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Recommendations Issued for Use of Gastrointestinal Surgery to Treat Type 2 Diabetes

Laurie Barclay, MD (Medscape)

December 1, 2009 - The Diabetes Surgery Summit (DSS) Consensus Conference reviewed pertinent research and made clinical recommendations regarding gastric surgery as a treatment of type 2 diabetes mellitus (T2DM). The new position statement, which consists of recommendations for clinical and research issues, as well as overall concepts and definitions in diabetes surgery, is published in the November 19 Online First issue of Annals of Surgery.

"Increasing evidence demonstrates that bariatric surgery can dramatically ameliorate type 2 diabetes," write Francesco Rubino, MD, from Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, and colleagues from the DSS Delegates. "Not surprisingly, gastrointestinal operations are now being used throughout the world to treat diabetes in association with obesity, and increasingly, for diabetes alone. However, the role for surgery in diabetes treatment is not clearly defined and there are neither clear guidelines for these practices nor sufficient plans for clinical trials to evaluate the risks and benefits of such 'diabetes surgery.'"

Specific recommendations in the DSS position statement, and their accompanying level of evidence rating, include the following:

• In acceptable surgical candidates with a BMI of 35 or more whose disease is inadequately controlled by lifestyle and medical therapy, gastrointestinal surgery, such as RYGB, laparoscopic adjustable gastric banding, or biliopancreatic diversion, should be considered for the treatment of T2DM (level of evidence, A).
• In suitable surgical candidates with mild to moderate obesity (BMI 30 - 35), a surgical approach may also be appropriate as a nonprimary option to treat inadequately controlled T2DM (level of evidence, B). RYGB may be an appropriate surgical option to treat diabetes in these patients (level of evidence, C).
• In early clinical studies, novel gastrointestinal surgical techniques (eg, duodenal-jejunal bypass, ileal interposition, sleeve gastrectomy, and endoluminal sleeves) have shown promising results for the treatment of T2DM. At present, however, they should be used only in the context of institutional review board-approved and registered trials (level of evidence, A).
• Establishing standards to measure clinical and physiologic outcomes of surgical treatment for T2DM is a high priority to obtain better-quality medical evidence (level of evidence, A).
• To evaluate the usefulness of gastrointestinal surgery to treat T2DM, the DSS strongly encourages more randomized controlled trials (level of evidence, A).
• Another important research priority is to identify the appropriate use of gastrointestinal surgery to treat T2DM in patients with a BMI of less than 35 (level of evidence, A). This should be accomplished with controlled clinical trials to assess the safety and efficacy of gastrointestinal metabolic surgery (level of evidence, A) and to identify parameters other than BMI to help guide selection of suitable patients (level of evidence, A).
• After laparoscopic adjustable gastric banding, weight loss alone accounts for diabetes control, based on available evidence from animal and clinical studies (level of evidence, A). However, mechanisms beyond those related to lowered food intake and body weight seem to be involved in intestinal bypass procedures such as RYGB, biliopancreatic diversion, and duodenal-jejunal bypass (level of evidence, A). In addition, distinct physiologic mechanisms that ameliorate T2DM are activated by anatomic changes in different regions of the gastrointestinal tract (level of evidence, B).

"Delegates unanimously agreed that patients with inadequately controlled diabetes and BMI >35 should be considered for GI [gastrointestinal] surgery," the DSS authors conclude. "This concurs with existing NIH [National Institutes of Health] guidelines and with the 2009 American Diabetes Association standards of care position statement, and it further emphasizes the role of GI surgery in severely obese patients, where mounting evidence shows that surgery improves overall survival."

DSS was supported by Covidien, Ethicon, Allergan, Storz, GI Dynamics, Roche, Amylin, and Power Medical Interventions.

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