Going, Going...GONE!

Photo by M Clock

In the baseball world, the Home Run is one of the most exciting plays to watch.  Not really all that uncommon, but still a thrill to see one go out of the park, with the obligate carefree trot around the base paths that ensues, and the simple math of automatic addition of runs on the scoreboard. Fun stuff.

It's even exciting to listen to on the radio / computer, as I did this week, as my son was at bat, 160 miles away.  He hit one to the outfield wall only to be caught by the right fielder ("with back at wall"). So close, and yet so far from the much needed runs and a celebratory trot.

So it is with Diabetes and Bariatric Surgery these days.  The word is getting out through study after study, the lay press, talk shows, and from patient to patient as they share their good fortune.  This is a big deal!

The one thing that I think is not all that clear about Diabetes and Bariatric surgery is, how long will the remission last?

And as we have discussed with the proposition of Bariatric surgery and the potential for resolution of diabetes in the first place, how can we accurately predict the duration of said remission, for those we identify as likely to significantly benefit from Bariatric and metabolic surgery?

I don't know. Well I kind of know. But not really.

We have certainly seen in our practice, somewhat longitudinally since starting to draw some 'predictive' C-Peptides with more frequency, the expected (and occasionally surprising) Diabetes improvement / resolution after surgery.  There are reports, however,  of the potential return of Diabetes after a certain amount of time (years?).

The question remains, though, as with the case for who responds to surgery initially, and who doesn't, that  there is likely a physiologic basis to predict this post operative effect as well.  I would expect it be tied in to the reserve of physiologic pancreatic function, as preserved by the surgery relative to the state of the islet cell function at the time of surgery.

There may be some other variables, along with age of the patient, duration of diabetes, degree of improvement in blood glucose regulation post op, etc.  Perhaps in the post op setting, just repeating the C Peptide at Q6 mo intervals in conjunction with other updated labs (including a fasting glucose) may elucidate a pattern that is consistent with the eventual return of elevated sugars.

I do suspect further, that even if the diabetes does return, it would most likely be a milder form and easier to control in the setting of significantly reduced weight and much less insulin resistance as compared to the preoperative diabetic state.  I have seen this be the rule in those that did not get the "Home Run" in the hospital, and get the free pass of being discharged after surgery OFF meds, that they needed much less in the amount of basal insulin, or just metformin to get back to decent blood sugar control and a normalized HgbA1C.

So, this was all about what I think, and some of what I have seen so far.  Let me put together a little literature review of some studies that may help us a bit more to give evidence-based medicine a crack at the product of my deductive reasoning.

I am honestly not sure what I will find on this topic of predicting the return of diabetes after it has gone into remission after surgery, but hopefully I am not too far off.