Obesity, Diabetes are the Epidemics; Is Bariatric Surgery the Cure?

The quick answer to this question is yes, at least for many (as opposed to all) patients, and at least according to the bariatric surgeons I heard and spoke with at their society meeting in mid-June. My take from that meeting was that bariatric surgery is working wonders these days–of course for obesity, but for type 2 diabetes too. It’s remarkably safe, yet way underused. Will that change soon? Is a golden age of bariatric surgery dawning, and will the big, two-headed medical epidemic now rampaging get tamed as a result?

Roux-en-Y gastric bypass; courtesy NIDDK, Wikimedia Commons

It’s a tall order, but my bet is on bariatric surgery, and there are hints that its long-standing status as the wallflower of surgical interventions may be shifting.

Last March, the International Diabetes Federation issued a position statement on bariatric surgery saying that it should be “considered earlier in the treatment of eligible patients.” The statement called bariatric surgery “an accepted option in people who have type 2 diabetes and a body mass index of 35 kg/m2 or more.” And for patients with a BMI of 30-35 kg/m2 the statement said that bariatric surgery “should be considered an alternative treatment option” for patients inadequately controlled by optimal medical therapy, especially when they also have major cardiovascular disease risk factors.

To someone like me, previously unfamiliar with where bariatric surgery stood these days, some of the facts I gleaned at the meeting were eye-opening. The perioperative mortality rate for laparoscopic gastric bypass surgery (Roux-en-Y), the type of bariatric surgery considered most practical and effective for treating types 2 diabetes by most surgeons I ran into, fell to a rate of 6/10,000 patients treated in 2009 at about 360 U.S. academic medical centers and affiliated hospitals. The non-fatal complication rates and need for repeat hospitalization was also low, placing the risk from bariatric surgery these days squarely in the ranks of many “routine” surgeries, such as hip replacement, appendectomy,  and gallbladder removal for stones. Gastric band placement is safer still, though not as effective for resolving type 2 diabetes.

The diabetes effect from gastric bypass is also impressive. One recent study compared 46 patients with diabetes who underwent laparoscopic gastric bypass at the Gundersen Lutheran Health System in La Crosse, Wis., with 41 matched patients with type 2 diabetes who remained on their standard medical treatment during 2001-2005.  One year after surgery, the average hemoglobin A1c in the surgery patients stood at a normal 5.8%, compared with their average baseline value of 7.4%. Twenty-seven of these 46 (59%) were in full diabetes remission, meaning they were off all diabetes medications and their HbA1c was below 6.0%. In contrast, just 2 of the 41 conventional-treatment patients (5%) went into remission a year after their baseline.

“If there was a pill that achieved remission rates like this and had a safety profile like this and you didn’t offer it to your patients it would be unethical,” said Dr. Shanu N. Kothari, director of the minimally invasive bariatric surgery center at Gundersen and lead author of this study.

Yet bariatric surgery is neglected by most patients–be they just obese or obese with type 2 diabetes–and by their physicians. At the meeting I heard that about 200,000 U.S. bariatric surgeries are done annually now, a scope dwarfed by the number of patients who are candidates.

Why the neglect? Several surgeons at the meeting noted the disconnect between acceptance in the medical community of bariatric surgery relative to just about every other type of medically driven surgery out there.

What’s also striking is that bariatric surgery’s success contrasts with the problems that medical weight loss and maintenance has faced recently. During the past year or so, the Food and Drug Administration has shot down lorcaserin (Lorqess), the combination of phentermine and topiramate (Qnexa) , and another combination, bupropion and naltrexone (Contrave), all because of concerns that these agents might cause cardiovascular adverse events. In contrast, a report at the bariatric surgery meeting showed that all forms of bariatric surgery actually led to significant reductions in cardiovascular disease events as well as increased patient survival.

With medical management of obesity in sorry shape, and lots of evidence building for surgery’s safety and efficacy, the ascendance of a surgical solution to obesity and diabetes may have begun.

—Mitchel Zoler (on Twitter @mitchelzoler)

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4 Comments

Filed under Blognosis, Cardiovascular Medicine, Endocrinology, Diabetes, and Metabolism, Family Medicine, Gastroenterology, IMNG, Internal Medicine, Practice Trends, Primary care, Surgery

4 responses to “Obesity, Diabetes are the Epidemics; Is Bariatric Surgery the Cure?

  1. We are always exhorted to practice “evidence-based medicine but there has never been a randomized, sham-operated controlled trial of bariatric surgery. Bariatric surgery should be subject to the same testing as any weight loss drug must be before it is marketed.

    See my blog for further comments.

    http://medicalmyths.wordpress.com/2007/03/09/bariatric-surgery-psychic-surgery/

  2. mzoler

    Perhaps the most famous randomized trial of bariatric surgery reported so far compared laparoscopic gastric banding with supervised lifestyle intervention. It appeared last year in JAMA: http://jama.ama-assn.org/content/303/6/519.full.pdf+html?sid=d4fe3f0e-06ab-499a-a78b-ea80f1c3e397 Granted this was not sham-surgery controlled, but demanding sham surgery as the control seems extreme to me.

    Many controlled trials of gastric bypass for treating type 2 diabetes are now in progress. For example, the TRIABETES trial at the University of Pittsburgh is comparing gastric bypass and gastric banding with lifestyle management. http://www.clinicaltrials.gov/ct2/show/NCT01047735?term=bariatric+surgery+and+diabetes+and+gastric+bypass&rank=4

    A full list of trials now in progress comparing gastric bypass and other interventions in patients with diabetes can be found at clinicaltrials.gov.

    Thanks for posting your comment.

  3. roro roberto

    See the studies of Dr. Rubino in New York, to believe that a cure has been found and the trials were done and there are several underway as today.
    The only problem we have in this country is that money is most important that the patient. Thanks God that other countries are not tie to our medical doctrine and are using these surgery to end the misery of so many.

  4. According to the study of the University Medical School in Melbourne, Australia, it’s the best therapy for diabetes that we have today, and it’s very low risk.

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