Durable remission of diabetes after bariatric surgery: What is the underlying pathway?

Background: In the past, type 2 diabetes mellitus (DM) was regarded as a progressive, incurable disease for which palliative therapy could not, over the long term, prevent the associated amputations, blindness, renal failure, and early mortality. This is no longer true. Full and durable remission of type 2 DM, with major decreases in morbidity and mortality, is now achieved regularly with several types of surgery that reduce contact between food and the foregut.Objectives: The aims of this article are to review the impact of bariatric surgery on obesity, remission of DM, and obesity-related morbidity and mortality, and the possible mechanisms for this advance.Methods: This article is based on our 2 meta-analyses of the literature published through April 30, 2006, as well as the most significant reports in the bariatric surgical literature that have been published in English since April 30, 2006. The studies included in our second meta-analysis provided the details of the methodology for the present literature review, including the levels of evidence.Results: Results of our 2 meta-analyses were published previously. Briefly, the analyses revealed that the clinical and laboratory manifestations of type 2 DM resolved or improved in most of the patients who underwent bariatric surgery; the responses were greatest in the patients who lost the most excess body weight; and the improvements were maintained for ≥2 years. The studies reported that intestinal operations such as gastric bypass reduced contact between food and the foregut, produced full and durable remission of DM, reduced mortality, and reversed other comorbidities associated with severe obesity (eg, asthma, gastroesophageal reflux, hypertension, stress incontinence). Insulin levels decreased markedly after surgery, as did glycosylated hemoglobin (A1C) and fasting blood glucose levels. Although these effects were initially attributed to weight loss, the rapid reversal of DM within a matter of days after surgery suggest that bariatric surgery changes the signaling mechanism of the gut with pancreatic islet cells, muscles, fat, the liver, and other organs.Conclusions: Bariatric surgery has opened new vistas, producing durable full remission of type 2 DM—a breakthrough previously considered impossible—with normalization of A1C levels over time and discontinuation of all antidiabetes medication for many patients. These advances create new opportunities for exploring the mechanisms of type 2 DM and its control through pharmaceutical approaches. DM is no longer an irreversible, incurable, or hopeless disease.     

Can body mass index predict percent body fat and changes in percent body fat with weight loss in bariatric surgery patients?

The primary objective of this study was to assess the validity of body mass index (BMI) in predicting percent body fat and changes in percent body fat with weight loss in bariatric surgery patients. Twenty-two bariatric patients (17 female, five male) began the study designed to include 12 months of testing, including data collection within 1 week presurgery and 1 month, 3 months, 6 months, and 1 year postsurgery. Five female subjects were lost to the study between 6 months and 12 months postsurgery, resulting in 17 subjects (12 female, five male) completing the 12 months of testing. Variables measured in the study included height, weight, percent fat (% fat) by hydrostatic weighing, lean mass, fat mass, and basal metabolic rate. Regression analyses predicting % fat from BMI yielded the following results: presurgery r = 0.173, p = 0.479, standard error of estimate (SEE) = 3.86; 1 month r = 0.468, p = 0.043, SEE = 4.70; 3 months r = 0.553, p = 0.014, SEE = 6.2; 6 months r = 0.611, p = 0.005, SEE = 5.88; 12 months r = 0.596, p = 0.007, SEE = 7.13. Regression analyses predicting change in % fat from change in BMI produced the following results: presurgery to 1 month r = -0.134, p = 0.583, SEE = 2.44%; 1-3 months r = 0.265, p = 0.272, SEE = 2.36%; 3-6 months r = 0.206, p = 0.398, SEE = 3.75%; 6-12 months r = 0.784, p = 0.000, SEE = 3.20. Although some analyses resulted in significant correlation coefficients (p < 0.05), the relatively large SEE values would preclude the use of BMI in predicting % fat or change in % fat with weight loss in bariatric surgery patients.     

González-Ulloa's Manifesto on aesthetic surgery

The realization that the proper development of aesthetic surgery was hindered by a bias against such practice by departmental heads and editors of medical journals led Dr. Mario González-Ulloa from Mexico to formulate a "Manifesto" on this speciality in the 1960s. This Manifesto has been of utmost importance to our speciality because it served to disseminate responsible opinion concerning aesthetic surgery among specialists. Although the bare text of the Manifesto was published in 1966, its content has so far been lost to future generations of plastic surgeons. Because its place in the history of aesthetic plastic surgery needs to be acknowledged, González-Ulloa's Manifesto is presented and discussed here.     

Chemoradiotherapy followed by surgery versus surgery alone in esophageal cancer patients: is it time for additional evidence?

In this letter I propose the name "Proliferative Multifocal Leukoplakia" with the goal of reducing under-diagnosis of this disease, improve the early diagnosis, try to make an early therapy and control, and prevent its malignant transformation.     

Will cardiac surgery improve my quality of life?

Background. The intention of this study is to analyse the correlation between a visual analogue scale (VAS) and the most common preoperative comorbidity and cardiac variables in patients undergoing elective cardiac surgery. This VAS is simple, easy to register and can be used as a global measurement of quality of life (QOL). Methods. Preoperative assessment of QOL in 1351 patients, 979 men and 372 women, with a mean age of 64.5±10.5 (18-88), undergoing elective cardiac surgery between January 2003 and December 2005. QOL was measured by the EuroQol questionnaire. Results. The mean VAS was 58.7±20.9, range 3 to 100. Univariate analysis showed a difference for sex (p=0.000), and NYHA (p=0.009) between patients with an isolated CABG and those with a combined revascularisation (p=0.05). Stepwise logistic regression analysis identified female gender (p=0.00), NYHA (p=0.00) and valve disease (p=0.03) as independent variables for a low QOL. The correlation between NYHA and QOL was low (r=-0.09, p=0.003). Conclusion. The clinical consequence is that using this simple VAS we can identify patients with a good QOL. If these patients present for high-risk surgery, with a better quality of life as primary indication, more extended counselling regarding their QOL is recommended. (Neth Heart J 2007; 15:51-4.)