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Diabetes Management
was a significantly decreased risk in the tight control group of can be controlled by deciding to eat less and exercise more.
diabetes-related deaths, strokes, and microvascular end-points.
14
In Accordingly, bariatric surgery is considered as an extreme way to
the Scandinavian Simvastatin Survival Study (4S) the authors reported enforce healthier lifestyle habits and a form of treatment that works
that patients with diabetes treated with a statin had a significant through mechanical changes rather than through alterations in the
relative reduction of major coronary heart disease (CHD) event risk underlying pathophysiology of the disease.
(CHD death or non-fatal myocardial infarction [MI]) compared with
patients treated with placebo.
15
In spite of clear evidence of the benefit Scientific data related to bodyweight regulation and the mechanisms of
of blood pressure and cholesterol control in patients with type 2 action of bariatric procedures clearly refute the common misconceptions.
diabetes, the available data show goals for blood pressure and Bodyweight is maintained within a relatively narrow range by a precise
cholesterol are not being met. NHANES 1999–2000 found that the and powerful biologic system and voluntary efforts to reduce weight are
goals of blood pressure and total cholesterol were attained only by resisted by compensatory biologic responses. On the other hand, recent
35.8 and 48.2% of subjects with type 2 diabetes respectively.
13
evidence shows that gastrointestinal surgery does not ‘treat’ diabetes
Only 7.3% of adults in this study had achieved all three recommended solely by restriction or malabsorption. Although the mechanism is
goals of HbA
1c
level <7%, blood pressure <130/80mmHg, and total incompletely understood, RYGB does alter gut hormone secretion,
20–22
cholesterol level <200mg/dl.
13
Data from major studies indicate that which may contribute to sustained reductions in food intake,
20
improved
conventional medical treatment of most patients with diabetes insulin sensitivity,
23–26
and enhanced insulin secretion.
16,24,26–28
generally does not produce satisfactory control.
12–13
The term ‘bariatric’ surgery, derived from the Greek word baros for
‘Metabolic’ Surgery weight,
29
defines a branch of general surgery that deals with the control
Available evidence has established that obese patients can frequently of weight. Successful outcomes of bariatric surgery are measured as
develop normal glycemia and HbA
1c
levels after bariatric procedures. percent of excess bodyweight loss. However, weight loss is only one of
Resolution (or remission) was defined as discontinuation of all diabetes- the outcomes of such surgery. The truly significant benefits of these
related medications and maintenance of blood glucose levels within the procedures include the resolution/improvement of obesity-related
normal range. In a recent meta-analysis by Buchwald and colleagues, a comorbidities, such as diabetes, hypertension, and hyperlipidemia.
complete remission of diabetes was found in 78.1% of patients who
underwent bariatric surgery. Taking into account either complete The argument explained above represents a strong rationale for a
remission or the improvement of diabetes, the percentage increases to conceptual shift that defines conventional weight-loss surgery and
86.6% of patients.
5
The rate of diabetes resolution was as high as novel gastrointestinal procedures as ‘metabolic surgery’ as opposed to
80.3–95.1% when only gastrointestinal bypass procedures were simply bariatric surgery.
included.
5
In type 2 diabetes patients following gastrointestinal bypass
procedures, Polyzogopoulou et al. found improved insulin sensitivity, Risk–Benefit Ratio
as well as improved beta-cell acute insulin response to glucose For the development of a meaningful risk–benefit ratio, it is important to
stimulation.
16
In an earlier meta-analysis, Buchwald and co-workers evaluate mortality data from conventional medical treatment. Among
found a rate of hyperlipidemia improvement of 70%.
17
Considering the UKPDS patients (individuals newly diagnosed with type 2 diabetes at the
gastrointestinal bypass procedures alone, 96.9–99.1% of patients had time of study entry), over the 10-year follow-up mortality was 44%, with
improvement of hyperlipidemia. Hypertension resolved in 61.7% of cardiovascular disease being the leading cause of death (51.5%).
11
patients and it resolved or improved in 78.5% of patients.
17
Further support for the significant effects of type 2 diabetes on mortality
comes from a 12-year follow-up of men who reported using medication
Given the defined benefits of tight metabolic control, it is not surprising for diabetes, who had an absolute risk of cardiovascular disease death
that surgical interventions result in significant reductions of that was three times higher than male controls.
31
As already discussed,
cardiovascular risk and improved survival.
18
A retrospective cohort study the decrease in diabetes-related mortality after RYGB is substantial, and
investigating long-term mortality among nearly 10,000 Roux-en-Y gastric in one study was up to 92%.
7
This potential survival advantage of surgery
bypass (RYGB) patients compared with severely obese controls found a needs to be balanced with the risk of death from the surgical procedure
40% decrease in adjusted long-term mortality from any cause in the itself. For this comparison we can evaluate mortality rates of bariatric
surgery group compared with the obese control group. The decrease in operations with those of other surgical procedures. A US average
diabetes-related mortality in the surgery group was 92%.
7
mortality rate for seven operations was calculated in 2000.
32
These
ranged from 0.3% for hip replacement to 10.7% for craniotomy. A meta-
In spite of its dramatic outcomes, bariatric/metabolic surgery is chosen analysis
35
suggests that mortality rates from bariatric surgical
by only 1% of the morbidly obese
19
and has not yet become an accepted procedures compare very favorably with those of other surgical
treatment for diabetes. Perhaps this may be related to the common procedures. Another more recent meta-analysis agreed, reporting a
perception of bariatric surgery, which is often seen as ‘extreme,’ to be total mortality at ≤30 days of 0.30%.
35–36
reserved as a treatment of last resort. Several other factors, however,
may limit surgical referral. Cultural barriers and widespread With any surgical procedure for any type of disease, the indication for
misconceptions about the regulation of bodyweight exist. In fact, severe surgical treatment is usually determined by the assessment of the
obesity is rarely viewed as a genuine disease and obese patients are too balance between risks from the disease and risk from surgery itself.
often victimized with social stigma based on the assumption that weight Diabetes should be no exception.
54 US ENDOCRINOLOGY
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