Which Bariatric Surgery Is Best for Obese Type 2 Diabetics?

November 10, 2011

By Will Boggs MD

NEW YORK (Reuters Health) Nov 08 - The best bariatric operation for type 2 diabetics depends on the patient's size and the outcome of interest, according to an October 4th online paper in Annals of Surgery.

"The RYGB (Roux-en-Y gastric bypass) should remain the gold standard for treatment of severe or greater obesity in the setting of type 2 diabetes," said lead author Dr. Robert B. Dorman in an email to Reuters Health.

He continued, "It far outperforms both medical management and the laparoscopic adjustable gastric band. For super-obese patients (BMI > 50 kg/m2), the duodenal switch should be considered; however, it should only be performed by surgeons and centers experienced in its utilization, and the patient must have a clear understanding of the increased risk for complications associated with the duodenal switch compared to the RYGB."

At the University of Minnesota in Minneapolis, Dr. Dorman and colleagues analyzed outcomes a year after surgery in 86 morbidly obese type 2 diabetics who had RYGB, 27 who had a duodenal switch procedure, and 30 who had laparoscopic adjustable gastric band surgery (LAGB). They also included a control group of 29 patients who had routine medical management.

RYGB was superior to nonsurgical treatment and to LAGB in percentage of weight lost, mean improvement in hemoglobin A1c, reduction in diabetes medication score, and resolution of diabetes.

RYGB and duodenal switch led to similar BMI and percentage of weight loss, but duodenal switch led to significantly greater improvements in HbA1c and diabetes medication scores and a higher rate of diabetes resolution (81.5% vs 48.1%; P=0.02).

Complication rates at one year were 10% for LAGB, 15.1% for RYGB, and 40.7% for duodenal switch. One-year readmission rates were 6.7% for LAGB, 11.6% for RYGB, and 14.8% for duodenal switch. There were no deaths.

"We conclude that if the endpoint is to improve HbA1c, then the duodenal switch is the superior operation compared to the RYGB for patients with a high BMI," the researchers say. "However, the higher complication rate associated with the duodenal switch precludes it from being the preferred operation."

"In our opinion," they add, "it is not appropriate to place an LAGB in a patient with severe type 2 diabetes if they are otherwise healthy enough to undergo an RYGB."

"If the duodenal switch were associated with fewer complications, say similar rates as the RYGB, then it would likely be the gold standard operation for obese patients with type 2 diabetes," Dr. Dorman said. "The severe malabsorptive nature of the procedure provides both its superior benefits as well as its most negative attributes."

He noted that the study didn't look at weight loss results five to ten years out. "The failure rate of the RYGB to maintain significant weight loss beyond the five- and 10-year time points is abysmal in patients with a pre-operative BMI > 50 kg/m2," he said. "The duodenal switch demonstrates superior long-term results related to weight loss. Therefore, the duodenal switch procedure should be offered to patients with a BMI > 50 kg/m2 if both the surgeon and the center are experienced in performing it."

SOURCE: https://bit.ly/rN2hL8

Ann Surg 2011.


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