Review Article“Metabolic” Surgery For Treatment Of Type 2 Diabetes Mellitus
Section snippets
INTRODUCTION
Type 2 diabetes mellitus (T2DM) is a prevalent disease associated with major comorbidities. In fact, the prevalence has increased rapidly during the past several decades (1). In 2005, it was estimated that more than 20 million people in the United States had diabetes, with approximately 30% being undiagnosed cases (2). Recent projections predict that the prevalence will continue to increase to more than 48 million Americans by 2050 (3).
The costs associated with diabetes are monumental.
LIMITATIONS OF CONVENTIONAL TREATMENT OF T2DM
Currently, diabetes is considered a chronic disease that necessitates ongoing medical therapy and self-management by the patient to decrease the risk of long-term complications, including both macrovascular and microvascular disease (9). Although intensive medical treatment and adequate glycemic control can reduce the risk of microvascular complications (10), reduction of macrovascular disease and cardiovascular mortality remains difficult to achieve with conventional therapeutic strategies.
The
BENEFITS OF BARIATRIC—OR “METABOLIC”—SURGERY
Currently, substantial evidence indicates that gastrointestinal bypass procedures performed in patients with T2DM and obesity can frequently induce long-term remission of diabetes. In a recent meta-analysis, Buchwald et al (5) found complete resolution of diabetes in 78.1% of patients who underwent bariatric surgery and resolution or improvement of diabetes in 86.6% of patients. Resolution was defined as discontinuation of all diabetes-related medications and maintenance of blood glucose levels
A RISK-BENEFIT ANALYSIS
Examination of mortality data related to diabetes managed by conventional treatment strategies is worthwhile. In the 10-year follow-up of UKPDS patients (individuals newly diagnosed with T2DM at the time of study entry), the overall mortality was 44%, with cardiovascular disease being the leading cause of death (51.5%) (11). Further support for the significant effects of T2DM on mortality is derived from a cohort study performed by Stamler et al (33). During a mean follow-up of 12 years, men
COST-EFFECTIVENESS OF METABOLIC SURGERY
The improvements in mortality and morbidity have led to reduced health care utilization in patients who have undergone bariatric surgery in comparison with control subjects 19., 38., 39.. A recent study (8) analyzed the effect of bariatric surgery on direct medical costs, focusing on the time required for third-party payers to recover the initial investment associated with bariatric surgery. After bariatric surgery patients were matched with obese control patients who did not undergo surgical
INDICATIONS FOR SURGICAL TREATMENT OF T2DM SHOULD NOT BE PRIMARILY BASED ON BODY MASS INDEX
Current National Institutes of Health guidelines define eligibility for surgical management of morbid obesity by using criteria that are primarily based on body mass index (BMI—weight in kilograms divided by height in meters squared). Specifically, patients with a BMI > 40 kg/m2 or those with a BMI > 35 kg/m2 with comorbidities (including diabetes) are eligible for surgical management of their obesity (49). In more general terms, BMI has been adopted worldwide as the predominant measure to guide
FUTURE DIRECTIONS
Although the preliminary data from studies on the effectiveness of surgical treatment of diabetes in patients with a BMI of less than 35 kg/m2 are encouraging, it is still premature to consider a surgical approach generally indicated in nonobese patients. In fact, because of the lack of well-controlled studies, it is not clear whether surgical intervention would yield satisfactory long-term efficacy and safety in patients with lesser degrees of obesity.
A large multicenter randomized clinical
CONCLUSION
Overall, T2DM is a prevalent disease associated with substantial health care costs. Both microvascular disease and macrovascular disease are responsible for the considerable morbidity and costs of diabetes. Several studies have demonstrated the benefit of intensive control of serum glucose levels, blood pressure, and the lipid profile in decreasing microvascular and macrovascular disease in patients with diabetes. Unfortunately, the current standards of long-term medical and lifestyle
DISCLOSURE
Dr. Rubino is a consultant for Covidien, Ethicon, GI Dynamics, and NGM Biopharmaceuticals; serves on the Scientific Advisory Board for GI Dynamics; and is on the speakers’ bureaus for Covidien and Ethicon. The other authors have no conflicts of interest to disclose.
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Cited by (22)
Obesity and inactivity, not hyperglycemia, cause exercise intolerance in individuals with type 2 diabetes: Solving the obesity and inactivity versus hyperglycemia causality dilemma
2019, Medical HypothesesCitation Excerpt :However, weight loss surgery in those who are obese is also an effective measure to treat diabetes [43]. Many individuals are able to maintain normal blood sugar levels with little or no medication following surgery [44] and long-term mortality is decreased [45]. Overweight and obese individuals have lower fitness levels due, in part, to being more sedentary than the general population [46] and having excess weight [47].
Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient-2013 update: Cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery
2013, Endocrine PracticeCitation Excerpt :Additionally, the BOLD data reported that the risk of VTE was greater in patients with an IVC filter (hazard ratio 7.66, 95% confidence interval 4.55-12.91) (303 [EL 3, SS]). R40(67-71). The principal update concerns leaks following LSG (305 [EL 3, CCS]; 306 [EL 3, SS]; 307 [EL 2, MNRCT]; 308 [EL 3, CCS]; 309 [EL 4, review]; 310 [EL 4, NE]; 311 [EL 4, position]).
Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient - 2013 update: Cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery
2013, Surgery for Obesity and Related DiseasesCitation Excerpt :Adjustable gastric banding has clearly been shown to result in improvement or remission of diabetes and metabolic syndrome (50 [EL 2, RCT]), but it appears that these effects may not be related to changes in gut hormones (67 [EL 2, PCS]). The early, weight-independent effects of RYGB, BPD/BPDDS, and LSG on T2D improvement have led many to refer to these procedures as “metabolic” operations (68 [EL 2, NRCT]; 69 [EL 2, PCS]; 70 [EL 2, NRCT]; 71 [EL 4, NE]). In a 2-year period, RYGB was associated with increased achievement of American Diabetes Association (ADA) composite endpoints (38.2% versus 10.5% with routine medical management; P<.001; A1c<7.0% + LDL-cholesterol<100 mg/dL, and systolic blood pressure [BP]<130 mm Hg) (72 [EL 3, SS]).
Bariatric surgery in patients with Type 2 diabetes: benefits, risks, indications and perspectives
2009, Diabetes and Metabolism
Published as a Rapid Electronic Article in Press at http://www.endocrinepractice.org on June 20, 2009. DOI: 10.4158/EP09170.RAR