Reviewed for medical accuracy by Dr Evelyne Jonniaux, Medical Advisor
Last updated 17 September 2026
Diabetes: 58.8% of surgical remissions had relapsed by ten years
That is the result of the only randomised trial with ten years of follow-up (Mingrone, The Lancet, 2021), and it is almost always left out. Of 34 patients in remission at two years, 20 relapsed. But the caveat changes everything: everyone who relapsed still had adequate glycaemic control at ten years, with a mean HbA1c of 6.7%. Relapse does not mean going back to the starting point. And the risk of diabetic complications remains fourteen times lower than with medical treatment. These figures describe populations, not one patient. Noria Health arranges a full metabolic work-up near Brussels within 24 to 48 hours.
Why published remission rates range from 5% to 72%
Because the trials are not measuring the same thing. The 2021 international consensus defines remission as an HbA1c below 6.5% measured at least three months after stopping all glucose-lowering treatment. Almost no trial uses that criterion.
| Trial | Criterion actually used | Result |
|---|---|---|
| STAMPEDE, NEJM, 2017 | HbA1c 6.0% or below, medication allowed | 29% after bypass, 23% after sleeve, 5% on medical treatment |
| Mingrone, The Lancet, 2021 | HbA1c below 6.5% and low fasting glucose, no treatment for a year | 25% after bypass, 50% after biliopancreatic diversion, 5.5% on medical treatment |
| ARMMS-T2D, JAMA, 2024 | remission as defined by consensus | 18.2% against 6.2% at 7 years, 12.7% against 0.0% at 12 years |
| SOS, JAMA, 2014 | low glucose and no treatment | 72.3% at 2 years, 30.4% at 15 years |
A remission figure without its definition means nothing. It is the first thing to ask when someone quotes one.
STAMPEDE, and what the most cited trial really shows
STAMPEDE randomised 150 patients with type 2 diabetes and a BMI of 27 to 43 between intensive medical treatment alone, bypass and sleeve. At five years the primary endpoint is met by 5% of the medical arm, 29% of the bypass arm and 23% of the sleeve arm.
Three caveats belong with those figures. Evaluable numbers are 38 to 49 patients per arm. The primary endpoint allows medication, so it is not remission in the consensus sense. And significance disappears in intention to treat, with p values of 0.08 and 0.17.
What remains solid in STAMPEDE are the continuous effects: an HbA1c fall of 2.1 points against 0.3, weight loss of 23% against 5%, insulin use down 35% against 13%, and a general health score improved by 17 points against 0.3.
The best data on durability
ARMMS-T2D (JAMA, 2024) pools four randomised trials and follows 262 patients for a median of eleven years.
| What is measured | Surgery | Medical treatment |
|---|---|---|
| HbA1c change at 7 years | -1.6% (-1.8 to -1.3) | -0.2% (-0.5 to 0.2) |
| Between-arm difference at 7 years | -1.4% (-1.8 to -1.0) | |
| Between-arm difference at 12 years | -1.1% (-1.7 to -0.5) | |
| Remission at 7 years | 18.2% | 6.2% |
| Remission at 12 years | 12.7% | 0.0% |
| Major cardiovascular events | no difference | |
Two important limits are written by the authors themselves. Twenty-five per cent of patients in the medical arm were eventually operated on, which pulls the two arms together artificially. And anaemia, fractures and gastrointestinal events are more frequent after surgery.
The HbA1c gap holds at twelve years, but it narrows. Complete remission becomes rare: one operated patient in eight at twelve years.
What surgery prevents, and this may be the main point
In Mingrone’s trial at ten years, the relative risk of diabetes-related complications is 0.07 with an interval from 0.01 to 0.48 for both surgical arms against medical treatment. At five years, 27% of the medical arm had had a major complication, including one fatal heart attack, against one patient after bypass and none after biliopancreatic diversion.
In other words, the most robust benefit of metabolic surgery is not remission, which often relapses. It is the reduction in complications, which persists even in those who have relapsed.
What the studies do not allow us to claim
No randomised trial has shown a reduction in major cardiovascular events from metabolic surgery. ARMMS-T2D, with eleven years of median follow-up, finds none. The favourable data come from matched cohorts, with the limits that implies.
And the numbers remain small: sixty patients in Mingrone, one hundred and fifty in STAMPEDE, one hundred and twenty in Ikramuddin. These are the best data available, but they are not large trials.
In practice, if this concerns you
Three questions structure the discussion. How long has the diabetes been running and is there still insulin secretion, since that is what predicts remission. What definition of remission were you given, since the figures vary fourteenfold with the criterion. And do you accept lifelong nutritional follow-up, since anaemia and deficiencies are more frequent after surgery.
Noria Health arranges a full metabolic work-up near Brussels within 24 to 48 hours: complete glycaemic assessment with C-peptide, screening for microvascular and macrovascular complications, nutritional and psychological assessment, and upper endoscopy before any surgical decision. The report is issued within 24 hours, follow-up is structured at D14, D30 and D90, and surgery is considered only around day 10 if it is needed.
What Noria Health does not do: promise a cure for diabetes. A hypoglycaemic collapse, persistent vomiting or acute abdominal pain after metabolic surgery are matters for the emergency services in your country, immediately, not for an appointment.
Further reading
- Surgery or GLP-1: no trial has ever compared them
- Metabolic surgery, what the trials measure
- Heart: 44% of people with hypertension do not know they have it
Sources
- Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes, 5-year outcomes, STAMPEDE. N Engl J Med, 2017;376:641-651. https://pubmed.ncbi.nlm.nih.gov/28199805/
- Mingrone G, Panunzi S, De Gaetano A, et al. Metabolic surgery versus conventional medical therapy in patients with type 2 diabetes, 10-year follow-up. The Lancet, 2021;397:293-304. https://pubmed.ncbi.nlm.nih.gov/33485454/
- Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric-metabolic surgery versus conventional medical treatment, 5-year follow-up. The Lancet, 2015;386:964-973. https://pubmed.ncbi.nlm.nih.gov/26369473/
- Courcoulas AP, Patti ME, Hu B, et al. Long-term outcomes of medical management vs bariatric surgery in type 2 diabetes, ARMMS-T2D. JAMA, 2024;331:654-664. https://pubmed.ncbi.nlm.nih.gov/38411644/
- Kirwan JP, Courcoulas AP, Cummings DE, et al. Diabetes remission in the ARMMS-T2D study. Diabetes Care, 2022;45:1574-1583. https://pubmed.ncbi.nlm.nih.gov/35320365/
- Ikramuddin S, Korner J, Lee WJ, et al. Lifestyle intervention and medical management with vs without Roux-en-Y gastric bypass, 5-year outcomes. JAMA, 2018;319:266-278. https://pubmed.ncbi.nlm.nih.gov/29340678/
- Sjostrom L, Peltonen M, Jacobson P, et al. Association of bariatric surgery with long-term remission of type 2 diabetes. JAMA, 2014;311:2297-2304. https://pubmed.ncbi.nlm.nih.gov/24915261/
- Courcoulas AP, King WC, Belle SH, et al. Seven-year weight trajectories and health outcomes in the LABS study. JAMA Surg, 2018;153:427-434. https://pubmed.ncbi.nlm.nih.gov/29214306/
- Riddle MC, Cefalu WT, Evans PH, et al. Consensus report, definition and interpretation of remission in type 2 diabetes. Diabetes Care, 2021. https://pubmed.ncbi.nlm.nih.gov/34462270/
See also: all our articles on bariatric and metabolic surgery.
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