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| From PlaidStallions.com |
Likewise, some things will be unpleasant if they do return.
Dating myself, I did have a leisure suit when I was in Jr. High, and I didn't wear it that often, but when I did, I sure felt 'fly'. I'm not sure if it was the look of the suit, the word descriptor 'leisure' that seemed to be an over-reaching adjective that implied that I was destined to enjoy myself at an event (a funeral, though?), or the stretchy, unrestricted feel of the polyester.... Good times, good times.
In some way, Diabetes is like those leisure suits, or like dated fashion that comes and goes, especially when it represents the worst of the times of a bygone era.
It's great to see the Diabetes go (after surgery) ...but will it come back ? If so, when? And, how 'bad' will it be when it does return?
I did a literature review, prompted by recent patient requests for an idea of the likelihood of a return of their Diabetes, and looking for some help with a description of how long the post-surgical benefit will last from Bariatric surgery.
Also, an article was recently published in Obesity Surgery, a multisite, retrospective cohort study, looking at 4,400 patients over 13 years and their rates of long-term remission and relapse of DM2 after Gastric Bypass. When they looked at rates of remission and relapse after surgery, they were also interested in possible predictors of complete remission and relapse. Remission and relapse criteria were defined clinically by laboratory measures of glycemic control, as well as diabetes medication use.
Of the 68% that did respond to surgery early (within 5 years of the procedure), 35 % of those did relapse within 5 years from their remission. The median duration of remission was 8.3 years.
Significant predictors of complete remission and subsequent relapse were:
* Poor preoperative glycemic control
* Insulin use
* Longer duration of Diabetes prior to surgery
Weight trajectories post op were also studied, and showed some differences among how the patients did with weight loss durably, and it did have a correlation with both remission and relapsing rates. Interestingly enough, those with the slightly more significant and durable weight loss after surgery had a little higher relapsing rates. Counterintuitive, but in need of further study.
You may remember the blog post on the Number 3 whereby I wrote about the study that was reporting a correlation between a C-Peptide level of 3 and predicting the remission rates of DM2 after Gastric Bypass. As you may remember, C-Peptide acts as a surrogate lab test to measure Islet cell mass and therefore remaining endogenous secretion.
Well, C-Peptide was not a part of this study, but as you can deduce, knowing that level, and perhaps checking it serially post op, I suspect that it may give us a warning as to when a relapse is likely or about to occur. Especially in those that have a lower C-Peptide to begin with, if it was drawn preoperatively.
The risk factors for relapsers were essentially the same as the above noted study delineated as the risk factors for those who were not as likely to immediately benefit from Bypass. Again, the lab measurement for the suspected most significant risk factors would likely have to do with C-Peptide, and resultant endogenous insulin secretion.
Much more needs to be studied to put this all together. Perhaps an algorithm is not too far off in the future. I know that there is large prospective study currently underway studying may aspects of DM2 and remission-relapsing, etc.
We have started to order more C-Peptides these days on patients in a variety of settings (preop, periop, and post op) to see what correlation we can detect, starting on an anectodal basis.
What I have seen, even without laboratory values, is that even if Diabetes does not completely remit after surgery, it is much easier to control immediately after surgery, with greatly reduced need for meds and/or insulin. Interestingly, I can recall a true type 1 Diabetic (C-Peptide of essentially zero, if we were to measure it) we did surgery on last year that has had her insulin needs cut by 2/3, with a much easier time at glycemic control and with improved glycohemoglobins. She is now over 9 mos out.
And to add one more layer to this information - Our sleeves seem to be doing nearly as well as our bypasses, at least initially, for improved glycemic effect. They also seem to enact a return of "metabolic memory" as it may have existed before the metabolic syndrome took hold.
Leisure Suits may never completely return, which would not be a bad thing. I wouldn't mind getting back to the hair I had in the 70's though.... Doesn't that model above look like Bobby Sherman?
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