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Metabolic surgery for treating type 2 diabetes mellitus: Now supported by the world's leading diabetes organizations

July 1, 2017 | Cleveland Clinic Journal of Medicine
Philip R. Schauer, MD ; Zubaidah Nor Hanipah, MD ; Francesco Rubino, MD
Author and Disclosure Information

Philip R. Schauer, MD
Director, Bariatric and Metabolic Institute, Cleveland Clinic

Zubaidah Nor Hanipah, MD
Bariatric and Metabolic Institute, Cleveland Clinic; Department of Surgery, Faculty of Medicine and Health Sciences, University Putra Malaysia, Selangor, Malaysia

Francesco Rubino, MD
Department of Metabolic and Bariatric Surgery, Diabetes and Nutrition Science Division, King’s College London, UK

Correspondence: Philip Schauer, MD, Director, Bariatric and Metabolic Institute, M61, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; schauep@ccf.org

Dr. Schauer reported research grant support from Ethicon, Medtronic, and Pacira Pharmaceuticals; consulting fees from The Medicines Company, AMAG Pharmaceuticals, GI Dynamics, and Neurotronics; honoraria for speaking from Novo Nordisk; and ownership interest in SE HQC LLC. Dr. Nor Hanipah reported no financial interests or relationships that pose a potential conflict of interest with this article. Dr. Rubino reported research grant support from NIMR (UK Gov) and Ethicon; consulting fees from Fractyl and GI Dynamics; and honoraria for speaking from Medtronic and Ethicon.

ABSTRACT

The term metabolic surgery describes bariatric surgical procedures used primarily to treat type 2 diabetes and related metabolic conditions. Originally, bariatric surgery was used as an alternative weight-loss therapy for patients with severe obesity, but clinical data revealed its metabolic benefits in patients with type 2 diabetes. Metabolic surgery is more effective than lifestyle or medical management in achieving glycemic control, sustained weight loss, and reducing diabetes comorbidities. Perioperative adverse events are similar to other gastrointestinal surgeries. New guidelines for type 2 diabetes expand use of metabolic surgery to patients with a lower body mass index.

KEY POINTS

  • Randomized clinical trials have shown that metabolic surgery is statistically superior to medical treatment in achieving targeted glycemic levels along with improvements in weight loss, remission of metabolic syndrome, reduction in medications, and improvements in lipid levels.
  • The safety of metabolic and bariatric surgery has significantly improved with the advent of laparoscopic surgery, resulting in complication profiles similar to those of cholecystectomy and appendectomy.
  • Metabolic surgery is now recommended as standard treatment option for type 2 diabetes in patients with body mass index levels as low as 30 kg/m2.

WHO SHOULD HAVE METABOLIC SURGERY?

Until recently, there was no clear national or international consensus on the role of metabolic surgery in treating type 2 DM. In 2015, the 2nd Diabetes Surgery Summit (DSS-II) Consensus Conference published guidelines that were endorsed by more than 50 diabetes and medical organizations.5 The recommendations cover many clinically relevant issues, including patient selection, preoperative evaluation, choice of procedure, and postoperative follow-up. The consensus conference delegates concluded that there is sufficient evidence demonstrating that metabolic surgery achieves excellent glycemic control and reduces cardiovascular risk factors.

Figure 5. Algorithm for the treatment of type 2 diabetes, as recommended by the 2nd Diabetes Surgery Summit's voting delegates.
According to the DSS-II guidelines, metabolic surgery should be recommended to treat type 2 DM in patients with class III obesity (BMI ≥ 40 kg/m2) regardless of glycemic control and in those with class II obesity (BMI 35.0–39.9 kg/m2) when hyperglycemia is inadequately controlled by lifestyle and optimal medical therapy. Surgery should also be considered for patients with type 2 DM and BMI 30.0 to 34.9 kg/m2 if hyperglycemia is inadequately controlled despite optimal treatment with either oral or injectable medications. These BMI thresholds should be reduced by 2.5 kg/m2 for Asian patients.

The treatment algorithm from DSS-II incorporates appropriate use of all 3 treatment modalities: lifestyle intervention, drug therapy, and surgery (Figure 5).5 The 2017 Standards of Care for Diabetes from the American Diabetes Association include those key indications in the recommendations for metabolic surgery (Table 3).2

SUMMARY

Recent evidence from multiple RCTs has provided level 1a evidence supporting metabolic surgery as an effective treatment for type 2 DM. These studies have shown the superiority of surgery vs medical therapy in achieving excellent and durable glycemic control as well as benefits in long-term weight loss, medication reduction, dyslipidemia, overall quality of life, and other cardiovascular risk factor reductions. Metabolic surgery is the only diabetes treatment proven to result in long-term remission in 23% to 60% of patients.

The safety of metabolic surgery has significantly improved with the advent of laparoscopic surgery and recent national quality improvement initiatives that have made gastric bypass and SG as safe as cholecystectomy and appendectomy. Although observational studies suggest that metabolic surgery is associated with a reduction in cardiovascular and diabetes complications and mortality, these observations have not been confirmed in long-term RCTs.

Based on the published evidence, metabolic surgery is now endorsed as a standard treatment option, which provides patients and practitioners with a powerful tool to help combat the life-impairing effects of type 2 DM.

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