New guidelines support use of metabolic surgery as standard treatment option for type 2 diabetes, obesity

A panel of experts recommends metabolic surgery as a treatment for type 2 diabetes.
A panel of experts recommends metabolic surgery as a treatment for type 2 diabetes.

Metabolic surgery should be considered a valid treatment option for patients with type 2 diabetes and obesity, according to a joint statement published in Diabetes Care.

The statement was released by the 2nd Diabetes Surgery Summit (DSS-II), which is comprised of a multidisciplinary group of 48 international clinicians and scholars, including representatives of leading diabetes organizations.

The DSS-II defines metabolic surgery as “the use of [gastrointestinal] surgery with the intent to treat [type 2 diabetes] and obesity.”

After reviewing studies from January 2005 through September 2015, the DSS-II developed 32 conclusions regarding the use of metabolic surgery for type 2 diabetes. The recommendations are organized into several categories: generalities, metabolic surgery versus traditional bariatric surgery, defining goals and success of metabolic surgery, patient selection, preoperative workup, choice of procedure, and postoperative follow-up.

Generalities

  • The GI tract's role in metabolic regulation makes it a clinically and biologically meaningful target for managing type 2 diabetes.
  • There is sufficient clinical and mechanistic evidence to include GI surgery as an antidiabetes intervention for patients with type 2 diabetes and obesity.
  • Algorithms for treating type 2 diabetes should include scenarios in which metabolic surgery can be considered a treatment option in addition to lifestyle, nutritional, and/or pharmacologic interventions.
  • Developing a chronic disease care model that integrates lifestyle, nutritional, pharmacologic, and surgical approaches is a key priority for diabetes care.
  • The clinical community should work together with healthcare regulators to recognize metabolic surgery as an intervention for type 2 diabetes and to introduce reimbursement policies for this surgery.

Metabolic surgery versus traditional bariatric surgery

  • Metabolic surgery should not follow the guidelines of traditional bariatric surgery, which is intended for weight loss. New guidelines consistent with international diabetes standards of care must be developed for metabolic surgery.
  • Bariatric surgery candidates are generally selected solely based on BMI; complementary criteria must be developed to better select patients for metabolic surgery.
  • Metabolic operations include Roux-en-Y gastric bypass (RYGB), vertical sleeve gastrectomy (VSG), laparoscopic adjustable gastric band (LAGB), classic type biliopancreatic diversion (BPD), and duodenal switch BPD (BPD-DS). Any other operations are considered experimental.
  • Metabolic surgery should be performed in high-volume centers by multidisciplinary teams with expertise in the management of diabetes and GI surgery.

Defining goals and success of metabolic surgery

  • GI surgery should be considered in addition to lifestyle modifications and current medical therapies to reduce complications associated with type 2 diabetes.
  • Whereas the goal of bariatric surgery is weight loss, the goal of metabolic surgery for patients with type 2 diabetes and obesity is reducing the complications of diabetes, as well as improving hyperglycemia and other metabolic abnormalities.

Patient selection

  • A multidisciplinary team including surgeon(s), internist(s)/endocrinologist(s), and dietitian(s) with expertise in diabetes management should assess patients' eligibility for metabolic surgery.
  • Contraindications for metabolic surgery include: diagnosis of type 1 diabetes (unless surgery is indicated for other reasons such as obesity); current drug or alcohol abuse; uncontrolled psychiatric illness; lack of comprehension of the risks/benefits, expected outcomes, or alternatives; and lack of commitment to nutritional supplementation and long-term follow-up.
  • Metabolic surgery is recommended as an option for treating type 2 diabetes in patients who:
    • Have class III obesity (BMI ≥40 kg/m2), regardless of glycemic control or glucose-lowering regimens
    • Have class II obesity (BMI 35.0 to 39.9 kg/m2) with inadequately controlled hyperglycemia despite lifestyle and medical interventions.
  • Metabolic surgery should be considered as an option for treating type 2 diabetes in patients with class I obesity (BMI 30.0 to 34.9 kg/m2) with inadequately controlled hyperglycemia despite optimal medical intervention by either oral or injectable medications, including insulin.
  • BMI thresholds should be reconsidered depending on the patient's ancestry.
  • Due to a lack of evidence, metabolic surgery is not recommended to treat type 2 diabetes in adolescent patients.

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