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Is treating diabetes with surgery the way to go?

Robin Wulffson MD's picture
bariatric surgery, weight loss surgery, type 2 diabetes, diet, complications

Type 2 diabetes is on the increase in the United States. This rise is directly related to the increase in obesity. Last July, the Centers for Disease Control and Prevention (CDC) noted that despite a steady mantra of warnings that obesity causes serious health problems and increases the risk of premature death, it has become a problem in every state. Type 2 diabetics who can shed those excess pounds can often rid themselves of diabetes as well. This can be accomplished through a diet and exercise program; however, many who embark on a weight loss program fail. For those individuals, bariatric surgery is an option.

Also known as weight loss surgery, the procedure involves reducing the size of the stomach and may also include modifying the way food passes through the intestinal tract. It is often done via laparoscopy.

Researchers at Catholic University in Rome, Italy conducted a study to evaluate whether bariatric surgery was superior to standard medical treatment for patients with type 2 diabetes. They published their findings online on March 26 in the New England Journal of Medicine.

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The investigators conducted a randomized trial, which included 150 obese patients with uncontrolled type 2 diabetes. The patients either received intensive medical therapy alone or medical therapy plus bariatric surgery. The surgical procedure was either a Roux-en-Y gastric bypass or a sleeve gastrectomy. The average age of the patients was 49 years and 66% were women. The average glycated hemoglobin level (a measurement of diabetes also known as HbA1c) was 9.2 ± 1.5%. The recommended level for this test ranges between 6.5% and 7.0%. The investigators established a successful outcome level as 6.0% or less 12 months after treatment. They noted this percentage to be the primary end point.

Most of the patients (93%) completed 12 months of follow-up. The percentage of patients who achieved the primary end point was 5 of 41 patients (12%) in the medical-therapy group versus 21 of 50 patients (42%) in the gastric-bypass group and 18 of 49 (37%) in the sleeve-gastrectomy group. Glycemic control improved in all three groups; the average glycated hemoglobin level was 7.5 ± 1.8% in the medical-therapy group, 6.4 ± 0.9% in the gastric-bypass group, and 6.6 ± 1.0% in the sleeve-gastrectomy group. Greater weight loss was achieved in the gastric-bypass group (64.7 ± 20 lbs) and sleeve-gastrectomy group (55.2 ± 18.7 lbs) than in the medical-therapy group (11.9 ± 17.6 lbs). The use of medications to lower glucose, lipid, and blood-pressure levels decreased significantly after both surgical procedures; however, those levels increased in patients receiving medical therapy only. The index for homeostasis model assessment of insulin resistance (HOMA-IR) improved significantly after bariatric surgery. Four patients underwent a repeat surgery. No deaths or life-threatening complications occurred.

The authors concluded that inn obese patients with uncontrolled type 2 diabetes, 12 months of medical therapy plus bariatric surgery was superior for glycemic control in significantly more patients than medical therapy alone. They noted that further research was indicated to assess the durability of their results.

Take home message:
This research confirms other studies that report that bariatric surgery not only results in weight loss but also can reverse type 2 diabetes. For those individuals who cannot successfully complete a diet and exercise program, it is an option. However, if successful, a diet and exercise program is far preferable. No surgical procedure is without risks, including death. Going under anesthesia has a risk of allergic reactions to the medications and breathing problems. Risks for any surgery include: blood clots in the legs that may travel to the lungs; infection, including in the incision, lungs (pneumonia), bladder, or kidneys; blood loss; and heart attack or stroke. Specific risks of bariatric surgery include: injury to the stomach, intestines, or other organs during surgery; leaking through the staples in the stomach after surgery, which may require an emergency surgery; and depression. Other risks may occur over time, including: breakdown of the pouch, which would require surgical repair; anemia from low iron or vitamin B12 levels, low calcium levels, which can cause early osteoporosis or other bone disorders; gallstones and gallbladder attacks, which occur more often when one loses weight rapidly; gastritis (inflamed stomach lining), heartburn, or stomach ulcers; poor nutrition; vomiting from eating more than the stomach pouch can hold; dumping syndrome (this occurs when the contents in the stomach move rapidly through the small intestine, resulting in discomfort and poor nutrition); incisional hernia, which is much more common when an open procedure is done; and kidney stones.

Reference: The New England Journal of Medicine

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