Metabolic surgery has a solid place nowadays in the treatment of diabetes. Type 2 Diabetes mellitus is the most common form of diabetes. It makes up around 95% of all diagnoses reported. While Obesity is not the cause of diabetes, studies show that obese people are more at risk of developing pre-diabetes and Type 2 Diabetes. In fact, obesity largely contributes to the increasing incidences of diabetes and other co-morbidities not only in Lebanon but in most other countries in the world.

Type 2 Diabetes also causes many other health problems including;co heart diseases, kidney failure, strokes, some cancers, blindness, impotency, and many other linked co-morbidities which all contribute to the alarming rise of mortalities associated with Type 2 Diabetes.

Second Diabetes Surgery Summit (DSS-II) for Metabolic Surgery as Treatment for Diabetes

An international consensus conference known as the 2nd Diabetes Surgery Summit (DSS-II) was convened in London from 28th to 30th September, 2015 to address the role of bariatric surgery as an intervention for Type 2 Diabetes. This conference was arranged by many leading diabetes organizations in the world including the American Diabetes Association, Diabetes UK, Diabetes India, Chinese Diabetes Society and the International Diabetes Foundation.

These leading organizations came together with the aim of developing guiding principles to inform and advise clinicians and policymakers worldwide about the benefits as well as the limitations of metabolic surgery as an intervention for Type 2 Diabetes.

Diabetes UK calls for full incorporation of the new guidelines into the existing Type 2 diabetes intervention guidelines so that everyone who meets the criteria for the surgery is considered for treatment. This will ensure that all Type 2 Diabetes patients and people who have been diagnosed with pre-diabetes and those who are at a higher risk of developing diabetes because of their (excess) weight can access effective treatments and interventions for their conditions.

Many professionals from various disciplines participated in the DSS-11 conference. They included a group of 48 clinicians and scholars (75% who were non-surgeons) as well as representatives of the leading diabetes organizations in the world. To gauge agreement for 32 data-based decisions, three rounds of Delphi-like questionnaires were used, after the evidence appraisal; MEDLINE (1st Jan 2005 to 30th Sept 2015).

These drafts were presented in the DSS-11 in September, 2015 in London and were open to unrestricted observations from other professionals and revised and corrected head-on by the Expert committee.

Metabolic Surgery as Treatment for Diabetes - 2017 Guidelines - Dr Nagi Jean Safa

What we use to think about Metabolic Surgery as Treatment for Diabetes

Currently, the only interventions for Type 2 Diabetes are anti-diabetes medications and total lifestyle changes including; eating the right foods, regular exercise, and weight loss. Strict observance to prescribed drugs and treatment program helps keep the blood sugar from rising dangerously high.
Combining medical treatment with total lifestyle changes has been found to cause remission of the disease in most cases. However, studies show that most overweight and overly obese people may not be able to lose the excess weight through lifestyle interventions alone.
While there is substantial evidence that supports bariatric surgeries as an intervention that significantly improves remission in Type 2 Diabetes and other co-morbidities among obese patients, existing Type 2 Diabetes interventions do not recognize nor provide surgery as an option. This unfortunately locks out many people who would have benefited from metabolic surgeries. These include obese Type 2 Diabetes patients and people who are overly obese and therefore at risk of developing Type 2 Diabetes.

What are the recommendations of the DSS-II for Metabolic surgery as a treatment for Diabetes

A lot of random clinical trials (although mostly short-term and mid-term) that have been carried out have shown that metabolic surgery significantly lowers blood sugar and other heart-related risk factors. It was found that because of its role in regulating metabolism, the gastrointestinal tract (GI tract) constitutes a significant objective in managing Type 2 Diabetes.

In light of such evidence, metabolic surgeries should therefore be RECOMMENDED as a Type 2 Diabetes treatment option for patients with class II and III / extreme obesity ( those with BMI≥35 kg/ m2) and CONSIDERED in those with Class I / mild obesity ( BMI 30.0 to 34.9 kg/m2) when blood sugar does not seem to be well controlled by Type 2 Diabetes medications and lifestyle changes.

It was also stated that metabolic surgery should be RECOMMENDED as an intervention for Type 2 Diabetes patients with a BMI of between 30.0 to 34.9 kg / m2 if the hyperglycemia (high blood sugar) is not properly controlled by an adequate anti-diabetic treatment, involving oral drugs and injectable medication.

CONCLUSION

While more clinical trials are needed to further determine long-term benefits of metabolic surgery for Type 2 Diabetes patients, there is adequate evidence that supports the inclusion of surgery as Type 2 Diabetes intervention for diabetic patients with excess weight or obesity. Currently, more than 45 medical studies and scientific societies worldwide have formally endorsed the DSS-11 guidelines. Health care supervisors should present proper compensation guidelines.

TAKE HOME POINTS
  • Type 2 Diabetes is associated with various other health complications resulting in increased cost, morbidity, and mortality. While anti-diabetes medications and lifestyle changes improves management of Type 2 Diabetes, there is sufficient evidence supporting the inclusion of surgery as an effective intervention.
  • Metabolic surgery should be recommended for Type 2 diabetes with Class 111(BMI 40 or above kg/m2), class 11 (BMI 30.0 to 34.9 kg/m2) obesity when hyperglycemia is not adequately controlled by medications and lifestyle changes.
  • BMI thresholds (starting points) should be reduced by 2.5 kg/m2 for Asian patients as they are more at risk.
  • Complementary criteria for selection suitable candidates for metabolic surgery need to be developed alongside the traditional BMI criterion.
  • Metabolic surgery should only be performed in developed centers by specialized teams with knowledge and experience in the management of GI surgery and diabetes.
  • Patients must be provided with further long-term monitoring and support after surgery in accordance with the post-op management of metabolic surgery by national and international specialized societies.