Studies show it works but cost, long-term effectiveness unclear
FRIDAY, Sept. 12 (HealthDay News) -- International health experts will convene in New York City next week to discuss an unconventional and arguably radical approach to treating people with type 2 diabetes: weight-loss surgery.
These "bariatric" procedures are normally reserved for the morbidly obese, but recent studies suggest that patients with type 2 diabetes may benefit as well, by improving disease symptoms, often driving it into remission, and reducing the risk of death from the illness.
"We have to address the fact that this could be a potential opportunity for more patients than the ones we have been offering surgery (to) until today," said Dr. Francesco Rubino, chief of gastrointestinal metabolic surgery at Weill Cornell Medical College in New York City, who orchestrated the gathering.
The 1st World Congress on Interventional Therapies for Type 2 Diabetes will serve as a forum for leading surgeons, scientists, endocrinologists and policymakers to examine and debate the evidence. Rubino also hopes to garner consensus on a set of guidelines drafted in Rome last year for the safe use of bariatric surgery in the treatment of diabetes. Without such guidance, "there is a potential for abusing these opportunities," he acknowledged.
In the United States alone, some 24 million people have diabetes, and the majority of these cases are type 2.
While obesity is a risk factor for diabetes, not all diabetics meet current guidelines for bariatric surgery. Generally, surgical candidates must be extremely obese, with a body-mass index (BMI) of 40 or more, or a BMI over 35 with another serious obesity-related medical condition, such as uncontrolled diabetes.
In 2008, an estimated 220,000 bariatric surgeries will be performed in the United States, says the American Society for Metabolic & Bariatric Surgery (ASMBS).
Typically, type 2 diabetes is managed through a combination of lifestyle modifications, including changes in diet and increased physical activity, various medications and sometimes insulin injections. Adding surgery to the mix would represent a seismic shift in the management of the disease.
Dr. Philip R. Schauer, director of the Cleveland Clinic Bariatric and Metabolic Institute and past president of the ASMBS, concedes that some endocrinologists are uncomfortable with the notion of treating diabetes surgically.
"Essentially, it's the quintessential medical disease, and for somebody to suggest surgery as a potential treatment or 'cure,' that's a very radical concept," he said. But Schauer believes the evidence thus far shows great potential. "I think an astute investigative clinician would recognize that there's enough there to say, 'Wow, we really should look at this,'" he said.
Prominent medical journals such as the Journal of the American Medical Association and the New England Journal of Medicine have recently reported findings that bolster the argument for a surgical approach.
In one pivotal study, Australian researchers compared conventional diabetes care with gastric banding. After two years, patients in the surgical group were five times more likely to experience a remission of their type 2 diabetes than those receiving the usual treatments.
In another study, a U.S. team compared two groups of obese patients -- one that had gastric bypass surgery and one that did not and followed them for an average of seven years. Deaths from diabetes were 92 percent lower among patients who had the surgery.
Most diabetes experts would like to see more data on the long-term safety of these procedures before forging ahead. There are also unanswered questions about the cost-effectiveness of bariatric surgery, which averages $17,000 to $25,000 per procedure, according to the ASMBS.
"It is a major form of surgery, and if it turns out that in the long run it's safe and in the long run, maybe, it prolongs life or reduces costs because these people are healthier, then that's great," said Dr. Sue Kirkman, vice president of medical affairs for the American Diabetes Association. "But I think those things need to be carefully looked at."
The ADA plans to convene a consensus conference in 2009 to examine the issue of bariatric surgery, Kirkman said.
"There are plenty of ways to treat diabetes that are safe and effective," added Dr. Jeffrey I. Mechanick, an endocrinologist at New York's Mount Sinai Medical Center and a member of the board of the American Association of Clinical Endocrinologists. "So if this is another way to do it, we need to know what the long-term safety and efficacy are going to be."
Visit the U.S. National Institute of Diabetes and Digestive and Kidney Diseases' Weight Control Information Network for more on bariatric surgery.
Francesco Rubino, M.D., chief, Gastrointestinal Metabolic Surgery, assistant professor, surgery, Weill Cornell Medical College, and assistant attending surgeon, NewYork-Presbyterian-Weill Cornell Medical Center; New York City; Philip R. Schauer, M.D., director, Cleveland Clinic Bariatric and Metabolic Institute, Cleveland, and past president, American Society of Metabolic & Bariatric Surgery; Sue Kirkman, M.D., vice president, medical affairs, American Diabetes Association, Alexandria, Va.; Jeffrey I. Mechanick, M.D., clinical professor, medicine, endocrinology, diabetes and bone disease, Mount Sinai Medical Center, New York City, and board member, American Association of Clinical Endocrinologists, Jacksonville, Fla.; ASMBS, Gainesville, Fla.; Weight-Control Information Network, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md.; Jan 23, 2008, Journal of the American Medical Association; Aug. 23, 2007, New England Journal of Medicine
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