Metabolic Surgery Cures Diabetes?

Dr. Daniel Tong - Co-Founding President (Surgical Chapter)

Historically, type 2 diabetes (T2DM) is managed by life-style modification in combination of pharmacotherapy. Despite advances in diabetes pharmacotherapy, few patients with achieve therapeutic goals let alone complete remission. Metabolic surgery is the use of gastrointestinal operations, originally designed to induce weight loss “bariatric surgery”, with the primary intent to treat T2DM and obesity. It has been more than a decade development of metabolic surgery in Hong Kong and the number of operation per year is rapidly rising. However, with various reasons, both the public and medical doctors still either not understand or not accepting surgery can cure diabetes. Herein, we discuss the current consensus from diabetes organizations worldwide to use metabolic surgery as a standard treatment option for T2DM. We also describe the mechanisms which explains why surgery can cure diabetes and which patient group can be benefit most from this treatment modality.

There is a joint statement endorsed by 45 international professional organizations urging that metabolic surgery be recommended treatment option for certain categories of T2DM patients especially those who has unsatisfactory control by conventional approach. A new practice guidelines also emerged from the Second Diabetes Surgery Summit in 2015 with endorsement by the American Diabetes Association (ADA), International Diabetes Federation (IDF), Diabetes UK, Chinese Diabetes Society (CDS), and Diabetes India. According to the guidelines for Asians, metabolic surgery should be recommended for 1) BMI > 37.5kg/m2; 2) BMI 32.5-37.4kg/m2 with
blood glucose inadequately controlled by life-style and medications; and 3) 27.5-32.5kg/m2 if hyperglycemia is unsatisfactory controlledby various approach.

Metabolic surgery entails removal part of stomach or small bowel re-routing. The alteration of gastrointestinal anatomy induces changes in gut hormones, microbiota, bile acid metabolism, central nervous system control of energy (glucose) regulations and other changes. Different procedures achieve the therapeutic effects via different mechanisms and choice of procedure for patient should be considered individually.

Safety concern of the procedure could be a barrier for patient to accept the procedure and medical doctors to refer relevant patients to surgeons. The risks have been proven in large scale of study that are comparable to laparoscopic cholecystectomy.

Certainly, metabolic surgery cure T2DM in appropriate selected patients. Appropriate choice of procedure and patient selection could achieve best outcome. More education is utmost important for the future development in this field.