5 things to know about metabolic surgery

Clinical Case

Metabolic surgery can be defined as the use of gastrointestinal operations with the intent to treat T2D and obesity. The main goal of bariatric procedures is weight loss whereas MS is a therapeutical strategy specifically INDICATED to treat T2DM. Since the 2000s, experimental evidence has shown that changes in GI anatomy can directly influence glucose homeostasis providing a mechanistic rationale for the use of surgery as an intentional treatment of diabetes. Metabolic Surgery alters not only the patient’s anatomy but also his/her physiology by inducing changes in a number of mechanisms of GI physiology involved in metabolic regulation such as insulin secretion and sensitivity, satiation and weight loss, GI hormone secretion and changes in the microbiome. Current clinical evidence indicates that surgical treatment is superior to medical management in a vast majority of type-2 diabetic patients. This statement is based on the results of 11 randomized trials with level 1 evidence as well as large, long-term case-controlled studies comparing surgery in overweight/obese people with type 2 diabetes. There is now sufficient clinical and mechanistic evidence to support inclusion of metabolic surgery among antidiabetes interventions for people with T2D and obesity. Therefore, metabolic Surgery should be RECOMMENDED for patients with: obesity class III (BMI > 40 kg/m2) irrespective of the level of glycemic control and obesity class II (BMI 35.0-39.9 Kg/m2) with inadequately controlled hyperglycemia despite lifestyle and optimal medical therapy. In addition, metabolic Surgery should be CONSIDERED for patients with obesity class I (BMI 30.0-34.9 Kg/m2) and inadequately controlled hyperglycemia despite optimal medical treatment by either oral or injectable medications (including insulin). Metabolic Surgery includes commonly performed procedures such as Roux-en-Y Gastric Bypass, Vertical Sleeve, Laparoscopic Adjustable Gastric Banding and Biliopancreatic Diversion. Currently there is no preferred procedure for MS. The technique indication should be personalized taking into account several factors such as age, nutritional status, surgical risk or other comorbidities. However, current results indicate that when considering glycemic control, surgical risk and long-term surgery-related side effects, the Roux-en-Y gastric bypass can be considered the procedure of reference for MS.