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Surgery and diabetic BMI<30

Review recommends surgery for diabetic BMI<30 patients

The authors stop short of recommending bariatric surgery for non-obese T2DM patients

According to a systematic review published online at PlosOne, researchers from West China Hospital, Sichuan University and the Chinese Evidence-Based Medicine/Cochrane Center, Chengdu, China, bariatric surgery can improve glycaemic control and weight loss in a very limited range, with doubled surgical complications in drug-refractory T2DM patients with BMI<30. Although the authors stop short of recommending bariatric surgery for non-obese T2DM patients, healthcare professionals should continue to follow-up of non-obese patients in existing studies to further address the long-term efficacy and safety of surgical treatment in this patient population.

The authors undertook the research, Bariatric Surgery for Type 2 Diabetes Mellitus in Patients with BMI <30 kg/m2: A Systematic Review and Meta-Analysis, to assess the role of bariatric surgery and discover the clinical evidence of metabolic surgery for the resolution of diabetes in non-obese patients with T2DM. The review included ten eligible prospective studies involving a total of 290 T2DM patients with a mean age of 51.4 years and with 58% of the pooled participants being male. Table 1 shows the baseline characteristics of the final studies that were included for the meta-analysis.

Table 1: Baseline characteristics of the included studies

The studies were conducted in populations from Brazil (3), Korea (2), Italy (1), Venezuela (1), China (1), Spain (1) and both Taiwan & Korea (1). The mean BMI was 26.62±2.19. The follow-up interval ranged from three months to two years and the mean duration of diabetes prior to surgery in each included study ranged from two to 20 years. The participants involved underwent bariatric surgery for the purpose of glycaemic control.

Various surgical procedures were investigated, with the performance of duodenal-jejunal bypass surgery (DJB) in three studies, sleeve gastrectomy (LII-DSG) in two, biliopancreatic diversion (BPD) in one, roux-en y in one, laparoscopic mini-gastric bypass (LMGB) in one and anastomosis gastric bypass (BAGUA) in one study. One study population was composed of 79% patients undergoing LMGB and 21% Roux-En Y gastric bypass. All of the patients were under treatment for diabetes, specifically by therapy with insulin, oral anti-hyperglycaemic agents or both. Insulin users accounted for 42.8% of the pooled population.

Outcomes

Resolution and remission of T2DM was defined and reported differently in each study. In the overall population, the rates of achievement of HbA1c levels of 6%, 6.5%, and 7% were 42.4% (n=90/212), 37% (n=10/27) and 37.2% (n=34/94), respectively. Although the remission rate was low, the reliance on anti-diabetic medications was reduced with statistical significance after surgery. Throughout the follow-up period after surgery, 76.2% of the patients were insulin free and 61.8% were medication free for blood glucose control. The prevalence of the co-existence of hypertension and dyslipidaemia was 21.7% and 41.7% in the overall population before surgery, respectively. After surgery, blood pressure was controlled in 88.9% of the patients without antihypertensive medications, and serum TC and TG improved in 45.8% and 38% of the overall patients, respectively.

The overall major surgical complication rate was 6.2%, including intestinal obstruction, intestinal perforation, and intra-abdominal bleeding. The rate of early surgical complications (<30 days) was 3.4%, including the presence of a fistula, gastrointestinal bleeding, urinary tract infection, pneumonia, and wound infection. In one of the included studies with a long follow-up period (21.7 months), 15.9% of the patients reported complications including prolonged diarrhoea, gouty attacks, prolonged emesis, urinary tract infection, or fungal esophagitis during the follow-up. No deaths were reported in any of the included studies, although the overall major complication rate from surgery was 6.2%, and the reoperation rate was 1.7%, almost twice as much as the rates in patients with slightly higher BMI levels

All the articles reported mean changes in the BMI. Compared with the preoperative status, the BMI reduction was 2.79 after surgery, when a random-effect model was applied because the heterogeneity among the studies was obvious (p<0.0001). Body weight loss was reported in four papers, and the overall weight loss was 9.71kg [95%CI 6.30~13.11, p<0.00001] in the fixed-effect model.

“Although our preliminary data suggested potential beneficial effects of surgery in non-obese T2DM patients, it is too early to suggest the clinical application of bariatric surgery for non-obese T2DM patients…” the authors note. “..Our results suggested that various metabolic surgeries could lead to significant reduction in insulin administration, as well as the use of oral medication, regardless of the surgical procedure.”

To access this paper, please click here

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