A follow-up analysis of a small randomized trial found the highest rates of long-term type 2 diabetes remission in patients randomized to biliopancreatic diversion (BPD), followed by Roux-en-Y gastric bypass (RYGB), then medical therapy. The trial, conducted at a single center in Italy, included 60 patients, all with HbA1c levels greater than 7.0% and body mass index of 35 kg/m2 or greater at baseline. Outcomes of 57 patients were analyzed at 10 years.
The analysis was published by The Lancet on Jan. 23, 2021. The following commentary by Shohinee Sarma, MD, MPH, and Lorraine L. Lipscombe, MD, MSc, was published in the ACP Journal Club section of Annals of Internal Medicine on June 1.
Although metabolic surgery has been associated with diabetes remission for up to 5 years, the trial by Mingrone and colleagues is the first to report results after 10 years of follow-up. The trial showed that metabolic surgery resulted in sustained weight loss, marked reduction in diabetes complications, and diabetes remission without medication in more than one third of patients—benefits that are clinically meaningful to patients considering invasive surgery. In this small trial, BPD offered a nonsignificantly higher likelihood of diabetes remission vs. RYGB but comparable benefits on weight loss and diabetes complications. Both surgical procedures led to higher quality of life than medical therapy, but patients who received RYGB scored modestly higher on vitality, physical role, and mental health. The BPD approach was associated with a higher risk for adverse effects related to malabsorption and is less commonly used in practice than RYGB.
Reduced 10-year cardiovascular risk and microvascular complications in the surgical groups are important secondary findings, particularly as >50% of patients in the medical therapy group were treated with agents such as sodium–glucose cotransporter-2 inhibitors or glucagon-like peptide-1 receptor agonists, which are associated with cardiovascular benefits.
Intensive weight loss management programs can induce short-term remission rates that are comparable to metabolic surgery in patients with <6 years of type 2 diabetes. Metabolic surgery should be offered to obese patients with long-standing diabetes who have failed lifestyle interventions. This trial reassures patients of the favorable long-term benefits and safety of this option.