Bariatric Surgery vs Medication to Treat Obese Patients w/Diabetes

Traditionally, treating patients w/diabetes was the domain & purview of the medical physician, at least once insulin was discovered.  Over the years, we've changed our demographics such that type 2 diabetes, as typified by insulin resistance associated w/obesity, has become much more commonplace at a younger age, than the original type 1 diabetes, which is due to pancreatic failure.

However, given the increasing prevalence of obesity (and diabetes), I would daresay that medicine is fighting a losing battle despite all the pharmaceutical options available to us, a veritable treasure trove compared to the simple sulfonylureas taught during my days of training. And given our prodigious predilection to prove the veracity of Newton's First Law of Physics, inertia, it's not surprising that very few persons are able to increase their level of physical activity to such a degree that they can match the results of those competing in NBC's The Biggest Loser TV show.

This prelude leads up to a dramatic (at least for me) announcement made yesterday at the American College of Cardiology meeting in which 2 studies published online first in the New England Journal of Medicine demonstrated the efficacy of surgery over medicine in treating diabetes in obese patients.

In the first study, the authors randomized 150 patients (two-thirds women avg 49yo w/BMI 36kg/m2 & HgbA1c 9.2%) to either intensive medical therapy alone or intensive medical therapy plus either Roux-en-Y gastric bypass or sleeve gastrectomy.  All operations were performed by just one surgeon.  At the end of a year, only 1 in 10 randomized to intensive medical therapy alone was able to bring his/her HgbA1c below 6% compared to 2 in 5 who underwent some form of gastric surgery.  Weight loss was also greater after both surgeries compared to those who did not have surgery.  Most notably, medication use decreased after both surgeries but increased in those randomized to intense medical therapy.

In the second study, the authors randomized 60 patients (50% women avg 43yo w/BMI 45kg/m2 & HgbA1c 8.65%) to either conventional medical therapy, laparoscopic Roux-en-Y gastric bypass or open biliopancreatic diversion.  Two surgical teams, each specializing in a particular procedure, were used to perform the operations.  At the end of two years, 75-95% of those who underwent surgery had achieved diabetic remission compared to no one randomized to conventional medical therapy.  Furthermore, HgbA1c dropped down to 7.69% in the conventional medical therapy group compared to 6.35% in the Roux-en-Y gastric bypass group and 4.95% in the biliopancreatic diversion group.

Surprised?  Well, I sure was!  But on the other hand, if I had remembered to read an article in the January 23, 2008 issue of JAMA, I would have read that a 2 year unblinded study of 60 obese patients w/T2DM randomized to either conventional medical therapy or laparoscopic adjustable gastric banding found that three out of four who underwent surgery achieved diabetic remission compared to just one in eight randomized to conventional medical therapy.

Furthermore, a systematic review & meta-analysis published in the January 2009 issue of American Journal of Medicine came to a similar conclusion: bariatric surgery appears to achieve diabetic remission for at least two years post-op, with greater success being associated with greater weight loss.

Unfortunately, we're still too early in this paradigm shift from medical management to surgical treatment of diabetes in obese patients.  The results thus far are clear: bariatric surgery is effective, at least in the short-term.  The bigger question is whether the results will hold up in the long run.  Even more importantly, can surgeons in the community w/less procedural volume replicate these same results?  Only time will tell . . .

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