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Bariatric surgery safe for BMI<35 type 2 diabetics

The study showed bariatric and metabolic surgery had a high degree of safety in lower BMI patients

Bariatric surgery is a safe option for the treatment of uncontrolled type 2 diabetes in those who are overweight or have mild to moderate obesity, according to researchers from Cleveland Clinic in Ohio. The findings from the study, ‘nationwide safety analysis of bariatric surgery in nonmorbidly obese patients with type 2 diabetes’, were presented at ObesityWeek 2015, hosted by the American Society for Metabolic and Bariatric Surgery (ASMBS) and The Obesity Society (TOS).

“Bariatric surgery is emerging as a safe and effective option for managing type 2 diabetes in patients with mild obesity,” said lead study author, Dr Ali Aminian, Laparoscopic and Bariatric Surgeon at the Cleveland Clinic Digestive Disease Institute. “We are seeing significant improvement or remission of type 2 diabetes in most lower BMI patients. Current evidence suggests that baseline BMI is unrelated to diabetes remission following bariatric and metabolic surgery. Our data, which is from a large sample size of patients with type 2 diabetes, shows a modest early morbidity (4%) and low mortality (0.2%) following bariatric surgery in non-severely obese patients. These data are important because most patients with diabetes fall into this BMI category.”

Cleveland Clinic researchers say this study is the largest ever-published series of bariatric surgery in patients with type 2 diabetes and BMI<35. They studied 1,003 patients from North America with a BMI25-35, with an average BMI33.5, 46 patients had a BMI<30. All had bariatric/metabolic surgery, between 2005 and 2013. Four-in-10 patients were taking insulin injections and 60 percent were on oral medications for their diabetes before surgery. Data was obtained from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

National Institutes of Health (NIH) guidelines, which have not been updated since 1991, consider surgery an option only for people with a BMI>35 with one or more obesity-related conditions such as diabetes or a BMI40. 

Aminian said over the last quarter century, however, the field of bariatric surgery has significantly evolved with introduction of new less invasive surgical approaches (e.g. laparoscopic surgery) and surgical procedures (e.g. sleeve gastrectomy), which have led to improvement in the safety profile of surgery.

The study showed bariatric and metabolic surgery had a high degree of safety in lower BMI patients. The operations included gastric bypass (57%), gastric banding (23%), sleeve gastrectomy (19%) and duodenal switch (1%). The 30-day postoperative mortality rate was 0.2 percent and the cumulative rate of 16 postoperative adverse events was 4 percent. The procedures were generally two hours in length and patients were discharged from the hospital within two days. 

Last year, Cleveland Clinic researchers presented a study that found the 30-day complication rate associated with metabolic surgery, specifically gastric bypass in patients with type 2 diabetes and BMIs of 35 or more, was 3.4 percent, about the same rate as laparoscopic cholecystectomy (gallbladder surgery) and hysterectomy. Hospital stays and readmission rates were similar to laparoscopic appendectomy. The month-long mortality rate for metabolic or diabetes surgery was 0.3 percent, about that of total knee replacement, and about one-tenth the risk of death after cardiovascular surgery (Published in the Diabetes, Obesity & Metabolism journal 2015; 17(2):198-201). 

Previous studies have shown that metabolic and bariatric surgery improves type 2 diabetes in nearly 90 percent of patients and diabetes goes into remission in up to 50 percent. 

“A two-hour operation and a two-day hospital stay has the potential to resolve or improve what is a chronic, progressive and dangerous disease,” said dr John M Morton, president of the ASMBS and Chief, Bariatric and Minimally Invasive Surgery, Stanford University School of Medicine, who was not involved in the study. “The risk-benefit profile that has emerged for bariatric surgery in people with type 2 diabetes and low BMIs is very favourable and should be considered as a treatment option in carefully selected patients.”

In addition to Aminian, study authors were Drs John Kirwan, Bartolome Burguera, Stacy Brethauer, and Philip Schauer.

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