A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
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Results at 12-month follow-up are as follows: • 12% of medical-therapy patients, 42% of RYGB, and 37% of SG patients reached the targeted glycated hemoglobin level of 6% or less; patients in the RYGB reached target without medications, unlike SG group. • Mean levels of glycated hemoglobin and fasting plasma were significantly lower in surgical groups compared to the medical-therapy group. • Patients in the medical therapy group tended to have an increase in the average number of diabetes agents per person per day. Diabetes drug use significantly decreased in surgical groups. • Changes in body weight, BMI, waist circumference, and waist-to-hip ratio were greater after surgical treatments than after medical therapy. • There was a significant decrease in triglyceride levels after gastric bypass. • There was an increase in high- density lipoprotein (HDL) cholesterol and a decrease in high sensitivity C-reactive protein level after surgical treatment. • Total and low-density lipoprotein (LDL) cholesterol levels did not differ significantly among the three groups. • There was a significant reduction in the use of cardiovascular medications after surgical treatment. • There were no differences in systolic and diastolic pressures between the three groups but there was a significant decrease in the use of hypertension medications after surgical treatment. EXPERT COMMENTARY MAJOR FINDINGS Those of us who perform bariatric surgery have known for some time the significant effects the operations we perform have had, not only on helping our patients lose weight, but on improving many of the medical problems that are associated with obesity. These two studies are significant in that they provide some of the first level-I, prospective, randomized evidence that confirms surgical interventions, including biliopancreatic diversion, RYGB, and SG, have a greater impact on the improvement and remission of T2DM than best medical management. Glycemic control and normalizing HgbA1c are crucially important the reduction of cardiovascular risk and other sequelae of diabetes. Studies such as these confirm, with the best • Additional surgical interventions were required in four patients, including laparoscopic procedures for blood-clot evacuation, assessment of nausea and vomiting, and cholecystectomy. • Serious adverse events requiring hospitalization occurred in 4 medical therapy patients, 11 RYGB patients, and 4 SG patients. • No deaths or life-threatening complications occurred during this study. CONCLUSION At one-year follow up, bariatric surgery plus intensive medical therapy provides significantly improved glycemic control compared to medical therapy alone. Multicenter, randomized studies with longer follow-up periods are needed to further demonstrate the durability of these findings. study designs available, that surgical intervention gives individuals the best chance to control their disease. LIMITATIONS These studies are limited by the time of follow up. It will be important to follow these patients for longer durations to study the durability of the effects of different surgical procedures. It will also be important to better understand what it is about these operations that impart these effects, and to what extent the effect is due to weight loss versus changes in gut physiology. Understanding exactly what we are accomplishing with surgery will not only help us choose the right operation for the each patient but perhaps vary our existing operations or create new ones to optimize the outcomes we desire. BRADLEY J. NEEDLEMAN, MD, FACS Associate Professor of Surgery, Director, Comprehensive Weight Management, Metabolic and Bariatric Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio WHY IS THIS STUDY IMPORTANT TO THE FIELD? The medical community critically reviews scientific literature, and prospective, randomized trials such as these are needed and will go a long way to show our medical colleagues that bariatric surgery must be considered as an option for patients who are obese and have T2DM. Until now, patients have been primarily referring themselves for weight loss surgery, frustrated with the weight gain and escalating medications associated with T2DM. It is important that we continue to provide level 1 evidence to convince primary care physicians and specialists who treat obesity-related comorbidities that bariatric surgery, in the hands of experienced surgeons in comprehensive programs, is safe and offers patients the best chance for optimal care or remission. June 2012 • Supplement • Bariatric Times 23S