Exhibit K: Buried!!

I consider myself fairly well-rounded.  I think most people I know would say so, too.

But, when I was digging out this past weekend from a nice solid snowstorm, and saw the cars heaped in snow, it made me think about the Pancreas.

(Maybe I am not as well rounded as a I thought- but at least I am open-minded.)

Yes, the Pancreas.  A Pancreas overwhelmed by many years of a toxic stew of hyperglycemia, insulin resistance, genetics, and the lack of the byproducts of effective lifestyle modification of diet, exercise, and weight control.

To zone in further on that point, I saw a representative patient in the office last week that illustrates this, and shows the degree of glycemic improvement in the perioperative time frame (1 week post op) that a Gastric Bypass can afford.

I bring you Exhibit K.

Demographics:  43 y/o M

Start Weight:  355#  BMI:  53

Date of Surgery:  12/13  Gastric Bypass

DM 2 Hx:  When he initially presented for Bariatric Surgery, he was taking 100 units of U500 insulin, spread throughout the day, the equivalent of 500 units of insulin per day.  His control was poor with a glycohemoglobin of >10, and the duration of his DM (more than 10 years) was evidenced by his C-Peptide of 1.8 (looking for 3 or higher, see previous blog posts for more info).  He had a history of many previous weight loss attempts, and short-lived successes, and was now looking for a more durable intervention for both his weight and his DM 2.

Further medical issues were HTN, Hyperlipidemia, OSA, and Depression.

Current DM 2 Hx:  Seen at his most recent visit, his weight is now down to 302#, and his DM coverage has been modified significantly.  In the hospital, we got by with a moderate to aggressive scale of Novolog, and with surprisingly reasonable control, he was DC with no DM meds, but with instructions to check at home to see where his sugars settled out,  with the addition of diet and activity.  His readings were in the 160s to 200 range and seemed to persist in that range. He was instructed to follow up with his PCP sooner than his appointed visit for 6 weeks from the time of his visit with us.

Take Home Point: Are you expecting Rah Rah Sis Boom Bah?  There is certainly room for a little of that, but what is more interesting to me is that I am very surprised he has done as well as he has so far.  This is a guy that has very limited pancreatic reserve, with markedly diminished insulin-producing capability, owing to the above factors, and now he is fairly well controlled off of meds / insulin.

I somewhat don't believe it, again not from a chest-thumping point of view, but from a medical / physiologic, experiential point of view.

And, this is why I had him see his PCP sooner, in order to facilitate closer followup, and likely re-initiation of meds, albeit dramatically reduced requirements, to see where he declares himself for the short and longer term.

Our experience with BG management after surgery is that the majority of the beneficial metabolic effect from surgery, and improved glucose autoregulation, is seen within the first 24-36 hrs after surgery.  The weight loss that follows does reinforce that effect somewhat, but the biggest change occurs perioperatively and not later if a patient gets to a magical weight or BMI.

I should also say that the effect you see perioperatively is somewhat variable, dependent upon the severity of the Diabetes, and does not always allow a patient to be off all meds immediately and stay off them permanently.  For example, we had 2 patients earlier this week that were able to cut their basal requirements by 60% right after surgery, but did require that amount when they went home.

Long term, weight loss (both amount loss and amount kept off) seems to play a role in recurrence rates for DM, but a lesser role that you might think.  Again, this plays into the dramatic immediate effect that surgery exacts metabolically.

This patient may also be the kind of guy that, irrespective of his degree weight loss /maintained weight loss, may end up with a higher likelihood of a recurrence of diabetic manifestations a few years down the road.  Again, because he came to surgery at a stage of partial pancreatic failure as part of his preexistent DM process.  Most studies do seem to show this return of DM feature in some patients, but they also point out that the disease at that point is generally easier to manage than it was before the metabolic surgery, if / when it returns.

So, we will see how it goes, but so far so good, and quite impressive at that.

The true take home point?  Maybe you've heard this before... Sooner is better, sooner is better.

The Easy Way!

Our patients will often tell me that one of the most annoyingly common things they hear as they visually shrink and morph back to a normal body weight, once they reveal their method of success is:

"Oh, no wonder! That's the easy way out!"

And, I too,  commonly hear, when I describe to someone 'what I do' (after sorting out Bariatrics from Geriatrics), is:

"Really?  Surgery for (overweight) people?  If they could only stick to a proper diet and exercise, they wouldn't need surgery.  That's the easy way out!"

Similar groups of people giving their sage opinions, widely held at that, with the same judgmental tone.  Not that it's unexpected, but it just gets old. 

They just don't know that they don't know.

As patients accurately portray it, from the initial decision to have surgery for their weight problem, to the exhaustive preoperative work up and weight loss, Psychological eval, and the myriad of diagnostic studies; to the day of general anesthesia for their operation; to the recovery and regular follow up required; and the ongoing daily decisions of modified behaviors to their diet and exercise and their overall life choices (with everyone watching and ready to give their advice without solicitation)..... 

               This Ain't Easy.

And that's just the start of it.  'Rising above' is mandatory for patients to get to their goals and for them to reach their individual benchmarks of success.  But I see it every day in the office, on our patient's faces, that it's worth it.

There will always be more than enough takers out there to impulsively and mindlessly volunteer to take you down and let you know what's what, as far as they see it.

After all they have dieted and had some degree of success, and if you would just eat this way... and do this exercise... and follow this book....  and take this supplement... You get the picture.

To this end, I have provided a copy of a recent article from ObesityHelp.com from a Bariatric Surgeon that has heard the "Easy" verbiage a bit too much as well, and his take on the well-worn phrase is an interesting one indeed. 

Surgery is NOT the Easy Way Out: A Bariatric Surgeon’s Perspective

July 11, 2013

Surgery is NOT the Easy Way Out!

by Matt Metz, MD, FACS

I was at a social function earlier this week and a woman asked me what I do for a living.

“I’m a bariatric surgeon,” I replied.

To which she said, “What do you think about that?  You know, people just taking the easy way out and having surgery for their weight.”

Whenever I tell people what I do for a living, the issues of self-control, discipline, and exercise come up.  I have people judge me as an enabler, and judge all of my patients as weak-willed.  Sometimes, it can be so frustrating that I don’t want to disclose any information about my career.  Then I think about my patients. My patients are hard-working, caring, sensitive, intelligent individuals that are battling a disease.

Should I ask people at parties to tell me from what diseases their grandparents or parents died?

“Your mother had lung cancer?  She shouldn’t have worked in that factory.  Your father had a heart attack?  He should have checked his cholesterol.  Your sister died of breast cancer? She should have gotten screened earlier. “

People that label bariatric surgery as the easy way out just don’t understand the disease process.   My patients have each tried dozens of diets. They have lost hundreds of pounds through aggressive medical weight loss programs, only to gain all the weight back and then some.  It’s not just a simple issue of discipline and a diet.  Obesity is a disease, just like cancer, diabetes, heart disease, and stroke.  Those diseases don’t go away with discipline and diet either!  Our ownAmerican Medical Association officially declared obesity as a disease earlier this year.

Obesity has genetic components, well documented in the medical literature.  There are socio-economic factors involved.  Many of our patients have an abuse history, and sub-consciously shroud themselves from unwanted physical attention through their weight; hence, obesity has a psychological component.  There are numerous metabolic issues at play, such as diabetes, hypo-thyroid issues, poly-cystic ovarian syndrome, and leptin insensitivity.

Now consider the thought process involved in undergoing surgery.  Patients need to admit to themselves and their families that they have a disease that is so profound that they need to see a doctor to treat it.  Then they have to see a mental health provider, to evaluate them for untreated mental illness and coping skills.  Next they have to see a dietitian, and may need to undergo 6 months of medically supervised weight loss, depending on their insurance.  Then they have to have a major surgical procedure.  Granted, it’s typically performed laparoscopically, but they still need to undergo general anesthesia, and have someone operate on them in order to help fight this disease.  They may incur significant expense, loss of time from work, and/or time away from school.  Finally, they have to take vitamins for the rest of their lives, and they have to follow up with a mean surgeon (me) forever!

Does that sound like the easy way out?  How do I explain to a woman at a party that, without surgical intervention, only 30% of my patients would live to see their 65th birthday?  How do I explain the humiliation involved in asking for a seat belt extender on an airplane?  To not be able to go to a movie, or an amusement park.  To have to have a family member do your toilet care because you simply cannot reach?  To not be able to run after your child when he or she is in danger? To have people judge you as lazy and slovenly before even shaking your hand?  To be discriminated against when applying for a job, just because of the way you look?

Obese people are the last population that folks think of as socially acceptable to ridicule.  Yet, over 30% of Americans are considered overweight.  While I’m thrilled that the AMA has declared obesity a disease, how long until the rest of society recognizes that ruling and stops discriminating?

To my patients:  I will continue to fight on your behalf. Your bravery, your willingness to take control of your health care, and your dedication to a constant battle makes me proud to be your doctor.  Keep up your efforts, and let’s work together!

Matthew Metz, MD, FACS is a the Medical Director of Bariatric & Aesthetic Surgery Associates and a  Board-Certified, Fellowship Trained, Bariatric Surgeon.  Additionally, Dr. Metz has been certified as a Bariatric Surgery Center of Excellence Surgeon by the American Society for Metabolic and Bariatric Surgeons.  In this capacity, Dr. Metz has completed specialized training and continuing education in bariatric surgery as well as performed a high number of surgeries each year.  Dr. Metz has also been named a Fellow of the American College of Surgeons.  He led Parker Adventist Hospital to achieve the designation as a Bariatric Surgery Center of Excellence (BSCOE).

Newly Studied Predictors of Diabetes Remission at 1 year Post Surgery

Seems like I am getting off easy these days with my Blog.

Maybe you are, too.

I continue to see this Blog as a place for those of you in Primary Care to get the latest updates, as well and some of the timeless facts and experiences of a Bariatric Surgery practice in Real-Time format.

If I am the messenger, so be it.  If the message comes directly from an authority or an article that I can summarize, even better.

Today, I found for you a 4 minute video presentation from a Doctor Philip Schauer, a noted expert Metabolic researcher and Bariatric Surgeon for the Cleveland Clinic.

He was filmed at the recent Obesity Week session that I described earlier in this blog, and he highlighted a just-released study that reinforces other studies out there with similarly big implications.

He reviewed a study from China that integrated remission of type 2 Diabetes at one year after Gastric Bypass, with preop C Peptide, Glycohemoglobin levels, and BMI of the patient.  As you may remember, age of the patient,  duration of Diabetes, and even types of therapy at the time of surgery have also been reviewed, with similar suggestion that residual beta-cell function is where the crux of the issue lies, but those may be of lesser importance.

Furthermore, he comments on additional areas of related impact in the way of when surgery should be performed on these patients (Spoiler Alert: EARLIER is better), and the potential role for Diabetes treatment via metabolic surgery in the sub BMI 35 crowd.

Good stuff.  Arm yourself with this updated information, it will be 4 minutes well spent.

I know you will be able to use it soon!