Bariatric Surgery and Diabetes: Implications of Type 1 Versus Insulin-Requiring Type 2

Transcription

1 Bariatric Surgery and Diabetes: Implications of Type 1 Versus Insulin-Requiring Type 2 Spyridoula Maraka 1, Yogish C. Kudva 1, Todd A. Kellogg 2, Maria L. Collazo-Clavell 1, and Manpreet S. Mundi 1 Objective: To report the impact of bariatric surgery on metabolic outcomes in patients with type 1 diabetes () versus insulin-requiring type 2 diabetes mellitus (). Methods: Ten subjects with were compared with 118 subjects with at baseline and at 1 and 2 years post-bariatric surgery for: anthropometric measures, HbA1c, and number of (antihyperglycemic, anti-hypertensive, lipid-lowering). Results: and groups lost similar amounts of weight 2 years post-bariatric surgery ( kg vs kg). subjects had significant improvements in HbA1c (7.8% 6 1.4% vs. 6.8% 6 1.4%, P value <0.0001) and decreases in number of anti-hyperglycemic ( vs , P value <0.0001), anti-hypertensive ( vs , P value <0.0001), and lipid-lowering ( vs , P value <0.0001). subjects had no improvement in HbA1c (8.2% 6 1.6% vs. 7.8% 6 0.9%) or use of anti-hypertensive ( vs ). Their use of lipid-lowering improved ( vs , P value 0.04). Conclusions: Our study suggests that improved glycemic control may not be an expected outcome when considering bariatric surgery in patients with ; however, additional investigation is warranted. (2015) 23, doi: /oby Introduction Sobering predictions have been included in recent publications analyzing contemporary and historical trends in the worldwide prevalence of obesity. Currently greater than two-thirds of Americans are considered over-weight (BMI 25 kg m 22 ) and over one-third are obese (BMI 30 kg m 22 ) (1). If current trends hold, the number of obese Americans is expected to increase to >50% by 2030 (1). Of particular concern is that individuals with BMI 40 kg m 22 (Class III obesity) are the most rapidly growing subset within the obese population. In fact, we have recently seen a 50% increase in individuals with BMI > 40 kg m 22 and a 75% increase in the prevalence of individuals with a BMI > 50 kg m 22 (2). Major studies have clearly correlated obesity with the development of chronic metabolic conditions such as type 2 diabetes mellitus (DM2), hypertension, and hyperlipidemia (3,4). Bariatric surgery continues to be the most effective means of longterm weight management in people with medically complicated obesity, producing a resolution or improvement in many debilitating and life-threatening medical problems as well as significantly improving quality of life. Not surprisingly, the number of procedures performed yearly has dramatically increased over the past decade. According to the American Society for Metabolic and Bariatric Surgery data, as of 2013 we are performing 200,000 bariatric surgeries annually in the U.S., a nearly 500% increase since the year Bariatric surgery leads to impressive improvements in the control of DM2. Pories et al. first reported on the impact of bariatric surgery on DM2 and noted that 82.9% of patients with non-insulin-dependent diabetes and 98.7% of patients with impaired glucose tolerance experienced euglycemia without when followed for 14 years (5). Buchwald et al. also noted similarly impressive remission of diabetes in 78.1% overall and an improvement or resolution in 86.6% (6). In this meta-analysis, resolution of diabetes for subjects followed >2 years was greatest for patients undergoing biliopancreatic diversion with duodenal switch (95.9% resolution rate) compared to 70.9% with Roux-en-Y gastric bypass (RYGB) and 58.3% with laparoscopic adjustable gastric banding (LAGB). Brethauer et al. conducted a similar meta-analysis for the gastric sleeve both as a staged and primary procedure (7). They reported a weight loss 1 Division of Endocrinology, Diabetes, Metabolism, and Nutrition and Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA. Correspondence: Manpreet S. Mundi (Mundi.Manpreet@mayo.edu) 2 Division of General Surgery and Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA. Funding agencies: This publication was supported by grant number UL1 TR from the National Center for Advancing Translational Sciences (NCATS). Disclosure: The authors declared no conflict of interest. Author contributions: S.M. collected the data, conducted the literature review, and wrote the manuscript. M.L.C-C. contributed to data interpretation and reviewed/ edited the manuscript. Y.C.K. contributed to data interpretation and reviewed/edited the manuscript. T.A.K. contributed to data interpretation and reviewed the manuscript. M.S.M. contributed to the study design, conducted the data analyses, and wrote/edited the manuscript. All authors had final approval of the submitted and published versions. Additional Supporting Information may be found in the online version of this article. Received: 31 August 2014; Accepted: 8 November 2014; Published online 22 January doi: /oby VOLUME 23 NUMBER 3 MARCH

2 of 60.4% of excess weight in patients when gastric sleeve was the primary procedure and 46.9% when it was used as a staged procedure. Seventy percent of patients with DM2 had an improvement or remission of their disease. However, most of these data focus on patients with DM2, which cannot be extrapolated to patients with type 1 diabetes () since immune dysfunction and complete or near complete absence of endogenous insulin secretion rather than obesity with insulin resistance is the main pathophysiologic factor for the development of. Currently, very little is known about metabolic outcomes in patients with after bariatric surgery. Increasing numbers of patients with are becoming obese. The prevalence of obesity in the United States among patients 3 to 19 years old with was found to be 12.6% (8). Many are considering and undergoing bariatric surgery despite the paucity of data regarding outcomes of bariatric surgery in this population. In fact at the time of this submission, only two major peer reviewed publications had focused on and bariatric surgery (9,10) with others suggesting that autoimmune diabetes may be more prevalent in the bariatric surgery cohort than once thought (11). To address the gap in knowledge pointed out above, we conducted a retrospective analysis comparing metabolic and vascular risk factor end points of bariatric surgery between patients with and insulin-requiring type 2 diabetes mellitus (). Methods The study was approved by the Institutional Review Board. The Mayo Clinic Rochester bariatric surgery database was analyzed for patients with insulin-requiring diabetes mellitus that underwent bariatric surgery from May 2008 to April Patients with DM2 treated with oral agents or diet alone were excluded. Additional information was obtained from review of electronic medical records. All patients met the Mayo Clinic criteria for bariatric surgery: (1) BMI 40 kg m 22 or higher, (2) BMI 35 to 39.9 kg m 22 and a serious weight-related health problem, such as DM2, high blood pressure or severe sleep apnea. Of the 176 patients who met the initial criteria and required insulin for management of diabetes, 48 patients were excluded (secondary bariatric surgery such as conversion from LAGB to RYGB or other revision surgery, immediate lost to follow-up, simultaneous liver transplant, etc.). The diagnosis of was verified for all patients by the presence of autoantibodies known to be associated with (GAD65 and insulin antibodies, measured by radioimmunoassay) and/or absence of C-peptide. Subjects with were compared to subjects with at baseline and at 1 and 2 years post-surgery. The patients follow-up included an evaluation by a physician in the Endocrinology Department and a visit with a dietician at 1 month, 3, 6, 12, and 24 months after bariatric surgery. The primary endpoint was improvement in HbA1c. HbA1c was measured by an Ion-Exchange Chromatography Quantitative assay. Secondary endpoints included changes in weight, improvements in hyperlipidemia, and number of used to manage diabetes mellitus, hypertension, and hyperlipidemia. Medication reconciliation was completed after thoroughly reviewing the patient s electronic medical record. Insulin pump use was reported separately (see Supporting Information Table). Long-acting insulin was counted as one medication and short acting insulin as another for management of diabetes. We were not able to obtain accurate data on change in total daily insulin requirements from the review of the patients medical records. Total and high-density lipoprotein (HDL) and triglycerides were determined using fasting serum and standard enzymatic methods. Low-density lipoprotein cholesterol was calculated using the Friedewald equation if triglycerides were less than 400 mg dl 21. For the patients with, we obtained further pertinent medical history from their medical record including: patient s report on frequency of hypoglycemia, emergency room visits for severe hypoglycemia or hyperglycemia, hospitalizations for diabetic ketoacidosis or severe hypoglycemia. Diabetic ketoacidosis was defined as glucose >250 mg dl 21 ; HCO 3 18 meq/l; anion gap >12; arterial ph <7.3; beta-hydroxybutyrate 3.8 mmol l 21 (12). Sub-analysis to compare and Additional sub-analysis was conducted to assess the effect of duration of diabetes on metabolic co-morbidities. Patients self-reported the onset of their diabetes. This was verified by review of the medical records for the patients that the diagnosis was made within the Mayo Clinic Health system. The duration of diabetes was determined using this information. From the group, individuals with duration of diabetes >14 years were chosen as a sub-group to ensure matching for age, initial BMI, and duration of diabetes with the group. Statistical analysis Data are reported as mean 6 SD for normally distributed data and as median (IQR) for non-normally distributed data. Student s t-test was used to compare the endpoints between the two groups if normally distributed and Wilcoxon rank-sum test for non-normally distributed data. Paired t-test was used to analyze changes between baseline and subsequent data at 1 and 2 years post-surgery. Comparisons between nominal variables were done with chi-squares test and Fisher s exact test where appropriate. Bonferroni correction was used to correct for multiple comparisons. Results Ten subjects with and 118 subjects with underwent primary bariatric surgery from May 2008 to April Baseline characteristics of the study population are presented in Table 1. At the time of surgery, there was no difference between and groups in age ( vs yr), BMI ( vs kg m 22 ), and HbA1c (8.2% 6 1.6% vs. 7.8% 6 1.4%) respectively. Subjects with had longer duration of diabetes ( vs years, P value <0.01). Four out of ten subjects with used insulin pump alone for management of diabetes, with one subject using insulin pump in addition to metformin, and the remaining five subjects using multiple daily injections of long-acting and short-acting insulin (see Supporting Information Table). Six subjects in the group used an insulin pump, two subjects used U500 insulin with the remaining using an average of for management of diabetes. Subjects with also had significantly lower triglyceride level ( vs. 179 ( ) mg dl 21, P value <0.01) and higher HDL ( vs mg dl 21, P value <0.01). There was no difference VOLUME 23 NUMBER 3 MARCH

3 Bariatric Surgery in Type 1 Diabetes Maraka et al. TABLE 1 Baseline characteristics of cohorts (n 5 10) (n 5 118) P value Age (yr) ns Gender (% female) 70% 65% BMI (kg m 22 ) ns Type of surgery RYGB 90% 75% Sleeve gastrectomy 10% 11% BPD-DS 14% Number of years with diabetes <0.01 HbA1c (%) ns Number of lipid ns Total cholesterol (mg dl 21 ) ns Triglycerides (mg dl 21 ) ( ) <0.01 HDL (mg dl 21 ) <0.01 LDL (mg dl 21 ) ns Number of anti-hypertensive ns SBP (mmhg) ns DBP (mmhg) ns Days of hospital stay after surgery ns Abbreviations: RYGB, Roux-en-y gastric bypass; BPD-DS, biliopancreatic diversion with duodenal switch; HDL, high-density lipoprotein; LDL, low-density lipoprotein; SBP, systolic blood pressure; DBP, diastolic blood pressure. Values are expressed as mean 6 SD for t-test and median (1st, 3rd quartile) for Wilcoxon rank-sum test. between the groups in terms of number of used for the management of hypertension and hyperlipidemia. There was no difference noted in the duration of hospital stay after the surgery between the two groups. Both and groups lost similar amount of weight 1 year ( vs kg) and 2 years ( vs kg) after bariatric surgery (Figure 1). Subjects with had a significant improvement in their HbA1c (7.8% 6 1.4% vs. 6.5% 6 1.3% P value <0.0001) 1 year after surgery, which was sustained 2 years after surgery (7.8% 6 1.4% vs. 6.8% 6 1.4% P value <0.001) (Table 2). Subjects with had a significant decrease in the number of anti-hyperglycemic ( vs P value <0.0001), anti-hypertensive ( vs P value <0.0001), and lipidlowering ( vs P value <0.0001) at the 2-year follow-up. Triglyceride levels improved significantly [179 ( ) vs. 125 (90 157) vs. 121 (94 185) P value 0.002] at 1 and 2 years after surgery, respectively. Figure 1 Changes in BMI after bariatric surgery. SD represented by error bars. Despite weight loss, subjects with did not show improvement in HbA1c (8.2% 6 1.6% vs. 8.3% 6 1.3% vs. 7.8% 6 0.9%). At baseline, 3 out of 10 subjects with were diagnosed as DM2 and by 1 year post-surgery, their diagnosis had been confirmed. By 2 years, 7 subjects were being treated with insulin pump, and the insulin doses required, when documented, had decreased significantly (see Supporting Information Table). Their use of lipid lowering improved ( vs vs ; P value 0.04) but there was no change in number of anti-hypertensive ( vs vs ) at 1 and 2 years, respectively. In the sub-analysis group, similar results were obtained. After matching for duration of diabetes, the groups did not vary significantly in terms of age, initial BMI, HbA1c, number of lipid lowering and anti-hypertensive (Table 3). Despite having same weight loss, the matched group had lower HbA1c when compared to baseline both at 1 and 2 years after surgery (7.6% 6 1.2% vs. 6.9% 6 1.3% vs. 7.0% 6 1.5%). Seven out of the 10 subjects with reported more episodes of hypoglycemia after their bariatric surgery, while 2 patients had an episode of diabetic ketoacidosis. Discussion The results of this study show that 2 years after bariatric surgery, patients with had similar weight-loss outcomes to patients with. However, in contrast to the patients with, the patients with did not show the same degree of improvement in glycemic control as determined by HbA1c measurement (Figure 2) or in the number of required for the management of hypertension. Sub-analysis revealed that duration of diabetes was not a confounding factor with patients with >14 years of diabetes still having significant improvement post-surgery. In our study, patients with achieved similar weight loss, improved glycemic control, and decrease in the need of for diabetes, hypertension, and hyperlipidemia as previously reported by Schauer et al. during the STAMPEDE trial (13). Recently, the same group reported the 3-year follow-up results of this study and showed that significantly more obese patients with diabetes who underwent bariatric surgery maintained long-term glycemic control compared with patients who received intensive medical therapy (14). 554 VOLUME 23 NUMBER 3 MARCH

4 TABLE 2 Study end points 1 and 2 years after surgery TABLE 3 Matched duration of diabetes sub-analysis (n 5 9) (n 5 102) P value (n 5 25) P value 1 year post-surgery BMI (kg m 22 ) ns Weight loss (kg) ns HbA1c (%) * Number of lipid * * ns Total cholesterol (mg dl 21 ) ns Triglycerides (mg dl 21 ) (90-157)* ns HDL (mg dl 21 ) LDL (mg dl 21 ) ns Number of anti-hypertensive * 0.02 SBP (mmhg) ns DBP (mmhg) ns (n 5 9) (n 5 63) P value 2 years post-surgery BMI (kg m 22 ) ns Weight loss (kg) ns HbA1c (%) * 0.04 Number of lipid * * ns Total cholesterol (mg dl 21 ) ns Triglycerides (mg dl 21 ) (94-185)* ns HDL (mg dl 21 ) LDL (mg dl 21 ) ns Number of anti-hypertensive * 0.03 SBP (mmhg) ns DBP (mmhg) ns Abbreviations: HDL, high-density lipoprotein; LDL, low-density lipoprotein; SBP, systolic blood pressure; DBP, diastolic blood pressure. Values are expressed as mean 6 SD for t-test and median (1st, 3rd quartile) for Wilcoxon rank-sum test. P value indicates statistical significance comparing to. *indicates P value <0.05 when comparing baseline to current value in matched pairs analysis. In contrast to, results of bariatric surgery in obese patients with are limited and leave a number of questions unanswered. Small studies have shown clinically significant weight loss, decreased insulin requirements but variability in the degree of improvement in glycemic control observed. Czupryniak et al. presented three cases of obese patients with poorly controlled (HbA1c: %). Followed for 5-8 years after RYGB surgery, the patients achieved significant weight loss accompanied by a significant decrease in insulin requirements and a remarkable improvement in blood glucose control and lipids (9). The authors suggested that RYGB led to improvement in insulin resistance, favorably affecting the glycemic control. Fuertes- Zamorano et al. (15) reported two patients with who underwent single-anastomosis duodeno-ileal bypass with sleeve gastrectomy. The first patient lost 56% of their body weight accompanied by a 56% reduction of insulin dose while the HbA1c decreased from 7.6% to 6.2%. The second patient lost almost 45% of her body weight with a 70% reduction in insulin requirements. Her HbA1c decreased from Baseline Age (yr) ns Gender (% female) 70% 64% ns BMI (kg m 22 ) ns Type of surgery RYGB 90% 76% Sleeve gastrectomy 10% 8% BPD-DS 16% Number of years with diabetes ns HbA1c (%) ns Number of lipid ns Number of anti-hypertensive ns 1 year post-surgery BMI (kg m 22 ) * * ns Weight loss (kg) ns HbA1c (%) * 0.01 Number of lipid * * ns Number of anti-hypertensive * ns 2 years post-surgery BMI (kg m 22 ) * * ns Weight loss (kg) ns HbA1c (%) # ns Number of lipid * * ns Number of anti-hypertensive * ns Abbreviations: RYGB, Roux-en-y gastric bypass; BPD-DS, biliopancreatic diversion with duodenal switch. Values are expressed as mean 6 SD for t-test. P value indicates statistical significance comparing to. * indicates P value <0.05 when comparing baseline to current value in matched pairs analysis. # indicates P value of 0.1 when comparing baseline to current value in matched pairs analysis. 7.5% to 6.9%, but she experienced several hypoglycemic episodes during the initial postoperative months. Similarly to our findings, Mendez et al. reported that 1 year after RYGB there was no significant improvement in the glycemic control of three obese female patients with (baseline HbA1c: 7.6% to 8.2%). The insulin requirements decreased for the two patients, but remained unchanged for the third (16). Recently, Brethauer et al. reported a >60% excess weight loss in 10 patients with associated with decreased daily insulin requirements. However, the glycemic control, although improved, remained suboptimal with a mean reduction in HbA1c from 10.0% to 8.9% (10). In our cohort, glycemic control at baseline was better but remained unchanged at 1- and 2-year follow-ups (8.2% 6 1.6% vs. 8.3% 6 1.3% vs. 7.8% 6 0.9%). One of the questions left unanswered by these reports was the impact of duration of diabetes on improvement in glucose homeostasis, since this has been shown to be dependent on the duration and severity of diabetes prior to surgery. A less robust improvement in VOLUME 23 NUMBER 3 MARCH

5 Bariatric Surgery in Type 1 Diabetes Maraka et al. The merit of bariatric surgery in obese patients with depends on whether the potential benefits outweigh the risks. Although operative mortality of bariatric surgery has decreased to <1% (19), serious adverse outcomes are still common even in the hands of experienced surgeons (20). Moreover, the glycemic control in can be challenging the first few months after bariatric surgery and improved glycemic control may not be an expected outcome in the already well controlled patient. The dietary changes, nausea, and vomiting could result in significant glucose variability, frequent hypoglycemia or episodes of diabetic ketoacidosis even in patients with previous adequate glycemic control (15). Figure 2 Changes in HbA1c after bariatric surgery. SD represented by error bars. glycemic control is seen in those patients who have had DM2 for a longer period of time and who have high insulin requirements preoperatively (14,17). Similar to our study, Brethauer et al. noted a median duration of of 22 years (range 2-43) and the remaining case reports when combined reveal an average duration of years (9,10,15). As opposed to the other studies, we were able to use our historical control to conduct a sub-analysis matching for duration of diabetes between the two groups. Despite having similar duration of diabetes and similar weight loss at 2 years as the group, the group still experienced a trend towards improved HbA1c and a significant improvement in number of antihyperglycemic (see Table 3), whereas no such trend was noted in patients with. The rate of obesity is increasing amongst patients with as is the number of patients considering bariatric surgery. However, as presented in this report metabolic outcomes after bariatric surgery may be different than those reported for patients with. Confirming the diagnosis of autoimmune with immunological studies in the patient considering bariatric surgery in addition to c-peptide measurement with simultaneous glucose can provide guidance regarding expected outcomes of this intervention since they can be clearly different when compared to patients with. Moreover, long-term recurrence of diabetes has been reported in 10-15% of patients with diabetes after bariatric surgery with one of the possible explanations being that these patients were incorrectly assumed to have DM2 (18). Similar findings were noted in our study as one third of our subjects were initially diagnosed as having DM2. It was only after significant weight loss and lack of improvement in diabetes, that additional testing with GAD65 autoantibodies and C-peptide yielded appropriate diagnosis. This stresses further the importance of preoperative evaluation for specific type of diabetes such as autoimmune diabetes before proceeding with bariatric surgery. Important limitations of our study include the retrospective design and the single-center nature of the study. Because of the small sample size and moderate control of diabetes prior to surgery, it is possible that our results cannot be generalized to patients with that have poorer glycemic control at baseline. However, the strength of this study is that it provides the longest follow-up to date of a large case series and examines the impact of duration of diabetes on clinical outcomes. Conclusion Our study shows that bariatric surgery resulted in significant and similar weight loss in obese patients with when compared to obese patients with. However, improvements in metabolic parameters (HbA1c) and need for medication for the management of hypertension were less amongst patients with when compared to patients with. Although bariatric surgery may offer many health benefits for patients with medically complicated obesity and, improved glycemic control and less need for may not be an expected outcome. Additional investigation is warranted. O Acknowledgments Parts of this study were presented in abstract form at the 96th Annual Meeting & Expo Endocrine Society meeting, Chicago, IL, June 20-24, 2014, and was awarded the Helmsley Charitable Trust Abstract Awards in Type 1 Diabetes. VC 2015 The Society References 1. Wang YC, McPherson K, Marsh T, Gortmaker SL, Brown M. Health and economic burden of the projected obesity trends in the USA and the UK. Lancet 2011;378: Sturm R. Increases in morbid obesity in the USA: Public Health 2007; 121: Hu FB, Manson JE, Stampfer MJ, et al. Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. N Engl J Med 2001;345: Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. JAMA 1999;282: Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it?. An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;222: ; discussion Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med 2009;122: e Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure. Surg Obes Relat Dis 2009;5: Liu LL, Lawrence JM, Davis C, et al. Prevalence of overweight and obesity in youth with diabetes in USA: the SEARCH for Diabetes in Youth study. Pediatr Diabet 2010;11: Czupryniak L, Wiszniewski M, Szymanski D, Pawlowski M, Loba J, Strzelczyk J. Long-term results of gastric bypass surgery in morbidly obese type 1 diabetes patients. Obes Surg 2010;20: Brethauer SA, Aminian A, Rosenthal RJ, Kirwan JP, Kashyap SR, Schauer PR. Bariatric surgery improves the metabolic profile of morbidly obese patients with type 1 diabetes. Diabet Care 2014;37:e51-e Deitel M. Update: why diabetes does not resolve in some patients after bariatric surgery. Obes Surg 2011;21: VOLUME 23 NUMBER 3 MARCH

6 12. Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in diabetes. Diabet Care 2004;27 (Suppl 1):S94-S Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012;366: Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes 3-year outcomes. N Engl J Med 2014;371: Fuertes-Zamorano N, Sanchez-Pernaute A, Torres Garcia AJ, Rubio Herrera MA. Bariatric surgery in type 1 diabetes mellitus: long-term experience in two cases. Nutr Hosp 2013;28: Mendez CE, Tanenberg RJ, Pories W. Outcomes of Roux-en-Y gastric bypass surgery for severely obese patients with type 1 diabetes: a case series report. Diabetes Metab Syndr Obes 2010;3: Schauer PR, Burguera B, Ikramuddin S, et al. Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Ann Surg 2003;238: ; discussion Deitel M. Slow-progression, autoimmune, type 1 diabetes in adults: a cause of failure of resolution of diabetes after bariatric surgery. Surg Obes Relat Dis 2009;5: Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg 2011;254: ; discussion Ikramuddin S, Korner J, Lee WJ, et al. Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. JAMA 2013; 309: VOLUME 23 NUMBER 3 MARCH