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Mini Review
Surgery or medical treatment for low
baseline BMI patients with type 2 diabetes
mellitus?
Valencia Esparza
José Ramón 1, Sandoval López José de Jesús 2, Sandoval López Luis Roberto
1,2, *.
|
1: Department of Bariatric Surgery Tlahuac Hospital Mexico 2: College of medicine UNAM university Mexico *
Corresponding author Correspondence to: drrobertosandoval@gmail.com Publication data: Submitted: November 28,2019 Accepted: January 22 ,2020 Online: March 15, 2020 This article was subject to
full peer-review. his art This is an open access
article distributed under the terms of the Creative Commons Attribution Non-Commercial License 4.0 (CCBY-NC) allowing to share and adapt. Share: copy and redistribute the material in any medium or format. Adapt: remix, transform, and build upon the licensed material. the work provided must be properly cited and cannot be used for
commercial purpose. |
Type
2 diabetes mellitus (T2DM) is one of the fastest growing epidemics in the
world. The disease is traditionally viewed as non-curable chronic medical
condition. However, accumulating evidence points that a complete remission of
T2DM is feasible. Current guidelines recommend multimodal approach consisting
in lifestyle management and hypoglycemic agents therapy [1]. However, less
than 40% of patients achieve glycemic control [2]. Bariatric
surgery is definitely indicated for severely obese patients with a body mass
index (BMI)>40kg/m2 or more than 35 kg/m2 with associated comorbidities.
These are almost the same indications since 1991(NIH guidelines) with few
updates and modifications since that date. For patients with severe obesity,
bariatric surgery leads to substantial weight loss and also to vascular and
endocrine associated comorbidities improvement and remissions [3]. T2DM
improve at an early time point after surgery. That seems to be independent
from major weight loss [4-6]. These facts have quickly led to the
establishment and the spread of the concept of metabolic surgery. Some
principles remained questionable despite all the generated knowledge and good
practices. The indications for bariatric-metabolic surgery are still based on
BMI- centric criteria. The BMI calculation can be misleading in daily
practice. BMI calculation is only a proxy for fat-mass measurement and the
correlation between BMI value and the and the amount of visceral fat is
unclear. Chronic associated diseases in obese patients cannot be managed on
only global body mass assessment basis [7]. Just
a few years ago, the use of insulin was the last line for T2DM treatment.
Some of the objective consequences of that was a beta-cell consumption,
inefficient glycemia control, installment of chronic complications and
related morbidities. Currently, the guidelines are completely different. The
management is based on early diagnosis and early prescription of the most
effective treatment [8]. Bariatric
surgery is more effective than medical treatment for the long-term remission
of T2DM in obese patients. The superiority of bariatric procedures over
medical management program was supported by multiple studies that brought the
grade 1a evidence for the question [9-14]. Based on the independence of
glycemia long control from the weight excess loss and the absence of correlation
between diabetes relapse and weight gain after surgery, demonstrating the
efficacy of metabolic surgery in T2DM reversal for patients with moderate
obesity (BMI 30-35 kg/m2), became interesting [15-17]. All of the bariatric
procedures are effective in DM2 treatment in superobese and obese patients.
The malabsorptive procedures are more effective in achieving regression and
cure of T2DM. Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is comparable to
min gastric bypass (MGB). Both techniques are superior than LGS regarding
T2DM long-term control. From that angle, the best procedure seems to be
biliopancreatic diversion (BPD). However, it has the worst metabolic
deficiencies [18]. These potential long-term deficiencies such as anemia,
vitamins and micronutrients loss and uncontrolled weight decrease are the
controversy for metabolic surgery in uncontrolled diabetic patients with
BMI<35Kg/m2 [19-21]. The Laparoscopic gastric sleeve (LGS) is less
effective than other techniques. The rate of metabolic complications is not
considerable, and the deficiencies are always manageable [22]. The
metabolic surgery related morbidity is nowadays almost nil and may offer a
T2DM long remissions which can stop the microvascular spread of this disease
and protect from systemic damages of the hyperglycemia [22,23]. These
exciting results made the American Diabetes Association (ADA) and some other
international diabetes organizations propose a BMI threshold of 30 kg/m2 for
considering metabolic surgery in patients with uncontrolled T2DM [24].
Several evidence-based facts from numerous randomized controlled trials
support new guidelines that advocate for the consideration of metabolic
surgery as one option, along with lifestyle and medical therapy, to treat
T2DM among patients with a BMI <35 kg/m2. However, the best surgical
technique is still non-consensual. The ideal technique for diabetic non-obese
patients seems to be the one that ensure an efficient control of the glycemia
with only a mild weight loss that permit to avoid the other deficiencies
installment. Recent procedures that replicate some of the intestinal anatomy
and physiology of RYGB without compromising the stomach can exert powerful
anti-diabetes effects with little or no weight loss. This is the case of
single anastomosis-based procedures [25,26]. Many reports proved the efficacy
and the safety of these procedures in non-obese T2DM Patients treatment. An
effective durable control of the diabetes was obtained with reduction of the
HB1c rates and again with no mortality and mild surgical morbidity [27-30].
The effect of the surgery on the high blood pressure and the lipid profile
was less pronounced. These solid evidence-based findings are still to be
worked out before the standardization. The
safety of the metabolic surgery is no more subject of discussion. The
indication of an anti-diabetic procedures is justified for a selected group
of patients among those with BMI<35kg/m2. A simplified malabsorptive
technique could ensure a T2DM remission and maybe cure with an acceptable
rate of surgical morbi-moratility. The medical treatment could be stopped
early after the procedures. However, we still believe in the importance of
the lifestyle management to ensure the durability of the procedure results. |
Key takeaways
·
Several lines of evidence justify contemplating the use of bariatric operations in lower-BMI
patients with
·
uncontrolled T2DM. The BMI will remain being considered as an eligibility criterion for surgery despite its evident insufficiency. The cut point of 35kg/m2
should be lowered and the indications update have to be accepted
worldwide to check the results of metabolic
procedures for T2DM patients with BMI<35kg/m2 in different
ethnic groups and different hands expertise.
·
The effect of the metabolic surgeries on T2DM control
is independent from the weight loss.
·
Patients with baseline low BMI loose less weight after bariatric surgery
than obese one. The effect
of metabolic surgery on T2DM control seems to comparable for patients with BMI<35Kg/m2 versus above.
·
In this group of patients,
the effect of the metabolic
surgery on the others cardiovascular
risk factors such as high blood pressure and dyslipidemia is still discussable.
·
The safety of most of the malabsorptive surgeries is evident with a mortality
almost nil and a neglectable morbidity. However, the rate of metabolic life-time
deficiencies will push the choice to a simplified procedure which
doesn’t affect
the weight for the low BMI patients.
·
The durability of the metabolic effect of the surgery can reach 5 years.
The rate of T2DM cure is considerable for low baseline BMI patients.
·
Overweight and T2DM are closely related to unhealthy lifestyle. The pharmaceutical interventions can be stopped early after a selected metabolic
procedure. However,
the lifestyle management should always follow.
Conflict of interest: none
References