Metabolic surgery in diabetes
Patient and procedure selection
Metabolic surgery in the treatment algorithm for type 2 diabetes: A joint statement by international diabetes organizations
This joint statement, developed by several international diabetes organizations, provides guidelines regarding metabolic surgery in the treatment of type 2 diabetes mellitus.
| Summary points |
- The 2nd Diabetes Surgery Summit (DSS-II), involving the American Diabetes Association, International Diabetes Federation, Chinese Diabetes Society, Diabetes India, European Association for the Study of Diabetes, and Diabetes UK, was convened to review available evidence and develop recommendations integrating medical and surgical therapies in a treatment algorithm for type 2 diabetes mellitus (T2DM).
- The gastrointestinal tract is an important target for T2DM treatment, and metabolic surgery has been shown to achieve excellent results in terms of control of hyperglycemia and reduction of cardiovascular risk factors.
- Several bariatric surgeries are associated with T2DM remission in most patients, and although such remission has been shown to erode over time, a substantial proportion of patients experience prolonged benefits – for example, the median disease-free period following Roux-en-Y gastric bypass surgery is 8.3 years.
- In those who are appropriate surgical candidates, metabolic surgery should be a recommended treatment option for T2DM in patients with class III obesity (body mass index [BMI] ≥40 kg/m2) regardless of level of glycemic control and in patients with class II obesity (BMI 35.0–39.9 kg/m2) with inadequately controlled hyperglycemia despite lifestyle and optimal medical therapy.
- Metabolic surgery should be considered an option in type 1 diabetes mellitus patients with class I obesity (BMI 30.0–34.9 kg/m2) and inadequately controlled hyperglycemia despite treatment.
- Metabolic surgery should be performed in high-volume centers utilizing multidisciplinary teams.
- Ongoing long-term monitoring of micronutrient status, nutritional supplementation and support is necessary following surgery.
- Metabolic surgery is a potentially cost-effective treatment option in obese patients with T2DM.
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Rubino F et al. Diabetes Care 2016; 39: 861-877. doi: 10.2337/dc16-0236
Operation of choice for metabolic surgery
This chapter discusses the various currently accepted metabolic surgeries in the treatment of type 2 diabetes mellitus, in terms of current evidence and potential mechanisms.
| Summary points |
- The International Diabetes Federation considers Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (SG), biliopancreatic diversion (BPD), and the duodenal switch variant (BPD-DS) as accepted metabolic procedures.
- Observational and nonrandomized trials have shown marked sustained improvement in type 2 diabetes mellitus (T2DM) in morbidly obese and less obese patients following metabolic surgery. For example, meta-analyses involving >100 studies have shown 80% early complete diabetes remission and 75% remission >2 years after surgery.
- Recent evidence from randomized controlled trials indicates that bariatric surgery is superior to conventional medical therapy for management of T2DM.
- There are few high-quality studies comparing the various surgical procedures in terms of diabetes outcomes, but overall, the diversionary procedures have been shown to have more profound effects on metabolic measures than non-diversionary procedures.
- The standard metabolic procedures each have their own risks and benefits, with more extensive procedures such as BPD associated with greater weight loss and metabolic benefits but also with greater risk.
- The exact mechanisms for the metabolic effects of the various surgical procedures remain to be elucidated. Based on available evidence, potential mechanisms include: physical restriction in meal size; attenuation of appetite mediated by reduction in ghrelin following SG and RYGB; loss of fat mass leading to normalization of inflammatory cytokines and adipokines, resulting in improved insulin sensitivity.
- LAGB and SG are the safest but least effective procedures for glycemic control; RYGB carries more risk but is much more effective. BPD appears to be the most effective antidiabetic procedure but is associated with higher risk.
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Schauer PR, Aminian A, Brethauer SA. In: The ASMBS textbook of bariatric surgery: Volume 1 bariatric surgery. Edited by Nguyen NT et al. Springer-Verlag New York, 2015; 1: 331. doi: 10.1007/978-1-4939-1206-3_29
Bariatric surgery: A potential treatment for type 2 diabetes in youth
Here, the authors review the burden of type 2 diabetes among adolescents and discuss bariatric surgery in this population.
| Summary points |
- The incidence and prevalence of type 2 diabetes mellitus (T2DM) in adolescents are increasing markedly, with nearly 85,000 adolescents predicted to be affected by 2050 in the US.
- Available evidence suggests that T2DM may have a more aggressive pathogenesis in adolescents than in adults, with a more rapid decline in β-cell function, requiring more intensive medication and greater need for insulin.
- Potential complications of T2DM in adolescents include cardiovascular complications, renal complications, and cerebrovascular complications.
- Lifestyle interventions and medical therapies are often ineffective in this patient population, hence weight-loss procedures are being examined as options for the treatment of obesity and T2DM in adolescents.
- Studies have shown substantial improvements in weight and cardiovascular risk in youth following various bariatric weight-loss procedures, and improvements in glucose and carbohydrate metabolism following gastric bypass surgery in adolescents with and without T2DM have also been observed.
- There is some evidence to suggest that remission rates following gastric bypass and vertical sleeve gastrectomy may be even greater among adolescents than adults with T2DM.
- The risks of bariatric surgery, both surgical and nutritional complications, must be considered.
- When considering timing of surgery in severely obese adolescents, diabetes duration, the speed of treatment escalation, glycemic control and rate of β-cell decline following diagnosis should be key considerations.
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Shah AS et al. Diabetes Care 2016; 39: 934–940. doi: 10.2337/dc16-0067