Score Predicts Diabetes Remission With Sleeve vs Bypass Surgery

Marlene Busko

May 12, 2017

Using data from the longest, largest study of obese patients with type 2 diabetes who underwent Roux-en-Y gastric bypass or sleeve gastrectomy, researchers at the Cleveland Clinic have developed a validated nomogram — known as the Individualized Metabolic Surgery Score — that classifies patients into three categories of diabetes severity and suggests which surgery type will provide the best balance between diabetes remission and procedure risk.

The model, based on a 5-year or longer follow-up, was developed in a cohort of more than 600 patients from their single center in Cleveland and then was validated in a cohort of more than 200 patients at another single center in Barcelona, Spain.

Ali Aminian, MD, associate professor of surgery at the Cleveland Clinic, Ohio, presented the findings recently at the American Surgical Association 2017 Annual Meeting in Philadelphia.

In the mild-diabetes subgroup, both bariatric procedures were highly effective, but gastric bypass was slightly better than sleeve gastrectomy for long-term diabetes remission and reduction in diabetes medications, so bypass is suggested as a better option for such patients, he told Medscape Medical News.

In the moderate-diabetes subgroup, on the other hand, gastric bypass was significantly more effective than sleeve gastrectomy, so this procedure is highly recommended.

In contrast, in patients with severe diabetes, both bariatric procedures were less effective for long-term diabetes remission, so sleeve gastrectomy — a less risky, less complicated procedure — is suggested for these patients, who have had diabetes for a long time and are typically on insulin.

Nomogram Will Help Guide Patients, Doctors on Procedure Selection

The nomogram, which is available online, can help guide procedure selection and may be "very useful for surgeons, endocrinologists, the referring physicians, the primary-care doctors — or even patients with obesity and type 2 diabetes who are contemplating bariatric surgery," said Dr Aminian.

"The study strongly highlights the importance of the surgical intervention in earlier stages of diabetes to get sustainable remission," he added. For example, about 90% of patients with mild diabetes had diabetes remission 5 years after the surgery, but only about 10% of patients with severe disease attained this.

"But we should realize that this is just a first attempt toward individualized procedure selection, and more work needs to be done," he cautioned.

The approach is similar to that of another group, from Geisinger Obesity Institute, Danville, Pennsylvania, who have developed the DiaRem score.

Sleeve Gastrectomy or Gastric Bypass for Patients With Diabetes?

Over the past 5 years, sleeve gastrectomy has become the more dominant bariatric-surgery procedure, and it is recommended for patients who have a high surgical risk, a very high BMI (70 or 80 kg/m2; weight 400 or 500 lb [200 or 300 kg]), or Crohn's disease or who are active smokers or transplant recipients/candidates or use nonsteroidal anti-inflammatory drugs (NSAIDs), said Dr Aminian.

Roux-en-Y gastric bypass is recommended for patients who have severe gastroesophageal reflux disease (GERD) or Barrett's esophagus.

Both procedures account for 95% of bariatric surgery performed in the United States in patients with type 2 diabetes, and diabetes-related outcomes differ depending on the initial disease severity.

Thus, the researchers created the nomogram to determine which of these two procedures was best for patients with different levels of severity of type 2 diabetes.

They developed the model using data from 659 patients who had Roux-en-Y gastric bypass (78%) or sleeve gastrectomy (22%) at the Cleveland Clinic during 2004 to 2011 and had at least 5 years of follow-up.

They then validated the model using data from 241 patients who had Roux-en-Y gastric bypass (49%) or sleeve gastrectomy (51%) at the Hospital Clinic Universitari, in Barcelona, Spain.

Long-term diabetes remission was defined as HbA1c < 6.5%, fasting blood glucose < 126 mg/dL, and off diabetes medications > 5 years after surgery.

Long-term glycemic control was defined as HbA1c < 7% irrespective of diabetes mediations > 5 years after surgery.

Overall, the patients in both cohorts had a mean age of 51 and a mean BMI of 46 kg/m2, and 67% were female

Preoperative glycemic control, use of insulin, mean number of diabetes medications, and mean duration of diabetes were each independent predictors of long-term diabetes remission after metabolic surgery.

Based on these four variables, the researchers developed a nomogram to determine a patient's "individualized metabolic surgery score." Scores of 0 to < 25, 25 to < 95, or > 95 corresponded to mild, moderate, or severe diabetes and were associated with different diabetes remission rates for different surgery types.

Percentage of Patients With Long-term Diabetes Remission*

Diabetes severity
Original cohort, RYBG
Original cohort, Sleeve
Validation cohort, RYGB
Validation cohort, Sleeve
Mild 92 74 91 91
Moderate 60 25 70 56
Severe 12 12 8 3
RYGB = Roux-en-Y gastric bypass
* > 5 y

Reiterating that the findings do need to be confirmed in further study, the online score calculator tool could nevertheless still be very helpful to both physicians and patients who are contemplating bariatric surgery, said Dr Aminian.

The DiaRem score uses four preoperative clinical variables — insulin use, age, HbA1c, and diabetes medication type — to generate a score of 0 to 22. The lower the score, the greater the chance of diabetes remission 1 year after Roux-en-Y gastric-bypass surgery.

Last week, findings validating the DiaRem score were reported at the American Association of Clinical Endocrinologists (AACE)  2017 Annual Scientific & Clinical Congress in Austin, Texas.

Dr Aminian reports that he has no relevant financial relationships.

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American Surgical Association 2017 Annual Meeting. April 22, 2017; Philadelphia, Pennsylvania. Scientific Session V, Presentation 27


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