Variations On A Theme

Photo by M Clock

This Chilean study caught my eye the other day, from the  February 2013 Obesity Surgery Journal.

It essentially mimics a report in Diabetes Care from 2012 noting similar results, as well as a Stanford study that led to an ASMBS news release in 2011 after it was presented at a national meeting.

The Chilean study showed the results of a group of 31 patients who were Diabetic and underwent Laparoscopic Gastric Bypass for their diabetes.  It also placed the surgical treatment fairly in context with other medical treatments for Diabetes.

Interestingly, the twist in all these reports is the fact that all the patients had a BMI between 30 and 35. As you are aware, those patients would not be approved for surgery in the US, yet still had significant / uncontrolled diabetes, as demonstrated average duration of disease at 5.8 years, and average preoperative BGs were 152 +\-70, and average HGBA1C was 7.7+\-2.1.  No mention of C Peptide results though, which would have been nice to see.

The results of surgery confirmed what we already know from the effects of Gastric Bypass on obese patients and their metabolic disease from the higher more traditional BMI groupings.  The implications from surgical treatment in this group are significant on a number of levels.

Notably, only one complication was reported in the study, a case of hematoperitoneum (post op bleeding) which caused a return to the OR, but no long term effects. At 36 mos average BMI decreased to 24.7. All patients showed evidence of greatly improved glycemic control, with 29/31 (94%) meeting the criteria for remission of their Diabetic disease.

Furthermore, the article also mentions other more commonplace standard, medical treatments for Diabetes, often treatment regimens that do not provide adequate long term control of the disease, let alone remission, and are not free from potential side effects.

Non-surgical treatments are not completely benign, unto themselves:
 
   *  Lifestyle Change - Difficult to do, and hard to maintain to impact disease state and reduce risk of complications long term

   *  Thiazolidinediones - Reported increased risk of fractures, heart failure

   *   GLP-1 Analogs - not evaluated in long term studies as of this time; possibility of acute pancreatitis, medullary thyroid cancer

   *   Inhibitors of dipeptidyl peptidase-4 - not studied long term trials for safety / efficacy

So, while not earth-shattering information, these studies do underscore a couple of points that have been recurrent concepts on this Blog.

Earlier  Referral for Surgery is Better, whether in the context of the existing BMI categories we have through NIH guidelines for referral, or in the sense of earlier in the disease process, or now even earlier in the BMI range, currently for research purposes only in the US, which may induce a change in the future to insurance coverage of Bariatric Surgery at a lower weight.  Earlier surgery = earlier benefit = greater long term benefit.

Surgery is Safe and Effective Treatment for Diabetes, as borne out of many studies, and the bang-for -the-buck is very worthwhile.  Surgically-induced effects on Diabetes cannot be matched by medical treatment as we currently know it.  Period.

Traditional Medical (Non-Surgical) Treatment for Diabetes is not Perfect, it has its flaws, side effects, and inherent lack of efficacy.  I don't think we honestly put that in the equation of medical vs surgical treatment,  risk - benefit ratio enough.

So, maybe we are on the eve of a change to the Clinical Guidelines statement from the American Diabetes Association "Standards of Medical Care in Diabetes".  Published in 2009, it recommends surgical treatment for patients with poorly controlled Diabetes and a BMI of 35 or greater, and below 35 under research protocols.

Identifying those patients that qualify currently for surgery with Diabetes, and there are more and more every day, and consistently offering them a surgical option as part of your treatment plan is a great place to start.