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Associations recommend surgery

ADA/AHA statement includes recommendations for surgery

Bariatric surgery may be particularly suitable for patients with type 2 diabetes mellitus and severe obesity (BMI≥35kg/m2)

The American Diabetes Association and the American Heart Association have released a revised joint scientific statement outlining best practices to reduce cardiovascular risk in adults with type 2 diabetes mellitus (T2DM), published in both Diabetes Care and Circulation. The statement, ‘Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence: A Scientific Statement From the American Heart Association and the American Diabetes Association.’, includes recommendations on surgical options for weight loss.

The statement acknowledges that bariatric surgery “is the most effective treatment for attaining significant and durable weight loss in severely obese patients,” and that bariatric/metabolic surgery is increasingly accepted as resulting in remission from T2DM. Indeed, both the International Diabetes Federation (2011) and the AHA/ACC/The Obesity Society guidelines (2014) recommend that adults with BMI>30 or >35, respectively, with an obesity-related comorbidity such as diabetes mellitus should be considered for referral to a bariatric surgeon

The statement assesses the data available for bariatric surgery including 136 meta-analysis studies. Although they were mostly short-term (<5 years) weight loss outcomes after >22,000 bariatric procedures, surgery resulted in an overall mean excess weight loss of 61.2 % for patients who underwent gastric banding, 61.6% for those who had gastric bypass, 68.2% for patients with gastroplasty and 70.1% for patients with biliopancreatic diversion or duodenal switch.

With regards to long-term follow up, the statement cites data from the Swedish Obese Subjects (SOS) study, which at 15 years reported weight loss of 27±12% for gastric bypass, 18±11% for vertical-banded gastroplasty and 13±14% for gastric banding compared with a slight weight gain for control subjects.

The statement also shows that multiple observational studies have demonstrated significant, sustained improvements in glycaemia in type 2 diabetes mellitus among patients with severe obesity (BMI ≥35 kg/m2) after weight loss procedures. A meta-analysis involving 19 studies (mostly observational) and 4,070 patients reported an overall type 2 diabetes mellitus resolution rate of 78% after bariatric surgery, typically defined as becoming non-diabetic with normal A1c without medications.

A few, mostly retrospective studies have evaluated the effect of metabolic surgery on the progression of microvascular disease such as retinopathy, nephropathy, and neuropathy in type 2 diabetes mellitus. The results suggest a potential reversal in or reduced development of nephropathy after bariatric surgery.

One of the key concerns regarding bariatric surgery is safety and complication of bariatric surgery and whether the potential benefits outweigh the surgical risks. A meta-analysis of published mortality data after bariatric surgery reported an overall 30-day postoperative mortality of 0.28% (n=84,931) and total mortality from 30 days to 2 years of 0.35% (n=19,928). The Longitudinal Assessment of Bariatric Surgery (LABS) study subsequently reported a similarly low 30-day mortality rate (0.3 %) among 4,776 patients. Immediate- and long-term perioperative morbidity rates for bariatric surgery are lower than might be expected for this medically comorbid population; the LABS Consortium reported a 4.3% incidence of major adverse events in the early postoperative period.

“Bariatric surgery can reverse or improve many obesity-related disease processes, including type 2 diabetes mellitus,” the paper states. “There is now evidence supporting decreases in short- and medium-term CVD, although these data are derived from observational studies only…Bariatric surgery may be particularly suitable for patients with type 2 diabetes mellitus and severe obesity (BMI≥35kg/m2) because these patients may benefit from obesity comorbidity improvement and significantly improved glycaemic control compared with medical therapy alone. Taken together, these data highlight how bariatric surgery can result in weight loss, A1c improvement, and CVD risk factor improvement. The durability of these metabolic improvements, particularly from the RCT literature, over time remains to be determined and represents an important future area of research.”

To access this paper, please click here

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