Diabetes: Is It Now a Surgical Disease?

Hi. I’m Dr. Henry Black. I’m Clinical Professor of Internal Medicine at the New York University School of Medicine, a member of the Center for the Prevention of Cardiovascular Disease at that institution, and former President of the American Society of Hypertension. If I had said 10 years ago that diabetes was going to become a surgical disease, I think I would have been laughed off the stage; yet, increasing evidence shows that this may not be a completely far-out idea. Two very small but important studies were recently published in the New England Journal of Medicine, one from the Cleveland Clinic^[1] and one from Italy.^[2] Both of them looked at people with high body mass index (BMI). BMIs were somewhat lower in the Cleveland Clinic study, with an average of about 34; in the Italian study, the average BMI was 45 and the average weight was about 300 lb. The investigators compared intensive medical therapy given by experts with surgical approaches. The Cleveland study looked at sleeve gastrectomies and bypass, and the Italian study compared intensive medical therapy (including exercise, which wasn’t specifically done in the Cleveland Clinic study) with ileojejunostomy and bypass.

The results were strikingly similar. These were small studies; there were about 20 patients per group in the Italian study and about 50 per group in the Cleveland Clinic study. They both showed dramatic reductions in weight that were generally seen within 3 months. Patients were followed for 1 year in Cleveland and 2 years in the Italian study, and a significant improvement in all the metabolic parameters that we follow in diabetics — including lipids, hemoglobin A1c, and even blood pressure — happened before the weight loss was completely achieved. Patients with jejunostomy and bypass were able to be taken off diabetic medicines and, in some cases, lipid-lowering therapy, something that was never seen in patients who received only medical therapy.

This implies that we have to start thinking about using one of these techniques sooner until we can find a way to deliver behavioral therapy that people will follow. There is no question that some things in this study are not necessarily generalizable. The Cleveland Clinic study had a single surgeon and the Italian study had teams that were well trained. We don’t know whether this is going to translate into every surgeon in every community, but it is an important thing to bear in mind. We also have to do some assessment of outcomes.

These were very small studies. Reoperations were necessary in both studies, but there were no fatalities. BMIs went to under 30 in the Italian study and were similar in the Cleveland Clinic study. It’s time for those of us who see obese patients with diabetes to start talking about this as something that is getting close to being proven. An old Swedish study^[3] showed outcome improvement with what was more complicated surgery than we are doing now. Also, how are we going to better deliver behavioral therapy? This is something the public needs to know and needs to know now. Thank you.

References

1. Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012;366:1567-1576. Abstract
2. Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012;366:1577-1585. Abstract
3. Sjostrom L, Lindroos AK, Peltonen M, et al; Swedish Obese Subjects Study Scientific Group. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351:2683-2693. Abstract

Source: Medscape.com