title: Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations.
abstract: Despite growing evidence that bariatric/metabolic surgery powerfully improves type 2 diabetes (T2D), existing diabetes treatment algorithms do not include surgical options.
  
  
  
  The 2nd Diabetes Surgery Summit (DSS-II), an international consensus conference, was convened in collaboration with leading diabetes organizations to develop global guidelines to inform clinicians and policymakers about benefits and limitations of metabolic surgery for T2D.
  
  
  
  A multidisciplinary group of 48 international clinicians/scholars (75% nonsurgeons), including representatives of leading diabetes organizations, participated in DSS-II. After evidence appraisal (MEDLINE [1 January 2005-30 September 2015]), three rounds of Delphi-like questionnaires were used to measure consensus for 32 data-based conclusions. These drafts were presented at the combined DSS-II and 3rd World Congress on Interventional Therapies for Type 2 Diabetes (London, U.K., 28-30 September 2015), where they were open to public comment by other professionals and amended face-to-face by the Expert Committee.
  
  
  
  Given its role in metabolic regulation, the gastrointestinal tract constitutes a meaningful target to manage T2D. Numerous randomized clinical trials, albeit mostly short/midterm, demonstrate that metabolic surgery achieves excellent glycemic control and reduces cardiovascular risk factors. On the basis of such evidence, metabolic surgery should be recommended to treat T2D in patients with class III obesity (BMI ≥40 kg/m(2)) and in those with class II obesity (BMI 35.0-39.9 kg/m(2)) when hyperglycemia is inadequately controlled by lifestyle and optimal medical therapy. Surgery should also be considered for patients with T2D and BMI 30.0-34.9 kg/m(2) if hyperglycemia is inadequately controlled despite optimal treatment with either oral or injectable medications. These BMI thresholds should be reduced by 2.5 kg/m(2) for Asian patients.
  
  
  
  Although additional studies are needed to further demonstrate long-term benefits, there is sufficient clinical and mechanistic evidence to support inclusion of metabolic surgery among antidiabetes interventions for people with T2D and obesity. To date, the DSS-II guidelines have been formally endorsed by 45 worldwide medical and scientific societies. Health care regulators should introduce appropriate reimbursement policies.
authors.affiliation: King's College London, London, U.K. francesco.rubino@kcl.ac.uk davidec@u.washington.edu.
authors.forename: Francesco
authors.initials: F
authors.lastname: Rubino
authors.affiliation: Harvard Medical School, Boston, MA.
authors.forename: David M
authors.initials: DM
authors.lastname: Nathan
authors.affiliation: University of Colorado Anschutz Medical Campus, Aurora, CO.
authors.forename: Robert H
authors.initials: RH
authors.lastname: Eckel
authors.affiliation: Cleveland Clinic, Cleveland, OH.
authors.forename: Philip R
authors.initials: PR
authors.lastname: Schauer
authors.affiliation: Imperial College London, London, U.K.
authors.forename: K George M M
authors.initials: KG
authors.lastname: Alberti
authors.affiliation: Monash University, Melbourne, Victoria, Australia.
authors.forename: Paul Z
authors.initials: PZ
authors.lastname: Zimmet
authors.affiliation: University of Pisa, Pisa, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Del Prato
authors.affiliation: Peking University, Beijing, China.
authors.forename: Linong
authors.initials: L
authors.lastname: Ji
authors.affiliation: Diabetes India, Mumbai, India.
authors.forename: Shaukat M
authors.initials: SM
authors.lastname: Sadikot
authors.affiliation: University of Michigan, Ann Arbor, MI.
authors.forename: William H
authors.initials: WH
authors.lastname: Herman
authors.affiliation: King's College London, London, U.K.
authors.forename: Stephanie A
authors.initials: SA
authors.lastname: Amiel
authors.affiliation: Harvard Medical School, Boston, MA.
authors.forename: Lee M
authors.initials: LM
authors.lastname: Kaplan
authors.affiliation: Philadelphia, PA.
authors.forename: Gaspar
authors.initials: G
authors.lastname: Taroncher-Oldenburg
authors.affiliation: University of Washington, Seattle, WA francesco.rubino@kcl.ac.uk davidec@u.washington.edu.
authors.forename: David E
authors.initials: DE
authors.lastname: Cummings
mesh_terms: D000465:Algorithms; D050110:Bariatric Surgery / Q000592:standards*; D002318:Cardiovascular Diseases / Q000517:prevention & control; D032921:Consensus; D003299:Cooperative Behavior; D003924:Diabetes Mellitus, Type 2 / Q000601:surgery*; D004704:Endocrinology / Q000458:organization & administration / Q000592:standards*; D006801:Humans; D038622:Internationality; D009765:Obesity / Q000601:surgery; D017410:Practice Guidelines as Topic; D012307:Risk Factors; D012955:Societies, Medical / Q000458:organization & administration / Q000592:standards