The Great Debate: Medicine or Surgery

What Is Best for the Patient With Type 2 Diabetes?

David Lautz, MD; Florencia Halperin, MD; Ann Goebel-Fabbri, PHD; Allison B. Goldfine, MD

Disclosures

Diabetes Care. 2011;34(3):763-770. 

In This Article

Abstract and Introduction

Introduction

In 1991, a National Institutes of Heath expert consensus panel recommended bariatric surgery to treat obesity for informed and motivated patients with BMI >40 kg/m2, or between 35 and 40 kg/m2 with high-risk comorbid conditions including diabetes, in whom operative risks are acceptable.[1] In December 2010, these guidelines were reviewed by the Gastroenterology and Urology Devices Panel of the Medical Devices Advisory Committee of the Food and Drug Administration, with recommendation to lower the criteria for use of the laparoscopic adjustable gastric band to BMI >30 kg/m2 for patients with comorbidity. Surgical treatments of obesity induce impressive absolute weight loss of 30–40 kg (~60% excess weight, or a 10–15 kg/m2 reduction in BMI),[2] which may be sustained over 10–15 years.[3] Increasing medical and public awareness of sustained weight loss, increased ease of recovery, and lowered complications with newer laparoscopic surgical procedures and the ongoing increased incidence of obesity have contributed to a 15-fold increase in bariatric surgical procedures in the past decade, with estimates of >200,000 procedures having been performed in the United States in 2007.[4]

Recent observational studies demonstrate that bariatric surgical procedures reduce the incidence of type 2 diabetes and lead to substantial improvement or "resolution" for many patients with preexisting disease. Type 2 diabetes has "resolved" (defined in the surgical literature as maintenance of normal blood glucose after discontinuation of all diabetes-related medications, in most studies with HbA1c <7%) in ~77% of patients who undergo obesity surgery, and resolved or improved in ~85%, with sustained improvements in multiple metabolic measures, such as fasting plasma glucose and insulin, percent glycosylated hemoglobin, and use of antidiabetic medications.[2,5–9] Patients with shorter duration of disease seem to have more complete or sustained disease resolution.[10] Furthermore, dyslipidemias and hypertension markedly improve or resolve in 70–95% and 87–95% of surgically treated patients, respectively. In one observational study, gastric bypass surgery resulted in a 40% decreased relative risk of death compared with matched control patients, and diabetes-related deaths were reduced by 92%.[11] Health economic evaluations suggest reductions in use of medications and overall health care costs for patients with type 2 diabetes who have undergone bariatric surgery.[8] Although some physicians consider bariatric surgery draconian,[12] these data suggest important health benefits of surgical interventions in patients with type 2 diabetes with BMI >35 kg/m2 and raise the question of whether surgical interventions should be considered earlier in the course of disease or for lesser magnitude of excess weight and specifically for the treatment of diabetes as opposed to treatment of obesity.

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