Bariatric Surgery Recommended for Obese Patients With Type 2 Diabetes

March 28, 2011

March 28, 2011 — Bariatric surgery is an appropriate treatment for people with type 2 diabetes who are obese, the International Diabetes Federation (IDF) announced today.

Although such operations cost anywhere from $20,000 to $30,000, they will reduce healthcare expenditures in the long run, according to a new IDF position paper on the subject. The surgery, the IDF explains, often normalizes blood glucose levels and reduces or avoids the need for medication.

Dr. Francesco Rubino

In addition, curbing diabetes can stave off costly complications such as blindness, limb amputations, and dialysis, said Francesco Rubino, MD, director of the IDF's 2nd World Congress on Interventional Therapies for Type 2 Diabetes, meeting today in New York City.

"When we talk about whether we can afford bariatric surgery, we have to ask what will be the cost if we don't treat the patient," Dr. Rubino told Medscape Medical News. "Studies have shown the surgery to be cost-effective. So there is a return on investment."

The IDF puts the lifetime cost of diabetes in the United States at $172,000 for a person diagnosed at age 50 years and $305,000 at age 30 years. More than 60% of this amount is incurred in the first 10 years after diagnosis.

Under the new IDF guidelines, patients with type 2 diabetes warrant bariatric surgery when their body mass index is 35 kg/m2 or higher, or when it is between 30 and 35 kg/m2 and their diabetes cannot be controlled by medicine and lifestyle changes. This latter indication is even stronger when there are other major cardiovascular risk factors, including hypertension, hyperlipidemia, and a history of heart attacks, said Dr. Rubino, chief of the Gastrointestinal Metabolic Surgery Program at New York-Presbyterian Hospital/Weill Cornell Medical Center.

The body mass index action points can be reduced by 2.5 kg/m2 for Asians.

The guidelines were drawn up by an IDF taskforce of diabetologists, endocrinologists, surgeons, and public health experts who met in December 2010.

Trials Needed to Compare Surgical Procedures

The new recommended indications for performing bariatric surgery on patients who are both diabetic and obese match those announced last month by the US Food and Drug Administration for expanded use of the Lap-Band Adjustable Gastric Banding System (Allergan) to treat obesity.

The US Food and Drug Administration originally approved the product, designed for laparoscopic adjustable gastric banding (LAGB), for adults with a BMI of 40 kg/m2 or higher and those with a BMI of 35 kg/m2 or higher who have additional risk factors. Under the expanded indications, the LAGB system also can be used for adults with a BMI of 30 to 40 kg/m2 and 1 additional obesity-related condition who have failed to lose weight despite diet, exercise, and pharmacotherapy.

The use of bariatric surgery to treat diabetes has sparked controversy in healthcare circles. Critics question the wisdom of wielding a scalpel to solve a medical problem, especially when clinicians have more drugs at their disposal to deal with diabetes.

At the same time, a study published online last week in the Archives of Surgery has raised doubts about the efficacy of LAGB. Researchers following 151 patients who underwent LAGB for obesity concluded that the procedure yielded "relatively poor long-term outcomes," with nearly half the patients needing their bands removed and 60% overall requiring some kind of reoperation. The authors, who performed the surgeries in question during the mid-1990s, added a caveat: they had used an older dissection technique.

"The band is only one option," Dr. Rubino told Medscape Medical News, noting that gastric bypass procedures have demonstrated a greater endocrine effect than LAGB. "We are learning that some types of diabetes are well treated by lap-banding early in the disease process. The answer is in patient selection."

The IDF taskforce calls for randomized controlled trials to compare different bariatric procedures for diabetes between themselves, "as well as emerging non-surgical therapies."

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