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Surgery and macrovascular disease

Surgery reduces macrovascular events in T2DM patients

The majority of patients (76%) has a Roux-en-Y gastric bypass, 17% sleeve gastrectomy and 7% adjustable gastric banding

People with T2DM and severe obesity who had bariatric surgery were 40 percent less likely to have a heart attack or stroke within five years than those who had usual medical care for their diabetes, according to a study at four systems in the Health Care Systems Research Network. During the same period, those who had surgery were also more than one-third less likely to develop heart disease and two-thirds less likely to die from any cause. The study’s findings were published in the paper, ‘Association Between Bariatric Surgery and Macrovascular Disease Outcomes in Patients With Type 2 Diabetes and Severe Obesity’, in JAMA.

David Arterburn

"For most people with diabetes and severe obesity, lifestyle changes and medication may not be successful at significantly lowering those risks," said internist and corresponding author, Dr David Arterburn, a senior investigator at Kaiser Permanente Washington Health Research Institute. "So we're excited about our results, which suggest that bariatric surgery may reduce new cases of heart attack and stroke - and risk of death from all causes."

The study, performed at Kaiser Permanente in Washington, Northern California and Southern California and HealthPartners Institute in Minnesota (the four systems in the Health Care Systems Research Network), examined whether there is an association between bariatric surgery and incident macrovascular disease event (defined as first occurrence of acute myocardial infarction, unstable angina, percutaneous coronary intervention, coronary artery bypass grafting, ischemic stroke, haemorrhagic stroke, carotid stenting, or carotid endarterectomy) in patients with severe obesity and type 2 diabetes.

The retrospective, matched cohort study, included 5,054 Kaiser Permanente and 247 HealthPartners patients with diabetes and severe obesity who received bariatric surgery. It also included a matched control group of 14,934 patients who had similar characteristics (on site, age, sex, body mass index, haemoglobin A1c, insulin use, observed diabetes duration, and prior health care utilization, with follow-up through September 2015), but received usual medical care for their weight and diabetes instead of bariatric surgery.

Outcomes

The results revealed that the mean age of the surgical and non-surgical patients was 50+10 years; 76% of the bariatric group and 75% of the non-surgical patients were female; and the baseline mean BMI was 44.7+6.9 in the surgical group and 43.8+6.7 in the and nonsurgical group. The majority of patients (76%) has a Roux-en-Y gastric bypass, 17% sleeve gastrectomy and 7% adjustable gastric banding.

Regarding macrovascular events, there were 106 in bariatric group patients (including 37 cerebrovascular and 78 coronary artery events over a median of 4.7 years) and 596 events in the matched control patients (including 227 cerebrovascular and 398 coronary artery events over a median of 4.6 years). Bariatric surgery was associated with a lower composite incidence of macrovascular events at five years - 2.1% in the bariatric group vs 4.3% in the non-surgical group, as well as a lower incidence of coronary artery disease - 1.6% in the bariatric group vs 2.8% in the non-surgical group. The incidence of cerebrovascular disease was not significantly different between groups at five years (0.7% in the bariatric group vs 1.7% in the non-surgical group).

"Our study's large size gives it the statistical power to examine important health outcomes," said senior author, Dr Stephen Sidney, director of research clinics at the Kaiser Permanente Division of Research in Northern California. "Another strength is the long follow-up and comprehensive information from our health care systems, which provide integrated care and coverage."

However, the study was observational, not a randomised clinical trial, so it cannot definitively prove that bariatric surgery caused the decrease in the rates of heart attack, stroke, heart disease and death.

"Ideally, randomised clinical trials would confirm - or refute - our findings," said first author, David P Fisher, who was the inter-regional chair of Kaiser Permanente Bariatric Surgery before his recent retirement. "But such trials are expensive and difficult to conduct, and they probably couldn't be done with enough patients to assess these relatively rare outcomes."

Members of the same research team have previously shown that diabetes goes into long-term remission (for an average of seven years) for about half of people who undergo gastric bypass. They also reported that people with diabetes who undergo bariatric surgery have half the risk of small-blood-vessel diseases of the feet, hands, kidneys and eyes within the first five years after surgery, compared to usual medical care for diabetes.

"Our results add to the evidence that should inform conversations between people with diabetes and severe obesity and their health care providers about the potential benefits and risks of weight-loss surgery," concluded Arterburn. "We hope this helps them make more informed decisions about their care."

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