Two common weight-loss surgeries may cause remission of type 2 DM

US: Bariatric surgery appears more effective than medical care alone for improving diabetes outcomes. Remission of type 2 diabetes (T2DM) is common after bariatric surgery and may reduce the risk for subsequent microvascular and macrovascular disease. However, T2DM remission rates after bariatric surgery vary substantially across procedures and populations. Type 2 diabetes (T2DM) is closely associated with obesity. Given that weight loss is associated with T2DM remission, there has been intense interest in diabetes outcomes following bariatric surgery.

Studies focusing on the 2 most common bariatric procedures, sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on type 2 DM was done. It is unclear which bariatric procedure has the most benefits for patients with T2DM.

Researchers from the University of Pittsburgh did a cohort study in 34 US health system sites in the National Patient-Centered Clinical Research Network Bariatric Study.9710 patients (median [interquartile range] follow-up time, 2.7 [2.9] years; 7051 female patients [72.6%]; mean [SD] age, 49.8 [10.5] years; mean [SD] BMI, 49.0 [8.4]; 6040 white patients [72.2%]) with T2DM who had bariatric surgery between January 1, 2005, and September 30, 2015, were included. Data analysis was conducted from April 2017 to August 2019.

Weight loss was significantly greater with RYGB than SG at 1 year (mean difference, 6.3 [95% CI, 5.8-6.7] percentage points) and 5 years (mean difference, 8.1 [95% CI, 6.6-9.6] percentage points). Patients with more advanced T2DM at the time of surgery for whom remission is more difficult to achieve (eg, those with older age, insulin use, more complex T2DM medications, and/or poor glycemic control) may expect larger improvements in T2DM with RYGB compared with SG.

Notable points from the study,

 1. Patients who underwent RYGB experienced larger and more-sustained HbA1c reductions than those using SG

 2. At 5 years, HbA1c levels remained 0.80 (95% CI, 0.72-0.88) percentage points below baseline among patients who had RYGB and 0.35 (95% CI, 0.19-0.51) percentage points below baseline among patients who had SG, a difference of 0.45 (95% CI, 0.27-0.62) percentage points

 3. 33% of patients who had RYGB and 42% of patients who had SG relapsed within 5 years of initial remission.

 4. Patients who had RYGB had higher prevalence of some comorbidities, such as sleep apnea (RYGB: 3607 patients [57.9%]; SG: 1740 patients [50.0%]), nonalcoholic fatty liver disease (RYGB: 1914 patients [30.7%]; SG: 730 patients [21.0%]), and gastroesophageal reflux disease (RYGB: 2609 patients [41.9%]; SG: 1264 patients [36.4%]).

 5. Typically, the RYGB group reflected 6.2% to 8.1% more total body weight loss than the SG group at each point.

Overall, these results indicate that RYGB is associated with better long-term T2DM and weight outcomes than SG in real-world clinical settings. This is at odds with recent randomized clinical trials that compared T2DM outcomes of RYGB and SG and found no significant differences due to longer duration of follow-up and smaller sample sizes, which may have limited their power to detect differences between the procedures.

For the clinicians and policymakers to make informed decisions about which procedure is best suited to patients' personal situations, additional data may be needed to understand the adverse event profile of the procedures as well as patient values regarding the choice of procedure and the role of surgery relative to other aspects of lifelong weight management.

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http://jamanetwork.com/article.aspx?doi=10.1001/jamasurg.2020.0087