Metabolic Surgery for Type 2 Diabetes in BMI <35: A Surgeon’s View

Excerpt

We read Dr. Lebovitz's literature review and opinion regarding metabolic surgery for type 2 diabetes with BMI <35 with great interest. This is a relevant topic since more than 25 million adults in the USA are type 2 diabetic and 79 million are pre-diabetic. This number continues to grow, nearly tripling in the past 20 years [1, 2]. Current treatment for type 2 diabetics with a BMI <35 is intensive medical management, however, with poor to mixed results. The look AHEAD research group recently published their results of cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. The trial was stopped early at mean follow-up of 9.6 years when futility analysis showed an intensive lifestyle intervention focusing on weight loss did not reduce the rate of cardiovascular events in overweight or obese adults with type 2 diabetes [3]. We now have several randomized, observational and retrospective trials looking at metabolic surgery for type 2 diabetes in patients with BMI <35. As the author discussed, Shimizu et al. reviewed 18 studies with 477 patients. They were able to achieve a 64.7 % remission rate (FPG <126 mg/dl, HgbA1c <6.5 %, off medications), and 86.8 % of patients had their anti-diabetic medications discontinued [4]. Blue Cross and Blue Shield technology evaluation center (TEC) published their review of bariatric surgery in type 2 diabetic patients with BMI <35. Their goal was to determine if bariatric surgery improved outcomes for patients with BMI <35 and type 2 diabetes. Their review of the literature showed remission rates ranging from 48 to 100 % at 1 year. The Blue Cross and Blue Shield Advisory Medical Panel recommended gastric bypass for type 2 diabetics with BMI <35 as the evidence met TEC criteria [5]. In addition, Schauer et al. published their randomized controlled trial of bariatric surgery versus intensive medical therapy for obese patients with diabetes. In this study, 34 % of the subjects had a BMI <35. They reported statistically significant remission rates for diabetes in the gastric bypass group versus the medical therapy group at 1 year (42 and 12 %, respectively) [6]. Ikramuddin et al. published the Diabetes Surgery Study Randomized Clinical Trial comparing gastric bypass to intensive medical management for control of type 2 diabetes, hyperlipidemia, and hypertension in obese patients. They had 120 patients followed for 12 months. Primary ADA endpoints were HgbA1c <7 %, LDL <100 mg/dl, and systolic blood pressure <130. Sixty percent of the patients in the gastric bypass group and 58 % in the medical group had a BMI <35. Primary endpoints were achieved in 49 % of the gastric bypass patients versus 19 % of the medically managed patients. HgbA1c <7 % was achieved in 75 % of the gastric bypass patients at 1 year compared to 32 % from the medical group. HgbA1c <6 % was achieved in 44 % of the gastric bypass patients compared to 9 % in the medical group [7]. …