Factors Associated with Relapse of Type 2 Diabetes Mellitus after Laparoscopic Sleeve Gastrectomy in Japanese Subjects: A Subgroup Analysis of J-SMART Study

Abstract

Introduction: Laparoscopic sleeve gastrectomy (LSG) for morbidly obese patients often result in remission of type 2 diabetes (T2DM), but diabetes relapses in some of those patients. The frequency of T2DM relapse in Asians and the factors involved have not been adequately investigated. Methods: The J-SMART study was conducted on 322 Japanese subjects with body mass index (BMI) ≥ 32 kg/m2 who underwent LSG at 10 accredited centers in Japan between 2011 and 2014. Of these, 82 T2DM subjects with diabetes in complete or partial remission at 1 year after LSG and followed postoperatively for 5 years were included in the subgroup analysis, and classified into two groups: diabetes remission maintained and diabetes relapse. Results: The mean age of all included subjects was 49.2 years, median BMI was 41.5 kg/m2, and median was HbA1c 6.7%. Compared with the diabetes remission maintained group, the diabetes relapse group at 5 years after LSG had significantly higher preoperative HbA1c, number of antidiabetic medications, and high-density lipoprotein cholesterol level; and lower BMI and homeostasis model assessment-beta cell function (HOMA-β). As many as 83.0% of the subjects were able to achieve HbA1c < 7% at 5 years after LSG, but 26.8% of the subjects had diabetes relapse. Preoperative HbA1c significantly contributed to diabetes relapse (odds ratio 1.54, p = 0.049). In addition, the diabetes relapse group tended to have lower percent total weight loss (%TWL) at 1 year after LSG and higher percent weight regain (%WR) from postoperative nadir weight, compared with the diabetes remission maintained group. The hazard ratio for diabetes relapse was 3.14-fold higher in subjects with %TWL ≥ 20% and %WR ≥ 25%, and 5.46-fold higher in those with %TWL < 20% and %WR ≥ 25%, compared with %TWL ≥ 20% and %WR < 25%. Conclusion: While LSG provides a high remission rate for T2DM, relapse is not uncommon. Preoperative HbA1c, poor weight loss and excess weight regain after LSG contribute to diabetes relapse, suggesting the importance of treatment strategies focusing on these factors.

Relationship between the magnitude of body mass index reductions and remission in patients with type 2 diabetes in real world settings: Analysis of nationwide patient registry in Japan (JDDM74)

“…Third, there was a lack of detailed information on bariatric surgery. Although the effectiveness of bariatric surgery for diabetic patients has been shown, the number of bariatric surgeries in Japan remains low 45,46 and the indication for bariatric surgery is BMI ≥35, which would apply to only 3.0% of our study participants. Therefore, patients with BMI <35 could achieve remission with non‐surgical treatment.…”

Once-weekly semaglutide administered after laparoscopic sleeve gastrectomy: Effects on body weight, glycemic control, and measured nutritional metrics in Japanese patients having both obesity and type 2 diabetes

“…Mean body weight, BMI, VFA, and HbA1c, which tended to increase at 12 months after LSG, decreased significantly after the patients were treated with once-weekly semaglutide for one year. Although metabolic surgery can achieve 30 % weight reduction and high remission rate of type 2 diabetes [ 22 ], studies have shown that some patients have relapse of type 2 diabetes due to postoperative weight recurrence [ 7 , [23] , [24] , [25] ], and some have poor metabolic improvement due to inadequate postoperative weight reduction [ 6 , 26 ]. The results of this study suggest that once-weekly semaglutide may be an effective treatment for weight recurrence and worsening diabetes after bariatric surgery, supporting the finding of a report [ 14 ].…”

“…A nationwide survey conducted by the retrospective study group “Japanese Survey of Morbid and Treatment-Resistant Obesity” (J-SMART) reported percent total weight loss (TWL) of 29.9 % and complete diabetes remission rate of 75.6 % at 2 years after LSG [ 6 ]. On the other hand, 26.8 % of subjects had recurrence of diabetes along with suboptimal weight reduction and excess weight recurrence within 5 years after LSG in the J-SMART study [ 7 ]. In several studies, 16–37 % of subjects showed significant weight recurrence in the long term [ 8 , 9 ].…”

Management of type 2 diabetes after metabolic bariatric surgery

“…However, in the long-term, intrinsic β-cell function shows minimal improvement despite clinical diabetes remission post-MBS, with progressive diminished function over time [31] . Other mechanisms of improvement in diabetes control after MBS include increase in gut glucose utilization and intestinal gluconeogenesis, reduced gut glucose absorption, changes in adipose tissue, circulating bile acids and gut microbiota, among others [35] . Hence, rapid improvement and even normalization of blood glucoses can be observed immediately after MBS, with diabetes remission occurring as early as 3-6 months after surgery.…”

“…The incidence of diabetes remission after sleeve gastrectomy (SG) and gastric bypass (GB) can range from 23% to 75% depending on the definitions used for diabetes remission, the type of surgical procedure, age and severity of T2D, amongst other factors [29,35] . Prediction models have been proposed to assess the likelihood of diabetes remission after bariatric surgery.…”