Metabolic Surgery Impact on Patients’ Quality of Life

How does intensive medical therapy (IMT) compare with metabolic surgery treatment in improving patients’ quality of life? 

Improving patients’ quality of life (QoL) and survival is the primary goal of any treatment. Metabolic and bariatric surgery are very effective treatments in patients with type 2 diabetes. Serval observational studies report that metabolic surgery lowers the mortality rate in patients by approximately 40% to 50%. Metabolic and bariatric surgery also benefit patients by helping them achieve weight loss, diabetes remission, and reducing cardiometabolic risk. The Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) was a randomized controlled trial done at a single center that compared intensive medical therapy (IMT) with surgical treatment. The study reported that surgery was superior to IMT for achieving weight loss and glycemic control, with patients being less reliant on diabetes medication. However, a lack of data looks at patients’ reported outcomes after metabolic surgical procedures and how it compares to medical treatment of obesity and type 2 diabetes. This study wants to compare the effects of these treatments by looking at patient-reported outcomes and QoL to increase the focus on reducing the burden of these chronic diseases and improving patients’ well-being. 

The STAMPEDE trial consisted of 150 diabetes patients in 3 groups. These groups had 26 patients on IMT alone, 41 on IMT and laparoscopic Roux-en-Y gastric bypass (RYGB), and 37 on a laparoscopic sleeve gastrectomy (SG). Patients were between 20 and 60 years old, had a BMI of 27 to 43 Kg/m2 and an HbA1c of greater than 7%. Patients were not allowed in the study if they had previous metabolic surgery, other complex abdominal surgery, or poorly controlled medical or psychiatric disorders. Patients received treatments outlined by the American Diabetes Association. 

The RAND 36- Item Health Survey and the European QoL 5-dimensions (EQ-5D) were used to determine a patient’s QoL. The diabetes-specific instrument was a questionnaire formulated by Ron Hayes, Ph.D., and used to assess the QoL. 

This study used means and standard deviation to assess continuous variables and frequency count. Clinical cutoff points of 6.0%,6.5%, and 7% for HbA1c were evaluated using the Pearson chi-square test or Fisher exact test. The RAND-36, EQ-5D, and the diabetes-specific questionnaire were analyzed using a mixed model for repeated measurements. The average scores were reported as Least Squares Means and included each visit. Critical baseline and follow-up factors were determined by a stepwise multivariable logistic model for changes in scores of the RAND-36 at five years. 

The participants in this study had comparable baseline characteristics in the three groups, with 55% of patients using insulin analogs at baseline and having an average BMI of 36.5 kg/m2 at baseline. Patients who had surgical intervention had better outcomes in body weight, fasting plasma glucose, HbA1c, high-density lipoprotein cholesterol, and triglyceride than patients on IMT after the five-year randomization. The RAND-36 showed that patients in the IMT group scores from baseline did not significantly improve, with the lowest scores coming from the pain, emotional well-being, and role limitations caused by emotional problems sections. However, the surgical group had significantly better scores on physical function, energy/fatigue, and general health. After five years, the metabolic surgery groups improved general health scores of 17.2 between RYGB and IMT, 13.4 difference between SG and IMT than the IMT group. The pain scores followed the same trend, with surgical intervention scoring better than IMT. For the EQ-5D questionnaire, the changes in the index score were not statistically different. In the diabetes-specific instrument questionnaire, the results indicate that RYGB was favored over IMT in maintaining a diet, going on vacation, planning meals, or eating out with others and family life. RYGB and SG showed no difference when assessed. 

In type 2 diabetes patients, metabolic surgery improved patients’ QoL in the physical health and diabetes-related categories more than IMT alone. Although metabolic surgery did better than IMT in many categories, it did not significantly improve self-reported physical health, long-term improvements in psychological, emotional, and social aspects of patients’ QoL. In the patients who received surgical intervention, one-third of them had long-term remission of their T2DM, and over half had reasonable glycemic control. Although patients did see lasting positive effects with surgical intervention, the peak of favorable results was more evident in the first three years. This can be due to patients regaining weight, diabetes relapse, or surgical adverse events. Weight loss plays a significant role in patients’ QoL since overweight is linked to mobility issues, pain, and discomfort. A gradual decline followed this peak improvement in QoL in adolescents. Based on the results of this study, metabolic surgery has a long-term favorable effect on patient-related outcomes and their quality of life. 

Practice Pearls: 

• Patients report better patient-related outcomes and quality of life with metabolic surgery vs. intensive medical therapy. 

• Many patients can achieve diabetes remission and maintain glycemic control with metabolic surgery.  
• Weight loss improves patients’ quality of life by eliminating issues related to obesity. 

Aminian, Ali et al. “Patient-reported Outcomes After Metabolic Surgery Versus Medical Therapy for Diabetes: Insights From the STAMPEDE Randomized Trial.” Annals of surgery vol. 274,3 (2021): 524-532. doi:10.1097/SLA.0000000000005003 

Jerrine Fletcher, Fourth Year Doctor of Pharmacy Candidate, Florida A&M University College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health