Expert Recommendations
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Diabetes. Oct 15, 2021; 12(10): 1587-1621
Published online Oct 15, 2021. doi: 10.4239/wjd.v12.i10.1587
Expert opinion on the preoperative medical optimization of adults with diabetes undergoing metabolic surgery
Saptarshi Bhattacharya, Sanjay Kalra, Nitin Kapoor, Rajiv Singla, Deep Dutta, Sameer Aggarwal, Deepak Khandelwal, Vineet Surana, Atul Dhingra, Viny Kantroo, Sachin Chittawar, Nilakshi Deka, Vivek Bindal, Puja Dutta
Saptarshi Bhattacharya, Endocrinology, Max Superspeciality Hospital, New Delhi 110092, India
Sanjay Kalra, Endocrinology, Bharti Hospital, Karnal 132001, Haryana, India
Nitin Kapoor, Endocrinology, Christian Medical College, Vellore 632004, Tamil Nadu, India
Rajiv Singla, Endocrinology, Kalpavriksh Super Speciality Center, New Delhi 110075, India
Deep Dutta, Endocrinology, CEDAR Superspecialty Clinic, New Delhi 110075, India
Sameer Aggarwal, Endocrinology, Apex Plus Superspeciality Hospital, Rohtak 124001, Haryana, India
Deepak Khandelwal, Endocrinology, Maharaja Agrasen Hospital, New Delhi 110026, India
Vineet Surana, Endocrinology, Manipal Hospitals, New Delhi 110075, India
Atul Dhingra, Endocrinology, Gangaram Bansal Super Speciality Hospital, Sri Ganganagar 335001, Rajasthan, India
Viny Kantroo, Respiratory Medicine & Critical Care, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110076, India
Sachin Chittawar, Endocrinology, Gandhi Medical College, Bhopal 462001, Madhya Pardesh, India
Nilakshi Deka, Endocrinology, Apollo Hospitals, Guwahati 781005, Assam, India
Vivek Bindal, Minimal Access, Metabolic and Bariatric surgery, Max Superspeciality Hospital, Patparganj, New Delhi 110092, India
Puja Dutta, Nutrition, Max Superspeciality Hospital, Patparganj, New Delhi 110092, India
Author contributions: Bhattacharya S, Kalra S, and Singla R conceived the study; Kapoor N, Kandelwal D, Dutta D, and Surana V conducted the literature search; All authors attended a meeting held at the sidelines of the Annual Society for Promotion of Education in Endocrinology and Diabetes Conference in February 2020, and multiple virtual meetings were attended by the authors to reach a consensus on controversial topics; Bhattacharya S, Chittawar S, Dutta P, and Deka N prepared the initial draft of the manuscript; Aggarwal S, Dhingra A, Bindal V, and Kapoor N revised the manuscript; All authors have read and approved the final manuscript.
Conflict-of-interest statement: None of the authors has any conflict of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Saptarshi Bhattacharya, FACE, MD, Doctor, Endocrinology, Max Superspeciality Hospital, Patparganj, 108A I P Extension, New Delhi 110092, India. saptarshi5@yahoo.com
Received: June 23, 2021
Peer-review started: June 23, 2021
First decision: July 15, 2021
Revised: July 18, 2021
Accepted: August 25, 2021
Article in press: August 25, 2021
Published online: October 15, 2021
Processing time: 112 Days and 1.6 Hours
Abstract

Diabetes mellitus (DM) and obesity are interrelated in a complex manner, and their coexistence predisposes patients to a plethora of medical problems. Metabolic surgery has evolved as a promising therapeutic option for both conditions. It is recommended that patients, particularly those of Asian origin, maintain a lower body mass index threshold in the presence of uncontrolled DM. However, several comorbidities often accompany these chronic diseases and need to be addressed for successful surgical outcome. Laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly used bariatric procedures worldwide. The bariatric benefits of RYGB and LSG are similar, but emerging evidence indicates that RYGB is more effective than LSG in improving glycemic control and induces higher rates of long-term DM remission. Several scoring systems have been formulated that are utilized to predict the chances of remission. A glycemic target of glycated hemoglobin < 7% is a reasonable goal before surgery. Cardiovascular, pulmonary, gastrointestinal, hepatic, renal, endocrine, nutritional, and psychological optimization of surgical candidates improves perioperative and long-term outcomes. Various guidelines for preoperative care of individuals with obesity have been formulated, but very few specifically focus on the concerns arising from the presence of concomitant DM. It is hoped that this statement will lead to the standardization of presurgical management of individuals with DM undergoing metabolic surgery.

Keywords: Diabetes; Obesity; Metabolic surgery; Bariatric surgery; Remission of diabetes

Core Tip: The ambit of metabolic surgery for diabetes has increased. Individuals with inadequate glycemic control can be considered for surgery if less severely obese, and even more so if they are of Asian origin. However, both diabetes and obesity are associated with multiple comorbidities that require optimization before surgery. There are several clinical guidelines for the preoperative management of individuals with obesity; however, specific suggestions addressing these concerns in persons with diabetes have not been recommended. It is important to achieve optimal glycemic control and diagnose and manage cardiovascular, pulmonary, gastrointestinal, and renal complications before surgery. Nutritional assessment, psychological evaluation, and ruling out specific endocrine disorders are other essential adjuncts. These guidelines will help to standardize the management of preoperative comorbidities and improve postoperative outcomes in individuals with diabetes who opt for metabolic surgery.