1st International Conference on Gastrointestinal Surgery to Treat Type 2 Diabetes, Rome 2007
1st World Congress on Interventional Therapies for T2 Diabetes Mallitus, New York, 2008
Recommendations for the Evaluation and Use of Gastrointestinal Surgery to Treat Type 2 Diabetes Mellitus
This statement is generated by 50 world class experts (endocrinologists, gastroenterologists, diabetologists, surgeons & basic science investigators) and endorsed by 21 diverse professional and scientific organizations like American Diabetes Association, American Society for Metabolic and Bariatric Surgery, American Gastroenterological Association, Diabetes United Kingdom, European Association for the Study of Diabetes, European Association for the Study of Obesity, International Federation for the Surgery of Obesity and Metabolic diseases, Italian Society of Diabetology, Society of American Gastrointestinal and Endoscopic Surgeons, Society for Surgery of the Alimentary Tract, are few of them.
Summary of Recommendation:
Gastro-Intestinal (G.I.) Surgery (ie, RYGB, LAGB, or BPD) should be considered for the treatment of T2DM in acceptable surgical candidates with BMI 35kg/m2who are inadequately controlled by lifestyle and medical therapy (A).*
A surgical approach may also be appropriate as a non-primary alternative to treat inadequately controlled T2DM in suitable surgical candidates with mild-to-moderate obesity (BMI 30-35 kg/m2) (B). RYGB may be an appropriate surgical option for diabetes treatment in this patient population (C).
Although novel GI surgical techniques (eg, duodenal-jejunal bypass, ileal interposition, sleeve gastrectomy, endoluminal sleeves) show promising results for the treatment of T2DM in early clinical studies, they should currently be used only in the context of IRB-approved and registered trials (A).
To improve quality of medical evidence, the development of standards for measuring clinical and physiological outcomes of surgical treatment for T2DM is a high priority (A).
Randomized controlled trials are strongly encouraged to assess the utility of GI surgery to treat T2DM (A). In patients with BMI35 kg/m2, determining the appropriate use of GI surgery for the treatment of T2DM is an important research priority (A). Controlled clinical trials in these patients should be performed to determine the safety and efficacy of GI metabolic surgery (A) as well as to identify parameters other than BMI as criteria for appropriate patient selection (A). Development of a standard registry/database is a high priority for research in this area (A).
In addition to clinical trials, animal studies can provide useful information about the efficacy and mechanisms of GI metabolic surgery to treat T2DM (A).
The study of GI metabolic surgery provides valuable, new opportunities for investigating contributions of the GI tract to glucose homeostasis and the pathophysiological mechanisms of T2DM (A). Available data from animal and clinical studies suggest that weight loss alone explains diabetes control after LAGB (A). In contrast, intestinal bypass procedures such as RYGB, BPD, and duodenal-jejunal bypass appear to engage additional anti-diabetes mechanisms beyond those related to reduced food intake and body weight (A). Furthermore, anatomic modifications of various regions of the GI tract ameliorate T2DM through distinct physiological mechanisms (B).
Collaboration among endocrinologists, surgeons, and basic scientists should be encouraged to facilitate greater understanding of GI mechanisms of metabolic regulation and to allow use of these insights to improve the treatment of T2DM (A).
The establishment of a multidisciplinary taskforce to guide the study and development of diabetes surgery is a high priority. This taskforce should include endocrinologists, surgeons, clinical and basic investigators, and bioethicists, among others (A).
*Capital letters in parentheses indicate the levels of consensus for individual statements, defined as follows: Grade (67%-77% agreement), Grade (78%-89% agreement), and Grade (90%-100% agreement).