Study: In diabetes fight, surgery beats medicine

Published March 27, 2012

For some people with diabetes, surgery may be the best medicine.

Two studies have found that weight-loss operations worked much better than the standard therapies for Type 2 diabetes in obese and overweight people whose blood sugar was out of control. Those who had surgery, which stapled the stomach and rerouted the small intestine, were much more likely to have a complete remission of diabetes, or to need less medicine, than people who were given the typical regimen of drugs, diet and exercise.

The surgery also helped many to lower their blood pressure and cholesterol.

The new studies, published Monday by the New England Journal of Medicine, are the first to rigorously compare medical treatment with these particular stomach and intestinal operations as ways to control diabetes.

Doctors had been noticing for years that weight-loss operations, also called bariatric surgery, could sometimes get rid of Type 2 diabetes. But they had no hard data.

Experts say better treatments are desperately needed for the disease. The question is whether major surgery, with its risks and complications, should be more widely used. Some surgeons and obesity experts are pushing to establish a role for the surgeries in treating diabetes, not just obesity, while other experts say more research is needed.

The president for medicine and science for the American Diabetes Association, Dr. Vivian Fonseca, said the two studies were "not game changers" because they were relatively small.

The disease, which causes high blood sugar, is linked to obesity and often becomes harder to manage as it progresses. It can bring devastating complications like heart disease, strokes, blindness, amputations and kidney failure.

Researchers said the operations used in the studies help control diabetes not just because they make people lose weight — a known treatment for the disease — but because the changes in anatomy alter the levels of gut hormones that affect the metabolism of sugars and fats.

One of the studies, conducted at the Catholic University in Rome, compared two types of surgery with usual medical treatment. After two years, the surgical groups had complete remission rates of 75 percent and 95 percent; there were no remissions in patients who received medical treatment.

The second study, at the Cleveland Clinic, compared two types of surgery with an intensive medical regimen. The remission rates one year after surgery were lower than in the Italian study — 42 percent and 37 percent — at least in part because the U.S. study used a stricter definition of remission. The intensive medical treatment led to remissions in 12 percent of patients.

Neither study involved the Lap Band, an implanted loop that cinches the stomach into a small pouch and that does not involve cutting the stomach or intestines.

According to the American Society for Metabolic and Bariatric Surgery, about 200,000 bariatric operations are performed each year in the United States, and cost from $11,500 to $26,000. Some insurers cover them. Patients may lose 100 pounds or even more after the surgery. Most gain some weight back; some gain a lot back.

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Fonseca said the two studies would probably not lead the group to change its recommendations. He said the studies were small and short, and each was conducted at a single institution, so it was hard to know if the results could be replicated.

The Cleveland Clinic study included 150 patients ages 20-60, with body mass indexes from 27 to 43. Patients had intensive medical treatment, gastric bypass or sleeve gastrectomy, which cuts out part of the stomach, taking it from the size of a football to that of a banana. It is a somewhat simpler and safer operation than gastric bypass and is growing in popularity. But the gastric bypass patients had a higher remission rate, 42 percent, than those with gastrectomy, 37 percent.

Dr. Philip Schauer, who led the study and performed the operations, said the remission rates were lower than expected. A possible reason was that the patients had very advanced diabetes.