Bariatric Times

JUN 2017

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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10 Interview Bariatric Times • June 2017 Individualized Metabolic Surgery Score: A New Nomogram for Procedure Selection Based on Diabetes Severity Bariatric Times. 2017;14(6):10–11. How did you determine the need to develop the Individualized Metabolic Surgery Score for patients with obesity and diabetes? Dr. Aminian: One of the unanswered questions in the field of bariatric surgery was how to choose the appropriate procedure in an individual with type 2 diabetes mellitus (T2DM). Long-term response to bariatric surgery differs according to diabetes severity; a patient with mild disease (e.g., diabetes for one year, good glycemic control with metformin) is considerably different than a patient with severe disease (e.g., diabetes for 15 years, poor glycemic control while taking 3 medications including insulin). This study aimed to construct and externally validate an individualized scoring system for evidence-based selection of metabolic surgery for T2DM based on disease severity. Would this score also be valid for patients with obesity without diabetes? Dr. Aminian: No. The Individualized Metabolic Surgery (IMS) score guides bariatric procedure selection in patients with T2DM. Does age play a role in your algorithm? Dr. Aminian: No. Age at the time of surgery was not an independent predictor of long-term diabetes remission after gastric bypass and sleeve gastrectomy. Our model was developed to stage the severity of diabetes preoperatively based on four independent predictors of long- term diabetes remission, including Hemoglobin A1c (HbA1c), preoperative duration of diabetes, number of diabetes medications, and insulin use before surgery (Figure 1). These factors are readily available in clinical practice and can serve as a proxy to the functional pancreatic ß-cell reserve. Were the surgical techniques used in Roux-en-y gastric bypass and sleeve gastrectomy the same when comparing the procedures performed in the United States and Spain? Dr. Aminian: There are minor variations in surgical techniques around the world. However, these minor changes would not have significant effects on long-term diabetes response. Findings on diabetes remission in each subgroup were relatively comparable in the cohorts from Cleveland and Barcelona. The number of patients who underwent SG is significantly lower than those who underwent RYGB. Please comment on whether this is relevant to the study's conclusions. A n I n t e r v i e w w i t h ALI AMINIAN, MD Ali Aminian, MD, is Associate Professor of Surgery, Cleveland Clinic, Cleveland, Ohio D eveloped from the largest reported cohort (n=900) with long-term postoperative glycemic follow-up, the Individualized Metabolic Surgery (IMS) Score is a new nomogram that classifies patients into three categories of diabetes severity—mild, moderate, and severe—and suggests which surgery type will provide the best balance between diabetes remission and procedure risk. The study included 650 patients from a single center in Cleveland, Ohio, and was then validated in a cohort of 250 patients at another single center in Barcelona, Spain. Study researchers concluded that in mild T2DM (IMS Score≤25), both Roux-en-y gastric bypass (RYGB) and sleeve gastrectomy (SG) significantly improve diabetes, and in severe T2DM (IMS Score>95), when there is limited beta-cell reserve/function, both procedures have similarly low efficacy in achieving diabetes remission. They also reported findings of an intermediate group in which RYGB is significantly more effective than SG, which they postulated was likely related to its more pronounced neurohormonal effects. T his month, we present an interview with Individualized Metabolic Surgery (IMS) Score study lead author Ali Aminian, MD, Associate Professor of Surgery at the Cleveland Clinic, Ohio, who presented these findings during the 137 t h meeting of the American Surgical Association, April 20 to 22, 2017, in Philadelphia, Pennsylvania. FIGURE 2. Individualized Metabolic Surgery Score Patient Example. Individualized Metabolic Surgery (IMS), accessible at http://riskcalc.org/Metabolic_Surgery_Score, can assist in treatment decision making. The patient in this example is considering bariatric surgery for treatment of type 2 diabetes mellitus (T2DM) and is 1) on three diabetes medications, 2) using insulin, 3) presenting with a T2DM duration of 11 years, and 4) with A1c of 6.8%. The IMS score for this patient is 106, which classifies him or her in severe subgroup. Since the glycemic outcomes after Roux-en- Y gastric bypass (RYGB) and sleeve gastrecyomy (SG) in this group are comparable, SG (less risky procedure) is suggested for surgical management of T2DM if there is no other reason to favor RYGB. FIGURE 1. The Individualized Metabolic Surgery score. The Individualized Metabolic Surgery (IMS) score, classifies patients into three categories of diabetes s everity—mild, moderate, and severe—based on four independent predictors of long-term diabetes remission. The online version of IMS calculator is accessible at http://riskcalc.org/Metabolic_Surgery_Score

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