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printer-friendly version| Recruiting Referring Physicians in the War Against ?Diabesity? by Tomasz Rogula, MD, PhD and Philip Schauer, MD, FACS - January 2007 As bariatric surgeons, we are well aware of the close association between diabetes and obesity so well described by the term, ?diabesity.? Substantial weight reduction is a priority in patients presenting with both obesity and Type 2 diabetes to reduce complications and mortality and improve control of blood glucose levels. Early and intensive treatment of Type 2 diabetes with bariatric surgery has been shown to reduce morbidity, mortality and the deterioration of pancreatic B-cell function, as well as improve quality of life. Unfortunately, diabetes is still widely considered a disease exclusively treated by medicine. Our challenge is to educate referring physicians to the advantages of weight reduction surgery in the management of patients with diabesity. Knowledge of a few key facts, including the four presented below, will help improve understanding of benefits of bariatric surgery in this population among referring physicians, which in turn will increase the likelihood that their patients will achieve substantial weight loss and the associated medical benefits. 1. The value of bariatric surgery for Type 2 diabetes has been confirmed in multiple large studies. The Roux-en-Y gastric bypass is a very effective method of controlling diabetes, resulting in normal concentrations of plasma glucose, insulin and glycosylated hemoglobin in 80 percent of patients. In one study of 1,025 morbidly obese patients treated with Roux-en-Y gastric bypass, 15 percent of participants had Type 2 diabetes mellitus. At one year after surgery, diabetes had resolved in 83 percent of these patients. At five to seven years, this figure had risen to 86 percent (1). In a similar study of 1,160 patients, in which 21 percent had impaired glucose metabolism or Type 2 diabetes, surgery decreased body mass index significantly from 50.1 kg/m2 to 34 kg/m2 for a mean weight loss of 97 pounds and mean excess weight loss of 60 percent. Fasting plasma glucose and glycosylated hemoglobin concentrations returned to normal levels in 83 percent of patients. Following surgery, 80 percent of patients no longer needed oral antidiabetic agents, and 79 percent were able to stop insulin (2). 2. Bariatric surgery reduces morbidity and mortality by reducing macrovascular and microvascular complications. Gastric bypass reduces mortality primarily by decreasing the number of cardiovascular deaths. For every year of follow-up, diabetic patients treated medically have a 4.5 percent chance of dying, compared with a 1 percent chance for those undergoing bariatric surgery. While the number of diabetic patients needing medical therapy with oral hypoglycemics or insulin reaches almost 90 percent over time, the need for medical management falls to less than 8 percent among those who have gastric bypass (3). Tight glycemic control achieved with bariatric surgery decreases the risk of microvascular complications (retinopathic, nephropathic and neuropathic) associated with diabetes. Some studies show that every 1 percent drop in HbA1c causes a relative risk reduction of 25 to 45 percent (4). 3. The risk of bariatric surgery is less than the risk of death from diabetic complications. Bariatric operations carry some risk, but the major morbidity is less than 10 percent and mortality is less than 0.5 percent. This is a reasonable risk for the tremendous clinical benefits of minimizing the progression of Type 2 diabetes in obese patients. The most common complications from gastric bypass include gastrointestinal leak, pulmonary embolism, bowel obstruction and internal hernia. However, the overall complication rate does not exceed 5 percent for all patients. The most common complications from the gastric banding procedure include slippage of the band, erosion of the band, esophageal dilatation and breakage of the device. The overall complication rate for gastric banding is 5 to 8 percent. Taking into consideration the risk-to-benefits ratio, bariatric surgery is extremely effective when compared to medical treatment. The risk of death from diabetic complications is greater than the risk of death from surgery. 4. The earlier the surgery, the better the outcome. A key finding of many studies is that the shorter the history of diabetes, the greater the likelihood of complete remission. Glucose toxicity, particularly in poorly controlled diabetes, accelerates B-cell failure. However, weight loss can improve B-cell responsiveness to glucose. If the bariatric surgical procedure is performed before irreversible Bcell failure has occurred, durable weight loss will be accompanied by a high likelihood of long-term remission (5).  Tomasz Rogula, MD, PhD, is a staff surgeon at the Cleveland Clinic Bariatric and Metabolic Institute. He has trained in weight loss surgery in the United States, Italy and France. In addition to bariatric surgery, his specialty interests include laparoscopic and robotic surgery, gastrointestinal surgery and hernia repair. Dr. Rogula has done multiple pioneering research studies on novel weight loss surgery procedures and published multiple articles and book chapters on bariatric and laparoscopic surgery. Philip Schauer, MD, FACS, is the Director of Advanced Laparoscopic and Bariatric Surgery at Cleveland Clinic and president of the American Society for Bariatric Surgery. In addition to bariatric surgery, his specialty interests include laparoscopic surgery, gastrointestinal surgery and colon surgery. A frequent national and international lecturer, Dr. Schauer also has published scores of articles on topics relating to bariatric and laparoscopic surgery, and his first textbook on this subject is due out in the summer of 2007, entitled ?Minimally Invasive Bariatric Surgery.?References: 1. Sugerman HJ, Wolfe LG, Sica DA, Clore JN. Diabetes and hypertension in severe obesity and effects ofgastric bypass-induced weight loss. Ann Surg. 2003 Jun;237(6):751-6; discussion 757-8. 2. Schauer PR, Burguera B, Ikramuddin S, Cottam D, Gourash W, Hamad G, Eid GM, Mattar S, RamanathanR, Barinas-Mitchel E, Rao RH, Kuller L, Kelley D. Effect of laparoscopic Roux-en Y gastric bypass on Type 2 diabetes mellitus. Ann Surg. 2003 Oct;238(4):467-84; discussion 84-5. 3. MacDonald K, Long S, Swanson M, Brown B, Morris P, Lynis D, Pories W. The gastric bypass operation reduces the progression and mortality of non-insulindependent diabetes mellitus. J Gastrointest Surg. 1997 May-Jun;1(3):213-20; discussion 220. 4. The relationship of glycemic exposure (HbA sub1c) to the risk of development and progression of retinopathy in the diabetes control and complications trial.Diabetes. 1995;44:968?983. 5. Dixon JB, Dixon AF, O?Brien PE. Improvements in insulin sensitivity and beta-cell function (HOMA) with weight loss in the severely obese. Homeostatic model assessment.Diabet Med. 2003 Feb;20(2):127-34. |
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