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exercise, and leisure time physical activity among diabetic
patients are still a difficult task, especially for optimal
blood pressure, glucose and lipid level control. Evidence from
clinical trial data, such as Steno-2 and Diabetes Complication
Study, showed behavioral intervention as important tools
for further cardiovascular risk prevention. Novel modalities,
such as information technology and behavioral economics
approaches, provide a new way for diabetes care through
behavioral and lifestyle intervention. In addition, the approach
through dietary modification of gut microbiota as a key organ
involved in metabolism is considered a new way to control
diabetes. In summary, Primary and secondary prevention
of diabetes is still a big challenge; however, innovative
modalities through evidence-based lifestyle and behavioral
intervention programs will provide insightful strategy for
diabetes control.
Update of Bariatric/Metabolic Surgery
S02-1
Current status of bariatric/metabolic surgery: ADSS data
Wei-Jei LEE
1,2
.
1
Department of Surgery, Min-Sheng General
Hospital, Taoyuan,
2
Department of Surgery, National Taiwan
University, Taipei, Taiwan
Obesity and associated type 2 diabetes mellitus (T2DM) is
becoming a serious medical issue worldwide. Bariatric surgery
has been shown to be the most effective and durable therapy
for the treatment of morbid obese patients. The advent of
bariatric surgery to treat T2DM morbidly obese patients offers
a new paradigm in T2DM therapy. Bariatric surgery has been
shown to confer long-term weight loss and glycemic control
in obese diabetics.
“
Metabolic surgery
”
has been proposed
as a treatment for T2DM in view of the relatively high
remission rates with bariatric surgery (range 36
–
93%) com-
pared to medical therapy alone. Increasing data indicates
bariatric surgery, played as metabolic surgery, is an effective
and novel therapy for not well controlled obese T2DMpatients.
Because Asian people had a higher incidence of T2DM and
tend to have an earlier onset T2DM than Caucasian, Asian
surgeons had more experience in using metabolic surgery to
treat T2DM in low BMI patients. Subjects are recruited as
part of a multi-institutional ADSS group consisting of 11
centers in 6 countries, including Hong Kong, India, Japan,
Korea, Singapore and Taiwan. There were a total of 4,380
subjects registered in this study between September 1997 and
December 2015. This report was performed to examine the
recent advancement of metabolic surgery in Asia can be
classified into 4 major fields. (1)
Improvement of safety:
Recent
advancement in laparoscopic surgery has made this mini-
mal invasive surgery more than ten times safe than a decade
ago. The safety profile of laparoscopic bariatric/metabolic
surgery is compatible with laparoscopic cholecystectomy
now. (2)
New metabolic surgery:
Laparoscopic sleeve gastrec-
tomy (LSG) is becoming the leading bariatric surgery because
of its simplexes and efficacy. Other new procedures, such as
single anastomosis (mini) gastric bypass and Duodeno-jejunal
bypass with sleeve gastrectomy have all been accepted as
treatment modalities for the bariatric/metabolic surgery.
(3)
Mechanism of metabolic surgery:
Restriction is the most
important mechanism for bariatric surgery. Weight regain
after bariatric surgery is usually associated with loss of
restriction. Recent studies demonstrated that gut hormone,
microbiota andbile acid change after bariatric surgerymay play
an important role in durable weight loss as well as in T2DM
remission. However, weight loss is still the cornerstone of
T2DM remission after metabolic surgery. (4)
Patients selection:
Patients who may benefit most from bariatric surgery was
found to be patients with insulin resistance. For T2DM
treatment, the indication has been set to not well controlled
(HbA1c >7.5%) with their BMI >27.5 Kg/m
2
in Asian. A novel
diabetes surgical score, ABCD score, is a simple system for
predicting the success of surgical therapy for T2DM.
S02-4
Management of residual diabetes and micronutrient
deficiencies after bariatric surgery
Keong CHONG
1
.
1
Department of Internal Medicine, Min-Sheng
General Hospital, Taoyuan, Taiwan
Bariatric surgery is regarded as
“
metabolic surgery
”
and
“
dia-
betic surgery
”
because of its noticeable effects on metabolic
syndrome and type 2 diabetes. Although many studies show
the effectiveness of bariatric surgery to treat diabetes, recent
studies document that a growing number of patients with type
2 diabetes do not achieve
“
remission
”
of diabetes or are unable
to sustain this effect long-term despite initial success with
weight loss after bariatric surgery.
Some possible factors associated with diabetes non-remission
or re-emergence were noted, such as older age, lower preope-
rative BMI, longer diabetes duration, insulin use, inadequate
weight loss and weight regain, surgery type and severity of
preoperative beta-cell dysfunction.
Currently, no clinical practice guideline is established for the
patients with
“
residual
”
diabetes after bariatric surgery.
According to the recommendation of ADA, metformin remains
the first line agent for T2DM in that it improved insulin
sensitivity. Thus the use of metformin for glycemic control
after bariatric surgery is reasonable due to low risk of
hypoglycemia and neutral/loss for weight gain. A report
demonstrated accelerated absorption and bioavailability of
metformin following gastric bypass and indicated that a
reduce dose of metformin may be required for achieving
glycemic control. In contrast, use of thiazolidinediones may
hamper weight loss efforts despite increasing insulin sensi-
tization and low risk of hypoglycemia.
Sulfonylurea drugs should generally be avoided in the imme-
diate postoperative period when insulin secretion may
enhance and increase the risk of hypoglycemia. However,
in patients with residual diabetes after bariatric surgery, who
cannot achieve the treatment goal by use of metformin, the
addition of sulfonylurea to metformin may restore glycemia
control by targeting pancreatic beta-cell failure.
Incretin analogue (i.e. DPP4 inhibitors and GLP-1 analogues)
enhance glucose dependent insulin secretion and offer
advantages for weight loss in obese type 2 diabetic patients
but evidence for their use in bariatric surgery is lacking. For the
favorable effects of SGLT2 inhibitors on glycemic control,
weight loss and blood pressure, SGLT2 inhibitors maybe
an attractive anti-diabetic agent to treat residual diabetes.
However, the use of these drugs increases the risk of genital
mycotic infection and dehydration.
For those patients with residual diabetes, who cannot achieve
the treatment goal by oral anti-diabetic agents and/or GLP-1
analogues, insulin therapy is indicated. Besides, all diabetic
patients underwent bariatric surgery should keep a lifelong
lifestyle modification.
Deficiencies in micronutrients, which include trace ele-
ments, essential minerals, and water-soluble and fat-soluble
vitamins, are common before bariatric surgery and often
persist postoperatively, despite universal recommendations
on multivitamin and mineral supplements. Recognition of the
clinical presentations of micronutrient deficiencies is import-
ant, both to enable early intervention and to minimize long-
term adverse effects.
Anemia without evidence of blood loss warrants evaluation
of nutritional deficiencies as well as age appropriate causes
during the late postoperative period. Iron status should be
monitored in all bariatric surgery patients. Treatment regi-
mens include oral ferrous sulfate, fumarate, or gluconate to
Speech Abstracts / Diabetes Research and Clinical Practice 120S1 (2016) S1
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