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Intention to treat

Study helps to define "metabolic surgery"

Describing surgery as “bariatric”, “metabolic” or “diabetic" is defined by patient characteristics
Intent to treat diabetes and metabolic disease characterizes metabolic surgery not procedures or BMI
Finding leads authors to suggest broad new “metabolic” specialty to avoid misconceptions about surgery by patients

Presenting bariatric surgery to patients as a treatment for metabolic disease, rather than excess weight, affects the demographic and clinical characteristics the patients who seek it out, according to a new study published in the Annals of Surgery.

The finding led the study authors to call for a new broad specialty, called gastrointestinal metabolic surgery, to be defined, encompassing the traditional use of bariatric surgery for weight loss as well as for the treatment of metabolic disorders.

“This definition is descriptive of the target organ and of the aim of surgery, independent of the type of procedures and the patient’s body mass index,” they write. “It is consistent with the evidence that gastrointestinal operations engage mechanisms of action beyond the mechanical restriction of energy intake and altered nutrient absorption.”

The study authors say that when they offered two identical surgical programmes at their centre, Presbyterian Hospital, New York, one for “metabolic surgery” and one for “bariatric surgery”, differing only in their stated goals, they recruited cohorts with significantly different characteristics.

They write that their evidence suggests that popular misconceptions about the role and effect of bariatric surgery exist within the population that could potentially be treated, acting as a barrier to surgery.

“This has important and practical ramifications for clinical care and support consideration of metabolic/diabetes surgery as a novel practice distinct from traditional bariatric surgery,” they said.

The study

The authors assessed the demographics, clinical characteristics and 30-day post-operative morbidity and mortality data from a prospective database of the first 100 patients who underwent surgery in each units.

Compared with the bariatric surgery group, the patient population in the metabolic surgery group was older (45.8 ± 13.4 v 41.8 ± 11.7, p<0.05), had a lower BMI (42.4 ± 7.1 vs. 48.6 ± 9.5; p<0.01), had more males (42% vs. 26%, p<0.05), presented with diabetes (62% vs. 35%; p<0.01), hypertension (68% vs. 52%; p<0.05), dyslipidemia (48% vs. 31%; p<0.05), and cardiovascular disease (14% vs. 5%; p<0.05).

In the metabolic surgery group, Roux-en-Y gastric bypass and sleeve gastrectomy were performed in 66% and 21% of cases, respectively. Laparoscopic gastric banding was performed in 8% of cases, and other procedures (one modified mini-duodenal switch, one band revision, and three band removals) were performed in 5% of cases. Of these, 7% were revisional surgery (conversions of failed bariatric procedures performed elsewhere).

In the bariatric surgery group, procedures were more equally distributed between Roux-en-Y gastric bypass (32%), laparoscopic gastric banding (29%), and sleeve gastrectomy (39%). Of these, 4% were revisional procedures.

There was no mortalities reported in either group and there were no significant differences in the number of major adverse events (3% in the bariatric group vs. 1% in the metabolic group) or minor complications (4% vs. 6%).

“The results of this study show that the name and, by inference, the intent of surgery exerts a significant influence on the selection of surgical candidates,” the authors write.

Diabetics who underwent metabolic surgery also had longer disease durations (as well as higher mean glycated haemoglobin levels, a greater percentage of insulin users, and a higher prevalence of cardiovascular disease at baseline), suggesting that the stated intent to treat diabetes at the Diabetes Surgery Center may have encouraged those patients with long-standing diseases.

Changing the aim of surgery (from weight loss to control of metabolic illness) will also require a re-assessment of using BMI for surgical eligibility, as access to “diabetes surgery” should also include comorbidities.

“Bariatric surgery was conceived as a mere weight loss intervention, but metabolic and diabetes surgery describes a physiological approach to treating disease, not a behavioural issue,” the authors write. “What these names suggest may well be the best way to improve access to surgery for those who need it.”

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