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Posts Tagged ‘gastric bypass’

After recent changes in the recommendations for the treatment of obesity and diabetes supporting the use of surgery (as previously discussed here) American hospitals have begun aggressively campaigning for medical tourists.. Several hospitals in Tennessee have created Bariatric programs to steer interested patients to their clinics – and in some cases are using TennCare dollars to do so. (TennCare is the Tennessee medicare program – which has been plagued with problems since it’s inception.)

With the FDA lowering the BMI restrictions for Lap-band procedures in particular, this procedure which is often marketed as the ‘easy bariatric surgery’ has taken off in popularity.  This is concerning since much of the research shows this device to be limited in effectiveness, particularly in the treatment of diabetes.

These BMI restrictions which were reduced from a BMI of 35 (with diabetes)  down to 30 can also be viewed as a government endorsement of the Lap-Band device since similar recommendations regarding the more definitive procedures such as Roux-en-Y have not been addressed.  It looks like a double win for this private company (Allergan) as the FDA prepares to approve this device for use in teenagers as young as 14, despite criticisms from the medical community.

Now in the past, I have strongly advocated for better and more aggressive treatment recommendations for diabetes and morbid obesity – but I have also believe in following the scientific data and research findings – which just don’t seem to support Lap-Banding for permanent / effective weight loss or blood sugar reductions.  Like we’ve seen several times before, these ‘easy’ quick fix solutions to try to take short cuts around surgery don’t always work – and in the end, you end off worse off then someone who didn’t have any procedures at all.  If patients want effective solutions to real problems – we should give it to them.  But we need to stop candy coating the risks and dangers, and hard selling devices, and give patients the actual facts.

I’d also like to recommend that interested readers sign up for Medscape.com accounts – it’s free and they have an entire section devoted to obesity/ diabetes/ bariatric procedures that highlights all of the research related to different procedures, and treatments.  I try to re-post when I can but it’s difficult for lengthy articles.

In that spirit – I have re-posted the latest gastric bypass article from Heartwire below.  (Interesting commentary that heartwire has a bariatric surgery section now.) It’s another Reed Miller report dated May 2, 2011:

Gastric Bypass Does More than Reduce Weight

April 29, 2011 (New York, NY) — Gastric-bypass surgery may provide benefits to patients with type 2 diabetes beyond the benefits that can be directly attributed to weight loss, a new study finds [1].

According to Dr Blandine Laferrère (St Luke’s Roosevelt Hospital, New York, NY) and colleagues, recent studies that show a strong correlation between the concentrations of plasma branched-chain amino acids (BCAAs) and related metabolites with insulin resistance and loss of insulin sensitivity raise the possibility that the rapid remission of diabetes seen in many diabetic patients after gastric-bypass surgery may be related to the pronounced changes in BCAAs or other metabolites and not the weight loss alone.

In a study published in the April 27, 2011 issue of Science Translational Medicine, Laferrère et al found the total amino acids and BCAAs decreased in the gastric bypass surgery group but not in a similar group of patients who lost the same amount of weight (10 kg) with diet alone. Also, the metabolites derived from BCAA oxidation decreased only in the surgery group. Levels of acylcarnitines and BCAAs and their metabolites were inversely correlated with proinsulin concentrations, C-peptide response to oral glucose, and the insulin-sensitivity index after weight loss, whereas the BCAAs and their metabolites were uniquely correlated with levels of insulin resistance.

These data suggest that the enhanced decrease in circulating amino acids that follows weight loss after gastric-bypass surgery is caused by a mechanism other than weight loss and may be related to why gastric-bypass patients often show more rapid improvement in glucose homeostasis than similar patients who lose weight without surgery, Laferrère et al conclude. However, the authors caution, “Whether the decrease in these metabolites and the implied activation of fuel oxidation is a cause or consequence of the diabetes remission after gastric bypass remains to be determined. . . . Future studies will further characterize the pathways involved in these metabolic alterations and will seek to understand whether the specific metabolic signature of [gastric-bypass surgery] is related to changes in gut peptides after surgery.”

In an accompanying perspective [2], Drs Robert E Gerszten and Thomas J Wang (Harvard University, Boston, MA) agree that “further work is needed to establish whether the reduction in concentrations of circulating amino acids after weight loss is the cause or a consequence of improvements in insulin sensitivity.”

Circulating amino-acid concentrations are likely to be determined partly by genetics and partly by environmental and nutritional factors, they explain, so “dissecting these effects will require nutritional manipulation studies with a variety of amino acids to be conducted in human subjects, especially given the availability of profiling technologies that permit characterization of the molecular consequences of such interventions,” the editorialists state.”

To the multiple readers who emailed me for more bariatric surgery/ diabetes information – I usually post whenever new or interesting information gets published. If you send specific questions about procedures, indications or related matter – I will try and address it in a future post.

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Another example in the realm of surgery where easiest doesn’t equal most effective: gastric banding (lap-band). This is one of those procedures highly touted in American medicine – and heavily advertised on television as an ‘easy’ way to lose weight..

First, let’s get some things clear – the ‘easy’ mentality needs to go away in medicine, and so does the pushing of this concept with patients.. None of this; not surgery, weight loss drugs, or conventional treatment is easy for the patient..It’s all hard work, so don’t mislead your patients – that sets them up for failure..

In the article linked here (from the LA times, February 2011) the two doctors interviewed do their best to avoid answering the easy/ effective question. “I let the patient decide,” which is a royal cop-out. Patients come to doctors for expert opinions and recommendations not wishy-washy information that doesn’t present the facts and evidence. The picture accompanying the article is disturbing as well, since it’s captioned as a patient awaiting lap-band.. The patient is clearly morbidly obese – yet is undergoing the least effective option available!

What makes this frustrating to me – is that in talking to patients – is that it’s usually such a long road to even get to bariatric surgery.. Contrary to popular belief and tabloid reporting, the majority of overweight people don’t jump to bariatric surgery.. These patients spend years (sometimes decades) dieting, gaining and losing weight..
This isn’t always the case in other countries where surgery is more readily available – but in the USA where insurance coverage or lack there of, usually dictates care – bariatric surgery is usually the end of a long, frustrating road..

I know I’ve discussed this before on the site – but I feel that there needs to be transparency in treatment options – and that we need to do away with the ‘easy’ concept whether it’s bariatric surgery, stents or even medications.. Don’t sell people easy – give them safe, proven and effective.

I’ll be updating the article over the next few days with links for more information – and hard facts about surgical options and obesity surgery.

Related Articles: Free full-text links: (my titles, the actual titles are a bit longer)

1. It’s Not Easy – a study looking at the patients perspective, and perceptions before and 2 years after bariatric surgery.

2. Current treatment guidelines and limitations – a discussion of current treatment guidelines in the USA and Canada

3. German study with 14 year outcomes after gastric banding – this is a nice study because they use terms that are easily understood for laypeople – and shows decent outcomes for patients with this procedure

4. Single port bariatric surgery – this has been a hot topic over at the sister site. This article discusses the most recent innovations in surgical techniques for bariatric surgery.

5. A review of the current data (2008) surrounding bariatric surgery, obesity, and diabetes and the cost of care.
This is a particularly good article (reviews often are) because it gives a nice summary of multiple other studies – so intead of reading about eight patients in Lebanon or some other small group – you are getting a good general overview..also it gives a good idea the scope of the problem..

I’m trying to collect a wide range of articles for patient education; unfortunately, since surgeons in Latin America are on the forefront of bariatric surgery – a lot of the most interesting articles are in Spanish and Portuguese (or paid articles). i haven’t posted the translations since they are secondary source and all of the other citations are primary source.

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There’s a great new article over at Medscape by David Lautz, MD; Florencia Halperin, MD; Ann Goebel-Fabbri, PHD; Allison B. Goldfine, MD
that was recently published in Diabetes Care 2011;34(3):763-770 entitled

“The Great Debate: Medicine or Surgery: What Is Best for the Patient With Type 2 Diabetes?”

It’s quite lengthy so I won’t repost here – but it’s definitely recommended reading for my diabetic readers out there. I have included some highlights from the discussion – which correlate with much of what we’ve previously discussed here.

Re-post from article:
“Recent observational studies demonstrate that bariatric surgical procedures reduce the incidence of type 2 diabetes and lead to substantial improvement or “resolution” for many patients with preexisting disease. Type 2 diabetes has “resolved” (defined in the surgical literature as maintenance of normal blood glucose after discontinuation of all diabetes-related medications, in most studies with HbA1c 35 kg/m2 and raise the question of whether surgical interventions should be considered earlier in the course of disease or for lesser magnitude of excess weight and specifically for the treatment of diabetes as opposed to treatment of obesity.”

It’s a nice well-balanced article, which discusses the theories behind the resolution of diabetes after surgery (Roux-en-Y gastric bypass), as well as the concerns of endocrinologists about the use of surgery for diabetes management. The authors give a nice detailed description of the various bariatric surgery procedures and nonsurgical treatment options, in a fair and balanced manner. It’s a timely article, coming on the heels of the recent AHA statement – which harks back to an era of blaming the patient and ignoring the problem..

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In honor of the Latin-American Bariatric Surgery Congress, currently in progress in Cartagena – (since I couldn’t make time in my research to go) I am posting a brand new article about bariatric surgery and the severely obese. It seems American medicine is finally starting to catch up, and take notice..

It’s hard concept out there – and I still have trouble with it myself, sometimes.. In our society, it seems we are too busy blaming ourselves, and others for being overweight and attaching labels; ‘lazy’, to really see how fundamentally things need to change to improve our health as a nation.

From my perspective, down here in Bogota – it’s interesting, because I am seeing Colombians just beginning to start to struggle with obesity – as more and more imported snack foods, and fast foods replace traditional diets. Obese people are still very rare here – and after several months, I can still say I’ve not seen a single super-obese person here, but the ‘chubbies’ are starting to grow in number..

At the same time, by being in such a walkable city, and having access to (cheap!), delicious, ripe fruit every day, I’ve managed to lose over ten pounds with almost no effort.. I’ve been tracking my walking, and I walk about 6 to 10 miles a day with my various errands. But these are things that aren’t readily available – in the urban sprawl of American life.. A week’s worth of fruit for several meals for ten dollars? Not hardly, unless you gorged yourself on bananas every single day..

Surgery as a solution seems drastic to American healthcare providers, myself including.. Removing/ destroying a perfectly functioning organ.. But then – when you look at the drastic effects, and the desperate states our patients are in – Bariatric surgery really is as lifesaving as cardiac surgery for many people.. Until we change society as a whole (which may never happen), we need to help these individuals regain their health,and their lives..

Bariatric Surgery for the Severely Obese

In the meantime, everyone, stay away from soft drinks (all soft drinks, including ‘diet drinks’, juices and fruit drinks, sweet tea) and stick to water, plain tea. Coffee too – if you remember not to load it up with too many calories.. Try it for a month, and I wager you will be unable to go back to the supersurgery drinks you formerly enjoyed out cringing..

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Everyone knows this already – but finally some scientists sat down and worked it out for the rest of us:  Obesity Kills!

Seems like a pretty timely article: Obesity Increases Risk of Deadly Heart Attacks – over on WebMD..

Here I am in Bogota, spending much of the week with Bariatric surgeons; discussing procedures, outcomes, meeting patients..

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I’ve re-posted the lastest medical article from medscape on Bariatric Surgery in Diabetes Mellitus.  As many of you know, I have a special interest in Bariatrics/ Diabetes due to the increased incidence of cardiovascular complications.  However, here in the USA – it’s easier to get cardiac bypass surgery then gastric bypass..

So – instead of helping people with real medical problems – we wait for drastic complications (heart attacks etc.)  Even then, society in general and medical society in particular can be rather judgemental about obese patients.  In stead of judging – make the information more available, and give people an opportunity to decide for themselves.

This is a straight cut and paste, with no editing or editorializing (except my comments above) for my interested readers.  Also – please let me know what other surgical procedures you are interested in hearing about and I will post articles with helpful information.

Authors and Disclosures :Journalist Daniel M Keller, PhD Daniel M. Keller is a freelance writer for Medscape. Daniel M. Keller has no disclosures.

From Medscape Medical News:

 Remission of Type 2 Diabetes Can Occur Within a Week of Gastric Bypass Surgery

Daniel M. Keller October 1, 2010 (Stockholm, Sweden) — Twelve patients with type 2 diabetes had improvements in insulin sensitivity and beta cell function just 1 week after Roux-en-Y gastric bypass surgery (RYGB), with concomitant reductions in fasting and 2-hour postprandial plasma glucose levels, compared with preoperative levels, according to a poster presentation here at the European Association for the Study of Diabetes 46th Annual Meeting. Lead author Nils Bruun Jørgensen, MD, from the Department of Endocrinology at Hvidovre Hospital in Denmark, showed evidence that the improvements in insulin sensitivity and beta cell function were associated with a 16-fold increase in secretion of glucagon-like peptide 1 (GLP-1). Type 2 diabetes patients with fasting plasma glucose of more than 7.0 mmol/L at the beginning of the study were given a mixed-meal tolerance test 1 to 3 days before and 4 to 6 days after surgery. The 200 mL, 1260 kJ liquid meal provided 15% of energy from protein, 50% from carbohydrate, and 35% from fat. The average age of the patients was 51.8 years, 7 were male, and they had diabetes for an average of 5.2 years. Significant reductions in fasting and in 120-minute postprandial plasma glucose levels occurred after surgery, compared with preoperative values (see table). Similarly, there were decreases in both fasting insulin and C-peptide serum levels. Subject Characteristics and Laboratory Values Before and After RYGB Surgery Variables Pre-RYGB Post-RYGB Change P value Glycated hemoglobin 7.0 ± 0.3 Fasting plasma glucose (mmol/L) 8.8 ± 0.7 7.0 ± 0.3 –21.2% .005 120-min plasma glucose (mmol/L) 11.4 ± 0.8 8.2 ± 0.7 –28.5% <.001 Fasting serum insulin (pmol/L) 132 ± 22 73 ± 9 –44.6% .006 Fasting serum C-peptide (pmol/L) 1542 ± 151 1175 ± 172 –23.8% <.001 Weight (kg) 129.8 ± 4 127 ± 3.8 –2.2% .001 Body mass index (kg/m2) 43.3 ± 1.5 42.4 ± 1.5 –2.1% .001 Waist (cm) 130.8 ± 2.9 131.3 ± 2.6 0.4% .734 Hip (cm) 121.0 ± 2.9 118 ± 2.7 –2.5% .051 Using the homeostasis model assessment of insulin resistance (HOMA-IR), Dr. Jørgensen determined that insulin resistance decreased by 54%, from 6.9 ± 1.0 before to 3.2 ± 0.43 after RYGB (P = .001). The Matsuda Index, a measure of tissue insulin sensitivity, increased in parallel with the decrease in insulin resistance, going from 2.58 ± 0.38 before to 4.16 ± 0.55 after RYGB (P = .01). “We also looked at the C-peptide levels in response to the meal, and although we couldn’t show any significant difference in the individual postprandial sample points, what we did get was an impression of the changed secretion dynamics, and we could show an increased incremental area under the curve for C-peptide,” he said. The area under the curve of concentration for C-peptide over time increased significantly after surgery (P = .04). The disposition index, a measure of the relation between the sensitivity of beta cells to glucose and tissue sensitivity to insulin, “improved dramatically,” according to the investigators. “We found a significant increase in the beta cell function, and when we related this to the ambient insulin resistance, we found a 3-fold increase in the disposition index,” according to Dr. Jørgensen — from 54 ± 12 before to 157 ± 30 after RYGB (P = .001). To determine the underlying cause of these improvements, the researchers investigated secretion of incretins, and “found a significant and very dramatic increase in the GLP-1 secretion after surgery,” he said. GLP-1 peak plasma levels increased 5.6-fold after surgery, compared with preoperative values (P < .001), and the incremental area under the curve for plasma GLP-1 was 16 times greater after than before RYGB (P < .001). There was no observed change in gastric inhibitory polypeptide. In conclusion, “gastric bypass surgery significantly reduced fasting plasma glucose levels and 2-hour postprandial glucose levels. These changes were associated with increased insulin sensitivity and beta cell function, and may involve the increased secretion of GLP-1,” Dr. Jørgensen told the audience. Discussion leader Ele Ferrannini, MD, professor of medicine at the University of Pisa Medical School in Italy, asked Dr. Jørgensen about the potential influence of caloric deprivation on the findings, “which would mimic these data almost perfectly,” Dr. Ferrannini said. Dr. Jørgensen replied that he could not dissect such a proposed mechanism from the results he saw after RYGB. Dr. Ferrannini noted that the literature contains studies of patients with type 2 diabetes who were subjected to low-calorie diets in the range used in this study. “And their findings, with the exception of the release of GLP-1, were precisely what is here, so this is a confounder in this particular finding,” he said. An audience member noted that the patients in this study had diabetes for an average of a little more than 5 years, and wondered what would be the result if one performed RYGB on patients who had their disease and had been on insulin much longer, in essence, questioning whether there would be enough preserved beta cell function to see effects similar to those in this study. Dr. Ferrannini replied that “there is evidence that . . . the longer the duration of diabetes, . . . the lower the remission rate, particularly if you look a year later. Any diabetic will go into remission if you starve them, but when they start eating again [after they lost weight], a year later or 2 years later, some will be in remission, others will not be in remission or will be halfway between remission and nonremission. Those that have had the disease the longest . . . may relapse if they remitted initially.” “And then to the point of the insulin secretion — it’s true that it’s not really very much higher, but this is in the face of lower glucose levels. So if you construct a kind of relationship between the insulin and the concomitant glucose levels, there will be an input, and this can be attributed also to the GLP-1. What you cannot ascribe to the increased GLP-1 levels is any improvement in insulin sensitivity, because of a lack of evidence that GLP-1 has any influence on insulin action,” Dr. Ferrannini said.

Dr. Jørgensen reports that his doctoral studies were partially funded by Novo Nordisk, and that 2 of his coauthors are Novo Nordisk employees. Dr. Ferrannini has disclosed no relevant financial relationships. European Association for the Study of Diabetes (EASD) 46th Annual Meeting: Abstract 668. Presented September 23, 2010. Medscape Medical News © 2010 WebMD, LLC

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New article on Medscape (a medical literature website for health care providers) discussing the benefits of bariatric surgery.  In this article they cite a surgery cost of at least $30,000 which is out of reach for many of the people who need it;  as morbid obesity and related complications push up health care costs for individuals. 

I’ve posted the link for you to read it for yourself:

http://www.medscape.com/viewarticle/726966?src=mp&spon=22&uac=63155MX

this website does require registration, (which I think is free.)

But as my readers know, there are more cost-effective alternatives, as mentioned in the entire chapter devoted to bariatric surgery in Cartagena. 

As readers know, in that chapter, I introduce you to one of Latin America’s most famous surgeons, Dr. Holguin, a former trauma surgeon at Maryland’s Shock Trauma hospital in Baltimore, MY in addition to several other excellent surgeons.  Most North Americans don’t know it but Cartagena is fast gaining a reputation for excellence in bariatric surgery, and is becoming a destination of choice for gastric bypass, lap-band, sleeve resection and other bariatric surgery procedures.

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