Surgery for Diabetes
Did You Know?
- Someone in the world dies from complications associated with diabetes every 10 seconds.
- Diabetes is one of the top ten leading causes of U.S. deaths.
- One out of ten health care dollars is attributed to diabetes.
- Diabetics have health expenditures that are 2.3 times higher than non-diabetics.
- Approximately 90 percent of type 2 diabetes mellitus (T2DM), the most common form of diabetes, is attributable to excess body fat.
- If current trends continue, T2DM or pre-diabetic conditions will strike as many as half of adult Americans by the end of the decade. (according to the United HealthGroup Inc., the largest U.S. health insurer by sales).
- The prevalence of diabetes is 8.9 percent for the U.S. population but more than 25 percent among individuals with morbid obesity.
- Metabolic and bariatric surgery is the most effective treatment for T2DM among individuals who are affected by obesity and may result in remission or improvement in nearly all cases.
Type 2 Diabetes Mellitus (T2DM)
T2DM is the most common form of diabetes, accounting for approximately 95 percent of all cases. Obesity is the primary cause for T2DM and the alarming rise in diabetes prevalence throughout the world has been in direct association increase rates of obesity worldwide. T2DM leads to many health problems including cardiovascular disease, stroke, blindness, kidney failure, neuropathy, amputations, impotency, depression, cognitive decline and mortality risk from certain forms of cancer. Premature death from T2DM is increased by as much as 80 percent and life expectancy is reduced by 12 to 14 years.
Current therapy for T2DM includes lifestyle intervention (weight-loss, appropriate diet, exercise) and anti-diabetes medication(s). Medical supervision and strict adherence to the prescribed diabetes treatment regimen may help to keep blood sugar levels from being excessively high although medications and lifestyle changes cause remission of the disease. In fact, T2DM often worsens with time, requiring even greater numbers of medication or a higher dosage to keep blood sugar under control. For this reason, T2DM has been considered a chronic and progressive disease.
Metabolic and Bariatric Surgery and T2DM
Nearly all individuals who have bariatric surgery show improvement in their diabetic state. Bariatric surgeries performed in more than 135,000 patients were found to affect T2DM in the following ways:
Improve T2DM in nearly 90 percent of patients by:
- lowering blood sugar and percent HbA1c
- reducing the dosage and type of medication required
- improving diabetes-related health problems
Cause T2DM to go into remission in 78 percent of individuals by:
- reducing blood sugar levels to normal levels
- eliminating the need for diabetes medications
- Cause the improvement or remission of T2DM to last for years
Types of Metabolic and Bariatric Surgery
The following are the most common bariatric surgeries performed in the United States and their known effects on T2DM.
- Roux-en-y Gastric Bypass is a surgery that alters the GI tract to cause food to bypass most of the stomach and the upper portion of the small intestine. The operation results in significant weight-loss and causes remission of T2DM in 80 percent of patients and improvement of the disease in an additional 15 percent of patients.
Improvement or remission of diabetes with gastric bypass occurs early after surgery and before there is significant weight-loss. The weight-loss independent mechanisms of diabetes improvement after gastric bypass are partially explained by changes in hormones produced by the gut after the surgery, and this is an active area of research in the field of metabolic and bariatric surgery.
- Sleeve Gastrectomy (Vertical gastrectomy) is an operation that removes a large portion of the stomach and, in doing so, causes weight-loss. The remaining stomach is narrow and provides a much smaller reservoir for food.
Sleeve gastrectomy also appears to have some weight-loss independent effects on glucose metabolism and also causes some changes in gut hormones that favor improvement in diabetes. Diabetes remission rates after sleeve gastrectomy is also very high (more than 60%) and, in some studies, similar to results seen after gastric bypass.
- The Adjustable Gastric Band is a weight-loss procedure that involves the placement of a band around the upper portion of the stomach. Remission of diabetes occurs in approximately 45-60 percent of patients. The remission or improvement of diabetes, however, is secondary to the weight-loss produced by the procedure, and there does not appear to be any other mechanism for diabetes improvement in band patients. In other words, patients who have diabetes and who are unsuccessful in losing weight with the AGB will unlikely see any improvement in diabetes.
- The Duodenal Switch is a malabsorptive procedure performed far less frequently than the gastric bypass, sleeve gastrectomy or the adjustable gastric band due to the complexity of the procedure and the greater risk of complications. Studies find, however, that the operation is most effective in inducing early and sustained remission or improvement of T2DM ( more than 85 percent remission rates with weight-loss independent effects)
Benefits vs. Risks
T2DM is a leading cause of death in the U.S. and is a major contributor to morbidity and mortality from heart disease, stroke and kidney failure. Each year millions of individuals die from the effects of T2DM. With the advancements in bariatric surgery, many of these individuals could be saved and experience an improved quality of health and life.
While bariatric surgery certainly has some risk, the long-term risk of continued diabetes (which is often inadequately treated with medication) typically outweighs the risk of a surgical procedure for most patients. Each patient’s individual risks for surgery, though, should be evaluated in the context of the duration and severity of their diabetes as well as their other obesity-related health problems.
International Diabetes Foundation Position Statement on Bariatric Surgery in the Treatment of T2DM
Last year, diabetologists, endocrinologists, surgeons, and public health experts convened at the 2nd. World Congress on Interventional Therapies for T2DM in New York City. Based upon the evidence presented by these world-renowned experts, The International Diabetes Foundation (IDF) released a Position Statement calling for bariatric surgery to be considered early in the treatment of T2DM.
The document recognized that:
- In addition to behavioral and medical treatments, bariatric surgeries constitute a powerful option to ameliorate diabetes in patients affected by severe obesity.
- Bariatric surgery is an appropriate treatment for people with T2DM and obesity not achieving recommended treatment targets with medical therapies
- Surgery should be an accepted option in people who have T2DM and a BMI of 35 or more.
- Surgery should be considered as an alternative treatment option in patients with a BMI between 30 and 35 when T2DM cannot be adequately controlled by optimal medical regimen, especially in the presence of other major cardiovascular disease risk factors.
- Bariatric surgery for treatment of T2DM is cost-effective
- The risk of complications and death with bariatric surgery is low and similar to that of well-accepted procedures such as gallbladder surgery
Metabolic and bariatric surgery for T2DM must be performed within accepted guidelines which include ongoing multidisciplinary care, patient education, follow-up, and clinical audit, as well as safe and effective surgical procedures.