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The Case for Bariatric Surgery
June 15, 2009
Earlier 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?
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.
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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