Diabetes remission after bariatric surgery: is that the only question? Remission of type 2 diabetes (T2D) after bariatric surgery (BS) has become a “trending topic.” A recent consensus conference developed global guidelines regarding the benefits and limitations of metabolic surgery for T2D (1).
Initial bariatric surgical series reported rates of T2D reversal of 37–95%, depending on the criteria used, the cohort of patients, the type of BS, and the time of follow-up. Then, using the criteria of Buse et al. (2), remission rates stabilized around a more realistic 50% 1 year after BS. However, studies have still used “à la carte” criteria, which, although medically less stringent—for instance, using HbA1c levels (3)—could be considered more practical.
In any case, and despite the specific biochemical thresholds used to define the cure of diabetes, remission criteria systematically involve the absence of hypoglycemic treatment. In fact, patients may regard themselves as cured from their diabetes, or any other comorbidity, only if they discontinue medication. However, is BS only intended to eliminate drugs? Is continuation of treatment a therapeutic failure when poorly controlled diabetes turns into a bearable condition?
Hypoglycemic agents may be withdrawn postoperatively in patients with milder forms of diabetes (i.e., shorter duration, higher pancreatic reserve, no previous need for insulin). But if drugs were restored to avoid glycemic fluctuations and promote metabolic amelioration, would patients and/or clinicians be disappointed? Was surgery only intended to resolve T2D from a “drug prescription” point of view, or was it offered considering all the patients’ factors potentially improvable?
The obsessive concern with T2D remission from an academic point of view may blur the key objective of BS. Patients’ global improvement is essential, and passiveness should not jeopardize an active management of any latent metabolic condition. If restoring medication maximizes metabolic control, has surgical success vanished?
The 2nd Diabetes Surgery Summit (1) timidly suggested that overall metabolic control outweighs diabetes remission as the sole clinical benefit justifying BS. Our group had already suggested this when we affirmed that diabetes remission, although desirable and targeted, should not be the only and foremost goal after BS (4). In our opinion, combined metabolic control is a success in itself, especially if target recommendations are met (5), even if patients still face minimal hypoglycemic treatment or mild transitional biochemical flaws.
We suggest using “optimal metabolic control” rather than the stricter “diabetes remission” for the long-term evaluation of BS patients. Diabetes remission solely regarded as biochemical normality underestimates the true overall value of BS for patients who suffered long-term and poorly controlled T2D. Why not consider the American Diabetes Association’s therapeutic targets (5)? Defining goals and success of metabolic surgery may be controversial, and this debate is enhanced by the dynamism and continuum of the issues involved. Loss of arbitrarily defined weight percentages seems to establish success from a bariatric point of view, but reliable biological and/or clinical markers for an exact definition of remission and/or cure in metabolic diseases, including diabetes, are still lacking. We suggest that strict criteria may be useful for academic and investigational purposes, but a broader view should be considered in metabolically ill patients who undergo bariatric/metabolic surgery.
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Duality of Interest. No potential conflicts of interest relevant to this article were reported.
