Surgery for diabetes?

Recently, two studies were published in the New England Journal of Medicine (NEMJ) providing compelling evidence that surgical methods of achieving weight loss can lead to better control of Type 1 diabetes mellitus (T1DM). It is well established that weight loss in an obese person can show marked improvement in the control of their DM.

As we are well aware, while T1DM results from the body’s failure to produce adequate amounts of the hormone insulin, Type 2 DM (T2DM) is a consequence of improper utilization of this hormone. Regardless of the type, DM becomes more difficult to manage as it progresses and ultimately leads to serious and severe complications such as heart disease, kidney failure, blindness and stroke.

Crucial to proper management of this disease is the adequate control of blood sugar centered upon lifestyle measures that encourage weight loss and physical activity. The weight loss regimen involving diet and exercise can be a mentally and physically painful process with often a less than desirable outcome. Many patients are unable to achieve good glycemic control, leading to the addition of medications, frequently with increasing number and dosage, and ultimately the addition of insulin therapy. Counter to the aim of the therapy, one of the side effects of insulin therapy is weight gain, thus rendering management more difficult.

It is no surprise then that more patients are starting to resort to surgery to decrease the size of their stomach. This type of weight loss surgery is termed bariatric surgery and involves gastrectomy (removal of part of the stomach), stapling or banding of the stomach. Although having been around for some time now, an upsurge in cases of bariatric surgery for the management of DM has been reported, mainly due to recent information from clinical studies that showed significant weight loss and subsequent improvement in diabetic control. These recent studies provide more dependable information because of their random and rigorous comparison between medical and surgical forms of treatment. There is now better proof that weight loss operations seem to work much better than standard medical management. 

Nevertheless, caution must be employed and it may be wise to examine the studies in depth and note their deficiencies. They involved only a small number of patients (150) and were of a short duration. As well as not being able to prove long-term benefits, it is also questionable if the results of bariatric surgery will be as good in routine clinical practice, or for that matter, in patients who are not as heavy as those in the studies. Since highly skilled surgeons performed the operations in these studies, results by others may not be as good. Surgical complications can range from infections, mineral and bone deficiencies and other injuries. Furthermore, these studies compared bariatric surgery with standard medical care involving medications, when in actual fact, the comparison should have been with medical weight loss therapy (diet, exercise, behavior change and other appropriate medical interventions). Patients succeeding with medical treatment would then have no necessity to undergo surgery at all.

To be fair though, bariatric surgery has been recognized as appropriate treatment, but only for those obese patients with Type 2 DM who are unable to reach their glycaemic targets with the prescribed medical therapies.

In conclusion, we should not rush to embrace bariatric surgery as a standard treatment alternative for DM despite the strong evidence suggesting so. Due recognition has to be given for the hard work put in by the researchers, but benefit must be shown in a larger numbers of patients, and over a longer period of time before we can determine the place of bariatric surgery in the management of Type 2 DM.

References:

Schauer PR et al. Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes. March 26, 2012 (10.1056/NEJMoa1200225)

Mingrone G et al. Bariatric Surgery versus Conventional Medical Therapy for Type 2 Diabetes. March 26, 2012 (10.1056/NEJMoa1200111)

Zimmet P, George K, Alberti MM. Surgery or Medical Therapy for Obese Patients with Type 2 Diabetes? March 26, 2012 (10.1056/NEJMe1202443)