Two articles in the New England Journal of Medicine point to the role of bariatric surgery in treating type 2 diabetes in obese patients (NEJM 2012; 366: 1567-76 & 1577-85). Type 2 diabetes looms as one of “the most challenging contemporary threats to public health.”
The first study was a randomized nonblinded single-center trial with 150 patients; mean BMI 36 with 34% having a BMI less than 35. Intensive medical therapy was compared to Roux-en-Y gastric bypass or sleeve gastrectomy. Mean patient age was 49 years. 42% of the gastric bypass group, 37% of the sleeve-gastrectomy group, and 12% of the medical treatment group achieved the primary end-point of a glycated hemoglobin level of ≤6% by the 12 month followup; the average starting glycated (HgbA1C) hemoglobin was 9.2%. At the conclusion of the study, the average HgbA1C was 6.4, 6.6, and 7.5 respectively in the three groups.
The second study used a similar trial with 60 obese patients; all had BMI >35 At 2 years, diabetes remission occurred in 75% of their gastric bypass group, 95% of their biliopancreatic-diversion group and in no patients receiving intensive medical therapy patients. HgbA1C had similar rates of improvement as the 1st study: 6.3 in gastric-bypass, 4.9 in biliopancreatic-diversion group, and 7.7 in medical-therapy group.
While surgery has risks (see related material below), its benefits are likely to alter future treatment strategies with surgery being contemplated prior to exhausting all medical treatments.
- -JAMA 2012; 307: 56-65. Bariatric surgery and long-term cardiovascular events.
- -JAMA 2011 [doi: 10.1001/jama.2011.817]). Large study failed to show that roux-en-Y gastric bypass prolonged life. n=850 VA pts to 41,244 controls. Same group showed no cost savings during initial 3 yrs: Med Care 2010; 48: 989-98.
- -NEJM 2011; 365: 1365. Increased frequency of bariatric surgery in adolescents.
- -NEJM 2009; 361: 445/520. perioperative safety.
- -NEJM 2007; 357: 741, 753, 818. Bariatric surgery improves mortality rate.
- NEJM 2007; 356: 2176. Review
Complications from surgery:
- Early: bowel obstruction, DVT, GI bleed, leaks, pulmonary embolism, wound infection
- After 30 days: anastomotic stricture, bowel obstruction, gallstones, dehiscence, fistula, Bleeding, Incisional hernia, nutrient deficiencies (iron, B12; calcium, Vit D (w RYGB), folate, B6/riboflavin).
- Complications from gastric band: food impaction, erosion (now banned in Finland!), band slippage, gastric volvulus, band too tight, port infection
- Roux-y gastric bypass:
anastomotic leak 1.2%, anastomotic ulcers/stricture
- Nutrient Monitoring–every 3months x 3, then yearly: Vitamin A, B12, Folate, Ceruloplasmin, Vit D-25OH, Iron studies, Zinc, thiamine, Selenium, Intact PTH, Mg, PT/PTT
- Suggested supplements: Calcium c vitamin D 1200-2000mg, Iron at least 18-27mg/day, MVI with zinc/selenium
- Also if duodenal switch, add Vitamin A 10,000 IU, and Vitamin D3 1200units daily or 50,000 units weeekly, Vitamin K 300 mcg,
Potential nutritional deficiencies:
- B12, B6 (pyridoxine), Riboflavin (B2), B1 (Thiamine), Folate (B9)
- Vitamins A,D,E, K
- Calcium, Copper, Iron, Selenium, Zinc
Recommendations from NASPGHAN Post-Graduate Course 2011:
- If post-op pain: epigastric –>do EGD & if neg do ‘RUQ w/u’, RUQ –> check U/S, LFTs possibly CT
- If post-op vomiting –>do EGD
- If post-op nausea –>Rx PPI and EGD if not improving
- Anastomotic stricture in stomach –>dilate to 10-12mm in 1 session
Related blog posts (includes additional references)