Spotlight on bariatric surgery
Three comparisons of bariatric surgery and medical management for obese type 2 diabetes patients were recently published in journals of the American Medical Association.
Three comparisons of bariatric surgery and medical management for obese type 2 diabetes patients were recently published in journals of the American Medical Association.
New observational data from the Swedish Obese Subjects study revealed the long-term effects of gastric banding, gastric bypass, or usual care on a study subset of more than 500 diabetic patients, all recruited between 1997 and 2001. Two years after surgery, 16.4% of control patients had diabetes remission (blood glucose <100 mg/dL [5.55 mmol/L] without medication) compared to 72.3% of surgery patients. However, at 15 years, remission rates had dropped to 6.5% in controls and 30.4% in surgery patients. The surgery group had a significantly lower rate of both microvascular (20.6 vs. 41.8 per 1,000 person-years) and macrovascular (31.7 vs. 44.2 per 1,000 person-years) complications. The results, published June 11 in the Journal of the American Medical Association, indicate that bariatric surgery is associated with more diabetes remission and fewer complications than usual care, but the findings require confirmation in randomized trials, the authors said.
Researchers from the U.S. conducted such a randomized trial, published on June 4 by JAMA Surgery, which assigned patients to either Roux-en-Y gastric bypass (RYGB) or an intensive medical and weight management program. They followed the 38 patients (who were age 21 to 65 years with a body mass index [BMI] of 30 to 42 kg/m2 and an HbA1c ≥6.5%) for a year after treatment. Patients in the surgery group had greater weight loss and improvement in cardiovascular risk factors. They were also more likely to achieve the study's main outcome of fasting glucose <126 mg/dL (7 mmol/L) and HbA1c <6.5% (58% vs. 16%; P=0.03). The study shows the potential utility of RYGB to treat type 2 diabetes, even in moderately obese patients, as well as the feasibility of randomized trials to evaluate this and other bariatric surgery approaches, the authors concluded.
However, a similar study, also published by JAMA Surgery on June 4, concluded that there are several potential challenges to randomized comparison of surgical and medical treatments for diabetes. The study compared RYGB, gastric banding, and an intensive weight loss intervention in patients age 25 to 55 years with diabetes and BMI between 30 and 40 kg/m2. After screening more than 600 patients, they randomized 69 among the 3 treatments, after which another 10% dropped out of the study. In an intention-to-treat analysis at 1 year, RYGB was associated with more mean weight loss and partial and complete remission from diabetes, followed by gastric banding, then the lifestyle intervention. No patients in the lifestyle group achieved remission, and both surgery groups had significant reductions in medication use. The authors concluded that these preliminary results suggest that RYGB is the most effective treatment, although the lower risk and reversibility of gastric banding may make it another treatment option for some patients. The results should be confirmed, but difficulties with recruitment and retention may pose obstacles to a large randomized, controlled trial, the authors concluded.