GPs have called for restrictions on bariatric surgery to be revised after a major study showed the intervention resulted in the remission of diabetes in up to 95% of severely obese patients.
The two-year study adds to the weight of evidence supporting the wider use of bariatric surgery, and showed it could result in better glycaemic control compared with conventional treatment.
NICE currently recommends bariatric surgery should be offered to patients with a BMI of over 35-40 who have other conditions caused by being overweight, such as diabetes or obstructive sleep apnea, and all other patients with a BMI over 40.
But in many areas restrictions on surgery are more stringent, often to save costs. Pulse revealed last year that restrictions based on lifestyle were being introduced, with smokers blocked from bariatric surgery unless they entered smoking cessation therapy.
The study in 60 patients compared bariatic surgery in patients with diabetes with a BMI of 35 with conventional drug and lifestyle interventions.
Researchers recruited patients with a five year history of type 2 diabetes who had a BMI of 35 or more and a HbA1c level of 7.0% or more. All 60 eligible patients were randomised into three groups – gastric bypass, biliopancreatic diversion or conventional medical therapy.
At two years, diabetes remission – defined as a fasting plasma glucose level of less than 100mg per decilitre and a HbA1c level of less than 6.5% for at least one year – had occurred in none of those in the medical therapy group, compared to 75% of the gastric bypass group and 95% of individuals who had biliopancreatic diversion.
Average percentage reductions in glycated haemoglobin levels were greater in the two surgical groups than medical therapy, with reductions of 6.35%, 4.95% and 7.69% respectively.
Study lead Dr Geltrude Mingrone, professor of medicine at the Catholic University in Rome, said: ‘These findings indicate that bariatric surgery may be more effective than conventional medical therapy in controlling hyperglycaemia in severely obese patients with type 2 diabetes.'
Dr Andrew Brewster, a GPSI in obesity and type 2 diabetes in Reading, Berkshire, agreed that the findings further strengthened the position of bariatric procedures in the treatment of type 2 diabetes.
‘Somehow we have thus far failed to see the link between the management of these two inextricably-linked conditions, so I am hopeful that this paper adds more weight to including bariatric referral for obese patients with type 2 diabetes when the NICE guidelines for the management of hyperglycaemia are revised.'
But Dr Brewster said he had some reservations over long-term complications of biliopancreatic diversion: ‘The potential long-term nutritional complications in these patients mean they will pose quite a challenge for GPs in the longer term.'
‘I think that a laparoscopic adjustable gastric band may be a more sensible approach to diabetes remission for both patients and primary care.'
N Engl J Med 2012, online 26 March
Average reduction in HbA1c
Conventional therapy: -8.39%
Gastric bypass: -25.18%
Biliopancreatic diversion: -43.01%
N Engl J Med 2012, online 26 March
