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Alpine Experts 2013

Diabetes scoring system aims to inform operation choice

Dr Surendra Ugale, who created the scoring system.
Simple scoring system aims to quantify T2DM severity
Creator calls for collaboration with other surgeons to help validate system

A surgeon has developed an objective scoring system for the severity of type 2 diabetes, which he says will help other surgeons avoid “overkill” when planning metabolic treatment.

Presenting at the 2013 Alpine Experts Meeting in Saalfelden, Austria, Dr Surendra Ugale, from Kirloskar Hospital, Hyderabad, India, said that he developed his system in order to help systemise the choice of operation that the surgeon recommends to the patient.

“I realised that there were so many disparate results in different levels of diabetes, and there was no standardisation,” said Ugale. “We were comparing apples and peaches and plums, trying to utilise procedures and compare these different things.”

Ugale’s Metabolic Surgery Assessment Score measures seven diabetic indications, with a patient receiving a score of 1 or 2 for each. Added together, the patient gets a cumulative score between 7 and 14; a surgeon can then use this score to establish the resolution rate of an intended operation.

“We analysed our own work, and then we found, for example, that if the score was 7 or 8 then jejunal ileal interposition gave 100% resolution,” said Ugale. “If the score was 9, there was only a 55% resolution, unless the BMI was high.”

“We realised that means that if we had a patient with a score of 9 and above, we should be doing the duodenal ileal interposition and not the milder procedure. This is going to help us in the future at choosing the right procedure to give the best result.”

Ugale hopes that the scoring system will help clear up surgeons’ “confusion” over procedure choice. He says that currently, “the choice of procedure is not based on a scientific basis – it’s based on your comfort level with the procedure. If you train at a centre which does the bypass, then you do the bypass.”

He says that in patients with a score of 12 or more, he did not find any patients who went into remission, even with the stronger duodenal ileal interposition. With these patients, he says, he is now able to advise them before their operation that they are not going to see a complete resolution of their symptoms, although they may see improvement.

The system uses the following indications:

Indication

Favourable (score +1)

Unfavourable (score +2)

Age

Between 30 and 60

Under 30 or over 60

BMI

Over 27

Under 27

Duration of diabetes

Up to 10 years

Over 10 years

Microvascular comorbidities

Absent

Present

Macrovascular comorbidities

Absent

Present

Mandatory insulin usage

Not required

Required

Stimulated C-Peptide (one hour after meal)

Over 4

Under 4

Ugale says that having as few indications as possible, and avoiding factors that cannot be directly measured by the surgeon, like the patient’s family history, means that the scale is simple to administer and objective in its outcomes.

While he has performed his research using the relatively unusual jejunal and duodenal ileal interposition operations, he says that he is working with other surgeons to validate the system for more common procedures, including sleeve gastrectomy and gastric bypass.

He is now looking for surgeons to apply his system to their own data retrospectively, in order to test its validity with larger groups of patients. “We would be able to gather a larger number with a publication that would be like a meta-analysis, with validation on a larger scale through all types of surgeries,” he says. “Let’s do that, because I strongly feel the surgical world needs a scoring system for standardising these surgeries.”

He urges interested surgeons to contact him, to get more information about the application of the scoring system.

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