laparoscopic vertical-banded gastroplasty for obesity. Ghrelin immunoreactivity was evaluated immunohistochemically with an anti-ghrelin antibody, and the density of ghrelin-positive cells determined per total glands of the gastric mucosa. Relationship between density of ghrelin-positive cells, histopathology of chronic gastritis scored by the Sydney system and clinical correlation was analyzed. Results: H. pylori was present in 62 (39.7%) out of 156 patients. The density of ghrelin-positive cells was significantly lower for H. pylori-infected patients. There was a significant stepwise decrease in density of ghrelin-positive cells, with progression of histological severity of chronic inflammation, neutrophil activity and glandular atrophy in the corpus. Obese patients positive for H. pylori were associated with older age and abnormal plasma triglyceride level, but not with sex, body mass index, liver function tests or glucose level. There was no relationship between density of gastric ghrelin-positive cells and body mass index. Conclusion: H. pylori infection has a negative impact on density of gastric ghrelin-positive cells in obese patients. Impaired density of gastric ghrelinpositive cells is associated with neutrophil activity, chronic inflammation and glandular atrophy induced by H. pylori infection. The potential role of H. pylori infection and density of gastric ghrelin-positive cells on the development of obesity and their biological significance warrants further investigation.

Background: The laparoscopic mini-gastric bypass (MGB) is a modification of Mason's loop gastric bypass, but with a long lesser curvature tube. With weight loss results similar to laparoscopic Roux-en-Y gastric bypass (LRYGBP), the MGB is a simpler operation with a low complication rate. Controversy exists concerning the efficacy and side-effects of this procedure. This report presents the technique of laparoscopic MGB and its results in 423 patients. Methods: From October 2001 to October 2004, 423 consecutive patients (87 males and 336 females) underwent laparoscopic MGB (LMGB) for morbid obesity. Mean age was 30.8 years, preoperative mean weight 120.3 kg and mean BMI 44.2 kg/m2. Results: All procedures were completed laparoscopically. Mean operative time was 130.8 minutes, and mean hospital stay was 5.0 days. 18 minor early complications (4.3%) were encountered, and 7 major complications (1.7%) occurred. Marginal ulcers were noted in 34 patients (8.0%) during follow-up, and anemia was found in 41 patients (9.7%). Mean BMI decreased to 29.2 and 28.4 kg/m2 at 1-year and 2-year follow-up, with mean excess weight loss 69.3% and 72.2%. The Gastrointestinal Quality of Life Index improved significantly 1 year after the operation. Conclusions: LMGB has a low complication and mortality rate. The learning curve is less steep than for LRYGBP, whereas the efficacy is similar.