They can go on to live diabetes-free without insulin or other medicines. Barbara Brennan, who has diabetes, was more than 100 pounds overweight when Dr. …
The Wall Street Journal
Front Page
CONTROVERSIAL CARE
To Heal Diabetes, Doctors
Push Weight-Loss Surgery
Studies Suggest Benefit
For Bariatric Procedure;
Debate on Cost, Science
By RON WINSLOW
August 22, 2007; Page A1
Doctors who have turned surgery into a popular treatment for obesity are
setting their sights on a burgeoning new market: diabetes patients
A growing amount of research suggests that bariatric surgery, which shrinks
the stomach and sometimes reroutes the intestines, has a lasting effect on
the most common form of diabetes, and not just because patients lose
weight Studies have found that more than 75 of patients with this type of
diabetes who undergo the surgery see their disease disappear They can go
on to live diabetes-free without insulin or other medicines
Even advocates of bariatric surgery say its too early to recommend it for
the broad mass of diabetics Bariatric surgery can lead to serious
complications such as nutritional deficiency The death rate from the
procedure is estimated to be between one in 100 and one in 1,000 An array
of medicines, plus better diet and exercise, can treat diabetes
effectively
without invasive procedures
Still, some doctors behind the research believe surgery could be a new
weapon against a disease that affects some 20 million Americans and 250
million people world-wide The idea that you could induce long-term
remission in diabetic patients without medication is unprecedented, says
Francesco Rubino, a surgeon at Catholic University in Rome who is one of
the leaders in the field Clearly theres something big going on here that
cant be ignored
Studies into bariatric surgerys impact on diabetes are shedding light on
little-understood hormones that reside in the small intestine and help keep
the bodys sugar levels in balance Researchers theorize that in diabetic
patients, food causes these hormones to go awry, but when surgery alters
the intestinal tract and diverts food away from them, the disease can
quickly recede Understanding how this happens could lead to new medicines
and nonsurgical strategies to fight diabetes
Bariatric surgery usually costs about 25,000 and is a big profit center
for some hospitals If even a small percentage of diabetics chose to
undergo surgery, it would
bring a gusher of new business for the
profession Over the short term, at least, the cost of surgery exceeds the
estimated 10,000 a year needed for conventional care of diabetics
As a primary treatment for diabetes, it simply doesnt measure up very
well, says Richard Hellman, president of the American Association of
Clinical Endocrinologists, specialists who treat diabetes
Treating Obesity
Bariatric surgery is currently recommended only for patients considered
morbidly obese — those who are at least 100 pounds overweight or about
75 pounds overweight and also have diabetes or other related conditions In
medical parlance, this corresponds to a body mass index, or BMI, of 40 and
35 respectively, according to a calculation based on height and weight
Obesity is defined as a BMI of 30 or higher A 5-foot-10-inch person who
weighs 245 pounds has a BMI of 35
Health insurers generally cover bariatric surgery for the severely obese,
though sometimes reluctantly It is unlikely that less-obese patients would
receive broad coverage without a significant body of research proving the
surgerys benefits in such cases
Death rates from bariatric
surgery have fallen in recent years, partly
reflecting new minimally invasive techniques and efforts to improve
quality But a few patients still die on the operating table or shortly
afterward Others suffer ill effects later, such as vitamin deficiency
Also, the surgery isnt foolproof as a weight-loss strategy Some patients
gain lost weight back
Daniel B Jones, director of bariatric surgery at Beth Israel Deaconess
Hospital in Boston, is among doctors who think diabetics with moderate
obesity may benefit from surgery If you have type 2 diabetes and your BMI
is 35, we absolutely intervene, says Dr Jones, referring to the more
common type of diabetes that typically strikes adults Maybe we should be
looking at BMIs of 30 Maybe were not being aggressive enough with the
amount of health impact we can have
Barbara Brennan, who has diabetes, was more than 100 pounds overweight when
Dr Jones operated on her July 2 Within a couple of weeks, she became
light-headed and had other signs of low blood sugar That is the reverse of
the usual problem with diabetics, who experience high blood sugar because
their bodies arent producing
enough insulin or arent properly using the
insulin that gets made Ms Brennan expects that she will soon be able to
drop her diabetes medicine She has lost 34 pounds since the procedure
I can see the medical benefit already and its not even two months, says
the 60-year-old, who retired as a property manager at Bostons Logan
Airport Taking less medication plus having my sugar levels being more
stable has really made me feel a lot better
However, she says, I dont know if Id ever recommend someone have the
surgery just for diabetes
Last year, 177,600 patients underwent bariatric surgery, according to the
American Society of Bariatric Surgery, nearly four times the figure five
years earlier Reflecting the potential for growth from expanding the
business to diabetes patients, the society plans to announce today a name
change to the American Society of Metabolic and Bariatric Surgery
Following a meeting in Rome earlier this year, the society is part of an
effort to publish a consensus paper on when the surgery is appropriate in
diabetes patients and what further research needs to be done
The prevalence of diabetes is growing at 5 a year,
according to data from
the US Centers for Disease Control and Prevention Diabetics are at
especially high risk for heart attacks as well as such ailments as stroke,
kidney disease, blindness, infertility and a clogging of blood vessels in
the legs and feet that can lead to amputations Studies indicate that just
35 to 55 of diabetics are able to keep their blood sugar under control A
treatment that could reduce this toll would be a major advance and an
economic boon to the health-care system
Aggressive Marketing
Aggressive marketing and a gold-rush atmosphere sparked a surge in
bariatric surgery for the severely obese early in this decade, resulting in
variable results for patients and a tarnished reputation for the procedure
We dont want to make the same mistake twice, says Dr Rubino, who will
move from Rome in October to head a new program for diabetes-surgery
research at New York-Presbyterian Hospitals Weill Cornell Medical Center
in Manhattan He says it could be a disaster if thousands of patients
were urged to get the procedure before further studies show who is likely
to get the most benefit from it
Evidence of bariatric
surgerys impact on diabetes has been building for
two decades In 1995, Walter Pories, a surgeon at East Carolina University,
Greenville, NC, and colleagues published a paper in the Annals of Surgery
titled, Who Would Have Thought It?
The report, based on 608 patients who had undergone the procedure over a 14-
year period, found not only weight loss but also long-term blood-sugar
control in 83 of the patients who had diabetes and 99 of patients with a
prediabetic condition called glucose impairment No other therapy has
produced such durable and complete control of diabetes, the researchers
reported
Radical Departure
Few diabetes specialists noticed the article in the surgical journal It
was such a radical departure from how diabetes is treated, it didnt get
much recognition by thought leaders in the diabetes world, says Philip R
Schauer, head of bariatric surgery at the Cleveland Clinic
In 2003, Dr Schauer, then at the University of Pittsburgh, and colleagues
reported in Annals of Surgery on a five-year study of 1,160 diabetics who
had the surgery Their finding was nearly identical: In 83 of the
patients, blood sugar returned to
normal, and it was markedly improved in
the others
Results from both papers suggested patients with milder forms of diabetes
and those who lost the most weight after surgery were most likely to
experience remission of the disease
Recent papers point to another phenomenon Among several variations of
bariatric surgery, there are two principal strategies One of the
strategies, marketed by Allergan Inc and known as the Lap-Band procedure,
involves an adjustable band that is cinched around the stomach to reduce
its size It is reversible and doesnt involve any rearrangement of the
intestines
The other strategy both shrinks the stomach and reroutes the passage of
food to avoid upper portions of the small intestine known as the duodenum
and some of the jejunum One specific example of this strategy is a
procedure known as Roux-en-y gastric bypass
Some doctors in the field say that although both forms of the surgery lead
to weight loss, patients who get the intestinal rerouting see faster
improvement in their diabetes That suggests weight loss alone isnt a full
explanation for how surgery might help diabetics
Testing
Surgery
While training as a surgeon at Mount Sinai Hospital in New York in the late
1990s, Dr Rubino became curious about whether surgery could address
diabetes without shrinking the stomach He came up with a procedure that
would bypass the duodenum and the upper portion of the jejunum but leave
the stomach intact, in contrast to the Roux-en-y procedure Then he tested
it on a strain of laboratory rats that had type 2 diabetes but werent
obese They were able to eat normally The procedure resulted in a dramatic
reduction of diabetes A report on the experiment was published in the
Annals of Surgery in 2004
That was the first evidence that the surgery could have a direct effect on
diabetes that wasnt related to losing weight, Dr Rubino says
Doctors are beginning to test the idea of intestines-only surgery in
humans Dr Rubino says about 100 patients, all of them outside the US,
have been treated with that approach, with encouraging early results
Fabrizio Michelassi, surgeon in chief at Weill Cornell, says such surgery
could be a valuable innovation The standard forms of bariatric surgery
typically leave patients with stomachs the
size of an egg They are
condemned to meals that are little purees for the rest of their lives,
says Dr Michelassi It may be, he says, that with Dr Rubinos procedure,
you can still eat your steak and potatoes and your diabetes gets
controlled
Other doctors say the stomach-reduction part of the traditional surgery
plays an important role in the antidiabetes effect It may help by
curtailing how quickly food flows into the intestine, they say
It looks as if there are rogue cells in the intestine that are causing
diabetes, says Dr Pories, the surgeon from East Carolina University The
surgery either reduces the amount of food that comes down to these cells or
detours the food around them
Studies Show Promise
Small studies of moderately obese diabetics in Brazil, India and Mexico
show promise for surgery, but the numbers are too small and the length of
the studies too short to reach solid conclusions
Dr Schauer at the Cleveland Clinic has started a five-year study of
diabetics with BMIs ranging from 30 to 40 Two groups of patients in the
study will receive forms of bariatric surgery A third group will get only
drugs and
other noninvasive therapies Dr Schauer wants to discover which
group sees the greatest effect on diabetes
When you get a gastric bypass, things are dramatically changed in your
favor, says Dr Jones in Boston We dont know what it is We know its
real and its reproducible If we can tease it out, it will be a huge
advance
Write to Ron Winslow at ronwinslow@wsjcom
