Surgery should not be considered as the last option



For diabetic morbidly obese patients, surgery should not be considered as the last option, but as an appropriate treatment, in particular when diabetes is not controlled or when other obesity-related comorbidities are poorly controlled, according to researchers from Università Cattolica del Sacro, Rome, Italy. In their systematic review, ‘Assessing the obese diabetic patient for bariatric surgery: which candidate do I choose? published in the journal Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, they state that bariatric/metabolic procedures are considered as an additional therapeutic option allowing improved diabetes control in most of patients, but surgery can result in the achievable goal of not curing resolving diabetes and this is particularly achievable in patients with a relatively short history of diabetes duration.

The aim of the paper was to review bariatric-metabolic surgery for obese diabetic patients and compare outcomes from numerous procedures and non-surgical programmes. They emphasise the importance of patient risk factors (high perioperative morbidity and mortality, patients’ preference, compliance of the patients to the postoperative follow-up protocol) and surgical factors (expertise and experience in the bariatric surgical procedures, the simplicity and reversibility of the procedure), when choosing the most suitable treatment. Although they add that the current evidence suggests that multiple factors play in concert to achieve the improvements in diabetic control observed after bariatric-metabolic procedures.

It is clear bariatric-metabolic surgery is an effective treatment for type 2 diabetes when compared with conventional nonsurgical medical treatment (Table 1). A meta-analysis supports these findings, showing an overall type 2 diabetes remission rate of 63.5% for the surgical group versus 15.6% for the conventional non-surgical group (p<0.001) at a mean follow-up of 17.3 months. This meta-analysis was based on the results of 16 studies including 6,131 patients. Although they acknowledge that the short follow-up time limits the results with few reporting long-term follow-up, apart from the {Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications.||Swedish Obese Subjects}} study. This study also reported that short diabetes duration at baseline is associated with higher remission rates at ten and 15 years after surgery.

“Given these findings, preoperative metabolic data could be of primary importance to asses which patients may effectively benefit from bariatric-metabolic surgery in diabetes control,” the researchers note.

Table 1: Comparison between bariatric surgery and conventional medical treatment for type 2 diabetes remission rate (%)

The authors state that not only do diabetic patients eligible for bariatric-metabolic procedures remain morbid and obese after they failure of nonsurgical options for weight loss, a patient with BMI<35 suffering from a significant obesity-related comorbidity simply on the basis of the BMI level does not appear to be clinically justified.

“A clinical decision should be based on a more comprehensive evaluation of the patient and on a more reliable prediction of future morbidity and mortality,” they write.  “Nevertheless, ideally a risk stratification (such as detection of early stages of atherosclerotic disease) should be provided to identify pre-diabetes conditions in obese subjects in order to identify high-risk individuals to potentially prevent the occurrence of type 2 diabetes and its related systemic complications.

An assessment of which patients could benefit from bariatric-metabolic surgery should include pre-operative metabolic work-up with an accurate evaluation of the glycaemic status (including fasting glucose, HbA1c, insulin sensitivity after oral glucose tolerance test, fasting insulin, fasting C-peptide).

“Bariatric-metabolic surgery should be proposed after an adequate careful risk–benefit analysis in high-volume centres with multi-disciplinary teams experienced in the management of obesity and diabetes,” they conclude. “Nevertheless, regular postoperative nutritional monitoring is required, with attention to appropriate diet after the procedure, monitoring of micronutrient status, and individualized nutritional supplementation. Further investigations are needed to clarify the duration of the benefit of surgery in diabetes remission, the mechanism of the success of surgery, and the mechanism associated with diabetic recurrence.”

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