Edward C. Geehr, M.D.

Is gastric-bypass surgery worth it?

Bariatric surgery is useful in the treatment of obese patients with type 2 diabetes, according to numerous studies. Questions remain, however, regarding the long-term consequences of surgery in terms of how long the benefits last and potential complications.

A study recently published in the New England Journal of Medicine found that among patients with uncontrolled type-2 diabetes, three years of medical therapy plus surgery resulted in better control of blood sugar and improved quality of life, compared to medical therapy alone. No major surgical complications were reported by the end of the clinical trial.

The study is important for several reasons. For one, results showed the benefits of gastric-bypass surgery on body shape and size. The surgical group also had superior improvements in body mass index (BMI), body weight and waist circumference. Another is the impact on blood fats, including levels of triglycerides and HDL (bad) cholesterol, compared to medical therapy.

The use of blood pressure medications and lipid-lowering agents were greatly reduced in the surgical group.

More good news: The study may also have an effect on insurance coverage for bariatric surgery. Insurance reimbursement for bariatric surgery usually is limited to patients with a BMI of 35 or higher. In the NEJM study, 36% of the patients had a BMI of 27 to 34, and these patients experienced similar benefits to patients with a BMI of 35 or more.

Other studies show improved glycemic control in mildly obese patients. The results of the NEJM study make it more likely that insurers will extend benefit coverage for bariatric surgery to this group too, especially for those struggling to gain control over their blood sugar levels.

In the current study, conducted by Cleveland Clinic researchers,150 obese patients ranging in age from 20 to 60 years were randomly placed into treatment and control groups. The average age was 49 years and the average BMI 36. The majority of study subjects were women. Almost all of the patients completed the 3-year study.

Surgery patients received either Roux-en-Y gastric bypass or sleeve-gastrectomy. The Roux-en-Y procedure shrinks the stomach to about the size of an egg and bypasses a portion of the upper small intestine. The smaller stomach makes patients feel fuller more quickly and the bypassed upper intestine reduces the absorption of food and nutrients.

A sleeve-gastrectomy removes more than half the stomach and staples the remaining portion into a banana-like shape. The reduced stomach size is permanent and causes people to feel full more quickly.

Weight reduction was greater in the Roux-en-Y gastric bypass group compared to the gastric sleeve group; both procedures were significantly better than medical management. Patients in the Roux-en-Y group also required fewer glucose-lowering medications and more patients stopped taking glucose-lowering medications, compared to the sleeve-gastrectomy group. There were some negative effects from surgery, but they weren't severe and were rare after the first year.

Surgery for obese patients with diabetes who are struggling to maintain good control over their blood sugar levels offers significant benefits compared to the risks of surgery.

For obese, type 2 diabetic patients who are unable to lose weight and gain glycemic control under a strict medical regimen, gastric surgery may be the answer.