First Clinical Guidelines to Recommend Surgery as Diabetes Treatment

The inclusion of surgery represents one of the "biggest changes in diabetes care in modern times."
The inclusion of surgery represents one of the "biggest changes in diabetes care in modern times."

A consensus statement endorsed by numerous international organizations is calling for metabolic surgery to be recognized as a treatment option for certain patients with diabetes, including those who are mildly obese and fail to respond to conventional treatment. Despite the evidence for its effectiveness, metabolic surgery has never been included clinical guidelines as a recommended treatment option for patients with diabetes.

The new guidelines stem from the Second Diabetes Surgery Summit (DSS-II), an international consensus conference; the goal of the summit was to develop global guidelines to inform clinicians about the benefits and risks of metabolic surgery for type 2 diabetes. Metabolic surgery, originally designed for weight loss purposes, is defined as the use of gastrointestinal operations with the primary intent to treat type 2 diabetes and obesity. The guidelines are based on evidence from 11 clinical trials showing that in most cases metabolic surgery can reduce glucose levels below diabetic thresholds or maintain adequate glycemic control despite a reduction in medication use. Economic studies also show that metabolic surgery is cost-effective. 

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According to the new guidelines, metabolic surgery should be recommended to:

    — Type 2 diabetes patients with Class III obesity (BMI ≥40kg/m2)

    — Type 2 diabetes patients with Class II obesity (BMI 35–39.9kg/m2) when hyperglycemia is inadequately controlled by lifestyle and medical therapy

    — Type 2 diabetes patients whose hyperglycemia is inadequately controlled and have BMI between 30 to 34.9kg/m2 (metabolic surgery should be considered)

For Asian patients, who often develop type 2 diabetes at lower BMI, each of these categories should be reduced by 2.5kg/m2.

The authors note that while metabolic surgery is considered to be as safe as gallbladder surgery, patients still do run the risk of surgical complications or long-term nutritional deficiencies. Also, relapse in hyperglycemia can occur in up to 50% of patients with initial remission, however most maintain substantial improvement in A1C in the long term.

"Surgery represents a radical departure from conventional approaches to diabetes. The new Guidelines effectively introduce, both conceptually and practically, one of the biggest changes for diabetes care in modern times," said Dr. Francesco Rubino, a Professor of Metabolic and Bariatric Surgery at King's College London in the UK, co-director of the DSS-II and the first author of the report. "This change is supported by documented clinical efficacy and by the evidence of an important role of the gut in metabolic regulation, which makes it an appropriate target for anti-diabetes interventions," he added.

The full consensus statement can be found here.

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