Bariatric Surgery Follow-up Is Key for Diabetes Control

March 07, 2014

DOHA, Qatar — Sustained long-term follow-up of obese individuals with type 2 diabetes who have bariatric surgery is vital to ensure the best possible outcomes with regard to their diabetes, as well as weight loss, says one expert.

The results seen to date with this operation "are not bad, but not excellent, and I truly believe this is due to lack of follow-up," which in turn affects durability of the procedure, said Davit Sargsyan, MD, of Hamad Medical Corporation, Doha, Qatar, speaking at the Excellence in Diabetes 2014 meeting there earlier this week.

Dr. Sargsyan, who is a bariatric surgeon, reviewed the evidence to date with regard to the role of surgery for controlling type 2 diabetes and said it indicates that weight-loss surgery "is safe with modern laparoscopic techniques" and "improves quality of life." It is also cost-effective, he maintained, although he acknowledged that more work remains to be done in this area and that reimbursement is a huge issue in many countries.

He believes bariatric surgery is the best treatment option for obese diabetics with a body mass index (BMI) of 35 or greater who are not responding to lifestyle advice and medical therapy and can be considered for similar patients with a BMI of 30 to 35.

Yet the scope of the obesity/type 2 diabetes problem is so gargantuan that, in reality, there aren't enough surgeons to operate on all the people who might qualify, he said. There are 500 million morbidly obese people in the world and 382 million people living with diabetes, yet only 500,000 bariatric procedures are performed each year, half of which are done in North America.

 
We don't have enough [surgeons] or bariatric centers."
 

"We don't have enough workforce [surgeons] or bariatric centers, and it takes 10 years to train a general surgeon and another 5 years to train a bariatric surgeon," he observed, noting that in his center alone, the waiting list consists of 3600 patients. Each week, planeloads of people leave Qatar to travel to Turkey, Jordan, and Kuwait to undergo such surgery privately, because demand far outstrips supply, he explained.

Hence it is vital that endocrinologists, diabetologists, and other doctors treating the morbidly obese liaise with their surgical colleagues to identify the most appropriate patients for surgery, he added.

Surgery Bests Medical Therapy

Dr. Davit Sargsyan

Dr. Sargsyan explained that, in 2011, the International Diabetes Federation issued a ground-breaking position statement noting that bariatric surgery is an appropriate treatment for people with type 2 diabetes and obesity (if they have not achieved recommended targets with medical therapies and especially if there are other major comorbidities).

Since then, the topic of whether surgery can "cure" diabetes has been a subject of heated debate, he observed. Recently, a whole series of papers published in Lancet Diabetes & Endocrinology called for US National Institutes of Health guidelines on bariatric surgery to be revised, stressing that it should not be used simply as a final resort.

But some have argued that modern trials are needed to properly compare the outcomes of bariatric surgery with those of best medical therapy.

In Doha, Dr. Sargsyan presented the findings of a new meta-analysis, just published (Obes Surg. 2014;24:437-455), which examines weight loss and type 2 diabetes remission in 16 studies — randomized controlled trials (RCTs) and observational studies — of bariatric surgery vs conventional medical therapy, with approximately 3000 patients in each arm (mean BMI 39–41; average age 47–49; around 70% women).

After an average of 17 months of follow-up, bariatric surgery was significantly more effective than conventional medical therapy in achieving weight loss, HbA1c and fasting plasma glucose reduction, and diabetes remission. Bariatric surgery showed excess weight loss reaching to 70% to 80% in both types of study and resolution of type 2 diabetes in up to 65% of patients.

The odds of surgery patients reaching type 2 diabetes remission ranged from 9.8 to 15.8 times the odds of patients treated with conventional therapy.

However, it has become apparent that bariatric procedures do have a significant relapse rate, both in terms of weight loss and type 2 diabetes remission, Dr. Sargsyan said, noting that the 1-year data from the Swedish Obesity Study (SOS) were the first to demonstrate this.

The SOS results showed a 72% rate of remission of diabetes 2 years after surgery, which plummeted to 36% at 10 years afterward.

Shahrad Taheri, MB, PhD, FRCP, from Weill Cornell Medical College, Al-Rayyan, Qatar, told Medscape Medical News he would like to see "a head-to-head randomized [contemporary] trial of bariatric surgery vs good medical management with long-term follow-up to know what the outcomes are."

SOS was performed before statins and good antihypertensives were available and employed now-defunct surgical techniques, he noted.

 
We need that medical comparison group to see if we are giving the right treatment to the right person.
 

In the meantime, he believes an international registry of bariatric procedures is needed. "Some countries are doing that already, such as the UK National Bariatric Surgery Registry." But, he added, "We need that medical comparison group to see if we are giving the right treatment to the right person.

"Certainly there is a rise in the extremely obese patient who is difficult to manage, so surgery is good in terms of weight loss, getting them mobility, and things like that, but it shouldn't be just for curing or treating diabetes; [rather, we should look] holistically at the patient and find that this is the best option for that patient at that time," Dr. Taheri concluded.

Follow-Up Is Key to Durability; Which Is Best Procedure?

Dr. Sargsyan said that, in all of the surgical literature, it is clearly apparent that the best results come from bariatric-surgery centers "with the very best follow-up."

With few bariatric surgeons to go around, it is the endocrinologists or primary-care doctors who need to ensure they continue to see patients regularly for many years to come, he stressed.

The root of the problem "is not that surgery is a failure" but that "you have to look after your lifestyle afterward," he pointed out. "But people don't; they go back to junk food and poor lifestyles.

"Most patients are seen by you after surgery, so don't sign them off!" he appealed to the conference attendees. "This is a crucial moment: diabetologists and bariatric surgeons cannot work separately, because if we do, both of us will fail."

 
This is a crucial moment: diabetologists and bariatric surgeons cannot work separately, because if we do, both of us will fail.
 

Another unanswered question concerns the best bariatric procedure to use, the surgeon explained.

"The worldwide trend favors 2 procedures for the time being: gastric bypass and sleeve gastrectomy. Gastric bands are on the decline, and duodenal switch procedures are done in only a few centers," he explained.

All other procedures are investigational, and although there are several very promising new ones, safety and reproducibility remain to be demonstrated, "because most are complex and challenging," he noted.

Speaking to the decline of gastric-band surgery, Dr. Sargsyan said this is being "abandoned worldwide; nobody does bands anymore, they are least effective, they have a lot of complications, and once you remove them, everything comes back, weight and comorbidities.

"The only country that reports excellent results [with the band] is Australia, and their secret is in the tight follow-up they maintain, with yearly instructions to patients, yearly tests, and yearly counseling."

When to Perform Bariatric Surgery

Another oft-debated topic among the surgical community is exactly when to perform a bariatric procedure, he said.

"As we all know, the later you do [the surgery], the less the chance of complete cure, because beta-cell function deteriorates with time and [the cells] become nonresponsive to bariatric surgery."

At the American Society for Bone and Mineral Research meeting last year, Dr. Sargysan said Cleveland Clinic surgeon Philip Schauer, MD, presented a paper concluding that bariatric procedures should be offered to type 2 diabetes patients with BMI of 35 and above if they had not responded to medical treatment and were not meeting targets after 1 year. For those with a BMI of 30 to 35, surgery could be considered after 3 years of unsuccessful lifestyle change or medical therapy.

And patient pressure itself is also now playing a role, as public awareness about weight-loss surgery increases, said Dr. Sargsyan. In Qatar — where more than 70% of patients are obese, and half the population already has prediabetes or type 2 diabetes — most potential patients "are young or middle-aged," and awareness about surgery is growing year by year, "with people now also requesting the procedure for diabetes and hypertension, as well as for obesity," he explained.

Indeed, he told the tale of a 72-year-old man on whom he had recently performed bariatric surgery who — when asked whether he understood all the potential risks — had said, "Yes, my whole family already had the surgery, I am the last one."

Dr. Sargsyan said he has also performed gastric-sleeve procedures on over 100 adolescents in his center, at which point session chair Abdul Badi Abou-Samra, MD, PhD, from Hamad Medical Corporation, said one of his concerns with this would be that "such young patients might think they are cured."

In fact, this thinking is common to all in the region who undergo such operations, said Dr. Sargsyan.

Hence, there is a great need for patient education with regard to follow-up, he stressed. "People just don't come back in this region; there are almost no visits 6 months after surgery. Patients change phone numbers or locations and they don't answer emails.

 
Everything depends on how committed doctors and patients are to follow-up: these patients can never be signed off.
 

 

"Everything depends on how committed doctors and patients are to follow-up: these patients can never be signed off. Once they are 6 months out from surgery, they think they are cured, and we lose them to follow-up, and then they go back to junk food and poor lifestyles and regain weight."

People who've had bariatric surgery should be seen at least once-yearly after their operations, he concluded.

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