Below are listed recommendations on when to consider metabolic surgery for type 2 diabetes. Decisions making would depend on BMI severity and glycemic control.
The joint statement advises surgery for patients with class III obesity, and in those with class II but have high A1c. Consideration should be given to adults with controlled class II or uncontrolled class I obesity.
Standards are listed below with a slightly modified wording for easier and succinct reading:
Given its role in metabolic regulation, the Gastro-Intestinal tract constitutes a clinically and biologically meaningful target for the management of T2D.
Complementary criteria to the sole use of BMI, the traditional criterion used to select candidates for bariatric surgery, need to be developed to achieve a better patient selection algorithm for metabolic surgery.
Metabolic surgery should be a recommended option to treat T2D in appropriate surgical candidates with class III obesity (BMI ≥40), regardless of the level of glycemic control or complexity of glucose-lowering regimens, as well as in patients with class II obesity (BMI 35–40) with inadequately controlled hyperglycemia despite lifestyle and optimal medical therapy.
Metabolic surgery should also be considered to be an option to treat T2D in patients with class I obesity (BMI 30–35) and inadequately controlled hyperglycemia despite optimal medical treatment by either oral or injectable medications (including insulin).
All BMI thresholds should be reconsidered depending on the ancestry of the patient. For example, for patients of Asian descent, the BMI values above should be reduced by 2.5 kg/m2.
Metabolic surgery should be performed in high-volume centers with multidisciplinary teams that understand and are experienced in the management of diabetes and GI surgery.
Metabolic surgery is a potentially cost-effective treatment option in obese patients with T2D. The clinical community should work together with health care regulators to recognize metabolic surgery as an appropriate intervention for T2D in people with obesity and to introduce appropriate reimbursement policies.