Call to Make Bariatric Surgery as Common as Coronary Bypass

Marlene Busko

July 02, 2015

A single-center study that randomized 61 obese patients with type 2 diabetes to Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, or an intensive, 1-year lifestyle intervention found that up to 40% of patients who underwent the bariatric surgery had at least partial remission of diabetes at 3 years, compared with no one in the nonsurgical arm.

These results, published online July 1 in JAMA Surgery, extend 1-year findings reported previously by Anita P Courcoulas, MD, from the University of Pittsburgh Medical Center, Pennsylvania, and colleagues.

"This study provides further important evidence that at a longer-term follow-up of 3 years, surgical treatments including Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding are superior to a lifestyle intervention alone for the remission of type 2 diabetes in individuals with obesity, including those with a body mass index [BMI] between 30 and 35 [class 1 obesity]," Dr Courcoulas told Medscape Medical News.

Indeed, she and her colleague say the latter point is one of the most important aspects of this study, as more than 40% of their sample had BMIs of 30 to < 35, "for whom data in the literature are largely lacking."

Bariatric surgery should therefore be considered for the obese patient with type 2 diabetes, especially those who have difficulty attaining glycemic control, Dr Courcoulas said.

In an accompanying editorial, Michel Gagner, MD, from Florida International University, in Miami, and Hôpital du Sacré-Coeur de Montréal, Quebec, goes even further.

The time has come for bariatric surgery to be as common as coronary artery bypass surgery, he urges. "We should consider the use of bariatric (metabolic) surgery in all severely obese patients with type 2 diabetes mellitus and start a mass treatment, similar to what was done with coronary artery bypass graft more than 50 years ago," he writes.

Can Bypass Surgery Provide Durable Diabetes Remission?

It is unclear whether bariatric surgery can provide durable, long-term remission from diabetes, and little has been known about bariatric-surgery outcomes in patients with class 1 obesity, Dr Courcoulas and colleagues write.

They randomized 61 obese patients with type 2 diabetes who were seen at their center to receive gastric bypass (24 patients), adjustable gastric banding (22 patients), or a 1-year "intensive lifestyle intervention" modeled after the Action for Health in Diabetes (Look AHEAD) and Diabetes Prevention Program (DPP) studies (23 patients).

The participants were mostly women (50 of 61 participants, 82%), they had a mean age of 47.3, and 13 (21%) were African American.

At baseline, they had an average weight of 100.5 kg and an average BMI of 35.7 kg/m2, and 26 participants (43%) had a BMI of 30 to 35. Their mean HbA1c was 7.8%, and they had had diabetes for an average of 4.8 years.

Patients in the lifestyle-intervention group attended weekly meetings for 6 months followed by meetings every 2 weeks for 6 months, where they learned about weight loss, diet, exercise, and behavioral strategies, Dr Courcoulas explained.

The program was structured around a healthy diet of 1200 to 1800 kilocalories/day and recommended moderate-intensity exercise 5 days a week, starting with 20 minutes a day and increasing to 60 minutes daily.

During the second and third year of the study, all participants received a "low-level lifestyle intervention," which was also modeled after the Look AHEAD and DPP studies. The patients were contacted twice a month and had regular "refresher" group sessions that focused on specific behaviors related to weight loss.

Partial remission of diabetes was defined as HbA1c < 6.5% with fasting plasma glucose < 125 mg/dL and no use of antidiabetic agents; complete remission was defined as HbA1c < 5.7% with fasting plasma glucose < 100 mg/dL and no use of antidiabetic agents.

At 3 years, eight patients (40%) who had gastric bypass and six patients (29%) who had gastric banding, but none of the patients who had the nonsurgical intervention, attained at least partial remission of diabetes (P = .004).

Moreover, three patients (15%) who had gastric bypass and one patient (5%) who had gastric banding, but none of the patients in the lifestyle arm, attained complete remission of diabetes (P = 0.21).

And two-thirds of patients who had had gastric bypass and one-third of patients who had had gastric banding, but none of those who had the nonsurgical intervention, no longer needed insulin or an oral antidiabetic agent at 3 years.

On average, at 3 years, patients who had had gastric bypass and those who had gastric banding had lost 25% and 15% of their initial weight, respectively, whereas patients who had received lifestyle counseling had lost 5.7% of their initial weight (P < .01).

More Research Needed on Best Fit for Individual Patients

Adjustable gastric banding was more common when the current study began in 2009, but gastric bypass and sleeve gastrectomy are now the most common types of bariatric surgery, Dr Courcoulas acknowledged.

But the only other randomized trial with 3 years of follow-up, STAMPEDE, did report that sleeve gastrectomy and gastric bypass were superior to intensive medical therapy for glycemic control, medication use, and quality of life (N Engl J Med. 2014;370:2002-2013), she noted.

Her group calls for more research to better identify which patients would benefit from which types of bariatric surgery, to understand the effect of such operations on complications of diabetes, and to help unravel the mechanisms by which bariatric surgical procedures induce their effects.

Dr Courcoulas has grants from Nutrisystem, J&J Ethicon, and Covidien, and she is a project consultant for Ethicon and Apollo Endosurgery. Disclosures for the coauthors are listed in the article. Dr Gagner has received honoraria for speaking engagements from Ethicon, Covidien, Gore, MID, Olympus, and Boehringer Laboratories, and equity from Transenterix.

JAMA Surgery. Published online July 1, 2015. Article, Editorial

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