All of this attention is indeed a good thing, for the issues of Bariatric Surgery and metabolic disease. And despite there always being some subtle, or not so subtle, bone to pick with the study itself or an implied bias of some sort, I still feel that this is kind of like adolescents. Any attention is good, sometimes no matter whether it is good or not so good.
This latest study is mostly of the beneficial type, as far as I can see. In Roux-en-Y gastric Bypass vs Medical Management for the Control of Type 2 Diabetes, Hypertension, and Hyperlipidemia, in the most recent JAMA publication, Gastric Bypass was compared with intensive medical management on a number of parameters. The goal was to achieve control of comorbid risk factors.
Centered in Taiwan and the US at 4 teaching hospitals, 120 patients were studied, with half of them being assigned Bypass after the entire group had lifestyle-intensive medical management for all of their comorbid conditions.
Outcomes and measures were a composite goal of glyco less than 7%, LDL less than 100 mg/dl, and systolic BP less than 130 mm Hg. You will recognize these as the "triple endpoint" as recommended by the ADA for DM 2 treatment.
The results?
At 12 months, 49% (28 pts) of the patients in the Gastric Bypass group met their endpoint goal, whereas only 19 % (11 pts) of the lifestyle-medical management group did. Both groups had improvement in their blood pressure and lipid levels, but the difference was much more striking in the blood sugar realm comparatively. Weight loss was not surprisingly superior in the Bypass group (26% change in body weight) vs. the non-surgical group (8% change).
Complications were higher in the surgically treated group with 'nuisance' adverse events (nutritional, stricture, ulcer, bleeding, bowel obstruction), as well as major event of one patient with a number of post op events including an anoxic injury. Not so nuisance there.
The associated editorial in the same issue of JAMA discussed the rate and type of complications in the surgical group that needs to be considered along with the offsetting improvement in the 3 parameters as outlined, even with the noted and significant Diabetes benefit. Long term safety in terms of continued issues of duration of those effects from complications will need to appropriately weighed out against the known effects of generally increasing weight and deteriorating goals of care in terms of BP, Lipids, and glucose control in the common Diabetic patient that is not on intensive treatment of any type. As I have said numerous times before, we all know where that road takes us, it's just a matter of when. Cost was also raised, as it commonly is, and rightly so. This is hard to accurately quantitate as well, as a cost benefit of 'quality of life is essentially immeasurable.
However, I do agree that quantifying what we are getting ourselves into from a surgical perspective is important to look at in the big picture of a realistic view of 'getting to goal' with non-surgical intensive lifestyle-medical management as it stands today.
In a very non-scientific way, with all of the medical vs. surgical cards accurately on the table, I would take the bet that surgery not only has it's place, but can achieve the ADA goals of care more consistently than the non-surgical treatment, especially when the patient who stands the most from it is selected in a timely manner.
Maybe someday this will all be hammered out, but the attention now is always good, as this is what continues to move the debate forward to a usable and practical best practice in the near future.
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| from postercreate.com |
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