An operation proves to be the most effective therapy for adult-onset diabetes mellitus
Walter J Pories, M.D., Melvin S. Swanso, Ph.D., Kenneth G. MacDonald, M.D., Stuart B. Long, B.S., Patricia G. Morris, B.S.N., Brenda M. Brown, M.R.A., Hisham A. Barakat, PhD., Richard A. deRamon, M.D., Gay Israel, Ed.D., Jeanette M. Dolezal, PhD., and Lynis Dohm, Ph
So says this landmark article published in the prestigious journal Annals of Surgery in 1995.
We are all used to treatment for Type 2 Diabetes involving diet and exercise, oral hypoglycaemic agents and sometimes even insulin. But there is a new paradigm of diabetic care emerging which challenges this time-honoured approach with the promise of dramatically-improved outcomes.
Bariatric surgery, initially conceived for weight loss, has demonstrated such remarkable efficiency in treating diabetes and resolving the medical complications of obesity, that the surgery is now used predominantly as a tool to treat metabolic illnesses. Bariatric surgery is no longer used for “cosmetic” weight loss and is now only used as an alternative form of treatment for bona fide medical conditions.
The term Bariatric surgery covers a wide range of treatments. They can be broadly divided into surgical treatments and endoscopic treatments.
Common surgical treatments include operations such as Roux-en-Y Gastric Bypass, Sleeve Gastrectomy, and Adjustable Gastric Banding (the LapBand). Each of these procedures are scientifically-proven to work, but none are 100% perfect. Each have their individual pros and cons, and what suits one person may not suit another. In general the operations are performed using minimal-invasive techniques, which means small incisions. Most patients are out of hospital within 3 days and back at work in 3 weeks. Older operations like duodenal switch and bilio-pancreatic diversion almost never used in Australia.
Endoscopic treatments include procedures such as the Orbera intragastric balloon, with several more novel procedures on the horizon. Endoscopic treatments do not require surgery, as they are performed through the mouth down the endoscope, often as same-day procedures with immediate return to work.
RESULTS OF SURGICAL TREATMENT OF DIABETES
The headline study by Pories in 1995 examined 608 morbidly obese patients, 83% of whom had T2DM, and 99% had impaired glucose tolerance (IGT). 97% of patients were followed for 7.6 years. They noticed glucose correction occurring within days of surgery, and that 98% of patients were prevented from progressing from IGT to T2DM.
In 2009 Buchwald published a meta-analysis of over 135,000 patients treated with Bariatric surgery, and reported overall 78% of diabetic patients had complete resolution of their illness, and diabetes was improved in a total of 87% of patients.
Finally, last month Migrone published in the Lancet, results of diabetic patients after 5 years of care. 50% of the diabetic patients had maintained diabetes remission at 5 years, compared with none of the diabetic patients treated with medication (and not surgery). There were 5 major complications (including death from heart attack) in the group treated with medication, and no major complications or deaths in the patients treated with surgery.
Many more similar publications exist in the literature, and in fact, Bariatric surgery has become one of the most studied fields in medicine, with an ever-growing abundance of new studies surfacing each year, all with remarkably similar results.
HOW DOES IT WORK?
With the LapBand it’s easy, the surgery works exclusively by inducing weight loss. However with Gastric Bypass, the surgery benefits diabetics by not only inducing substantially greater weight loss, but by preventing absorption of fats, sugars and bile acids in the upper intestine. It is believed that the rapid progression of these nutrients to the lower parts of the bowel following surgery, results in in the exaggerated secretion of gut hormones which have a beneficial effect on the pancreas gland by enhancing its function.
CONCLUSION AND FUTURE
Professor Schauer from The Cleveland Clinic in USA recently said “In the past 3 years, 11 randomised controlled trials in nearly 800 patients have demonstrated consistent superiority of metabolic surgery versus medical treatment of Type 2 diabetes with respect to glycaemic (blood sugar) control and cardiovascular risk reduction”.
So although Bariatric surgery may seem like the new kid on the block, and that articles like this might be seen to be shaking the tree, one could argue that this useful field of endeavour has been in the shadows far too long and that a new dawn for diabetic management is well and truly upon us.
Author: Dr. Justin Bessell MBBS MD FRACS is a General and Upper Gastrointestinal Surgeon and Head of the Australian Obesity Surgery clinic at Wakefield Hospital. He is a Senior Lecturer in Surgery at Flinders University, and a Senior Consultant Surgeon at Flinders Medical Centre. For any further information he can be contacted on 8359 2411.