Editorial
From Bariatric to Metabolic Surgery
Marcus Vinicius Dantas* *Corresponding author: Marcus Vinicius Dantas, Barra D´or
Hospital and Unimed-Rio Hospital,
Av. Ayrton Senna, 3079 - Barra da
Tijuca, Rio de Janeiro - RJ, 22775-002,
Brazil Published: 10 Apr, 2017 The prevalence of type 2 diabetes mellitus is rapidly increasing worldwide. In 2010, the global
prevalence was estimated at 8,3% of the adult population, a proportion that is projected to increase
to 9,9% by 2030 [1]. Uncontrolled diabetes leads to macrovascular and microvascular complications,
including myocardial infarction, stroke, blindness, neuropathy and renal failure in many patients.
Despite improvements in pharmacotherapy, fewer than 50% of patients actually achieve and maintain
therapeutic thresholds [2]. In 1998, the results of the UKPDS were welcomed as they showed that
intensive treatment was associated with a significant reduction in diabetes-related events [3]. New
megatrials were published in the following years. The results of the action to Control Cardiovascular
Risk in Diabetes (ACCORD) [4], Action in Diabetes and Vascular Disease(ADVANCE) [5] and
Veteran Administration Diabetes Trial(VADT) [6] were published in 2008 and 2009. Almost
25.000 type 2 diabetic patients have been enrolled in these trials. The results showed no reduction
of cardiovascular risk. Even worse, the ACCORD trial was prematurely interrupted because of
excess mortality among intensively treated patients. In the other hand, observational studies have
suggested that bariatric surgery can rapidly improve glycemic control and cardiovascular risk factors
in severely obese patients with type 2 diabetes [7,8]. The Swedish Obese Subjects (SOS) study, [9]
which provides the best evidence for long-term effects so far, was initiated more than 20 years ago.
Many randomized clinical trials has been published demonstrating that bariatric/metabolic surgery
achieves superior glycemic control and reduction of cardiovascular risk factors in obese patients
with type 2 diabetes compared with various medical and lifestyle interventions [10-14]. Beyond
inducing weight loss related metabolic improvements, some operations engage mechanisms that
improve glucose homeostasis independent of weight loss, such as changes in gut hormones, bile
acid metabolism, microbiota, intestinal glucose metabolism and nutrient sensing [15]. In the last
years, the concept of a metabolic surgery has become widely recognized and most major worldwide
bariatric surgery societies have included the word “metabolic” in their names.
Department of Surgery, Barra D´or Hospital and Unimed-Rio Hospital, Rio de Janeiro, Brazil
Cite this article as: Dantas MV. From Bariatric to Metabolic
Surgery. Ann Clin Case Rep. 2017; 2:
1328.Editorial
Candidacy for weight loss surgery is an evolving field. The original 1991 National Institute
of Health guidelines recommending surgical intervention in patients with BMI > 40 Kg/m2 or
BMI > 35 Kg/m2 plus significant obesity-related comorbidities [16]. The International Diabetes
Federation (IDF) was the first to propose new additions to bariatric candidacy in 2011. They support
consideration of surgery for patients with type 2 diabetes mellitus (T2DM) and obesity (BMI>30
Kg/m2) who are failing to achieve treatment targets with optimal medical therapy, especially in the
presence of additional cardiovascular risk factors [17]. In the UK a national registry of over 3000
patients with diabetes operated on between 2011 and 2013 shows that 65% had acceptable glycaemic
control without medications after surgery [18]. An economic analysis for National Institute for
Health and Care Excellence (NICE) showed that bariatric surgery is cost effective compared with
non-‐
surgical treatment [19]. In patients with diabetes, for example, the cost of surgery will be
recouped within three years through reduced prescriptions [20]. It’s time to review. Complementary
criteria to the sole use of BMI need to be developed to achieve a better patient selection algorithm
for metabolic surgery. From September 28th to 30th the Diabetes Surgery Summit II(DSS-II) was held
in London. It was an international consensus conference convened in collaboration with leading
diabetes organizations to develop global guidelines to inform clinicians and policymakers about
benefits and limitations of metabolic surgery for type 2 diabetes. The conclusions were published
at Diabetes Care a few months later [21]. Forty-five world medical and scientific societies endorsed
the DSS-II guidelines. There is sufficient clinical and mechanistic evidence to support inclusion of
metabolic surgery among ant diabetes intervention for people with type 2 diabetes and obesity and
health care regulators should introduce appropriate reimbursement policies.References