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Gastric Bypass Leads to Diabetes Remission in 74% of Cases, Study Shows

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  1. Dr.Scorpiowoman

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    Advocates say the procedure is underutilized in diabetes care

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    Use of roux-en-Y gastric bypass (RYGB) surgery led to remission in 74% of individuals with type 2 diabetes after one year, Danish researchers reported in a population-based matched cohort study.

    "The findings add to the growing body of evidence on the effects of bariatric surgery, specifying that RYGB does remit type 2 diabetes and is associated with a reduced risk of microvascular, and possibly macrovascular, complications," Lene Madsen, MD, PhD, of Aarhus University Hospital, and colleagues wrote in Diabetologia.

    Although questions remain about whether or to what extent metabolic surgery is safe and appropriate, the new study is the latest evidence that it can create remission. At the same time, gastric bypass surgery advocates are touting the safety of the procedures and calling for more widespread referrals.

    "There is controversy because the literature now is so full of studies that show benefits," explained Eric DeMaria, MD, president of the American Society for Metabolic and Bariatric Surgery. "The question is why doctors are not referring more and more patients for gastric bypass."

    Remission and Relapse

    For the study, Madsen and colleagues evaluated 1,111 individuals with type 2 diabetes who received RYGB and 1,074 with type 2 diabetes who did not. Diabetes remission was defined as no glucose-lowering drug use with HbA1c <48 mmol/mol (<6.5%) or metformin monotherapy with HbA1c <42 mmol/mol (<6.0%). The outcomes evaluated were microvascular complications (diabetic retinopathy, diabetic neuropathy, and diabetic kidney disease) and macrovascular complications (ischemic heart disease, cerebrovascular disease, and peripheral and abdominal vascular disease).

    During the first six months of follow-up, 65% of the RYGB cohort met remission criteria. That number increased to 74% at 6-12 months and held steady thereafter, surpassing 70% prevalent remission for every six-month period in the first five years.

    There was significant relapse in the cohort, however: among those who were in remission within the first year of follow-up, 6% (47/746), 12% (82/689), 18% (111/ 620), and 27% (133/492) had relapsed at two, three, four, and five years after RYGB, respectively. Therefore, of those who entered remission after one year, 73% (359/492) were still in remission after five years.

    Madsen and colleagues suggested that other participants had achieved remission after the one-year mark, but still observed a legitimate chance of relapse back into type 2 diabetes over time. "There is a substantial risk of relapsing into type 2 diabetes, which should be accounted for when advising patients and planning post-surgery care," the researchers wrote.

    Those who did not achieve remission within the first year broke down among several predictors:

    • Age group 50-60 years (RR 0.88 [95% CI 0.81 to 0.96]) or ≥60 years (RR 0.83 [95% CI 0.72 to 0.97]) versus age group <40 years
    • Diabetes duration 5-8 years (RR 0.87 [95% CI 0.79 to 0.97]) or ≥8 years (RR 0.73 [95% CI 0.62 to 0.86]) versus <2 years
    • HbA1c ≥53 mmol/mol (≥7.0%) (RR 0.81 [95% CI 0.75 to 0.88]) and use of glucose-lowering drugs other than metformin (RR 0.90 [95% CI 0.81 to 1.00]), with insulin use being the strongest predictor of non-remission (RR 0.57 [95% CI 0.48 to 0.68])


    All microvascular complications tracked were lower in those who received RYBG compared with those who did not. Incident rates (IRs) for any microvascular event were 21.5/1,000 person-years among RYGB-operated individuals and 38.7/1,000 person-years among the comparison group (incident rate ratio [IRR] 0.56 [0.44, 0.70]). Diabetic retinopathy occurred in 13.9/1,000 person-years of RYGB-operated individuals versus 27.6/1,000 person-years of comparisons (IRR 0.52 [0.39, 0.69]).

    Diabetic kidney disease occurred in 3.6/1,000 person-years of RYGB-operated individuals versus 6.6/1,000 person-years of comparisons (IRR 0.54 [0.31, 0.94]). Diabetic neuropathy occurred in 5.1/1,000 of RYGB-operated individuals versus 6.1/1,000 of comparisons (IRR 0.84 [0.50, 1.39]).


    The two cohorts were more closely matched for macrovascular events. IRs for any macrovascular event were 11.7/1,000 person-years among RYGB-operated individuals and 15.0/1,000 person-years among individuals in the comparison group (IRR 0.78 [0.56, 1.09]). Ischemic heart disease occurred in 2.9/1,000 person-years among RYGB-operated individuals versus 5.3/1,000 person-years among comparisons (IRR 0.54 [0.29, 1.00]).

    Cerebrovascular disease occurred in 4.1/1,000 person-years among RYGB-operated individuals versus 3.2/1,000 person-years among comparisons (IRR 1.29 [0.69, 2.41]). Peripheral and abdominal vascular disease occurred in 5.9/1,000 person-years of RYGB-operated individuals versus 5.3/1,000 person-years among comparisons (IRR 0.75 [0.47, 1.18]). Relative to the comparison cohort, the crude HR for any macrovascular event was 0.83 (95% CI 0.59 to 1.17), with an adjusted HR of 0.76 (95% CI 0.49 to 1.18).

    The researchers said that although specifics have varied and some questions remain, the results generally aligned with those of previous studies: "Our real-world data are largely consistent with previous non-population-based, single-center observations of high one-year diabetes remission rates and five-year relapse rates of approximately 30-50%."

    Pros and Cons

    Bariatric surgery itself has become far safer in recent years. For example, a 2017 study in Obesity Surgery found an overall complication rate of 10.7%; on the other hand, lifestyle changes are essentially free of complications, and the procedure can be expensive.

    Cost-effectiveness ratios for medical treatment, laparoscopic sleeve gastrectomy, and RYGB, respectively, were $1,589.02, $1,028.97, and $1,197.44 per quality-adjusted life-years, according to a 2016 study in Medicine. The authors concluded that laparoscopic sleeve gastrectomy was a cost-effective option for type 2 diabetes treatment.

    In 2016, the American Diabetes Association and 44 other professional organizations released new guidelines for diabetes and bariatric surgery, urging in a statement "that metabolic surgery be recommended or considered as a treatment option for certain categories of people with diabetes, including people who are mildly obese and fail to respond to conventional treatment."

    The guidelines recommend metabolic surgery to treat type 2 diabetes in patients with Class III obesity (body-mass index [BMI] ≥40 kg/m²) and Class II obesity (BMI 35-39.9 kg/m²) when hyperglycemia is inadequately controlled by lifestyle and medical therapy. The procedures should also be considered for patients with type 2 diabetes with a BMI of 30-34.9 kg/m² if hyperglycemia is inadequately controlled, the guidelines state.

    DeMaria, also a bariatric surgeon at East Carolina University in Greenville, North Carolina, said that despite these guidelines and the mounting evidence, bariatric surgery as a whole remains an underutilized option. Moving forward, he said, clinicians will need to address lingering concerns and find a consensus on best practices.

    "There are fewer diabetes-related complications in patients with gastric bypass," he noted. "Diabetes organizations are suggesting that gastric bypass be considered, and yet we really aren't seeing patients being referred. The question is how to change practice. The data are there to support it. It's just not being implemented."

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