Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions
Metabolic Surgery as Treatment Option for T2D
JAMA; 2017 Feb 14; Brito, Montori, et al
Metabolic surgery is recommended as an option in type 2 diabetes (T2D) patients with a body mass index (BMI) of 40 or higher regardless of glycemic control or complexity of medical regimen, and in patients with a BMI of 35-39.9 with poorly controlled diabetes despite optimal therapy. It may be considered an option for obese T2D patients with class I obesity and poorly controlled diabetes, according to a joint statement by international diabetes organizations and developed by delegates of the Second Diabetes Surgery Summit. The joint statement targets patients with T2D and includes the following recommendations:
- Metabolic surgery is recommended as an option to T2D patients with class III obesity (BMI ≥40) regardless of glycemic control or complexity or glucose-lowering regiments and in patients with class II obesity (BMI 35.0 to 39.9) with inadequately controlled hyperglycemia despite lifestyle and optimal medical therapy.
- Metabolic surgery should be considered to treat T2D patients with class I obesity (BMI 30.0 to 34.9) and inadequately controlled hyperglycemia despite optimal medical treatment by oral or injectable medications (including insulin).
- Metabolic surgery should be performed in high-volume centers with multidisciplinary teams experienced in the management of diabetes and gastrointestinal surgery.
Brito JP, Montori VM, Davis AM. Metabolic surgery in the treatment algorithm for type 2 diabetes. A joint statement by International Diabetes Organizations. JAMA. 2017;317(6):635-636. doi:10.1001/jama.2016.20563.
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It is important to note that this surgery has been renamed from “bariatric” surgery to “metabolic” surgery. In addition to weight loss, these procedures lead to changes in gut hormones, microbiome, and intestinal glucose metabolism that all lead to beneficial effects on diabetes control.1 Over 15 randomized trials have looked at the effect of metabolic surgery on diabetes outcomes and have shown impressive results. Metabolic surgery is more effective than medical therapy with lifestyle intervention in achieving both control of diabetes (A1c<6.5%) and remission of diabetes (A1c<5.7%), with an odds ratio of 8.5. It is important to recognize that about 50% of patients who initially have a diabetes remission do develop diabetes again over time. Also, surgery is not without risk and often leads to long-term nutrition and micronutrient deficiency. The mortality rate with metabolic surgery is 0.1% to 0.5%, the rate of major complications 2% to 6%, and the rate of reoperations or revision over 5 to 10 years is 0.6% to 20%, depending upon the study. It is an area where there is significant benefit but also significant risk and it is now on the map to consider in the treatment of diabetes. An approach of shared decision making and discussing potential benefits and risks remains important. —Neil Skolnik, MD