Wednesday, April 16, 2014

"Can't I Just Take A Pill For That?"

From surgerywithoutmedicalinsurance.com

Admittedly, it would be nice.  To have a Bariatric surgical  procedure, with the weight loss and the metabolic benefits of the procedure, without the hassle and potential risk of the surgery itself.  None of the associated surgical and anesthetic risks. Just the benefits. Like the frosting without the cake, right?

So, are we yet to the point yet that medical therapy, in today's advanced age of interventions, non-surgical treatments and pharmacotherapy, that we can duplicate the wide-ranging effects that Bariatric Surgery can provide?

I have spent some time reviewing an article in the International Journal of Obesity, from 2014, that sets out to illuminate us on such a question.

In "Can medical therapy mimic the clinical efficacy or physiological effects of bariatric surgery?" the authors from London, England make their case, and describe where we are as of now. 

Certainly we have come a long way in new medical (Non-surgical) interventions and pharmacotherapy, as we have also come a long way in our understanding of the significance of the benefit and some (but not all) of the physiologic mechanisms of how / why bariatric surgery works.

But, as the article concludes, we are not totally there yet.  Closer than we ever have been to purely medical treatments, yes, but not all there yet.

And, as I have said many times in this blog, surgery is not for everyone.  For most obese patients, with their obesity and their comorbidities, weight loss is weight loss, and in a perfect world if they can lose a substantial amount of weight, and keep it off, we are still talking apples and apples (or pears in the morbidly obese world).

But, in the real world, there aren't many that are very successful with non-surgical weight loss, especially in the context of keeping it off.

And there aren't many that see the long term benefit of weight loss, either to degree or duration, to make a longstanding difference in their comorbidites, their quality of life, or to their longevity of life.

However, that being said, as the article details, there have been many 'new' developments that help us to inch closer to mimicking what a Bypass, Band or Sleeve can do, for example. Here are a few of the developments.

* T2DM benefit after surgery seems to come from improved beta cell function and reduced insulin resistance, as well as a change in gut nutrient sensing.  As the search for how bariatric surgery seems to work physiologically, it has opened new potential metabolic targets for medical therapy to effect.  Both a change in diet amount / portion, calories, and makeup of the diet have been studied to carry about a similar effect.  New T2DM agents, such as GLP-1 agonists and DPP-4 inhibitors and SGLT-2 inhibitors have a new role in the step care approach to T2DM.

*Lifestyle modification for weight loss begins with caloric intake restriction. In a perfect world, it is certainly aided by appetite reduction, as occurs at least temporarily with bariatric surgical procedures, and is reinforced longer term by the restrictive element of the surgical 'tool' that is created through the patient's Sleeve, Bypass or Band.  Medically, newer agents such as Qsymia, in addition to conscious lifestyle modifications, may offer a somewhat similar effect. Further studied dietary makeup, both for calorie amount (?1000-1200) as well as composition (Low glycemic, high protein, high fiber) may offer additional benefit in conjunction with the above. 

*Furthermore, Devices that are now available are also in play.  An endoscopically-placed duodenal-jejunal bypass liner, is a potentially less invasive treatment that aims to recreate the 'bypass' of the duodenal-jejunal region as occcurs in the Gastric Bypass surgically.  Studies have shown that this is a powerful part of the rerouting of the ingested nutrients that changes how the body, and the GI tract specifically, handles the ingested nutrients, and seems to greatly benefit how blood sugar is regulated. The experience with this approach is very early, and has had some complications, in so far as the need for explantation by 6-12 mos, some reports of bleeding, obstruction, abdominal pain, vomiting, etc. Gastric stimulators and intragastric balloons are other devices also in trials at a very early stage in their usage. Results remain to be seen.

So, yes, we have come a long way in our understanding of how and why surgery works so well for obesity and especially it's associated metabolic disease.  We are closer now than we have ever been to maximizing those medical therapeutics and procedures that may avoid surgery, but retain some of the benefits that surgery has shown to exact.

But, in summary, we are still a very long way away, I think, from being able to believably say that a pill, or a device, or a lifestyle change (or a combination of all of these) can mimic the established effects that bariatric surgery can produce for obesity and it's attendant comorbid disease states.

And so my job at this time is still somewhat secure, at least from the fate that has take the cardiac surgery subspecialty by storm over the past 10+ years. In somewhat of a similar phenomenon of scale that is potentially prposed here, with the advent of endovascular techniques (PCI - Percutaneous Coronary Interventions), the rate of CABG  for CAD decreased per hospital caseload by 28% from 2001-2008 in one study, whereby the rates of PCI stayed about the same over that time.

I guess in the area of medicine, and surgery specifically, the more things change, the more they stay the same...

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