Sleeve Gastrectomy May Be Best at Earlier Stage of Diabetes

Marlene Busko

November 25, 2014

BOSTON — One of the first studies to look at intermediate-term outcomes following sleeve gastrectomy among obese patients with type 2 diabetes concludes that the procedure may be best at an early stage of diabetes.

The impact of sleeve gastrectomy on diabetes was significant in the first year, a trend that continued over 5 years but to varying effect depending on disease severity.

Only 10% of patients with more severe diabetes taking insulin were still in diabetes remission 5 years after surgery, compared with 59% of those taking oral antidiabetic agents and 81% of those who were on the cusp of developing diabetes but not yet taking medication for it.

"Patients with more advanced diabetes experienced the lowest rates of remission, despite having lost just about as much weight as those with lesser disease," said Dr Samantha Beaulieu-Truchon (Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC), who presented the findings at Obesity Week 2014.

"The longer one has diabetes, the more resistant it appears to be to remission. This may be an important consideration for doctors and patients who hope to achieve remission after sleeve gastrectomy," she added.

A session moderator pointed out that gastric bypass would likely provide better rates of diabetes remission than sleeve gastrectomy.

Dr Ricardo V Cohen (Oswaldo Cruz Hospital, São Paulo, Brazil) told Medscape Medical News that "several papers prove that [in the] long-term, gastric bypass is better than sleeve."

However, he acknowledged that sleeve gastrectomy is now the most popular type of bariatric surgery in the United States and that these new intermediate-term results "provide important data to help the clinician, surgeon, and patient choose the right procedure."

Sleeve Gastrectomy Now the Most Popular Procedure in the United States

In a statement issued at the meeting, the American Society for Metabolic and Bariatric Surgery (ASMBS) explained that last year sleeve gastrectomy, where surgeons remove about 80% of the stomach, "emerged as the most popular method of weight-loss surgery in America, surpassing laparoscopic gastric bypass, which had been the most common procedure for decades."

In 2013 in the United States, sleeve gastrectomy accounted for 42.1% of the 179 000 bariatric procedures performed, followed by gastric bypass (34.2%), gastric band (14%), and biliopancreatic diversion with duodenal switch (1%).

And although other studies of sleeve gastrectomy have reported diabetes remission rates of around 66% at 1 year, Dr Beaulieu-Truchon explained that little is known about longer-term diabetes remission rates or whether a patient's stage of diabetes prior to surgery helps predict the outcome.

She and her colleagues analyzed data from 173 consecutive patients aged 18 years or older with a BMI of at least 35 kg/m2 and type 2 diabetes who underwent sleeve gastrectomy at their center from January 1, 2006 to December 31, 2011.

They divided patients into three groups, depending on whether they were taking no antidiabetic drugs, oral hypoglycemic agents, or insulin at baseline.

Perhaps not surprisingly, patients taking insulin were significantly older, had had diabetes for a longer time, were taking more antidiabetic drugs, and had poorer glycemic control compared with patients in the other groups.

"Control of diabetes was worse for patients using insulin, showing that medications did not control the disease completely," Dr Beaulieu-Truchon pointed out.

Five-Year Follow-up

Patients were followed for a mean of 30 months and up to 5 years. On average, 85% of patients were retained for follow-up each year.

There was no significant difference in weight loss between the three groups. One year after the sleeve gastrectomy, on average patients lost 50% of their excess weight and their body mass index (BMI) was about 36.0 kg/m2.

At 4 years, they had lost about 44% of their excess weight. At the last follow-up, their BMI had only increased by 2.0 kg/m2.

At 1 year, among patients not taking any diabetes treatment or who were on oral drugs, average HbA1c dropped to normal levels: 5.5% and 5.9%, respectively.

In the insulin group, HbA1c dropped to 6.9% at 1 year, but gradually crept up to presurgery levels at 5 years.

For each increase in the number of antidiabetic drugs taken, the odds of diabetes remission were reduced by 69%. Also, for each increase in the number of years of diabetes, the odds of diabetes remission were reduced by 14%.

Baseline Characteristics of the Three Patient Groups

Characteristic No OAD (n=26) OAD (n=95) Insulin (n=52)
Age, years 48.6 50.2 54.6
Females, % 58 60 52
BMI, kg/m2 50.0 48.2 47.7
HbA1c, % 6.4 6.9 7.9
Fasting glucose, mmol/L 7.3 7.5 9.4
Number of antidiabetic drugs 1.6 2.9
Duration of diabetes, years 0.3 5.4 12.3
OAD: oral antidiabetic drug

The researchers conclude that "Sleeve gastrectomy should be considered as treatment for type 2 diabetes before disease progression for better intermediate-term results."

Cumulative 5-Year Improvement in Diabetes

Diabetes remission status No OAD OAD Insulin
No improvement, % 14 0 6
Less than partial remission, % 0 40 81
Partial remission,* % 81 59 10
Complete remission,** % 4 1 2
*HbA 1c 6.0–6.4% and fasting plasma glucose 5.6–6.9 mmol/L without pharmacotherapy for at least 1 year
**HbA 1c < 6% and fasting plasma glucose <5.6 mmol/L without pharmacotherapy for at least 1 year
OAD: oral antidiabetic drug

Sleeve Gastrectomy Acceptable As First-Line Surgery Option

In response to Dr Cohen's suggestion that patients on insulin may have had greater improvements in their diabetes if they had a gastric bypass instead of sleeve gastrectomy, Dr Beaulieu-Truchon replied that those in the study were offered only two choices: more invasive biliopancreatic diversion with duodenal switch or less invasive sleeve gastrectomy.

The ASMBS now recognizes sleeve gastrectomy as an acceptable first-line bariatric surgery option, as per an updated position statement published in 2012.

"Substantial comparative and long-term data have now been published demonstrating durable weight loss, improved medical comorbidities, long-term patient satisfaction, and improved quality of life after sleeve gastrectomy," the organization said in a statement.

Meanwhile, the other session comoderator, Dr Stacy A Brethauer (Cleveland Clinic, Ohio), pointed out that in the study groups that were untreated or taking oral antidiabetic drugs, "it looks like the patients were glucose intolerant and all of them would have diabetes that resolved with any type of weight loss."

Nevertheless, he agreed that the study drives home the point that sleeve gastrectomy may be most appropriate at an early stage of diabetes.

Dr Beaulieu-Truchon reported no relevant financial relationships. Dr Cohen is a researcher for Ethicon and GI Dynamics. Dr Brethauer is a speaker and researcher for Covidien and a researcher for Ethicon.

Obesity Week 2014: The American Society for Metabolic and Bariatric Surgery and the Obesity Society Joint Annual Scientific Meeting; November 6, 2014; Boston, MA. Abstract A704.


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