Surgery for the Management
of Type II Diabetes

There are 23.6 million people in the United States, or 8% of the population, who have diabetes. The total prevalence of diabetes increased 13.5% from 2005-2007. Only 24% of diabetes is undiagnosed, down from 30% in 2005 and from 50% ten years ago. 1 Most people (90-95%) with diabetes have what is called “Type 2 Diabetes” (see reference note 1 below). 

Many of the people who have Type 2 Diabetes are also obese. The two epidemics are closely linked. People with Type 2 Diabetes also often have high cholesterol and high blood pressure. These four risk factors: Type 2 Diabetes, Obesity, High Blood Pressure and High Cholesterol put people at high risk for heart disease and stoke. People who have a Body Mass Index of 35 or greater may be able to have normal blood sugar and be off all of their medications when treated with a surgical procedure, previously performed primarily for obesity. 

Three commonly performed surgical procedures have an effect on diabetes. The most effective is the Gastric Bypass Roux en Y. In this procedure the stomach is separated into a small “pouch” and a larger portion of stomach that is disconnected from the food flow. Most importantly the food does not go through the first part of the small intestine or duodenum. This has recently been proven to be very important in the putting diabetes into remission. The other two procedures, adjustable gastric band and sleeve gastrectomy seem to work primarily through decreasing weight. The table below gives the relative rates of remission of diabetes balanced against the risk of the surgery. Surgery has become relatively safe in recent years and almost all procedures are done through small incisions (laparoscopic). Even in patients where diabetes does not go into complete remission (off medications with normal blood sugar) the patients usually has much better control. 

Surgery for Diabetes has been included in the most current guidelines by the American Diabetes Association. Surgery not only improves the control of diabetes or puts it into complete remission but also decreases a person’s mortality risk from diabetes by 92% (see reference note 2 & 3 below). Weighing the risks and benefits of surgery is important for each individual patient. Ask your doctor if you should be considering surgery for the management of your diabetes. 

Cost of Diabetes Based on the 2007 Estimates

Total (direct and indirect): $174 billion
Direct medical costs: $116 billion
Indirect costs: $58 billion (disability, work loss, premature)

After adjusting for population age and sex differences, average medical expenditures among people with diagnosed diabetes were 2.3 times higher than what expenditures would be in the absence of diabetes.  

American Diabetes Association 

Bariatric surgery should be considered for adults with BMI >/=35 kg/m2 and type 2 diabetes, especially if the diabetes is difficult to control with lifestyle and pharmacologic therapy Although small trials have shown glycemic benefit of bariatric surgery in patients with type 2 diabetes and BMI 30-35 kg/m2, there is currently insufficient evidence to generally recommend surgery in patients with BMI <35kg/m2 outside of a research protocol 

Diabetes Care (Jan) 2009; 32: 525 

References: 

1. National Diabetes Fact Sheet 2007 from Centers for Disease Control and Prevention, HHS 
2. Diabetes Care (Jan) 2009; 32: 525 
3. Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. Aug 23 2007; 357(8): 753-761. 

Additional references of interest: 

Pories WJ, Swanson MS, MacDonald KG, et al. who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. Sep 1995; 222(3): 339-350; discussion 350-332 

Rubino F, Forgone A, Cummings DE, Vix M, Gnuli D, Mingrone G et al. The mechanism of diabetes control after gastrointestinal bypass surgery reveals a role of the proximal small intestine in the pathophysiology of type 2 diabetes. Ann Surg. 2006 Nov; 244(5): 741-9. 

Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta- analysis. Jama. Oct 13 2004;292(14):1724-1737.