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Veilleux et al. Mini-invasive Surg 2020;4:4 I http://dx.doi.org/10.20517/2574-1225.2020.01 Page 5 of 7

Potentially, sleeve gastrectomy converted to an anastomotic procedure can be more efficacious than what is
achieved with the primary anastomotic procedure alone. If some patients are destined for eventual relapse,
even after anastomotic procedures, perhaps a stepwise approach would yield a greater number of total years
in remission.

The ability of two procedures to surpass the diabetic results of the primary procedure may draw skepticism
based off the results we have seen for revisional surgery and obesity. Revisional bariatric surgery has
shown variable outcomes with weight loss when compared to the primary procedure. Indeed, in some
observational studies, it has yielded lower total weight loss, with inferior durability [24-26] . However, the same
assumptions of inferiority should not be made for the effect of revisional surgery on diabetes. This has yet
to be fully evaluated. We know there is not a direct correlation between a patient’s weight loss and degree
of diabetic improvement and that studies have shown multiple metabolic effects from surgery which are
completely independent of weight loss [7,20] . For example, improvement in glycemic control often occurs
prior to any substantial weight loss and the degree of diabetic improvement does not parallel changes in
BMI [6,7,27] . Interestingly, in one sample of 105 gastric bypass patients who had inadequate weight loss (Excess
Weight Loss < 15%), substantial glycemic improvement was still observed at one-year follow up (change in
[20]
mean HbA1C from 7.3 ± 1.9 to 6.1 ± 1.0) . Additionally, newer studies have theorized several metabolic
gastrointestinal modulations caused by surgery that act independent of weight loss. One such observation
reveals that increased stimulation to the terminal ileum and large intestine by rapid nutrient delivery
(increased gastric emptying or intestinal bypass) appears to have beneficial incretin (GLP-1) secretory
effects [20,27] . Although much research is still underway, it is clear that metabolic and bariatric procedures
cause a complex change in gut physiology, with each procedure likely to have its own distinct response.
Thus, an approach that combines multiple procedures to target separate pathways may one day be found to
be the most efficacious for long-term diabetic improvement.

CONCLUSION
More than a decade of efforts to recognize the incredible glycemic improvement possible with surgery have
now provided the foundation for further discoveries. Recently, the cardiovascular benefits from metabolic
surgery in obese diabetics have shown dramatic risk reduction in complications such as heart failure, A-fib,
[28]
stroke, myocardial infarction, and all-cause mortality . As we continue to recognize additional benefits,
further study is needed to continue to guide appropriate procedure/patient selection and to formalize a
surgical plan for the long-term care of diabetes.

DECLARATIONS
Authors’ contributions
Both authors contributed equally to the entire editorial.

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.