The Relapse Riddle: Who’s at Risk After Diabetes Remission with TB Surgery?

Alright, let’s talk about something super important in the world of tackling Type 2 Diabetes (T2DM), especially when surgery comes into the picture. You know, metabolic bariatric surgery (MBS) is often a game-changer for many people with T2DM, helping them achieve remission – basically, getting their blood sugar back to normal levels without medication. It’s fantastic news! But here’s the tricky part, the “riddle” if you will: for some folks, that remission isn’t permanent. After a while, the diabetes can creep back. This study dives deep into *why* that might happen, specifically after a procedure called Sleeve Gastrectomy with Transit Bipartition (TB).

TB is one of the surgical options, maybe not as widely known as some others, but it’s gaining traction. We know that different surgeries have different success rates for getting T2DM into remission. And there are even scoring systems, like the ABCD score (that’s for Age, BMI, C-peptide, and Diabetes Duration), designed to predict how likely someone is to hit remission after MBS. We’ve seen that the ABCD score is pretty good at predicting remission after TB. But predicting remission is one thing; predicting *relapse* after you’ve already achieved that amazing remission? That’s a whole different ball game, and honestly, we haven’t had a ton of long-term data on it, especially for TB.

Digging into the Data: What They Looked At

So, what did these researchers do? They went back and looked at the records of patients who had TB surgery, achieved complete remission (CR) from T2DM, and were followed for *more than 5 years*. That long follow-up is key because relapse often happens down the road. They analyzed data from 56 patients – a decent group for this kind of long-term look at a specific procedure. The median follow-up time was 71 months, which is over 5 years, stretching up to 101 months for some.

Out of these 56 patients who were initially free from diabetes after surgery, 11 of them, or about 19.6%, saw their T2DM relapse during the follow-up period. That might sound like a bummer, and yeah, it is disappointing for those individuals. But understanding *why* it happened to them is crucial for helping future patients.

The ABCD Score Strikes Again (But Differently)

Remember the ABCD score I mentioned? It’s usually used to predict *remission*. Well, this study found it’s also a really strong predictor for *relapse*, but in reverse! Patients who had a *lower* ABCD score (less than 4 points) *before* surgery had a significantly higher chance of relapsing after achieving remission. Think about that: a lower score initially meant they were less likely to get into remission in the first place, and if they *did* achieve it, they were much more likely to lose it.

The numbers back this up big time. For patients with an ABCD score less than 4, the relapse rate was a whopping 76.9% compared to just 2.3% in those with a score of 4 or higher. The ABCD score, with that < 4 cut-off, was pretty spot on for predicting relapse, showing high sensitivity (90.9%) and specificity (93.3%). It's like a warning sign we can look at *before* surgery.

Beyond the Score: Other Risk Factors Emerge

The ABCD score isn’t the only piece of the puzzle, though. The study identified several other preoperative factors that increased the risk of relapse:

• Lower C-peptide level: C-peptide is a marker of how much insulin your pancreas is making. A lower level suggests your beta cells (the insulin-producing ones) aren’t working as well. If your beta cells are already struggling before surgery, it makes sense that maintaining remission long-term might be harder.
• Higher LDL-cholesterol level: This is often called “bad” cholesterol. Higher levels point to broader metabolic issues, and this study suggests it’s linked to relapse risk.
• Longer duration of T2DM: This is a factor that pops up in many studies. The longer you’ve had diabetes, the more established the disease is, and potentially, the more damage has been done to your beta cells and other systems. It makes sense that achieving and maintaining remission would be tougher.
• Higher FIB-4 index: This one is really interesting! The FIB-4 index is a calculation based on blood tests (age, AST, ALT, platelet count) used to estimate liver fibrosis, often due to Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as NAFLD. This study found that a higher FIB-4 index, suggesting worse liver fibrosis, was a significant risk factor for T2DM relapse. This is a pretty novel finding and highlights the connection between liver health and diabetes outcomes after surgery.

So, if you had TB surgery and achieved remission, but *before* surgery you had a low C-peptide, high LDL, had diabetes for a long time, a low ABCD score, or signs of liver fibrosis, this study suggests you might be at a higher risk of the diabetes coming back.

Putting It in Perspective: Comparing Notes

Relapse after MBS remission isn’t unique to TB. Other studies on procedures like Roux-en-Y Gastric Bypass (RYGB) and standard Sleeve Gastrectomy (SG) have also reported relapse rates, though the numbers vary quite a bit depending on the study, the follow-up time, and how they define relapse. Some studies have pointed to factors like less weight loss, weight regain, gender (women), and the number of medications used before surgery as potential risk factors for relapse.

What’s interesting in *this* study on TB is that while they confirmed that longer diabetes duration and poor beta-cell function (low C-peptide) are risk factors, they *didn’t* find gender or the number of antidiabetic medications to be independent predictors of late relapse in this particular group. This could be due to various reasons, maybe even how well controlled the patients were before surgery.

The finding about liver fibrosis (via the FIB-4 index) being linked to relapse is particularly noteworthy because it hasn’t been widely studied in the context of T2DM relapse after MBS. It adds another layer to understanding the complex metabolic picture.

What Does This Mean for You (or Someone You Know)?

This study, despite its limitations (it was retrospective, a relatively small number of patients for a long-term study, and some patients were lost to follow-up – which is common in long-term research!), provides valuable insights. It’s the first to specifically look at long-term relapse risk after TB surgery and link it to preoperative factors, especially the severity of diabetes.

The biggest takeaway? If someone has T2DM and is considering TB surgery, or has had it and achieved remission:

• Pay close attention to that ABCD score before surgery. If it’s less than 4, the risk of relapse after achieving remission is significantly higher. These patients definitely need closer monitoring *after* surgery, even if they hit remission.
• Consider assessing liver health. Since liver fibrosis seems linked to relapse, maybe tools like elastosonography or even a liver biopsy during surgery could help identify those at higher risk. Knowing this might influence the choice of surgical procedure (perhaps a different type of MBS known for stronger anti-diabetic effects) or lead to even more intensive post-operative follow-up and lifestyle support.
• Factors like diabetes duration, C-peptide levels, and LDL cholesterol are also important pieces of the puzzle.

Basically, it reinforces the idea that not all T2DM is the same, and the risk of relapse after surgery varies depending on your metabolic profile *before* the operation. While achieving remission is a huge win, understanding these risk factors helps doctors and patients prepare for the long haul and tailor follow-up care. It’s about staying ahead of the curve and giving everyone the best possible chance at long-term health.

Source: Springer