Rand Health, Santa Monica, California, USA.
JAMA. 2013 Jun 5;309(21):2250-61. doi: 10.1001/jama.2013.4851.
Bariatric surgery is beneficial in persons with a body mass index (BMI) of 35 or greater with obesity-related comorbidities. There is interest in using these procedures in persons with lower BMI and diabetes.
To assess the association between bariatric surgery vs nonsurgical treatments and weight loss and glycemic control among patients with diabetes or impaired glucose tolerance and BMI of 30 to 35.
PubMed, EMBASE, and Cochrane Library databases were searched from January 1985 through September 2012. Of 1291 screened articles, we included 32 surgical studies, 11 systematic reviews on nonsurgical treatments, and 11 large nonsurgical studies published after those reviews. Weight loss, metabolic outcomes, and adverse events were abstracted by 2 independent reviewers.
Three randomized clinical trials (RCTs) (N = 290; including 1 trial of 150 patients with type 2 diabetes and mean BMI of 37, 1 trial of 80 patients without diabetes [38% with metabolic syndrome] and BMI of 30 to 35, and 1 trial of 60 patients with diabetes and BMI of 30 to 40 [13 patients with BMI <35]) found that surgery was associated with greater weight loss (range, 14.4-24 kg) and glycemic control (range, 0.9-1.43 point improvements in hemoglobin A1c levels) during 1 to 2 years of follow-up than nonsurgical treatment. Indirect comparisons of evidence from observational studies of bariatric procedures (n ≈ 600 patients) and meta-analyses of nonsurgical therapies (containing more than 300 RCTs) support this finding at 1 or 2 years of follow-up. However, there are no robust surgical data beyond 5 years of follow-up on outcomes of diabetes, glucose control, or macrovascular and microvascular outcomes. In contrast, some RCT data of nonsurgical therapies show benefits at 10 years of follow-up or more. Surgeon-reported adverse events were low (eg, hospital deaths of 0.3%-1.0%), but data were from select centers and surgeons. Long-term adverse events are unknown.
Current evidence suggests that, when compared with nonsurgical treatments, bariatric surgical procedures in patients with a BMI of 30 to 35 and diabetes are associated with greater short-term weight loss and better intermediate glucose outcomes. Evidence is insufficient to reach conclusions about the appropriate use of bariatric surgery in this population until more data are available about long-term outcomes and complications of surgery.
减重手术对体重指数（BMI）为 35 或更高且存在肥胖相关合并症的人群有益。人们对 BMI 为 30 至 35 且患有糖尿病的人群使用这些手术方法很感兴趣。
评估减重手术与非手术治疗在 BMI 为 30 至 35 且患有糖尿病或糖耐量受损的患者中的体重减轻和血糖控制方面的关联。
从 1985 年 1 月至 2012 年 9 月，对 PubMed、EMBASE 和 Cochrane 图书馆数据库进行了检索。在筛选出的 1291 篇文章中，我们纳入了 32 项手术研究、11 项非手术治疗的系统评价以及 11 项发表于这些综述之后的大型非手术研究。由 2 名独立审查员提取体重减轻、代谢结果和不良事件的数据。
三项随机临床试验（RCT）（N = 290；包括一项 150 例 2 型糖尿病患者[平均 BMI 为 37]和一项 80 例无糖尿病[38%存在代谢综合征]和 BMI 为 30 至 35 的患者的试验，以及一项 60 例糖尿病和 BMI 为 30 至 40 的患者[13 例 BMI<35]）发现，在 1 至 2 年的随访期间，手术与非手术治疗相比，体重减轻（范围为 14.4-24kg）和血糖控制（血红蛋白 A1c 水平改善 0.9-1.43 点）更大。对减重手术程序的观察性研究的间接比较证据（约 600 例患者）和非手术治疗的荟萃分析（包含超过 300 项 RCT）支持这一发现，即随访 1 或 2 年。然而，在糖尿病、血糖控制或大血管和微血管结局方面，没有超过 5 年随访的稳健手术数据。相比之下，一些非手术治疗的 RCT 数据显示，在随访 10 年或更长时间后仍有获益。外科医生报告的不良事件发生率较低（例如，医院死亡率为 0.3%-1.0%），但数据来自精选中心和外科医生。长期不良事件尚不清楚。
现有证据表明，与非手术治疗相比，BMI 为 30 至 35 且患有糖尿病的患者进行减重手术与更大的短期体重减轻和更好的中期血糖结果相关。在获得更多关于手术长期结果和并发症的数据之前，关于在该人群中适当使用减重手术的结论证据不足。
