| Algorithm for the Treatment of Type 2 Diabetes |
 These indications are intended for patients who are appropriate candidates for elective surgery.
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| Patient Selection |
| Contraindications for metabolic surgery: |
Grade A |
- Type 1 diabetes diagnosis – unless surgery is otherwise indicated, such as for severe obesity
- Current drug or alcohol abuse
- Uncontrolled psychiatric illness
- Lack of comprehension of the risks/benefits, expected outcomes, alternatives
- Lack of commitment to nutritional supplementation, long-term follow-up
- In adolescent patients, GI surgery is inappropriate (Grade U)
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Metabolic surgery is recommended as a treatment option in patients with:
- Class III obesity (BMI ≥40 kg/m2)* regardless of the level of glycemic control or complexity of glucose-lowering regimens
Grade U
- Class II obesity (BMI 35.0-39.9)* with poor glycemic control despite lifestyle and optimal medical therapy
Grade A
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Metabolic surgery may be considered as a treatment option in patients with:
- Class I obesity (BMI 30.0-34.9)* with poor glycemic control despite optimal medical treatment by oral or injectable medications
Grade B
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| *BMI thresholds should be reconsidered depending on ancestry; reduce by 2.5 for Asian patients (Grade B) |
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| Preoperative Workup |
Patient evaluation
Grade U |
- Include assessment of endocrine, metabolic, physical, nutritional, and psychological health
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Evaluation
Grade A |
- Include routine clinical tests and diabetes-specific metrics
- Recommended tests:
- Standard preoperative tests used for GI surgery at individual providers’ institution
- Tests to characterize current diabetes status – eg, A1C, FPG, lipid panel
- Tests to distinguish type 1 from type 2 – eg, fasting C-peptide, anti-GAD antibodies
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Pre-surgery
Grade A |
- Improve glycemic control!
- Reduces risk for postoperative infection due to hyperglycemia
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| Metabolic Surgery Types |
RYGB (gastric bypass)
Grade U |
- More favorable risk-benefit profile vs other options in most patients with type 2 diabetes
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Vertical sleeve gastrectomy (VSG)
Grade B |
- Effective weight loss
- Major improvement of type 2 diabetes in short to medium term (1-3 years – longer-term studies requried)
- Valuable option for patients concerned about risk of operations with bowel diversion
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Laparoscopic adjustable gastric banding (LAGB)
Grade B |
- Effective in improving glycemia in patients with obesity and type 2 diabetes primarily by causing weight loss
- Greater risk for reoperation/revision due to failure, complications
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Biliopancreatic diversion (BPD)
Grade B |
- Most complex surgery – most effective for glycemic control/weight loss but risk-benefit profile is less favorable
- Significant risk of nutritional deficiencies
- Highest perioperative morbidity/mortality
- Should be considered only in patients with BMI >60
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| Postoperative Follow-Up |
| After surgery, patients should be managed by multidisciplinary teams |
Grade A |
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| Evaluation |
- At least every 6 months during the first 2 postoperative years
- At least annually thereafter
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| Monitor glycemic control as in standard care (Grade U) to avoid potential hyperglycemia relapse (Grade A) |
| Stable nondiabetic glycemic for <5yrs |
- Monitor for complications
- 5-yr remission: reduce monitoring frequency
- Persistent normoglycemia & no complications: cease screening for complications
Grade B
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In first 6 months, evaluate for glycemic control and tapering of diabetes medications
- After 6 months, further diabetes treatment should be dosed accordingly
- Discontinue meds only after stable normoglycemia for at least two 3-month A1C cycles
Grade B
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If glucose levels quickly reach normoglycemic range early post-surgery:
- Adjust therapy to prevent hypoglycemia
- Metformin, TZDs, GLP-1 receptor agonists, DPP-4 inhibitors, alpha-glucosidase inhibitors, and SGLT2 inhibitors are suitable for early postoperative diabetes care
Grade A
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| Offer ongoing and long-term monitoring of micronutrient status, nutritional supplementation, and patient support |
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| Summary of Recommendations |
Metabolic surgery is recommended to treat:
- Type 2 diabetes in patients with Class II and Class III obesity when glycemia is inadequately controlled by lifestyle and optimal medical therapy
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Metabolic surgery may be considered to treat:
- Type 2 diabetes in patients with Class I obesity if glycemic control is poor despite optimal treatment with oral or injectable medications
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| Surgery should be performed in high-volume centers with multidisciplinary teams that understand and are experienced in the management of diabetes and GI surgery |
| Mortality rates with bariatric/metabolic operations are typically 0.1%-0.5% |
| Major complications rates are 2%-6%, with minor complications in up to 15 |
| Postoperative follow-up: Ongoing and long-term monitoring of micronutrient status, nutritional supplementation, and support |
| Short/mid-term RCTs have shown that metabolic surgery achieves excellent glycemic control and reduces CV risk factors. Surgical value is more related to improved glucose homeostasis than weight loss. Additional studies are needed to demonstrate long-term benefits. |
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