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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11 Interview Bariatric Times • June 2017 Dr. Aminian: T hat is correct—the number of patients who underwent SG was significantly lower than those who underwent RYGB. While this study is the largest reported s eries of SG in diabetic patients with long-term glycemic outcome, the sample size is not as good as RYGB cases. Only a quarter of the Cleveland cohort underwent SG, w hich may impact the outcomes in these patients. However, similar findings were observed from the validation cohort (Barcelona's cohort) where nearly half of the p atients underwent SG. In patients with mild diabetes (classification based on HbA1C, preoperative duration of T2DM, number of diabetes medications, and insulin use before surgery), would you still recommend RYGB over SG despite the outcomes being similar? Dr. Aminian: According to our nomogram, diabetes is considered mild if the IMS score is ≤25 points. In these patients, both RYGB and SG were highly effective in the treatment of diabetes with significantly high long-term remission rates of 92 percent and 74 percent, respectively. This finding is not surprising as a mild disease is likely an indirect reflection of a less advanced diabetes associated with higher functional pancreatic ß-cell reserve. Thus, both metabolic procedures are highly effective and good options for patients with mild diabetes. Since RYGB resulted in better long-term diabetes remission rates and reduction in medications, we suggest it as the metabolic procedure of choice in those with mild diabetes if there is no other reason to favor SG. Does this score also consider the potential for complications when making recommendations for surgery? Dr. Aminian: Our model has been generated based on the long-term efficacy of surgical procedures and we did not analyze the complications on this study. Our recommendation for surgery in each subgroup is based on the assumption that SG is a less complicated procedure than RYGB. This has been shown in multiple studies. 2 For patients with severe diabetes (IMS Score>95), both procedures have similarly low efficacy for diabetes remission. Thus, we suggest sleeve gastrectomy as the bariatric procedure of choice given better risk-benefit ratio. In mild diabetes (IMS Score≤25), both procedures significantly improve diabetes, yet if risk-benefit ratio permits, we s uggest gastric bypass since it leads to higher long-term remission. There is an intermediate group, for whom Roux-en-Y gastric bypass is significantly more effective than s leeve gastrectomy in achieving long-term diabetes remission. Where can readers access the IMS Score nomogram? Dr. Aminian: The IMS online calculator (Figure 2) is accessible at http://riskcalc.org/Metabolic_Surger y_Score REFERENCES 1 . Aminian A, Brethauer S, Andalib A, et al. Individualized Metabolic Surgery Score: Procedure Selection Based on Diabetes Severity. Presented at: 137th Annual Meeting of the American Surgical Association, Philadelphia, PA; April 20-22, 2017. 2. Hutter MM, Schirmer BD, Jones D B, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg. 2011;254(3):410–420. F UNDING: No funding was provided in the preparation of this manuscript. FINANCIAL DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article. ADDRESS FOR CORRESPONDENCE: Ali Aminian, MD, Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue, M61, Cleveland, OH 44195, Office (216) 444- 6704, Fax (216) 445-1586, aminiaa@ccf.org