Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes

Abstract

Type 2 diabetes affects 12% to 14% of persons in the United States, with prevalence rates exceeding 20% in non-Hispanic black, Asian, and Hispanic populations. 1 Pharmaceutical and behavioral approaches to restore glucose homeostasis and to avoid longterm complications of diabetes may be effective, but sustaining adherence is often difficult. 2 Gastrointestinal operations (Roux-en-Y gastric bypass, vertical sleeve gastrectomy, laparoscopic adjustable gastric banding, and biliopancreatic diversion) provide substantial weight loss and often improve function and reduce obesity-related complications. 3 Some consider bariatric interventions as metabolic surgeries when the goal is to improve metabolic health rather than weight alone, and these procedures can lead to changes in the gut microbiome and hormones, bile acid metabolism, and other factors that affect glucose homeostasis independent of weight loss. 4 Recent studies and an emerging consensus suggest metabolic surgery to treat T2D in some patients. However, a firm link between controlling diabetes through metabolic surgery and preventing diabetes complications has yet to be established. Characteristics of the Guideline SourceThis guideline was published by delegates of the Second Diabetes Surgery Summit (DSS-II), an international consensus conference organized in collaboration with major diabetes organizations (Table ). 4 The DSS-II organizing committee tasked 48 academic experts (75% nonsurgeons) with unclear relevant financial relationships to write a guideline for the surgical treatment of T2D. Prior to meeting, delegates received an evidence summary and the proposed recommendations. They used an interactive feedback process to reach agreement (Ն67%). Consensus recommendations were presented Clinical Review & Education JAMA Clinical Guidelines Synopsis

Surgical treatment of obesity

“…Bariatric surgery as a treatment for obesity, as well as its benefits on associated chronic medical conditions, continues to gain acceptance and popularity worldwide. Obesity-associated type 2 diabetes as an indication for bariatric surgery is a clear paradigm shift in diabetes management in recent years 85 , 86 . With these clinical changes, a number of important questions continue to arise that are shaping the current and future research landscape.…”

“…We speculate that operating in individuals at lower body weight (25–30 kg/m 2 ) who are at high risk for weight gain and metabolic illness over time may become more commonplace in the coming years. The new clinical guidelines that recommend consideration of “metabolic surgery” in patients with a BMI of less than 35 kg/m 2 with intractable diabetes 85 , 86 are a direct extension of this rationale. Regardless, changes in clinical practice to include individuals with a BMI of less than 30 kg/m 2 are not currently supported by any randomized or controlled trials, and any further changes in clinical practice will require further studies.…”

Ghrelin regulation of glucose metabolism

“…In line with obesity being the major risk factor for the development of type 2 diabetes, weight loss achieved by either dieting [ 5 ] or through pharmacology [ 6 ] or bariatric surgery [ 7 , 8 ] improves glucose handling and numerous clinical studies have demonstrated that placebo-subtracted weight loss in the magnitute of even 5% is sufficient to show meaningful improvements in systemic glucose metabolism and of other obesity linked co-morbidities [ [9] , [10] , [11] , [12] ]. Further underlining the direct relation between body weight and glucose control, weight loss induced by bariatric surgery most often results in complete resolution of type 2 diabetes, an observation that prompted the American Diabetes Association (ADA) to even recommend such surgical intervention under certain circumstances for the treatment of type 2 diabetes [ [13] , [14] , [15] ]. Since the correlation between body weight and glucose control is solidly confirmed by numerous preclinical and clinical studies [ 16 , 17 ], drugs to control body weight appear intuitively promising to also improve glucose metabolism.…”

Increased Energy Expenditure and Energy Loss through Feces Contribute to the Long-term Outcome of Roux-en-Y Gastric Bypass on Diet Induced Obese Mouse Model

“…Excessive fat accumulation was the key factor for the development of insulin resistance and metabolic syndrome, thus reduction of fat mass would ameliorate metabolic disorders [21][22][23]. Clinical studies proved that RYGB could lead to higher remission rate of type 2 diabetes than SG and medical treatment in long-term [4,24]. In this study, body composition was found to be altered after RYGB as fat mass was significantly reduced, and this alteration was kept unchanged at 8 and 12 weeks after surgery.…”

“…Bariatric surgery has been demonstrated to be effective not only for body weight loss, but also for the improvement of obesity related comorbidities, such as type 2 diabetes, by a number of retrospective studies in last decades [1,2]. Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) were proved to be superior to medical treatment for type 2 diabetes mellitus(T2DM) according to a 5-year perspective randomized clinical trail [3] which lead to the consensus that bariatric surgery was listed in the treatment algorithm of T2DM [4]. Moreover, RYGB showed better long-term effect than SG [3] which raised the interests about the physiological change in the long-term period after RYGB.…”