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Gastrointestinal Surgery can be a Cure for Type 2 Diabetes Finds New Long-term Study (Medicine)

The results of a randomised clinical trial with the longest follow up to date show that metabolic surgery is more effective than medications and lifestyle interventions in the long-term control of severe type 2 diabetes.

The study, published today in The Lancet, also shows that over one-third of surgically-treated patients remained diabetes-free throughout the 10-year period of the trial. This demonstrates, in the context of the most rigorous type of clinical investigation, that a “cure” for type 2 diabetes can be achieved.

Researchers from King’s College London and the Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy report the 10-year outcomes of a trial that compared metabolic surgery with conventional medical and lifestyle interventions in patients with type 2 diabetes.

The study involved 60 patients with advanced type 2 diabetes and treated at a major academic hospital in Rome, Italy. The patients randomly underwent drugs plus lifestyle interventions or metabolic surgery (gastric bypass or biliopancreatic diversion). At the start of the study, all patients had severe disease, with poorly controlled blood sugar levels and more than five years history of diabetes.

The results of the study show that 37.5% of surgically-treated patients were able to maintain non-diabetic glycaemia without need for diabetes medication – a condition referred to as diabetes remission – for the duration of the 10-year study period. In 2009, American Diabetes Association defined “cure” of diabetes as a continued state of disease remission for more than five years.

Professor Francesco Rubino, senior author of the report and Chair of Bariatric and Metabolic Surgery at King’s College London and a consultant surgeon at King’s College Hospital in London said: “The findings from this study provide the most robust scientific evidence yet that full-blown type 2 diabetes is a curable disease, not inevitably progressive and irreversible. In addition to represent a major advance in the treatment of diabetes, metabolic surgery is our best lead to the elusive cause of the disease”.

Compared to conventional medical treatment, surgery also resulted in better overall metabolic control, lower cardiovascular risk, better kidney function and quality of life. Notably, patients treated surgically had a significant lower incidence of diabetes-related complications, including cardiac, renal, and neurological adverse events. Metabolic surgery also reduced medication usage, including drugs for diabetes, high blood pressure and dyslipidaemia.

The study investigated the early and long-term safety of the different intervention strategies. Patients who underwent biliopancreatic diversion had more incidences of serious adverse events, including events associated to both disease and intervention, compared to subjects in both other groups. Patients treated by conventional medical therapy had significantly higher incidence of serious adverse events compared to patients who underwent surgery by Roux-en-Y gastric bypass.

Professor Geltrude Mingrone, first author of the report, Professor of Medicine at the Catholic University of Rome and a Professor of Diabetes and Nutrition at King’s College London said: “These data corroborate the notion that surgery can be a cost-effective approach to treating type 2 diabetes. The evidence is now more than compelling that metabolic surgery should be considered as a main therapeutic option for the treatment of patients with severe type 2 diabetes and obesity.”

Previous studies had shown that bariatric or weight loss surgery can induce long-term remission of diabetes in patients with very severe obesity; however, most patients who undergo traditional weight loss surgery have typically mild or recent-onset diabetes. This trial shows the potential curative effect of metabolic surgery for patients with severe disease.

Diabetes is one of the leading causes of mortality and morbidity in Western societies and significantly increases the risk of severe COVID-19 and mortality from the virus. Despite the evidence that surgery can rapidly and dramatically improve diabetes, less than 1% of surgical candidates have access to metabolic surgery in most countries. Furthermore, metabolic surgery operations have been suspended for even longer than other elective surgical procedures during the current pandemic.

Professor Rubino added: “Metabolic surgery is arguably the most effective available therapy for type 2 diabetes and can be a life-saving option for many patients. It should be appropriately prioritized in times of pandemic and beyond.”

Reference: Prof Geltrude Mingrone, Simona Panunzi, Andrea De Gaetano, Caterina Guidone, Amerigo Iaconelli, Esmeralda Capristo, et al., “Metabolic surgery versus conventional medical therapy in patients with type 2 diabetes: 10-year follow-up of an open-label, single-centre, randomised controlled trial”, Vol. 397, Issue 10271, pp. 293-304. 2021. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32649-0/fulltext https://doi.org/10.1016/S0140-6736(20)32649-0

Provided by King’s College London

Improved Survival After Obesity Operation In Patients With Previous Myocardial Infarction (Medicine)

Researchers at Karolinska Institutet and Danderyd Hospital in Sweden have studied the risk of additional myocardial infarctions and early death in severely obese patients who undergo metabolic surgery following a myocardial event. The registry study covering 1,018 individuals shows a lower risk of additional myocardial infarctions and improved survival that cannot be simply attributed to the loss of weight. The study is published in the journal Circulation.

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According to the WHO and the Body Mass Index measurement it devised, there are currently two billion people who are overweight today, 650 million of whom are classified as obese, with a body mass index (BMI) greater than 30 kg/m2.

Severe obesity (in this study defined as BMI greater than 35 kg/m2) increases the risk of several health problems, including type 2 diabetes, hypertension, cardiovascular disease and cancer.

People who lose weight can improve their health and it has previously been shown that after metabolic surgery, diabetes and hypertensions go into a period of remission in which the symptoms disappear, at least temporarily.

In the current study, researchers at Karolinska Institutet, Orebro University and Uppsala University examined the risk of additional myocardial infarction and early death in people with severe obesity and a previous infarction who subsequently underwent metabolic surgery.

By cross-referencing the quality registries SOReg (Scandinavian Obesity Surgery Registry) and SWEDHEART (for people who have suffered myocardial infarction) between 1995 and 2018, the researchers were able to identify severely obese individuals who underwent a gastric bypass or gastric sleeve procedure as a treatment for their obesity after suffering a myocardial infarction.

A gastric bypass involves disconnecting much of the stomach and part of the small intestine; a gastric sleeve involves removing most of the stomach to leave a tube-like structure that leads food into the intestines.

The group of 509 individuals who underwent surgery was matched with people of the same gender, age and BMI, and who had suffered a myocardial infarction in the same year but not undergone metabolic surgery.

“We found that individuals operated on for their obesity were at a much lower risk of suffering another myocardial infarction, of death and of developing heart failure,” says the study’s first author Erik Naslund, professor at the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet and consultant surgeon at Danderyd Hospital. “These data suggest that severely obese people who suffer a myocardial infarction should be offered metabolic surgery for their obesity as a secondary prevention.”

According to the researchers, it is unlikely the weight loss is the only reason for the study’s observed correlation between metabolic surgery and a lower risk of cardiopathic events, such as stroke, myocardial infarction or early death.

One theory is that metabolic surgery per se has a positive impact on cardiometabolic risk factors, which is to say physiological conditions that increase the risk of cardiovascular disease.

“Many of the patients who underwent metabolic surgery in this study had clinical remission of type 2 diabetes, hypertension and dyslipidemia (high blood lipids). An earlier study, Look AHEAD, demonstrated that long, intensive non-surgical lifestyle intervention in patients with type 2 diabetes resulted in weight loss of 6 per cent, but did not lower the risk of myocardial infarction.”

Before the results of the study can become part of clinical praxis, more research is needed in which severely obese people who have suffered myocardial infarction are randomly assigned to either surgery or to regular post-infarction care.

References: “Association of Metabolic Surgery With Major Adverse Cardiovascular Outcomes in Patients With Previous Myocardial Infarction and Severe Obesity: a nationwide cohort study”. Erik Naslund, Erik Stenberg, Robin Hofmann, Johan Ottosson, Magnus Sundbom, Richard Marsk, Per Svensson, Karolina Szummer, and Tomas Jernberg. Circulation, online 26 October 2020, doi: 10.1161/CIRCULATIONAHA.120.048585 link: http://dx.doi.org/10.1161/CIRCULATIONAHA.120.048585

Provided by Karolinska Institute