Metabolic Surgery for Diabetes Management

Abstract

The debate regarding the effectiveness of metabolic surgery compared to medical therapy for type 2 diabetes started more than 3 decades ago with the insight of Pories and colleagues in their revolutionary article "Is Type II Diabetes Mellitus (NIDDM) A Surgical Disease?" 1 In this report, the authors noted that gastric bypass surgery provided exceptional glycemic control for patients with non-insulin dependent type 2 diabetes. Following these foundational observations, there have been multiple prospective trials that have clearly delineated the superior effectiveness of metabolic surgery for glycemic outcomes in patients with type 2 diabetes and overweight or obesity. [2][3][4] For instance, the Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial 2,3 randomized patients with type 2 diabetes to intensive medical therapy or intensive medical therapy with metabolic surgery. This trial demonstrated that metabolic surgery was superior to intensive medical therapy at 3 and 5 years for glycemic outcomes, including reaching hemoglobin A 1C (HgbA 1C ) goals established by the American Diabetes Association. The importance of achieving these HgbA 1C thresholds with metabolic surgery is these outcomes translate to reduced longterm cardiovascular complications, like heart failure and coronary artery disease. In a cohort study of nearly 50 000 patients with type 2 diabetes, each 1% increase in HbA 1C was associated with an 8% increased risk of new heart failure. 5 The total annual cost of diabetes care in the US in 2022 was $412.9 billion, with $106.3 billion (26%) attributed to lost productivity at work, unemployment from chronic disability, and premature mortality. 6 Conversely, metabolic surgery in patients with type 2 diabetes compared to historical control individuals receiving usual care was associated with a reduction in the likelihood of all-cause mortality by 39% at 8 years 4 and has been demonstrated to be cost effective in numerous studies with increasing savings over longer periods. 7 In 2017, the 2nd Diabetes Surgery Summit published recommendations for the use of metabolic surgery for type 2 diabetes following consensus-guideline development from 48 international experts (surgeons and nonsurgeons) and multiple diabetes-focused societies including the American Diabetes Association. 8 These recommendations included unanimous support to include metabolic surgery as a treatment option for type 2 diabetes for patients with class 3 obesity (body mass index [BMI] ≥40, calculated as weight in kilograms divided by height in meters squared). Metabolic surgery was also recommended for patients with type 2 diabetes and class 2 obesity (BMI 35.0-39.9) with inadequately controlled hyperglycemia despite medical therapy. Furthermore, the delegates concluded with 87% consensus that metabolic surgery should be considered to treat type 2 diabetes in patients with class 1 obe-Opinion EDITORIAL