For Diabetes, Surgery May Offer the Best Medicine

Two recent studies, published in The New England Journal of Medicine, have found that metabolic surgery works much better for poorly controlled Type 2 Diabetes than the standard medical treatment. Both studies concentrated on patients who were overweight. Patients that underwent gastric bypass surgery for diabetes were more likely to control their blood sugar with less medication, and some had a complete remission! Patients given the traditional regimen that includes drugs, dietary counseling and exercise experienced little or no improvement.

Medical experts have known for many years that Type 2 Diabetes, the most common type of diabetes, causes serious, sometimes gruesome medical problems over time, including blindness, heart attacks, strokes, kidney failure and amputations. The medical community has been crying out for therapy that cures diabetes, or at least improves treatment. Over the past 20 years scientific data has accumulated showing that weight-loss operations, also known as bariatric or “metabolic surgery,” result in dramatic improvements in diabetes, sometimes eliminating any sign of the disease altogether.

The most recent study is from the Cleveland Clinic, and a similar previous study was from Catholic University, Rome. The Rome study looked at the gastric bypass, which is the most commonly performed weight loss operation in America, and the biliopancreatic diversion, an operation less commonly performed. Thus study showed that biliopancreatic diversion resulted in a 95% remission rate for diabetes and gastric bypass resulted in a 75% remission. The Cleveland Clinic study, just published in May 2014, examined the gastric bypass and the gastric sleeve procedure. Most surgical patients had a dramatic improvement in their diabetes, with 38% of gastric bypass patients still experiencing complete remission at 3 years after surgery, sleeve gastrectomy showed a 24% remission, and medical therapy resulted in only a 5% remission rate.

The Italian study included 60 patients and the American study included 150 patients. One reason for the lower remission rate in the American study may be that patients in this study had more advanced diabetes. Some evidence suggests that earlier use of surgery for Type 2 Diabetes results in better outcomes.

Other positive findings from the Cleveland Clinic study include improvements in hypertension and a decrease in cholesterol, in addition to the improvement in diabetes, after surgery.

1991 guidelines from the National Institutes of Health support surgery for obesity at a body mass index over 40, or for a BMI over 35 if the person has illnesses related to obesity, based on assessment of the benefit of surgery versus the risk. After more than 20 years of surgical innovation and improvements in safety, many current bariatric surgeons believe that metabolic operations for diabetes may be justified for patients with diabetes at a BMI of 30, or even lower. Studies evaluating metabolic operations at lower body mass index are underway.

N Engl J Med 2012; 366:1577-1585April 26, 2012

N Engl J Med 2014; 370:2002-2013May 22, 2014