Curr Atheroscler Rep (2012) 14:588–596

DOI 10.1007/s11883-012-0288-2

LIPID AND METABOLIC EFFECTS OF GASTROINTESTINAL SURGERY (F RUBINO, SECTION EDITOR)

Impact of Gastrointestinal Surgery on Cardiometabolic Risk

Fady Moustarah & Audrée Gilbert &
Jean-Pierre Després & André Tchernof

Published online: 7 October 2012

# Springer Science+Business Media New York 2012

Abstract Bariatric surgery has gained acceptance as the only been reported to offer some of the best long-term weight loss
treatment with long-term efficacy for severe obesity. Recent for obese patients. Approximately 9 out of 10 patients treated
publications emphasize the usefulness of bariatric surgery in with this surgical procedure show long-term remission rates of
the reduction of long-term cardiometabolic risk, cardiovascu- T2DM. Significant improvements in the cardiometabolic risk
lar disease incidence and mortality, and the management of profile are also observed after BPD-DS; they are especially
uncontrolled type 2 diabetes (T2DM), an important cardio- pronounced regarding dyslipidemia. In conclusion, bariatric
vascular risk factor in individuals with severe obesity. The procedures improve the cardiometabolic risk profile, a phe-
present review article offers a brief overview of the literature nomenon that appears to be only partly explained by the
published over the past several months relevant to cardiome- magnitude of the weight loss. Significant variations are ob-
tabolic outcomes in bariatric surgery patients. A recent report served with respect to the type of surgery and patient charac-
from the Swedish Obese Subjects (SOS) study specifically teristics. More research is clearly needed on the short and
reported a reduced incidence of cardiovascular events on long- long-term cardiometabolic outcome of obesity surgeries.
term prospective follow-up after bariatric surgery. In addition,
abundant studies have been recently published on gastric Keywords Cardiometabolic risk . Bariatric surgery .
bypass surgery showing high T2DM remission rates as well Roux-en-Y gastric bypass . Biliopancreatic diversion .
as improved blood lipids and inflammatory markers after Sleeve gastrectomy . Lipid profile . Inflammatory markers .
surgery. Sleeve gastrectomy is increasingly performed as a Excess weight loss
stand-alone operation. Recent reports on this surgery pertain-
ing to cardiometabolic risk showed variable T2DM remission
rates that may possibly be explained by age of the Introduction
patients and duration of T2DM. Available data suggest a
possible favorable impact of the surgery on CRP levels and The obesity pandemic, afflicting over 300 million adults,
improvements in the blood lipid profile. How sleeve gastrec- has widened beyond industrialized nations to include devel-
tomy compares to other surgical approaches will require fur- oping regions, adding significance to obesity’s impact on
ther study. Biliopancreatic diversion with duodenal switch has the health of societies and associated healthcare costs [1, 2].
Severe obesity is associated with numerous co-morbidities
contributing to increased mortality risk [3], as well as
F. Moustarah : A. Gilbert : J.-P. Després : A. Tchernof (*) physical and psychological disorders [4–6]. Associations
Institut universitaire de cardiologie et pneumologie de Québec between morbid obesity and the risk of hypertension, coro-
(IUCPQ) and Université Laval,
nary artery disease, diabetes, cancer and respiratory condi-
2725 Chemin Ste-Foy,
Quebec, QC G1V 4G5, Canada tions have also been well-documented [7–11]. Lifestyle and
e-mail: [email protected] medical interventions are poorly effective for severely obese
F. Moustarah patients [12–15], and bariatric or weight loss surgery (also
e-mail: [email protected] recognized as metabolic surgery) has gained acceptance as
J.-P. Després the only treatment with durable, long-term effects for this
e-mail: [email protected] condition [16–18] in terms of weight loss and improvements
Curr Atheroscler Rep (2012) 14:588–596 589

in diabetes and other intermediate risk factors for cardiovas- to obesity. There have been many publications related to
cular disease [9]. bariatric surgery over the past few months; three major
Bariatric procedures promote weight loss and improve- studies, however, are worth highlighting here for their rele-
ment in comorbidities through multiple mechanisms. vance in terms of how bariatric surgery improves cardiovas-
Classically, however, bariatric operations have been de- cular risk factors, including diabetes mellitus [26••, 27••,
scribed as either restrictive, malabsorptive, or a combination 28••]. The Swedish Obese Subjects (SOS) study is an on-
of both. Restrictive approaches limit the amount of food going, nonrandomized, matched, prospective, controlled
consumed by reducing the size of the stomach, whereas study in which more than 4,000 patients were enrolled and
malabsorptive approaches limit the absorption of nutrients followed forward over time in Sweden. Reports on the prima-
by bypassing portions of the intestine [12, 16]. Among ry endpoint of the SOS project, overall mortality, were pub-
procedures used to induce weight loss, the Roux-en-Y gas- lished in 2007, where a 23.7 % overall unadjusted (30.7 %
tric bypass (RYGB), an operation with both a restrictive and adjusted) mortality decrease was observed in bariatric surgery
malabsorptive component and subsequently resultant hor- patients at 10 years compared with a well-matched non-
monal mechanisms, remains the most commonly performed surgical control population [29]. This improvement in overall
bariatric procedure in North America and globally [19–21]. mortality after bariatric surgery, which has also been demon-
The sleeve gastrectomy (SG), a more contemporary primary strated in smaller retrospective studies, along with the repeat-
bariatric procedure, was initially developed in the early 90’s ed observations of the beneficial effect of bariatric surgery on
as an acid-reducing and restrictive component of a bilio- diabetes, dyslipidemia and hypertension, suggest that such
pancreatic diversion with duodenal switch (BPD-DS) [18, surgery directly influences cardiovascular disease. The most
22]. It was later offered laparoscopically as a first step of a recent report from the SOS project [27••] describes the impact
two-staged approach to the BPD-DS to reduce peri- of obesity surgery on the predefined endpoints of myocardial
operative complications in high-risk patients; the second infarction and stroke, reported as total (fatal and non-fatal)
step, or the duodenal switch component, was then per- cardiovascular event incidence rates. The study groups includ-
formed after some weight loss had been obtained [11, 12]. ed 2,010 bariatric surgery patients (BMI≥34 kg/m2 in men;
However, it was observed that some patients experienced BMI≥38 kg/m2 in women) receiving gastric bypass (13.2 %),
appreciable weight loss with the SG alone and did not gastric banding (18.7 %) or vertical banded gastroplasty
require a second-stage surgery, thus avoiding a malabsorp- (68.1 %) and 2,037 contemporaneously matched obese con-
tive procedure [18]. The popularity of SG as a stand-alone trols receiving usual medical care. Over a median follow-up of
operation has increased due to its perceived technical sim- 14.7 years (range: 0–20 years), bariatric surgery was associ-
plicity and favourable early outcomes [18]. Another major ated with a reduction in the number of cardiovascular deaths
weight loss operation is the BPD-DS, which consists of both and first time cardiovascular events (fatal or non fatal), after
the SG and an intestinal bypass component where the first controlling for the cardiometabolic risk profile at baseline
part of the duodenum is anastomosed with 250 cm of ileum [27••]: Compared with controls, for total cardiovascular
measured from the ileocecal valve (alimentary limb). The events, the adjusted hazard ratio (HR) of bariatric surgery
distal duodenum, jejunum, and proximal ileum, which con- was 0.67 (95 % CI: 0.54-0.83; P<0.001); and for fatal car-
tain biliary and pancreatic secretions, receive no nutrients; diovascular events, the adjusted HR was 0.47 (95 % CI: 0.29-
and this biliopancreatic limb of intestine is anastomosed to 0.76; P00.02). Of note is that weight loss was only about
the distal ileum 100 cm from the ileocecal valve. This 16 % at 15 years in the treatment group, whereas overtime the
common limb becomes the only major site for lipid absorp- control group showed weight changes around a maximum of
tion [23, 24]. 1 %. Interestingly, secondary subgroup analyses of the SOS
Research into bariatric surgery began more than 50 years data failed to demonstrate an association between initial BMI
ago [25], and numerous publications have documented var- and postoperative health benefits of bariatric surgery. Even the
ious aspects of the commonly performed operations. The magnitude of surgery-induced weight loss did not predict
aim of this review article is to provide an overview of the cardiovascular events in this cohort. This puts into question
literature published in the past several months relating to the current clinical practice of using BMI as a main indication
cardiometabolic outcomes after bariatric surgery. and eligibility criterion for bariatric surgery, when cardiovas-
cular benefits are realized independent of differences and
changes in body weight [30, 31]. Further post-hoc analysis
Bariatric Surgery and Cardiometabolic Disease: of the SOS data revealed that, unlike baseline BMI or the
Highlights of 2012 magnitude of postoperative weight loss, a high baseline insulin
level was in fact a predictor of cardiovascular events in the
The development of cardiovascular disease and associated study. These results point to the important role of bariatric
morbidity and mortality represents an important risk related surgery in improving the cardiovascular risk profile, in
590 Curr Atheroscler Rep (2012) 14:588–596

addition to decreasing the overall incidence of fatal and non- remission rates after gastric bypass averaged approximately
fatal cardiovascular events in severely obese patients in the 92 % over a follow-up time of 1 to 6 years [19, 37, 39, 40].
long term. They also suggest that weight-independent mecha- Such changes have been accompanied by improvements in
nisms rather than weight loss alone may explain part of the circulating lipid levels. For example, a retrospective study
cardiometabolic benefits of surgery. In addition, while the performed in 949 participants showed that plasma concentra-
majority of surgical patients in the SOS cohort underwent tions of triglycerides, HDL-cholesterol and LDL-cholesterol
procedures infrequently offered today, similar positive results were all significantly improved one year after Roux-en-Y
are expected to be observed, and with perhaps greater magni- surgery [41•]. These improvements were predicted in part by
tude, when the more frequently performed malabsorptive pro- the amount of lost weight [41•]. A small prospective study
cedures, RYGB and BPD-DS, are offered. assessing apolipoprotein B levels showed a 22.9 % reduction
In addition to the latest update from the SOS group, two at 3 months and 32.1 % reduction at 6 months [38]. Changes
other studies recently examined, through a prospective random- in the ApoB100/ApoA1 ratio were significantly correlated
ized design, the impact of bariatric surgery on diabetes control with changes in cholesterol, LDL-cholesterol and triglyceride
when compared with current medical therapy [26••, 28••], levels [38]. Short-term changes in the blood lipid profile in
thereby addressing an important and common cardiovascular response to gastric bypass have been examined in another
disease risk factor in severely obese patients. When Mingrone study of patients stratified according to initial BMI value
et al. randomized patients between biliopancreatic diversion, [42]: triglyceride levels were significantly reduced in all
RYGB, or standard medical therapy, better glycemic control BMI categories 30 days following surgery, and then improved
was observed in the surgical groups after 2 years. In addition, further at 6 months. However, HDL-cholesterol showed a
no remission from diabetes was seen in the medical group, transient decrease at 30 days, specifically in the subgroups
whereas remission rates were 75 % and 95 % after RYGB and with initial BMI values above 40 kg/m2. HDL-cholesterol
BPD, respectively [28••]. Schauer et al. showed that after 1 year, levels improved later during the follow-up, but this change
a glycated haemoglobin level of ≤6 % was achieved in 42 % was of lower magnitude compared to improvements in tri-
after RYGB, 37 % after SG, and in only 12 % after intensive glyceride levels [42]. This transient decrease in HDL-
medical therapy, when patients were randomized between these cholesterol levels has also been reported in other weight loss
three arms [26••]. Together, the short- and long-term results studies [33, 37] and has been suggested to result from the
from these three seminal studies published in 2012 clearly dramatic reductions in caloric and lipid intake immediately
emphasize the important role bariatric surgery plays in the after surgery, which reduce lipid levels overall [42].
management of uncontrolled T2DM, as well as of long-term Age at the time of surgery is deemed a significant predictor
cardiovascular disease risk in individuals with severe obesity. of 10-year Framingham risk score [34]. Specifically, subjects
younger than 45 years experienced a greater improvement in
cardiometabolic risk compared to older patients; this was
Recent Studies on Cardiometabolic Outcomes reflected in a better risk score at follow-up [34]. A study also
of Bariatric Surgery showed some impact of initial obesity level on the cardiome-
tabolic response to surgery as metabolic improvements
Roux-En-Y Gastric Bypass appeared to be observed more readily among patients with
an initial BMI value lower than 50 kg/m2 [34].
A large number of reports were published in the past 2 years Inflammatory markers were specifically examined in a
on the metabolic effects of RYGB surgery. A detailed re- number of RYGB studies. Previously, lifestyle intervention
view of all these studies is beyond the scope of this article. studies had been shown to decrease circulating levels of the
This section will summarize some of the recently published inflammatory marker C-reactive protein (CRP) in obese indi-
works on cardiometabolic outcomes of RY gastric bypass. viduals [43, 44]. Similarly to diet-induced weight loss, gastric
In general, gastric bypass surgery tends to result in sig- bypass was shown to reduce CRP levels [32, 41•, 45–47]. For
nificant improvements in the cardiometabolic risk profile example, in 431 patients followed for an average of 325 days
that are proportional to the magnitude of weight loss [19, post-operatively, CRP values were above 3 mg/dL in only
32–34]. For example, recent studies showed that 12-month 9.8 % of patients, compared with 34.6 % that were above this
post-surgery T2DM remission rates ranged from 64 % to cut-off value before surgery [41•]. Regarding other inflamma-
96 % [19, 35–40]. Interestingly, two of the studies reporting tory markers or adipose tissue-derived cytokines, one prospec-
remission rates in the range of 60 % were performed in tive study showed no significant impact of gastric bypass on
Asian populations with initially lower BMI values com- IL-6 and IL-10 levels, although leptin, PAI-1 and CRP levels
pared to other populations [35, 36]. The other study with a decreased significantly at three and six months of follow-up.
remission rate of around 60 % comprised a small number of Fibrinogen and IL-1Ra levels decreased significantly and
subjects with T2DM [38]. In the remaining studies, T2DM adiponectin significantly increased only at 6 months of
Curr Atheroscler Rep (2012) 14:588–596 591

follow-up [32]. Recent studies showed significant increases in compared with 100 % resolution in a group of 40 who had
interferon-gamma synthesis and peripheral blood mononucle- diabetes for <10 years T2DM duration [61]. The lowest
ar cell secretion of IL-12, IL-18 [48]. Others have shown that %T2DM remission (18.2 %) was observed in a super-
circulating IL-6 and TNF-alpha were not affected by surgery obese population [57]. At this point, it remains premature
[46]. Studies on adiponectin changes in response to gastric to conclude that the SG is as effective as the RYGB in terms
bypass also report significant increases in adiponectin levels 3 of T2DM resolution.
and 6 months after surgery [32, 45–47]. Two comparative studies, however, have not observed any
significant difference between both surgeries [40, 59•].
Sleeve Gastrectomy Interestingly, the latter study which included 786 patients un-
dergoing Roux-en-Y and 811 patients undergoing SG noted a
As mentioned, SG is increasingly performed as a stand-alone better remission rate in the SG group with 90.9 % compared to
obesity surgery [18]. Outcomes after SG remain short and 86.6 % for the Roux-en-Y group [59•]. However this case-
intermediate-term in nature. Recently, percentage excess control study did not match patients for comorbidities and the
weight loss (%EWL) at 12 months after SG has been reported HbA1c level at baseline reflected worse control in the RYGB
to range from 43.6 % to 96.2 % [49–53, 54•, 55, 56]. The study group. Another study performed in 30 diabetic patients under-
with the highest %EWL was performed in a sample of teen- going Roux-en-Y and 30 diabetic patients undergoing SG
agers [50]. When excluding studies performed in adolescents, reported discordant results, with a 93 % T2DM remission rate
the average 12-month %EWL was 61.2 % [51–53, 54•, 55, 56]. at 1-year for the first group compared to 47 % in the second
This is more in line with our experience with the SG, where an group [39]. These findings appear to be more consistent with
average of 52 % EWL is observed at 12 months. Population the results of the recently reported randomized trial by Schauer
characteristics need to be, of course, considered when compar- et al. showing a control of HbA1c at <6 % in 37 % of the SG
ing these parametric statistics. Available studies indicate a group at one year [26••].
possible inverse correlation between initial body mass index Since inflammation is emerging as a predictor of cardio-
(BMI) and %EWL at 12-months [49–53, 54•, 56, 57]. A study vascular disease, inflammatory changes after SG have also
in 174 patients directly addressed this question by showing that been evaluated. One recent prospective study assessed the
participants with BMI values above 50 kg/m2 had a 7–10 % impact of sleeve gastrectomy on circulating levels of CRP
lower excess weight loss compared to those with BMI values [64]. Over a 6-month follow-up, the number of patients with
below 50 kg/m2, at least for the 6- and 12-month follow-up CRP values below 3 mg/dL increased from 3 out of 29
[51]. This trend is less apparent in other studies, one of which before surgery to 13 out of 29 postoperatively. In that study,
has been performed on a noticeably older population [56]. decreases in CRP levels were directly proportional to
Studies are not unanimous as to whether the efficiency of SG decreases in BMI as well as to the initial BMI [64].
is as good as the Roux-en-Y regarding %EWL. While some Regarding improvements in the lipid profile after SG,
studies support the notion that outcomes of SG may be as good studies are not as discordant as observed for %EWL results
as that of the RYGB [40, 58, 59•], others report no significant and T2DM remission rates. RYGB and SG both lead to
difference between the two procedures. Moreover, many have similar improvements in HDL-C level and TG levels [39,
documented better %EWL with the RYGB than with SG [39, 58, 59•]. A study performed on 140 Spanish obese patients
40, 58, 59•]. The active weight loss phase seems shorter for the did not report significant differences in cardiovascular risk
SG than for the Roux-en-Y. According to recent studies, weight estimated using both 10-year Framingham risk score and the
loss slows down approximately one year after SG compared to Registre Gironi del cor (REGICOR) model [40]. However,
one to three years for Roux-en-Y surgery [19, 32–34, 36–38, differences have been reported in all studies comparing both
40, 50, 54•, 56, 58, 59•, 60–62]. surgeries in regards to changes in LDL-C levels [39, 40, 58,
Early results of the SG show that it is able to induce 59•]. Indeed, significant decreases in LDL-C concentrations
improvements in metabolic comorbidities. Recent studies are observed after Roux-en-Y surgery, but not in patients
reporting percentage of T2DM remission following SG are who had a SG [39, 40, 58, 59•]. Total cholesterol was shown
summarized in Table 1. Remission rates have been reported to increase after sleeve gastrectomy in two recent studies [40,
to be highly variable, with values ranging from 18.2 % to 58]. Another study reported a persistently higher metabolic
93.8 % [49–51, 53, 54•, 56, 57, 61, 63]. Many factors have syndrome prevalence of 60 % following SG compared to 7 %
been proposed to explain such wide variability. The highest after Roux-en-Y [39].
resolution rate was 93.8 % and was observed in young
(<21 years old) obese individuals [49]. The shorter duration Biliopancreatic Diversion
of T2DM in this young population may explain the ob-
served results. Casella et al. reported a T2DM resolution Among the bariatric procedures, BPD-DS is known to offer
rate of 31 % in 16 obese with diabetes for >10 years, some of the best long-term weight loss and resolution of
 592

Table 1 Type 2 diabetes (T2DM) remission rates following sleeve gastrectomy in recent studies

Study N M/F Average initial Average Initial Initial % Design Follow-up Diabetes Diabetes Remission
BMI (kg/m2) age (yrs) with T2DM duration (years) medication rate (%)

Magee et al. [57] 68 39/29 68a 45a 32.35 Retrospective 12 mo - - 18.3

Chopra et al. [51] 174 25/149 48.97±8.25 39.6±10.7 25.86 Retrospective Avg: 16±8.96 mo - - 33.0
Range: 6-36 mo
Bobowicz et al. [53] 84 21/63 44.62 39 26.19 Retrospective Avg: 22±6.75 mo - - 41.0
Observational Range: 14-56 mo
Boza et al. [50] 51 10/41 38.5±3.7 18±1.45 3.9 Retrospective Range: 6-24 mo - - 50.0
Gluck et al. [54•] 204 49/155 45.7 45 28.43 Retrospective Range: 3-36 mo - - 70.7
Nonrandomized
Behrens et al. [63] 34 1/33 50.3 48 56 Retrospective Avg: 10 mo - - 74.0
Range: 2-23 mo
Slater et al. [56] 22 17/5 46 55.3 100 Retrospective Avg: 7 mo - 77 %: more than 75.0
of prospective 1 medication
database 55 %: insulin
Casella et al. [61] 56 15/41 Group A: 42.7 Group A: 52.7 100 Retrospective Avg group A: 11 mo Group A: >10 Group A: 43.7 % Total: 80.3
HGO, 6.3 % insulin,
50 % HGO+insulin
Group B: 44.9 Group B: 50.4 Avg group B: 10 mo Avg: 14.8 Group B: 87.5 % Group A: 31.0
Range: 3-18 mo Group B: <10 HGO, 7.5 % insulin, Group B: 100
Avg: 2.8 5 % diet
Alqahtani et al. [49] 108 53/55 47.4 a 13.9±4.3 14.81 Retrospective Range: 3-24 mo - - 93.8
Observational

a: median value; HGO: hypoglycemic oral agent; Avg: average; mo: months
Curr Atheroscler Rep (2012) 14:588–596
Curr Atheroscler Rep (2012) 14:588–596 593

comorbidities for obese patients [15, 23]. Since its first descrip- 100 % [68, 69]. The long-term follow-up data available after
tion in the literature by Marceau et al. [22], the BPD-DS has BPD-DS certainly supports its efficacy as a possible cure for
been the standard surgical procedure of choice in our Center for morbid obesity and related metabolic comorbidities [23];
most patients with severe obesity [22, 23]. In terms of %EWL, life-time nutritional follow-up remains, of course, an essen-
we reported a value 76±22 % in a sample of 810 obese indi- tial component of care for the bariatric patient after any
viduals with a mean BMI of 44.2±3.6 kg/m2 [23]. This study malabsorptive procedure.
was performed over a long follow-up period of 8.6 years. Of the
patients examined, 92 % reached a BMI below 35 kg/m2 [23]. In
another analysis with a follow-up of 7.9±4.2 years, a total of Conclusions
1,271 patients experienced a 68.6±21.4 %EWL [65]. The num-
ber of individuals with a persistent BMI above 40 kg/m2 was Bariatric surgery clearly improves the cardiometabolic risk
only 10 % eight years after surgery [65]. Initial BMI value was profile and cardiovascular outcome in patients with severe
found to have a significant impact on %EWL, with a higher obesity. The degree of initial obesity as well as the extent and
initial BMI being predictive of slightly lower %EWL durability of weight loss beyond a certain minimum only partly
values [65]. Recent studies from other groups reported explain these effects, as suggested by the recent report from the
%EWL values ranging from 61 to 78 % with mean follow- SOS group. This rekindles the debate on the proper indications
up durations of up to 11 years [66–69, 70••]. for bariatric surgery, particularly as it pertains to the role of
Mingrone et al. [28••] evaluated diabetes remission after BMI as a criterion for surgical eligibility or a predictor of
BPD in a prospective randomized study, where remission was benefit. In light of accumulating new evidence, a review and
defined as a fasting glucose of <5.6 mmol/L and a glycated update of the 1991 NIH criteria for bariatric surgery may very
haemoglobin of <6.5 % in the absence of drug therapy. At well be in order [72]. There are significant variations with
2 years, they observed remission in 95 % of patients who respect to the type of surgery as well as the patients' initial
underwent BPD, a value which was far greater than that seen characteristics and the postoperative results, which should be
with the other two arms of the study. In another study comparing considered, as additional evidence is collected overtime to
SG vs. biliopancreatic diversion with duodenal switch outcomes better outline the health benefits of bariatric surgery. Body
[60], no difference was reported between the procedures regard- composition, fat distribution, metabolic dysfunction, insulin
ing improvements of anthropometrics, adiponectin, leptin and resistance and diabetes may in fact play a bigger role than
CRP levels [60]. Homeostasis model of assessment-insulin re- BMI or the amount of weight loss in predicting response to
sistance (HOMA-IR) significantly decreased 3 months after bariatric surgery and postoperative changes in cardiometabolic
both procedures, but this index worsened 15 days after the risk. Currently, there is substantial evidence demonstrating the
operation and later decreased in the SG subgroup [60]. This role of bariatric surgery in inducing significant and sustained
observation suggests that glucose and insulin may not be mod- weight loss over time as well as improvements in diabetes,
ulated through the same mechanism depending on the type of dyslipidemia, hypertension and other comorbidities, as sum-
bariatric surgery [60]. Serum glucose, insulin, TG and free fatty marized in many systematic reviews on the topic. However,
acids were reduced after both surgeries, but changes were sig- evidence from well-controlled prospective trials for the health
nificant only in the case of BPD-DS [60]. BPD-DS seems to benefits and cardiovascular risk reduction after bariatric sur-
have a longer active weight loss phase than SG; even longer than gery remains in its infancy. The SOS results have started to
the Roux-en-Y [19, 23, 32–34, 36–38, 40, 50, 54•, 56, 58, 59•, provide a glimpse of what that evidence may look like in the
60–62, 67, 68, 70••]. Indeed, weight loss has been reported to long-term. More research is clearly needed on the short and
slow down approximately two to five years following BPD-DS long-term cardiometabolic outcomes of some of the contem-
[23, 60, 67, 68, 70••]. porary and newer procedures, such as the SG. In addition,
Our observational results show that diabetes remission is weight dependent and independent mechanisms of bariatric
durable after many years of follow-up after BPD-DS surgery. procedures explaining the metabolic improvements seen in
In our patients, T2DM remission rates were in the magnitude obese patients undergoing surgery remain of great clinical
of 92.5 % [23]. After a follow-up of 667 patients over interest both in the early and late postoperative periods.
5.5 years (range 2 to 14 years), 96 % of diabetic patients
Acknowledgements AT and FM are respectively Chair and Co-chair
could discontinue their medication [71]. Regarding other
of a Research Chair in Bariatric and Metabolic Surgery funded by
cardiometabolic risk factors, most studies support a signifi- Ethicon Endo-Surgery. AG is the recipient of a studentship from the
cant improvement in several risk factors including hyperten- National Science and Engineering Research Council of Canada. JPD is
sion, triglyceride concentrations and cholesterol levels [23, the Scientific Director of the International Chair on Cardiometabolic
Risk based at Université Laval.
66, 68, 71] which remained significantly improved on
follow-up [68]. The results are particularly striking regarding Disclosure No potential conflicts of interest relevant to this article
dyslipidemia, with observed remission rates of 95 % to were reported.
594 Curr Atheroscler Rep (2012) 14:588–596

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