Metabolic surgery and type 2 diabetes: the best or worst of times?

Do recent studies showing unprecedented success for weight loss-inducing medications spell an end for surgical interventions to treat obesity and type 2 diabetes? Far from it, say Professor Carel Le Roux and Dr Dimitri Pournaras in the latest contribution to our series ‘The long and the short of it’.

“It was the best of times. It was the worst of times.” Whichever way you look at it, these are exciting times for the treatment of obesity and type 2 diabetes. At the forefront of most of our minds are the results from the STEP 2 trial of semaglutide (2.4 mg), which averaged a remarkable 15% weight loss and significantly improved type 2 diabetes.

“These sorts of studies will change clinical care pretty quickly for a large number of people,” says Dr Dimitri Pournaras. His long-time colleague, Dublin-based clinician scientist Professor Carel Le Roux agrees – and adds a significant corollary: “In many people’s minds this means that surgery is dead and buried.”

But Dimitri, a bariatric surgeon from North Bristol, UK, has no plans to go on holiday. “This is the best time. And that goes for surgery too. We need a variety of approaches; the more we have and the better success we have with each approach, the better for clinical care.”

Recent studies looking at surgery as a treatment for type 2 and obesity – including 10-year surgical data from the Mingrone/Rubino study – have also revealed remarkable results (25% diabetes remission over 10 years for gastric bypass; 50% with bileopancreatic diversion). But arguing the case for one approach above another (what Carel describes as ‘the circular firing squad’) doesn’t interest them. What’s needed, they argue, is a multimodal approach. Says Dimitri: “Other diseases are treated with multimodal treatment. Cancer is the most common example. We don’t see studies of surgery versus medications there. We work together and try to find what’s the best combination of treatments – or which is the best modality for an individual patient.”

In fact, far from anticipating a decline in the use of surgery over the coming decades, Carel believes we’ll be doing significantly more operations than we are today. However pressing obesity is as a health issue for individuals and society, few people receive any kind of treatment for it – pharmacological, dietary or surgical. “We need to be better at finding out who benefits most and when,” says Dimitri. “And we need to change our expectations and control obesity with better outcomes than we have today.”

Carel agrees. “We need to treat obesity as a disease. We need more diets, more medicines and more surgery to actually make this routine care.

“The future is very bright – and surgery is certainly a part of that.”

Watch out for modules on metabolic surgery from Professor Carel Le Roux and Dr Dimitri Pournaras, launching on the EASD e-Learning platform at the end of this month.

For more on the results of the STEP 1 and STEP 2 study, see our article ‘GLP-1 receptor agonist shows promise as obesity treatment’ and ‘STEP 2 does it again: unprecedented weight loss and diabetes improvement with GLP-1 receptor agonist’

For more on GLP-1 receptor agonists, enroll on our course ‘GLP-1 receptor agonists’.