After the STAMPEDE: Surgical versus Medical Treatment for Obese Patients with Diabetes

Published - Written by Rena Xu

Today the perils of obesity hardly remain a mystery.  Many patients who are obese also have Type 2 diabetes, a condition that can be difficult and expensive to manage, and the search for effective treatment options has become a public health priority.

In 2012, an article in NEJM reported the results of the Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial, which compared surgical versus medical treatment for patients of precisely this profile– obese (with body mass indexes ranging from 27 to 43) and diabetic (with glycated hemoglobin levels above 7%).  The study reported that patients who received bariatric surgery — either a gastric bypass or a sleeve gastrectomy — had better outcomes than their counterparts who only received intensive medical therapy.  The surgical patients achieved better glycemic control and needed fewer diabetes medications.  Their cardiac risk factors also improved.  The authors concluded that bariatric surgery was a “potentially useful strategy for management of uncontrolled diabetes.”

Would the initially observed benefits of surgery stand the test of time?  According to findings from a three-year follow-up study to STAMPEDE, also recently published in NEJM, the answer is yes.  The STAMPEDE trial investigators analyzed glycated hemoglobin levels to see how well glycemic control was maintained after three years.

This new analysis, based on 137 of the 150 original patients, found that those who underwent surgery still had better outcomes after three years than those who were assigned to medical therapy.  In absolute terms, the glycated hemoglobin levels among surgical patients decreased by an impressive 2.5 percentage points, versus only 0.6 percentage points for medical therapy patients (P<0.001).  More than a third of gastric bypass patients and roughly a quarter of sleeve gastrectomy patients achieved the target glycated hemoglobin level of 6% at three years (P<0.001 and P=0.01); in contrast, only 5% of medical therapy patients reached this goal.  Surgical patients also needed fewer diabetes medications.  Remarkably, under 10% of surgical patients were using insulin at three years, versus 55% of patients from the medical therapy arm (P<0.001).

Surgical patients also fared better in terms of weight loss.  The baseline weight decreased only 4.2% in the medical therapy arm, versus 24.5% in the gastric bypass (P<0.001) and 21.1% in the sleeve gastrectomy arms (P<0.001).  Sixteen percent of the patients on medical therapy actually gained excessive weight (defined as a >5% increase over baseline) at three years, while none of the surgical patients did (P<0.05).

There were other benefits, too.  Surgical patients had greater decreases in triglyceride levels and greater increases in high-density cholesterol.  When asked about their quality of life (via the RAND 36-Item Health Survey), the surgical patients also scored much higher than their medical therapy counterparts on “general health,” “physical functioning,” and “emotional well being.”

Today there are still vocal critics of bariatric surgery.  Surgery is not without risk, and it constitutes a dramatic physical and psychological step that many physicians are reluctant to recommend and many patients are reluctant to take.  But as more data indicate there are clear, lasting benefits to bariatric surgery, it becomes harder to consider surgery a radical or last-ditch treatment option.  Particularly as health care reform pushes for more cost-effective ways to keep patients healthy, further studies are warranted to characterize the impact of bariatric surgery on morbidity, mortality, and health care spending.  For some patients, it may be the best option available.

In your practice, how do you counsel patients who have obesity and Type 2 diabetes?  Under what circumstances would you recommend bariatric surgery?  What other interventions have you found particularly effective?

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