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Diabetes Management
The Role of Gastrointestinal Metabolic Surgery in the
Management of Type 2 Diabetes
Federica del Genio, MD, PhD,
1
Gladys Witt Strain, PhD, RD
2
and Francesco Rubino, MD
3
1. Post-doctoral Research Fellow, Diabetes Surgery Center; 2. Director of Research for Laparoscopic and Bariatric Surgery, and
Associate Research Professor of Nutritional Sciences in Surgery; 3. Assistant Professor, Chief, Section of Gastrointestinal Metabolic Surgery, and
Director, Diabetes Surgery Center, Department of Surgery, Weill Cornell Medical College
Abstract
Bariatric surgery has dramatic effects on obese patients with type 2 diabetes. It carries a low risk of short-term mortality and a significant survival
advantage over the long term, especially if compared with the long-term risks from diabetes. Gastrointestinal bypass procedures in particular have
been reported to achieve improvement/remission of diabetes and related metabolic alterations by mechanisms beyond those related to weight loss.
The remarkable control of type 2 diabetes in severely obese patients raises the question of whether surgery may be a therapeutic option also for
moderately or non-obese subjects. Current body mass index (BMI)-based criteria for patient selection do not seem appropriately inclusive to define
surgical indications for diabetes treatment and the evaluation of the risk profile and risk–benefit ratio of patients with diabetes. Large-scale
randomized controlled trials comparing surgery with best medical care should be prioritized to define the role of surgery in diabetes management
and to define new, more appropriate parameters for surgical interventions.
Keywords
Type 2 diabetes, bariatric surgery, gastric bypass, metabolic surgery, gut hormones, obesity, body mass index (BMI), gastric banding
Disclosure: Federica del Genio, MD, PhD, and Gladys Witt Strain, PhD, RD, have no conflicts of interest to declare. Francesco Rubino, MD, is a consultant to GI Dynamics, NGM Biotech,
and Covidien, and has received speaker honoraria from Covidien and Ethicon.
Received: October 15, 2009 Accepted: December 15, 2009
Correspondence: Francesco Rubino, MD, Department of Surgery, Section of Gastrointestinal Metabolic Surgery, Room: P-714, Weill Cornell Medical College, 525 68th Street,
New York, NY 10065. E: frr2007@med.cornell.edu
The prevalence of type 2 diabetes is increasing worldwide.
1
More than the risk of microvascular complications can be decreased with intensive
20 million people in the US were suffering from diabetes in 2005, with medical treatment and adequate glycemic control,
10
reduction of
approximately 30% being undiagnosed.
2
It is estimated that by 2050 over macrovascular disease and cardiovascular mortality remain difficult to
48 million Americans will have diabetes.
3
In the US more than $132 billion obtain with conventional therapeutic strategies. The Action in Diabetes
was spent in 2002 on type 2 diabetes and its related complications. and Vascular Disease:  Preterax and Diamicron Modified Release
Nearly $92 billion was spent on direct medical expenditures and $40 Controlled Evaluation (ADVANCE) study showed that intensive medical
billion to cover indirect costs resulting from lost productivity secondary treatment significantly reduces microvascular events but causes no
to disability and early mortality.
4
The costs are anticipated to grow to significant effects in major macrovascular events.
11,12
$192 billion by 2020.
4
While these large clinical trials have reported positive results, several
Evidence suggests that bariatric surgery may represent a valid and cost- studies show the difficulty of patients reaching glycemic goals. The
effective treatment for diabetes, concomitantly inducing a consistent UK  Prospective Diabetes Study (UKPDS) examined the percentage of
survival advantage.
5–8
However, surgical procedures are not yet patients who attained the target successful glycemic control in three
considered a standard of care for diabetes management. This review different treatment modalities. Glyated hemoglobin (HbA
1c
) levels <7%
focuses on the metabolic effects of bariatric procedures and possible were achieved after nine years of monotherapy with diet, insulin, or
cultural barriers that may affect the acceptance of surgery as a sulfonylurea by only 9, 28, and 24% of patients, respectively.
12
Data from
treatment for patients with type 2 diabetes. the National Health and Nutrition Examination Survey (NHANES)
1999–2000 have recently showed that only 37% of adults with previously
Conventional Treatment for Type 2 Diabetes diagnosed diabetes achieved the target HbA
1c
goal of <7%.
13
Currently, according to the American Diabetes Association (ADA),
diabetes is considered “a chronic illness that requires continuing Diabetes management includes the control of related comorbidities.
medical care and patient self-management education to prevent acute The UKPDS group investigated the effects of tight control of blood
complications and to reduce the risk of long-term complications.”
9
While pressure compared with a less tight antihypertensive treatment. There
© TOUCH BRIEFINGS 2009 53
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