Bariatric surgery versus intensive medical therapy for diabetes

Long-term results from randomised, controlled trials that compare medical therapy with surgical therapy in patients with type 2 diabetes are limited. A study published in the New England Journal of Medicine (N Engl J Med 2017; 376:641-651February 16, 2017DOI: 10.1056/NEJMoa1600869) reports on outcomes five years after 150 patients who had type 2 diabetes and a body-mass index (BMI) of 27 to 43 were randomly assigned to receive intensive medical therapy alone or intensive medical therapy plus gastric bypass or sleeve gastrectomy. The primary outcome was a glycated haemoglobin (HbA1c) level of 6.0 per cent (42 mmol/mol).

Of the 150 patients who underwent randomization, one patient died during the five-year follow-up period; 134 of the remaining 149 patients (90 per cent) completed five years of follow-up. The mean age of the 134 patients was 49 years, 66 per cent were women, the mean HbA1c level was 9.2 per cent (77 mmol/mol), and the mean BMI was 37. At five years, the criterion for the primary end point (HbA1c) was met by five per cent of patients who received medical therapy alone, as compared 29 per cent who underwent gastric bypass and 23 per cent who underwent sleeve gastrectomy. Patients who underwent surgical procedures had a greater mean percentage reduction from baseline in HbA1c than did patients who received medical therapy alone.

At five years, changes from baseline observed in the gastric-bypass and sleeve-gastrectomy groups were superior to the changes seen in the medical-therapy group with respect to body weight (−23 per cent, −19 per cent, and −5 per cent, respectively). Reductions in triglyceride level (−40 per cent, −29 per cent, and −8 per cent), HDL (32 per cent, 30 per cent, and 7 per cent), and use of insulin (−35 per cent, −34 per cent, and −13 per cent) were also superior as were quality-of-life measures (general health score increases of 17, 16, and 0.3). No major late surgical complications were reported except for one reoperation.

Take home message

For patients with type 2 diabetes and a BMI of 27 to 43, bariatric surgery plus intensive medical therapy is more effective than intensive medical therapy alone in decreasing or in some cases resolving, hyperglycemia.

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