Two new randomized trials offer evidence that bariatric surgery is highly effective in obese patients with diabetes. The results, according to Paul Zimmet and K. George M.M. Alberti, writing in an editorial in the New England Journal of Medicine, “are likely to have a major effect on future diabetes treatment.”
In the STAMPEDE trial, which was presented at the American College of Cardiology and published simultaneously in the New England Journal of Medicine, 150 obese patients with uncontrolled type 2 diabetes were randomized to medical therapy alone or medical therapy plus either Roux-en-Y gastric bypass or sleeve gastrectomy. Philip Schauer presented the main results.
Percentages of patients with glycated hemoglobin level of 6% or less at 1 year:
- medical: 12%
- gastric bypass: 42%
- sleeve gastrectomy: 37%
Mean glycated hemoglobin at 1 year:
- medical: 7.5
- gastric bypass: 6.4
- sleeve gastrectomy: 6.6
Weight loss at 1 year:
- medical: -5.4 kg
- gastric bypass: -29.4 kg
- sleeve gastrectomy -25.1 kg
Patients in the medical-therapy group increased their use of diabetes medications, whereas the surgical patients significantly dropped their use of these drugs. Some 38% of medical-therapy patients used insulin compared with only 4% and 8% in the gastric-bypass and sleeve-gastrectomy groups, respectively.
The authors concluded that “bariatric surgery represents a potentially useful strategy for management of uncontrolled diabetes, since it has been shown to eliminate the need for diabetes medications in some patients and to markedly reduce the need for drug treatment in others.”
In a second study, also published in the New England Journal of Medicine, bariatric surgery was also found to be highly effective for diabetic subjects. Sixty obese patients with diabetes were randomized to bariatric surgery (Roux-en-Y gastric bypass or biliopancreatic diversion) or conventional medical therapy.
Diabetes remission at 2 years:
- medical therapy: 0%
- gastric bypass: 75%
- biliopancreatic diversion: 95%
In their editorial, Zimmet and Alberti wrote that one important implication of the studies is that bariatric surgery should perhaps “not be seen as a last resort.” For some obese patients with diabetes, surgery “might well be considered earlier in the treatment.”
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Impressive short-term results. But, before incorporating this treatment in the standard guidelines, we will have to wait for not only the long-term side-effects,but also the durability of glycemic control, given the progressive nature of beta-cell dysfunction. After all, this is a truly “By-pass” procedure & not addressing the basic pathophysiology of diabetes.
Has anyone compared the gastric bypass &/or sleeve gastrectomy with a medical control group that lost a similar amount of weight (as on a VLCD)and similar exercise regimen? What is the purported mechanism or is it simply weight loss and exercise?
A comparative effectiveness review on this subject is being prepared by the Agency for Healthcare Research and Quality’s Effective Healthcare Program. Should be out later this year.