Two new randomized trials offer new evidence that bariatric surgery is highly effective in obese patients with diabetes. The results, according to Paul Zimmet and K. George M.M. Alberti, writing in an editorial in the New England Journal of Medicine, “are likely to have a major effect on future diabetes treatment.”
In the STAMPEDE trial, which was presented at the American College of Cardiology and published simultaneously in the New England Journal of Medicine, 150 obese patients with uncontrolled type 2 diabetes were randomized to medical therapy alone or medical therapy plus either Roux-en-Y gastric bypass or sleeve gastrectomy. Philip Schauer presented the main results.
Percent of patients with glycated hemoglobin level of 6% or less at 1 year:
- medical: 12%
- gastric bypass: 42%
- sleeve gastrectomy: 37%
Mean glycated hemoglobin at one year:
- medical: 7.5
- gastric bypass: 6.4
- sleeve gastrectomy: 6.6
Weight loss at 1 year:
- medical: -5.4 kg
- gastric bypass -29.4 kg
- sleeve gastrectomy -25.1 kg
Patients in the medical-therapy group increased their use of diabetes medications while the surgical patients significantly dropped their use of these drugs. 38% of medical-therapy patients used insulin compared with only 4% and 8% in the gastric-bypass and the sleeve-gastrectomy groups.
The authors concluded that “bariatric surgery represents a potentially useful strategy for management of uncontrolled diabetes, since it has been shown to eliminate the need for diabetes medications in some patients and to markedly reduce the need for drug treatment in others.”
In a second study, also published in the New England Journal of Medicine, bariatric surgery was also found to be highly effective for diabetic subjects. 60 obese patients with diabetes were randomized to bariatric surgery (Roux-en-Y gastric bypass or biliopancreatic diversion) or conventional medical therapy.
Diabetes remission at 2 years:
- medical therapy: 0%
- gastric-bypass: 75%
- biliopancreatic-diversion: 95%
In their editorial, Zimmet andAlberti wrote that one important implication of the studies is that bariatric surgery should perhaps “not be seen as a last resort.” For some obese patients with diabetes, surgery “might well be considered earlier in the treatment.”
More than a comment, I have some questions: what about quality of life? What about interventions’ Side effects?
Is this the Eureka moment or Flavor of the decade for type 2 diabetes treatment? Hyperglycemia is not diabetes even though that is what we measure and treat in diabetes. The development of diabetes and its microvascular and macrovascular complications are genetically determined and aggravated by obesity and other risk factors. Bariatric surgery can bring about remission of hyperglycemia but not remission or cure of diabetes, as seen in these studies.
Will this glucose control induce remission of diabetic complications as well in this population in the long run? Are we trading glucose control by bariatric surgery with another life long post-surgery syndrome/disease with all other associated problems that comes with it?
The editorialists’ comment that bariatric “procedures might well be considered earlier in the treatment of obese patients with type 2 diabetes” appears to be premature if not irresponsible, granted that many of the researchers have a vested interest to overstate their case.
Joseph Chemplavil, MD