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Mini bypass

MGB results encouraging, more evidence needed

Surgery resulted in a significant and consistent reduction in BMI, glycaemia and HbA1c values
The prevalence of diabetes remission was evident in both groups and increased overtime, regardless of the type

Despite “encouraging” results regarding the effectiveness of mini-gastric bypass on diabetes remission, additional studies are needed to provide definitive conclusions in selecting the ideal procedure for diabetes remission before the procedure can be seen as a valuable alternative to the Roux-en-y gastric bypass, according to a study published in the World Journal of Gastroenterology.

The aim of the study was to investigate the weight loss and glycaemic control status (blood glucose, haemoglobin A1c (HbA1c) and hypoglycaemic treatment), following sleeve gastrectomy (SG) or mini-gastric bypass.

Data from  patients referred during a three-year period (from January 2009 to December 2011) to the University of Naples “Federico II” diagnosed with obesity and diabetes were retrieved from a prospective database.

A total of 53 subjects who underwent sleeve gastrectomy or mini-gastric bypass for obesity and diabetes were screened for the inclusion in this study. Of these, four subjects were excluded because of surgical complications, seven subjects were omitted because young surgeons conducted the operations and 11 subjects were removed because of the lack of follow-up.

Thus, a total of 31 obese patients (15 males and 16 females; mean age: 38.32 ± 3.21 years; BMI: 44.78±4.25) were recruited for this study. All patients were diagnosed with type 2 diabetes [15 (48.4%) on metformin and 16 (51.6%) on metformin + insulin], 18 subjects (58.1%) reported hypertension and eight presented with hypercholesterolemia.

The mean glycaemia value was 169.87±35.76, and the mean HbA1c level was 8.5±1.0. A total of 15 subjects underwent SG (48.4%), and 16 patients underwent MGB (51.6%).

The authors report that following surgical intervention, “a significant and consistent reduction in BMI, glycaemia and HbA1c values were observed relative to the baseline values” (Figure1).

Figure1: Changes in BMI (A), glycaemia (B), and haemoglobin A1c (C) values following surgery.

With regards to surgery type, sleeve gastrectomy and mini-gastric were both associated with similar percent changes in BMI (-24.33 ± 4.48 vs. -24.19±4.42, p=0.931), glycaemia (-24.30 ± 11.40 vs. -28.42 ± 14.03, p=0.379) and HbA1c (-22.57±8.70 vs. -22.67±8.46, p=0.975).

However, significant correlations were not detected in the percent change from baseline to 12-mo follow-up between BMI and glycaemia, as well as between BMI and HbA1c (Figure2).

Figure 2: Scatter plot of Pearson’s correlations between the percent in glycaemia and BMI (A) and haemoglobin A1c and BMI (B).

The results were confirmed based on the type of surgery and the percent change in BMI did not correlate with changes in glycaemia (r=-0.119, p=0.673 for sleeve and r=0.462, p= 0.071 for mini bypass) or with changes in HbA1c (r=-0.349, p=0.202 for sleeve and r=-0.018, p=0.946 for mini bypass).

The prevalence of diabetes remission was evident in both groups and increased overtime, regardless of the type (Figure 3). At three months post-surgical intervention, diabetes remission was reported by 18 subjects (53.3% sleeve vs. 62.5% mini bypass, p=0.722). The results were confirmed at six-months (53.3% sleeve vs. 68.8% bypass p=0.473) and 12-months (66.7% sleeve vs. 87.5% mini bypass, p=0.220).

Figure 3: Prevalence of subjects achieving diabetes remission in the sleeve gastrectomy group and mini bypass group.

The percent change in BMI was similar between patients achieving diabetes remission and patients who did not (-24.28 ± 4.33 vs. -24.15 ± 4.53, respectively, p=0.97).

However, after adjusting for various clinical and demographic characteristics in a multivariate logistic regression analysis, a high HbA1c was considered a negative predictor of diabetes remission at 12 months (OR=0.366, 95%CI: 0.152-0.884). Using the same regression model, mini bypass showed a clear trend towards a higher diabetes remission rate relative to SG (OR=3.780, 95%CI: 0.961-14.872).

“Although we observed a clear trend in our study, this did not achieve statistical significance,” the authors note. “A multivariate analysis was performed to adjust for major clinical and demographic variables, but because of the relatively small sample size, our results need to be validated in larger studies. Thus, the present work could be considered a preliminary study, providing the rationale for a randomised prospective trial.”

The study authors noted that the exclusion of the duodenum could suggest the potential superiority of mini-gastric bypass over sleeve gastrectomy to obtain diabetes remission and that this mechanism could suggest the potential superiority of mini-gastric bypass over sleeve gastrectomy to obtain diabetes remission.

“Thus, although the gold standard for diabetes remission is still the Roux-en-y gastric bypass, being similar mechanisms of diabetes remission involved and being easier to be performed, the mini-gastric bypass could become a valuable alternative,” they conclude

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