Review
Diabetes after Bariatric Surgery

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Abstract

Bariatric surgery has now emerged as an effective means of glycemic control in individuals with diabetes and obesity. However, long-term data show recurrence of hyperglycemia years after the procedure. Although the exact prevalence of diabetes relapse is unknown because of attrition and limited data on long-term follow up after the surgery, a significant percentage of patients experience relapse of diabetes. The mechanism of diabetes relapse is not completely understood and is not always linked to weight regain. The clinical implications of hyperglycemia after bariatric surgery for patients and healthcare providers is reviewed.

Résumé

La chirurgie bariatrique est aujourd'hui reconnue comme un moyen efficace de rétablir l'équilibre glycémique chez les personnes obèses atteintes de diabète. Toutefois, les données à long terme indiquent un retour de l'hyperglycémie plusieurs années après l'intervention. Bien que la prévalence exacte de la rechute du diabète soit inconnue en raison de l'attrition et du manque de données de suivi à long terme après la chirurgie, un pourcentage considérable de patients diabétiques connaît une rechute. Le mécanisme qui sous-tend la rechute du diabète n'est pas entièrement élucidé et n'est pas systématiquement lié à la reprise de poids. Cet article explore les conséquences cliniques de l'hyperglycémie à la suite d'une chirurgie bariatrique chez les patients et les professionnels de la santé qui les soignent

Introduction

The prevalence of obesity and type 2 diabetes mellitus in North America and across the world has been increasing at alarming rates. Obesity is a critical risk factor for the development of type 2 diabetes. The relative risk for type 2 diabetes in individuals with obesity (body mass index [BMI] ≥ 30 kg/m2) is 10 times greater than in those with normal BMIs (≥18.5 to ≤24.9 kg/m2). In addition, 90% of all individuals with type 2 diabetes are overweight or obese (1). Although intensive lifestyle modification, with diet-induced weight loss, exercise and intensive medical therapy can result in good control and even remission 2, 3 of type 2 diabetes, the majority of patients find it difficult to achieve sustained control of blood glucose. In addition, intensification of medical therapy can lead to hypoglycemia and weight gain.

Therefore, many have turned to bariatric surgery (BS) or metabolic surgery for treatment of obesity and type 2 diabetes. Surgical weight loss provides marked improvement in glycemic control, with the rate of type 2 diabetes remission varying from 24% to 95% at 2 years, depending on the type of surgery, the definition of remission and the type of subjects enrolled 2, 4, 5, 6. The definition of remission varies from study to study but is generally defined as normoglycemia and glycated hemoglobin (A1C) levels below 6%, without the need for glucose-lowering medications for at least 1 year (7). Recent long-term data, however, suggest that relapse of type 2 diabetes is common in the years following BS. Here we review clinical studies of type 2 diabetes relapse after BS and discuss pathophysiology and determinants of type 2 diabetes relapse and its clinical implications.

Section snippets

Bariatric Surgery and Diabetes Remission

Anecdotal evidence of improved glycemic control after gastrointestinal surgery in patients undergoing gastric resection for peptic ulcer disease or gastric cancer was reported as early as the first half of the 20th century (8). In the early 1980s, surgeons recognized firsthand that many patients with type 2 diabetes undergoing Roux-en-Y gastric bypass (RYGB) experienced resolution of their type 2 diabetes. Pories et al conducted a retrospective single-cohort study of 298 patients with type 2

Risks and Benefits of Bariatric Surgery

Although BS can have numerous benefits, all surgical procedures and medical treatments are associated with risks. The rigorous preparation of patients, the development of centres of excellence and the elective nature of BS, now performed almost laparascopically, have reduced mortality and complications. Short-term 30-day postoperative mortality and longer term mortality associated with the surgical procedure is very low, less than 1% for all procedures and a bit higher for RYGB than for VSG or

Screening and Treatment of Diabetes after Surgery

A significant number of patients experience either persistent type 2 diabetes after surgery or, after a few months or years in remission, experience relapse in the years following their surgery. The distinction between persistent and relapsing type 2 diabetes may be important in terms of mechanism. However, the 2 may be hard to distinguish if diabetes status is not documented by longitudinal screening. Buse et al recommended at least a 5-year continuous state of complete remission before a

Conclusions

BS improves glycemia by inducing calorie restriction and sustained weight loss, thus improving insulin sensitivity and β cell function. Additionally, some surgeries, such as RYGB and VSG, may have weight-independent effects, possibly via enhancement of the incretin system and insulin secretion, particularly during meals. The International Diabetes Federation and the American Diabetes Association now recommend BS as a part of the algorithm in type 2 diabetes management 53, 54. Although BS does

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