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Operational choices

Target surgical outcome depends on disease severity

Surgery must be approached on a case by case basis – no one size fits all approach exists for bariatric surgery
Roux-En-Y gastric bypass technique beat non-surgical controsl and LAGB over one year for T2DM patients
RYGB "should remain the gold standard"

The optimum bariatric operation depends on the disease severity and the type of outcome that best suits patients with type 2 diabetes mellitus (T2DM), according to research published online in the October 2011 issue of the Annals of Surgery.

The study, conducted by investigators at the University of Minnesota in Minneapolis, concluded that after one year of follow-up, Roux-en-Y gastric bypass (RYGB) was superior to non-surgical controls (NSC) and laparoscopic adjustable gastric band surgery (LAGB) with respect to weight loss and improvement in diabetes.

“This study provides an important perspective about the comparative efficacy of LAGB, DS, and NSC to the RYGB for treatment of T2DM among obese patients,” said lead author Dr Robert B Dorman. “We conclude that if the endpoint is to improve HbA1c, then the DS is the superior operation compared to the RYGB for patients with a high BMI.”

Although it is known that RYGB resolves T2DM in a high proportion of patients and is considered the standard operation for T2DM resolution in morbidly obese patients, no data exists comparing the efficacy of medical management and other bariatric operations to the RYGB for treatment of T2DM in comparable patient populations.

As a result, investigators designed the study to compare the relative efficacy of medical management, the duodenal switch (DS), and LAGB to RYGB for treatment of T2DM. They performed a retrospective case-matched study of 86 morbidly obese patients with T2DM who had undergone medical management (nonsurgical controls [NSC]; n=29), LAGB (n=30), or DS (n=27) and were compared with matched T2DM patients who had undergone RYGB. Matching was performed with respect to age, sex, body mass index, and hemoglobin A1C (HbA1C).

Outcomes assessed were changes in body mass index, HbA1C, and diabetes medication scores at one year. At one year, RYGB produced the greater weight loss, HbA1C normalization, and medication score reduction compared to both NSC and LAGB-matched cohorts. However, led to significantly greater improvements in HbA1c and diabetes medication scores and a higher rate of diabetes resolution (81.5% vs 48.1%; p=0.02), despite no greater weight loss at one year. Complication rates at one year were 10% for LAGB, 15.1% for RYGB, and 40.7% for duodenal switch.

One-year readmission rates were 6.7% for LAGB, 11.6% for RYGB, and 14.8% for duodenal switch. There were no deaths. According to the researchers, RYGB should remain the gold standard for treatment of severe or greater obesity in the setting of type 2 diabetes, as the procedure has better outcomes than both medical management and the laparoscopic banding. However, they added that for super-obese patients (BMI> 50kg/m2), the duodenal switch should be considered; although only performed by experienced surgeons and centres.

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