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

Diabetes Care. 2011;34(3):763-770.

Conclusions

Emerging data suggest that bariatric surgery results in substantial improvements in glycemia, blood pressure, and cholesterol; weight loss is durable; survival may be improved; and surgical risks are low. Novel surgical approaches are under development. At the same time, there have been substantial medical advances, and multiple pharmacologic agents are now available to treat diabetes and manage cardiovascular risk; pharmacologic weight loss agents and multipronged lifestyle strategies with multidisciplinary care are showing promise. Understanding the relative risks and benefits of different treatment approaches for individuals with type 2 diabetes, as well as the health care and other costs of such treatments, on a societal level will be of utmost importance in the coming years. Lessons from the study of the neurohormonal changes after bariatric surgery may inform not only the best surgical procedure but also lead to development of novel medical therapies, gastrointestinal interventions, or combination approaches to offer optimal management for the prevention or treatment of type 2 diabetes.

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Acknowledgments
This research was supported by National Institutes of Health Grants 1RC1-DK-086918 and KL2-RR-025757 (to F.H.), and DERC P30-DK-36836.
Additional funds and supplies to support the trial are provided by Covidien; Nestle; LifeScan, a Division of Johnson & Johnson; and Mercodia. D.L. has worked occasionally as a consultant for Covidien, largely reviewing their instrumentation; this has always been less than $2000/year and has always been vetted by the Brigham and Women's Hospital Corporate Sponsored Research office. Neither D.L. nor A.B.G. has personal financial interest in Covidien. No other potential conflicts of interest relevant to this article were reported. The authors note they are conducting an investigator-initiated clinical trial sponsored by the National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases (clinical trials identifier NCT01073020).
D.L., F.H., A.G.-F., and A.B.G. researched data and wrote and edited the article.
The authors thank Dr. Mary Elizabeth Patti, Joslin Diabetes Center, and Dr. Donald Simonson, Brigham and Women's Hospital, for thoughtful discussions.

Cite this: The Great Debate: Medicine or Surgery - Medscape - Mar 01, 2011.

Table 1. Ongoing randomized controlled trials comparing various surgical and medical treatment strategies for type 2 diabetes (as listed on Clinicaltrials.gov)
Study name [trial identifier]	Institution	Interventions	Primary outcomes	BMI range (kg/m²)	Duration of follow-up	Estimated enrollment
Surgery or Lifestyle Intervention for Type 2 Diabetes (SOLID) [NCT01040468]	University of Pennsylvania	Surgical: RYGB; LAGB Medical: intensive lifestyle modification	Rates of diabetes remission over 1 year (definition not specified)	30–40	1 year	32
Trial to Compare Surgical and Medical Treatments for Type 2 Diabetes (TRIABETES) [NCT01047735]	University of Pittsburgh	Surgical: RYGB;LAGB Medical: lifestyle weight loss intervention	Feasibility study	30–40	1 year	60
Diet and Medical Therapy Versus Bariatric Surgery in Type 2 Diabetes (DIBASY) [NCT00888836]	Catholic University of the Sacred Heart	Surgical: RYGB; BPD Medical: antidiabetic drugs and behavioral suggestions	Inductions of partial or total remission of diabetes (definition not specified)	>35	2 years	100
Laparoscopic Bariatric Surgery to Treat Type 2 Diabetes in Obese Patients [NCT00428571]	McMaster University (Canada)	Surgical: RYGB; LAGB Medical: intensive medical management (medication, diet, lifestyle)	Diabetes control as assessed by HbA_1c	30–40		72
Surgery or Lifestyle With Intensive Medical Management in the Treatment of Type 2 Diabetes (SLIMM-T2D) [NCT01073020]	Joslin Diabetes Center and Brigham and Women's Hospital	Surgical: RYGB; LAGB Medical: intensive medical diabetes and weight management	Diabetes control at 1 year, defined by FPG <126 mg/dL and HbA_1c <6.5%	30–42	3 years	100
Diabetes Surgery Study: Intensive Medical Management of Type 2 Diabetes With and Without Gastric Bypass Surgery (DSS) [NCT00641251]	Multinational (University of Minnesota, Columbia University; Taiwan)	Surgical: RYBG Medical: intensive medical management	HbA_1c <7% SBP <130 mmHg LDL <100 mg/dL	30–40	1 year	120
A Surgical Approach to the Management of Type 2 Diabetes Mellitus in Patients With a BMI Between 25 and 35 kg/m² [NCT01197963]	University of Texas Health Science Center, Houston	Surgical: sleeve gastrectomy and ileal transposition Medical: dietary and medical management	Resolution of diabetes defined by FPG <100 mg/dL and HbA_1c <6%	25–35	Not provided	20 (Not yet enrolling)
Surgical Therapy And Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) [NCT00432809]	The Cleveland Clinic	Surgical: RYGB Medical: advanced medical therapy for diabetes	Resolution of diabetes at 1 year, defined by HbA_1c <6%	27–43	1 year	150
Multicentric Prospective Randomized Trial on Surgery Versus Standard Medical Care in Type 2 Diabetic Patients BMI 30–35 kg/m² (DIA-CHIR-MULT) [NCT010417568]	Azienda Ospedaliera Universitaria San Martino (multicenter)	Surgical: BPD; RYGB Medical: medical management of diabetes	Complete remission (HbA_1c <6%) or control (HbA_1c 6.1–7.1%) of diabetes without antidiabetic medications	30–35	5 years	300
Prospective Randomized Trials of Gastric Bypass Surgery in Patients With Type II Diabetes Mellitus [NCT00540462]	Min-Sheng General Hospital	Surgical: RYGB, sleeve gastrectomy Medical: medical management of diabetes/no intervention	Blood glucose levels, HbA_1c levels, need for medications, OGTT, MMTT	27–35	1 year	120
Sleeve Gastrectomy Versus Medical Management for Remission of Diabetes in Mild to Moderately Obese Patients [NCT00965302]	Wilford Hall Medical Center	Surgical: LSG Medical: intensive medical management	Diabetes remission (definition not specified)	30–34.9	1 year	70

BPD, biliopancreatic diversion.

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The Great Debate: Medicine or Surgery

What Is Best for the Patient With Type 2 Diabetes?

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