Diabetes Self-Management Blog

Dr. Michael BilofEarlier this year, we featured a guest post by Dr. Nicholas Yphantides, a family physician who underwent dramatic weight loss, that was highly critical of bariatric (weight-loss) surgery. This surgery has recently been touted not just as a way to shed pounds, but also as a potential remedy for Type 2 diabetes. For a different perspective, Diabetes Self-Management’s Quinn Phillips interviewed bariatric surgeon Dr. Michael Bilof.

Quinn Phillips: What led you to become a bariatric surgeon?

Michael Bilof: I used to do vascular surgery; I’m a board-certified vascular surgeon. About five years ago, I left my vascular practice and started doing bariatrics. The reason I switched was that most diabetics have, if they’re diabetic long enough, some sort of vascular problems — either in their eyes or their kidneys or their peripheral circulation — and end up needing the services of a vascular surgeon, either for extremity bypass, for dialysis access, or if it really gets bad, for amputation. And it was not the most satisfying practice for me. The analogy I always use is, it’s like closing the barn door after the cow got out. By the time they got to me, my job was not so much to reverse the process but simply to slow the rate of decline. Personally, that’s not what I got into medicine for. Bariatrics gave me a chance to close the barn door before the cow got out, to see patients 20 years before they would end up seeing a vascular surgeon.

QP: What proportion of your patients have diabetes?

MB: I’d say it’s anywhere from a third to 40%. I make an effort to attract diabetic patients.

QP: What procedures do you perform?

MB: I do two types: gastric bypass, which is sort of becoming the gold standard for bariatric procedures, and gastric banding.

QP: How successful is gastric bypass in reversing Type 2 diabetes?

MB: The best published data shows resolution in around 85% of Type 2 diabetics. That’s been a pretty consistent number in different studies. My own practice is pretty similar; it’s about 85% to 90%. And it’s basically a function of how long the patient has been diabetic and whether they’re taking insulin. Patients who have gastric bypass soon after diagnosis have virtually a 100% resolution rate because their bodies are actually making more insulin than they need. So once blood sugar comes down, the pancreas resumes making normal amounts of insulin and their diabetes resolves very quickly — possibly within days or weeks. Whereas for someone who’s been diabetic for five, eight, ten years and is taking 15 units of insulin three times a day, the resolution rate isn’t as good because their body isn’t making as much insulin. Improvement can take months, and they may not resolve their diabetes, but almost all of them get off insulin. When I say resolution, by the way, I mean no medications, normal fasting blood sugar, and an HbA1c level under 6% — biochemically not diabetic.

QP: How much do we know about the mechanism through which gastric bypass does that?

MB: Whoever figures that out goes to Stockholm and picks up their prize. There’s a lot of research going on; my practice is involved with a study looking at something called GLP-1 levels. Other hormone levels are affected too, even independent of weight loss. It’s got to be something hormonal, resulting from diverting food from the stomach and the first portion of the intestines. Because as I’ve witnessed many times in my practice, even before bypass patients lose significant weight, their blood sugar is better. If you compare bands and bypasses, bands actually have a fair amount of diabetes resolution as well — but it only occurs as a result of weight loss.

QP: Have most of your patients been encouraged to lose weight the “regular way” before signing up for surgery? Do you have weight requirements for the surgery?

MB: The vast majority, 80% or 90%, have tried many, many different things. The most common history I get is a patient who’s been overweight their whole life. You need to be at least about 100 pounds overweight to qualify for bariatric surgery, a little less for diabetics. We don’t actually go by weight; we go by body-mass index. For diabetics, a BMI of 35 or higher would qualify you for bariatric surgery; if you’re not diabetic, then it would be a BMI over 40.

QP: How do people pay for the surgery?

MB: The vast majority are covered by insurance. Most are what you’d describe as lower-middle class, typically people who have union jobs with very good benefits, or the relatives of such people.

QP: What complications have you seen in your bypass patients, and how common are they?

MB: There are two categories of risk: immediate and long-term. The most common and dangerous immediate complication is what’s called a leak, which is a life-threatening complication. I’ve had two out of about 600 operations. Probably 50% of deaths after gastric bypass are the result of a leak. I’ve heard numbers like 1% for leak complications, which seems very high to me. I suspect that includes surgeons who don’t do bariatric surgery exclusively. Any surgery has a learning curve, and proficiency increases with the number of cases.

The next most common immediate complication is a pulmonary embolism, or a blood clot that goes to the lungs. And the next most common, which is not that common, would be cardiovascular events, heart attacks and strokes. In my five-and-a-half years of doing bariatric surgery, I’ve only had one postoperative heart attack. That patient was diabetic and had a pretty well known history of coronary artery disease, but had a normal stress test preoperatively. He did fine; it was a minor heart attack.

In terms of long-term complications, there are obviously concerns about malnutrition, which is exceedingly rare — 1% maybe. If a patient is following up, we get blood levels of vitamins and proteins, so if it is happening we can get on it quickly. Ulcers and hernias can also happen, but they’re pretty rare with the laparoscopic form of the surgery. I do laparoscopic procedures exclusively. But I think nationwide a fair number of the procedures are still open surgery, in which the hernia rate is around 50%.

QP: What about dumping syndrome and diarrhea?

MB: Well, dumping syndrome I wouldn’t describe as a complication. That’s a well-known side effect of the surgery; in my opinion, it’s one of the reasons the surgery works so well. It typically will only occur if patients are eating concentrated sweets or concentrated fats, and if you’re morbidly obese you shouldn’t eat those foods. So it sort of forces patients to eat healthier foods.

In terms of change in bowel habits, actually constipation is the most common pattern we see after surgery — mostly because patients aren’t eating as much and they’re somewhat prone to being dehydrated because their stomach is so small. That tendency usually goes away within a month or two.

QP: Do some patients regain significant weight?

MB: Yes; the published number is about 10%. The procedure has about a 90% success rate at ten years, with success defined as losing about 80% of your excess body weight. For diet, exercise, and medication, the published success rate for weight loss is about 10%. Now, a surgical procedure should have a higher success rate than something noninvasive. But compare the two.

What I would say in closing is that people may focus on the risk of the surgery — and that’s appropriate for a surgical procedure — but I always say, what’s the risk of being a diabetic for ten years? Diabetes is the leading cause of blindness, limb loss, and renal failure in this country. I used to deal with dialysis patients, and I’ve never seen an unhappier group of people.

If tomorrow Merck came out with a pill that could resolve 90% of Type 2 diabetes, it would be on the front page of every newspaper in this country. Gastric bypass does that. Not only do a lot of people not know that, but we have to fight a battle to convince people to have it done. I think one reason for this is that people don’t get a lot of symptoms from diabetes — until they do. And then once they do, it’s sort of too late. Once the nerve damage occurs, once the vascular damage occurs, the cow is out of the barn.

COMMENT: What are your thoughts on bariatric surgery? Have you had it? Are you interested?

Dr. Bilof is the surgeon at Garden State Bariatrics and Wellness Center in Millburn, New Jersey. To read more about the types of surgery he performs, visit www.gsbwc.com.

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Comments
  1. I had a LAP gastric bypass 9/8/08 and I am thrilled with the results! I have had diabetes since 1992 & I only take metformin now and will be off that soon. Before I was taking 4 different pills, novalog 3 times a day & levemir 1 time a day. I have lost 90 lbs. I feel GREAT! I make sure I take my vitamins’s, drink water & get in enough protein while watching my carbs. I’d wish I’d known sooner about GBY.

    Posted by CHARVEY |
  2. I have 50 lbs to lose and am 64 years old 5′5″ tall. I have tried every diet and though I eat healthy food (veggies, fruit,etc) I am unable to lose the weight. I have high blood pressure. Would I be a candidate?

    Posted by Diane |
  3. I had gastric bypass surgery in 2002 and I can honestly say it has changed my,all for the better.I have lost a total of 217 pounds,and I feel wonderful.I am able to do things I could only dream of before the surgery.It was done by Dr. Joseph Caruna in Buffalo N.Y.,he is truly a life saver.Needless to say I would recomend the surgery to anyone that is able to undergo it.

    Posted by Kathy Dickinson |
  4. I actually wanted surgery & asked my endocrinologist and primary care Dr., but neither would advise it. In fact they discouraged it. I meet the overweight requirements, & am type 2 diabetic. The reason?….I’m not bad off enough? I was told only persons who were heavy enough to die from the weight, or are crippled (bad knees, etc.) from being heavy should get it. I have had diabetic retinopathy in both eyes, & I consider that serious enough reason to have surgery. Besides, I would love to quit taking all these meds daily! I understand the risks, & researched it well. Could it be a ‘patient cured’, is a patient lost?

    Posted by Gloria |
  5. What about type 1 diabetics? I have had a lap band that is now leaking and needs to be removed. I hesitate to have gastric bypass due to malabsorption and some of the medication I take for my thyroid condition, and neurological condition, things that won’t go away with or without surgery. Any experience with gastric bypass surgery and type 1 diabetics? The insurance has yet to approve a sleeve gastrectomy for me so I have sitting with a lap band that is doing nothing for a year now. Thanks.

    Posted by Nancy Kramer |
  6. I have been diabetic for 16 years. 2years ago I was found to have a low thyroid form having the thyroid gland removed some 40 years ago and never given any medication. So I have been fighting weight for many years then became diabetic. I have a bad back and my knees need to be replaced. I have been thinking a lot about doing this. I am 66 and very unhappy with my self. There is so much to live for and I am tired of being in pain and sick.
    Going to check with my heart Doc.
    Vie

    Posted by Vie |
  7. My Primary Physician recommends bariatric surgery and the teaching hospital has a program for it. I am just afraid of it. I once lost 90 pounds as a vegan. I was overly strict, but counting calories and some exercise got the weight down. Then I started craving different foods and put it all back on. Now I Type 2 diabetic. Should I give in and go ahead wih the surgery? It’s been about 5 years since I lost the weight and I don’t see me counting calories either.

    Posted by Judy |
  8. bariatrics is great, if your diabeties is weight related, only I had the surery and I am type 2 diabetic I was 80 lbs overweight and for a while everything was great but because the diabetes is also genetic it is creaping back very fast and up and down more so than ever before the only thing I have going is I am still not up to needing
    U-500 insulin but it won’t be long the way it is going they need to do more testing on the genetics end of this

    Posted by Linda Lovell |
  9. I would love to get bariatric surgery. I’ve tried everything else and it would work for awhile then I gain the weight right back. I’ve been a diabetic for 3 years now and I’m praying for a real solution.

    Posted by Patricia |
  10. I have type 2 diabetes, COPD, Hashimotos disease, sleep apnea, hypertension and cannot lose any weight on my own. My insurance will cover the lap band procedure. I need to lose over 100 lbs.
    This is my problem…after two general anesthesias I experienced respiratory arrest. The second episode was the worst. Was on a ventilator for four days.
    I am wondering if I would be a candidate for this procedure, given my medical history. I recently learned from my respiratory therapist that anyone who has sleep apnea had better be put back on their c-pap or bi-pap immediately following surgery or they will not survive. This knowledge gave me a little encouragement. Being in the operating room with all the life saving equipment is not the problem….it is after that I worry about.
    Anyone else share the same concerns?

    Posted by granny Pat |
  11. I had Laproscopic Gastric Bypass Surgery on April 15th, 2009. I started out at 343 and had to lose about 40 pounds to even have the surgery. Two months later I’m at 262. I had the surgery primarily because I am a Type 2 Diabetic. I was diagnosed in 2001 and take Metformin. At one point I took that as well as Actos, Hydrochlorithiazide, and other meds to control my diabetes and blood pressure. My high blood pressure caused me to become legally blind in 2003. I am still monitoring the diabetes and the numbers are alot better. I hope to be off all the diabetes meds soon. I would strongly recommend this surgery. Yes I was able to drop weight prior to surgery, but I would always plateau and get to a point where I couldn’t lose anymore. In 2004 I walked 5 miles every other day, and could not get below 272. Having the surgery has given me back my life, my energy, and a whole new outlook on living longer, and healthier.

    Posted by Scott Roberts |
  12. I’m a diabetic for the past 9 years who is also obese. I’m soon to be 59 years of age with complications. I suffer from neuropathy in my feet and legs, my kidneys don’t seem to produce enough urine but my eyes still remain healthy except during my frequent high blood sugars. Lets just be honest, I love to eat and enjoy my social cocktail or 2. I’ve looked into the lap.bariatric surgery procedure over the past few years, but have questions! What effect does this have on the by-pass/re-routing procedure for “long term” pt’s? What if an illness comes later that affects the surgical areas involved? This surgery can’t be un-done so to speak, so what does a pt. do say, if he or she developes cancer of the stomach,esophagus(please excuse my poor spelling)? FEAR comes to my mind, but necessity is quickly coming to realism of my options. Please,try to put all this in simple answers. Thank You. Sharon Lonardo of Warwick,R.I.

    Posted by sharon lonardo |
  13. I have been a diabetic since 1992. I am on lantus 2x’s/day and numalog 4 x’s/day. I am looking at the gastric band surgery, but it is not covered in Canada yet. I do have a question though. After you’ve lost all that weight, what happens to all the loose skin where the fat was before?

    Posted by Janet |
  14. I’M 51 Y.O. HT 5′51/2″ WT 240LBS, DIANOISE WITH HIGH Bp YEAR AGO AFTER SURGERY, HA1C 7.9%,HAVE HERNIAED DISK @
    L5, ALONG WITH KNEE PROBLEMS. I’VE TRIED ALL KINDS OF DIETS AND PROGRAMS AND WILL ONLY LOOSE 3-5 LBS, BUT NOW MY BACK PREVENT ME FROM MOST EXERCISES. THE ARTICLE SOUND GOOD BUT WILL IT HELP ME.

    Posted by Bobby Jackson |
  15. My husband was very over weight and was going through all the pre-surgery tests that are required for by-pass surgery. During this time he had some digestive problems and went for an upper endoscopy. The results of the upper endoscopy were that he had Barretts esophagus and a small spot of cancer. He had to have surgery and they removed most of his esophagus and part of his stomach. The cancer was found early enough where all was removed and he needed no further treatment. The surgeon who removed his cancer told him if he had had the bypass surgery the cancer would never have been found and it would have ate through his stomach and he would have been dead within a year. He will be two years post-op December, 2009 and we are so happy he did not have the bypass surgery before his cancer occurred.

    Posted by Rose |
  16. I had Bariatric surgery 9 months ago and I have gone from 305 lbs. to 185 lbs. I’m 6′2″ tall and I
    HAD Type-2 Diabetes.My blood sugar readings now are 85 - 110. I use to take two insulin shots a day ,I haven’t taken any insulin in months. My blood pressure is now normal and this is the best I have felt in twenty years. I agree with Dr. Michael Bilof 200%.

    Posted by Paul F. Schattler |
  17. I find this doctor to be sincere in his hopes to help diabetics, but I also find him more into the numbers and not the individuals. Since I do not know him, I can’t be sure, but this is my perception from what he says.

    I would not ever recommend this surgery, though I know for many people it has helped. So many more have not conquered their food issues before they have this life-altering procedure done. Afterward they do well at the beginning and then slip back into old patterns. Thankfully, it works for some, but with the discipline you need to keep the regimen going, you would have been able (for most people) to go on a new way of life diet. One that truly works with moderation as the rule. You have to realize that you will be on a lifetime supplements, unless there is a complication then other medications as well.

    I respect the opinions of others, but would not want anyone who is not truly morbidly obese to even consider this as an answer.

    Posted by Linda G |
  18. I was suffering from bad lower and cervical back problems. Feet, diabetes, High Blood pressure, Depression, and just all around general fatigue. I had my Gastic Bypass 11-28-06. I was able to lose 117 lbs in 10 months. I then lost another 14 lbs. I am 4′11″ and now weigh 105lbs.
    I now longer have to take insulin, hbp meds and hardly ever take pain meds for my back. This did not cure my back problems due to 5 different degenitive aspects. I also have ostoprosis. I am a much happier, more outgoing person today.
    I can honestly say that I would do it all again. I followed all my doctor’s instructions to the letter. Just make sure you take the supplements and get enough protein (90grams) and plenty of water. The water is the hardest for me. So I drink tap temp, not iced.

    Posted by Trish M |
  19. I think the surgery is a God send for those of us that have type 2 diabetes. I have had it for 18 years and would love to have it done. My doctors don’t agree that I should have it done. I would like to be a candidate for stem cell research trials also.

    Posted by Carol J. Thompson |
  20. Yes, I considered the Lap Band, in fact had all the pre-surgery tests to show that I was a candidate. My BMI was 34 at the time. I did not follow thru because after seeing an Endocrinologist, he advised against it because I have fibromyalgia along with injuries that require meds that when on them I gain and retain weight. When off I loose the weight. The doctor took me off one pill alone and I lost 20 pounds, however with Lyrica and other steroid type meds, despite, diet, exercise and can’t seem to loose more than this 20-25 pounds and now menopause is a factor. I would like to loose 75 pounds because now I must take Metformin when I have not had to take anything. My blood sugar now pikes highs and lows although my last Ac1 was 6.5, it does not appear that the 1000mg of Metformin is helping. I find myself taking 1500 to 2000 some days, and other days only 500 with no variation in my eating. Any suggestions would be appreciated. Would Lap Band help me when I don’t overeat and engage in exercise to help with the fibromyalgia and injuries?

    Posted by Linda Tyson |
  21. I have been considering gastric bypass for a long time.I recently had an endoscope exam. It showed that I have a hyetal hernia and problems with my esophogus. I take medication for the heartburn and nausea. I am diabetic, blood pressure slightly elevated, tremors,stress incontinence,hemachromatosis,and I am severly obese. My question is -can I have the hyetal hernia repaired so I can have bariatric surgery? I weigh 288 lbs. and am 5′4″. I’ve had a hip replaced and a knee replaced. Both are sucessful.My weight is 25 lbs. lighter than my heaviest weight. Presently it is steady. I am beginning to get frustrated because I follow the diabetic pyramid religiously. My A1C is 5.6. It’s perfect.I exercise even though I can’t walk without a walker. I have a doctor picked out and I know I can get answers from him, but was curious as to what your impresssions are.

    Posted by Sally Metler |
  22. My son had bariatric surgery on Jan 11, 2009. He weighed 400 lbs and is 6′8″ tall. His present after surgery weight is 300. In the last 2 months, increasingly he feels light-headed and has even fainted. He has had an extensive heart & head workup and found that there is no problem there. He is being told that he faints because he has low blood pressure, is anemic and is so tall. He now wears compression knee high stockings and is on the medication called Midodrene. He continues to feel awful. Would a unit of blood be helpful in restoring some normalcy?

    Posted by Ann Hoxie |
  23. I had Gastric Bypass surgery 9-16-2002 and lost 105 pounds 100% of my exess body fat. I had no other conditions but I do need to watch my B-12 level now… I take shots 1 per month now to keep it up so I don’t get Low Iron levels (tired). Other than that it is GREAT!! Just do it!! Start living!!!! I did and boy am I glad I did!!!

    I am 140 pounds 5′11″ and full of energy!!

    A Wonderful Thing this surgery is let me tell you!!!!!

    Thank you & Good luck to all of you!

    Posted by Cathy W |
  24. I had gastric bypass in 4/27/09 and hve lost 139 pounds. Do it now. You owe it to yourself to get the advantages of weiht loss. It was the best thing to happen to me. I exercise most dys and enjoy it. It is a miracle…no more diabetes!

    Posted by Stacie Salyard |

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Flashpoints
Prediabetes: Overhyped? (07/23/14)
Screen Time (07/16/14)
School Lunch Showdown (07/09/14)
Fruits, Veggies, and Weight (07/02/14)

 

 

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