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Fearon et al. Metab Target Organ Damage 2022;2:13 https://dx.doi.org/10.20517/mtod.2022.12 Page 9 of 13

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weight (4.4%, 6.1 kg) and BMI (2.13 kg/m ) between the IGB and control groups (placement time three to
[36]
eight months) . A recent study from Abu Dayyeh et al. randomised participants to either an adjustable
IGB and a lifestyle intervention program or a lifestyle intervention program alone . Participants had the
[37]
adjustable IGB for eight months and were followed up for six months. They underwent endoscopic
adjustments during the eight months, depending on their intolerance symptoms and weight loss. The
average weight loss in the IGB group was 15% compared to 3.3% in the diet and exercise group alone. A
small subgroup of participants with T2DM had an improvement of 0.73% in HbA1c. Importantly, volume
adjustment at the 18-week point prevented the removal of 75% of IGB in those who reported intolerance
symptoms . Unfortunately, it remains the case that these devices are only suitable for short-term use, and
[37]
the likelihood of long-term weight regain is high; however, they remain a good option for short-term weight
loss and improvement in glycaemic control and improvements in tolerability are to be welcomed.
Endoscopic sleeve gastroplasty may be another option as a bridging intervention; Zorron et al. describe a
case series whereby they include bridging to renal or liver transplant as an indication for ESG.
Unfortunately, the details of subsequent procedures and outcomes are not reported . The Multicentre
[38]
Randomised ESG Trial (MERIT) recently reported a mean percentage of total body weight loss of 13.6%
(8.0) after ESG at 52 weeks and 0.8% (5.0) for the control group (P < 0.0001). Secondary outcomes included
co-morbidities, and the authors report significant improvement in fasting glucose concentrations, HOMA-
IR and HbA c levels in the ESG group compared to the control group. Furthermore, 25 (93%) of 27
participants in the ESG group, compared with only four (15%) of 27 participants in the control group,
reported a clinical improvement in DM .
[39]
There has been recent discussion about proceeding with bariatric surgery in the context of poor glycaemic
control and a high HbA1c as improvement or remission in T2DM is an intrinsic benefit of metabolic
surgery, and a large observational study from Albaugh et al. showed no difference in outcomes for people
undergoing bariatric surgery who had a higher HbA1c. The mean preoperative HbA1c was 8.2 +/- 2.7% (66
+/- 29.5 mmol/mol) for the entire cohort; the outcomes of interest were a composite of major
complications, a composite of infectious complications, length of stay > 5 days, re-admission within 30 days
and re-operation within 30 days .
[40]
PERIOPERATIVE
The literature around the management of perioperative glycaemia is evolving. Several randomised control
trials have been published evaluating perioperative glucose targets for cardiac surgery. This high-risk
surgical group provides a setting where it is feasible to randomise fewer people due to the increased power
to detect a difference. The GLUCO-CABG trial randomised people with and without T2DM to either a
conservative or intensive glucose target. In participants with T2DM, there was no difference in the
composite complication score; however, in those without T2DM (48% vs. 49%), there was a lower
complication score in the intensive glucose target group (34% vs. 55%) . A subsequent pilot RCT
[41]
randomised 60 people without T2DM to preoperative (24 h beforehand) sitagliptin or placebo and found no
[42]
impact on perioperative hyperglycaemia and the need for insulin therapy . These outcomes appear to
apply to non-cardiac surgery, where observational studies show similar findings. A retrospective study from
van den Boom et al. has shown that HbA1c is a good predictor of perioperative glucose levels in both
cardiac and non-cardiac surgery. However, it has challenged the evidence on HbA1c as a predictive marker
for 30-day mortality . Observational studies have shown that people with T2DM undergoing laparoscopic
[43]
cholecystectomy are 17% more likely to have a more than three-day stay if preoperative glucose levels were
≥ 128 mg/dL (taken within 48 h before surgery) . This has also been shown for elective laparoscopic
[44]
nephrectomy for renal cancer and elective orthopaedic, colorectal and breast surgery [45-49] . Liraglutide, a
GLP1 receptor agonist, has been suggested as a possible perioperative agent as an alternative to insulin in