Surgery






Using weight loss surgery to cure type II diabetes
 


Gastric bypass surgery for weight loss in obese patients is very effective at reducing weight and has also recently been shown to cure type II diabetes. Andrew Jenkinson, Consultant Gastrointestinal and Bariatric Surgeon, The London Clinic, explains.

Type 2 diabetes is becoming a major health problem in the Middle East. In the UAE alone 25% of people now have type 2 diabetes. The reason for the dramatic rise in the incidence of diabetes is its relationship to obesity. The Middle East has seen a sharper rise in the obesity prevalence than the rest of the world due to its rapid industrial development.

Medical treatment for type 2 diabetes does not adequately control the condition in a third of patients leaving them at risk of developing complications such as retinopathy, heart disease, renal failure and amputation. The high prevalence of diabetes plus the ineffectiveness of medical treatment mean that we will see healthcare resources stretched to limit in the near future. In these circumstances bariatric, or weight loss surgery, is gaining increasing acceptance as a highly effective treatment for not only weight control but also the treatment of diabetes.

The most common procedure available at present in the Middle East for obesity and therefore for type 2 diabetes is the sleeve gastrectomy. However, it is well known that the gold standard procedure for cure of diabetes is the laparoscopic gastric bypass. Recent research from my unit at University College Hospital London shows that gastric bypass surgery should always be offered in preference to the sleeve gastrectomy in diabetic patients. This research of over 200 patients showed that diabetes was cured in 85% of patients after a gastric bypass but in only 70% of patients after a sleeve gastrectomy. In addition to this, patients with diabetes lost significantly more weight after gastric bypass.

How it works

There is much worldwide interest in how the gastric bypass works to improve glucose control. The current consensus of opinion is that the reconfiguration of the stomach and small bowel after a bypass causes rapid delivery of nutrients to the mid jejunal area. This tricks the gastrointestinal tract into thinking that a very large meal has been consumed when in actual fact only a small snack has been eaten. In response to undigested nutrients being sensed by the jejunum gut peptide hormones in the form of Glucagon-like peptide-1 (GLP-1) and Peptide YY (PYY) are released. These have profound effects on decreasing appetite and increasing satiety. In addition, GLP-1 has a major effect in improving insulin release from the pancreas and decreasing peripheral insulin resistance. This effect is immediate and in the majority of patients following gastric bypass there is a complete remission of their diabetes within hours or days of surgery.

Following gastric bypass many patients will come in having been dependent on insulin and oral hypoglycaemic medication to control their glucose. By discharge from hospital two days following the procedure the majority will not require any diabetic medication.

The gastric bypass itself is perceived by patients to be a lot more complicated and risky than it actually is. In the hands of an experienced bariatric surgeon working in a high volume bariatric unit, the procedure should take less than 1 ½ hours. The procedures are always performed and completed laparoscopically, meaning that there are only 5 small scars measuring between 5mm and 10mm in the upper abdomen.

Due to the decreased tissue trauma, patients are generally very surprised by the comfort they have even the morning after surgery. The day after surgery most patients will be walking around comfortably and be able to take a shower. They will be freely drinking any type of fluids they require and having soup and milk-based drinks.

Complications after gastric bypass, if the procedure is performed by an experienced surgeon who performs bariatric surgery on a daily basis, are rare. I would quote a 1 in 50 chance of complications and these would generally be easily dealt with by prompt re-laparoscopy. In comparison to the very low complication rate and low risk of the procedure the benefits are immense. As well as resolution of type 2 diabetes, patients can expect that their hypertension will be significantly improved or cured and sleep apnoea will be cured. Most patients will lose at least 80% of their excess body weight within 9 months of surgery and they will lose this weight seamlessly and easily. This is because the profound changes in appetite and satiety mean that the patient does not think about food and will eat for nutrition purposes only. In addition to the major health benefits, patients will be psychologically much happier and their quality of life will significantly improve. Recent research has also shown that bariatric surgery is an excellent cure for infertility and following weight loss, pregnancy and childbirth will be safer.

People eligible for gastric bypass surgery would be any patient with a body mass index of 35 kg/m² or over. Most patients will have tried without success through dietary methods to lose weight for many years before realising that surgery is the only solution to their problems. Patients should obviously be fit for a general anaesthetic and we would do our best to pre-optimize their health status by better diabetic and blood pressure control and diagnosis and treatment of sleep apnoea. This pre-optimization can make a major difference in the safety of surgery.

In patients with type 2 diabetes who are considering bariatric surgery, the gastric bypass should be the first option they consider. This is now accepted as a far superior procedure over the sleeve gastrectomy or gastric band in diabetes remission and also in the extent of weight loss that occurs compared to other procedures. The bypass in experienced hands has very low risk and massive health and quality of life benefits.


Survival advantage for coronary artery bypass compared with non-surgical procedure

A new comparative effectiveness study found older adults with stable coronary heart disease (CHD) who underwent bypass surgery had better long-term survival rates than those who underwent a nonsurgical procedure to improve blood flow to the heart muscle – revascularisation. Middle East Health reports.

A US National Institutes of Health-supported study compared coronary artery bypass graft (CABG) with non-surgical procedure percutaneous coronary intervention (PCI). While there were no survival differences between the two groups after one year, after four years the CABG group had a 21% lower mortality.

Principal investigator William Weintraub, MD, of Christiana Care Health System in Newark, Delaware in the US, and colleagues presented these findings March 27 at the American College of Cardiology’s annual meeting in Chicago. The findings are published the 19 April 2012 issue of the New England Journal of Medicine. Two companion papers that describe the statistical prediction models used to forecast long-term survival rates are published in the 27 March 2012 issue of Circulation.

“In the United States, cardiologists perform over a million revascularization procedures a year to open blocked arteries. This study provides comprehensive, largescale, national data to help doctors and patients decide between these two treatments,” said Susan B. Shurin, MD, acting director of the NIH’s National Heart, Lung, and Blood Institute (NHLBI), which funded the study.

Comparative effectiveness research results provide information to help patients and healthcare providers decide which practices are most likely to offer the best approach for a particular patient, what the timing of interventions should be, and the best setting for providing care.

Each year, more than half a million Americans die from coronary artery disease.

In CABG, or bypass surgery, the most common type of heart surgery in the United States, blood flow to the heart muscle is improved by using (“grafting”) a healthy artery or vein from another part of the body to bypass the blocked coronary artery.

PCI is a less invasive, non-surgical procedure in which blocked arteries are opened with a balloon (also called angioplasty). A stent, or small mesh tube, is then usually placed in the opened arteries to allow blood to continue to flow into the heart muscle.

With NHLBI support, the American College of Cardiology Foundation (ACCF) and the Society of Thoracic Surgeons (STS) came together to compare short- and long-term survival outcomes after CABG versus PCI. The investigators linked medical data available in their ACCF and STS databases with follow-up information in the Medicare Provider Analysis and Review database of the Centers for Medicare and Medicaid Services.

Linking these three datasets from 644 US hospitals allowed researchers to analyse information from the STS database on 86,244 older adults (average age 74) with stable CHD who underwent CABG between 2004 and 2007 and 103,549 older adults (average age 74) with stable CHD from the ACCF database who underwent PCI between 2004 and 2007. Follow-up ranged from one to five years, with an average of 2.72 years.

At one year there was no difference in deaths between the groups (6.55% for PCI versus 6.24% for CABG). However, at four years there was a lower mortality with CABG than with PCI (16.41% versus 20.80%). This longterm survival advantage after CABG was consistent across multiple subgroups based on gender, age, race, diabetes, body mass index, prior heart attack history, number of blocked coronary vessels, and other characteristics. For example, the insulin-dependent diabetes subgroup that received CABG had a 28% increased chance of survival after four years compared with the PCI group.  

 Date of upload: 20th Jun 2012

 

                                  
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