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Gastric Bypass Better for Pancreas – uniquely restored pancreatic B-cellfunction. STAMPEDE trial. Diab Care March 2013

 

Gastric bypass durably reversed diabetes better than medicine alone or another type of bariatric surgery that does less against belly fat, a subanalysis of the STAMPEDE trial determined.

At 2 years, hemoglobin A1c had dropped to a mean 6.7% with the Roux-en-Y surgery versus 7.1% with sleeve gastrectomy and 8.4% with optimal medical therapy, Sangeeta R. Kashyap, MD, of the Cleveland Clinic, and colleagues reported online in Diabetes Care. The differences between each type of surgery and medical treatment were significant at P<0.05.

Insulin sensitivity rose 2.7-fold and beta-cell function jumped almost six-fold with gastric bypass over that period but didn’t improve in either of the other groups.

”Gastric bypass essentially was like CPR to a failing pancreas,” Kashyap told MedPage Today. ”It was able to restore its function and this led to durable blood sugar control for these patients.”

These benefits of gastric bypass significantly correlated with loss of truncal fat and prandial free fatty acid levels, suggesting there’s something uniquely important about tackling about the gut, she said in an interview.

These results ”suggest that rather than targeting blood sugars with medications, with insulin, for instance, or pills that often cause weight gain, physicians should be more concerned about getting patients to lose weight, to lose belly fat as a way to restore the pancreas,” she argued.

Still, surgery shouldn’t be a first-line treatment for diabetes, Kashyap agreed.

”I would suggest that a patient should intensively try diet and exercise for weight loss and optimize pills and drugs for blood sugar control,” she said. ”Bariatric surgery offers a therapeutic option for patients not able to respond to lifestyle and medication. It can really help some patients, but we know it doesn’t help everybody.”

The STAMPEDE (Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently) trial subanalysis was based on the first 20 patients in each of the three treatment arms — gastric bypass, gastric sleeve, and medical care (intensive diabetes management with lifestyle counseling, recommended to include Weight Watchers).

Patients in the trial were moderately obese — mean 36 kg/m2 body mass index — similar to the diabetes population typically seen in clinical practice, Kashyap pointed out.

Although the reduction in body fat was similar between the surgery groups at the 24-month follow-up, the gastric bypass group saw a 16-percentage point drop in percent of belly fat versus a 10-percentage point decline with sleeve gastrectomy (P=0.04).

Glucose tolerance at a mixed meal test showed normalization by 24 months in the gastric bypass group with somewhat less effect in the gastric sleeve group and little change in the medical therapy group.

Among patients not on insulin therapy, insulin sensitivity rose 2.3 points on the Matsuda index in the gastric bypass group (P=0.004). The 0.9 point improvement in the gastric sleeve group wasn’t significant.

Beta-cell function measured by the oral disposition index increased by 0.196 points (up 5.8-fold from baseline, P=0.001 versus medical therapy) versus 0.058 with sleeve gastronomy and 0.027 with medical therapy (P=0.30 between the two).

That difference is particularly notable given that the natural history of type 2 diabetes is deterioration of pancreatic beta-cell function and hemoglobin A1c levels despite medication, the researchers pointed out.

Longer-term research is needed to test durability of the effects, they noted.

Other limitations were the small sample size of the substudy and single-center design, Kashyap added.

Her group is now looking for factors that predict surgical response in obese diabetes patients.

Primary funding for the STAMPEDE trial came from Ethicon Endo-Surgery, with additional funding from the American Diabetes Association.

Kashyap reported research grant funds from Ethicon Endo-Surgery, National Institutes of Health, and the American Diabetes Association.

 

 

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