Bariatric Surgery for Diabetes

There’s no doubt that excess weight is linked to diabetes.

For one thing, that extra weight makes it harder to control blood sugar which is key to managing the disease.

Debbie Wagner knows this all too well.

She takes medication, has made some lifestyle changes but is still about a hundred pounds overweight.

WAGNER: You lose weight and it comes back…It’s very hard to control being a diabetic.

If she goes on like this, the consequences could be grave.

Phil Schauer, a doctor at the Cleveland Clinic, spells it out.

SCHAUER: More than half the people with diabetes do not have their blood sugar in good control. We know there’s a high likelihood that these folks, eventually, are going to get secondary complications—amputations, blindness, strokes, heart attacks.

Schauer is Wagner’s bariatric surgeon--one of the few in the country who perform “gastric bypass” operations as a treatment for diabetes.

In a way, it’s particularly fitting that Wagner is having her insides streamlined.

After all, that’s sort of what she does in her job as a supply chain planner in Parma – rearrange things so they perform better.

WAGNER: Hopefully with the surgery I should no longer be a diabetic. It’s going to cure everything that I currently take medications for. I’m praying it’ll all be gone.

(Sounds of scrubbing in)

Dr. Schauer scrubs in; I join him in the OR.

(Sounds of OR fade in)

After about an hour he’s at a primary juncture in the procedure.

SCHAUER: This is the stomach and we’re going to reduce it quite a bit.

He staples it, (Sound of stomach stapling), and creates a new one about the size of a golf-ball.

SCHAUER: A kid’s meal, probably half a kid’s meal—initially—will fill her up.

But he’s not done yet.

He also bypasses some of the intestine.

And then hooks it all back together so food flows from the new stomach into the now shorter digestive track.

The bypassed bits just stay in the body, empty and harmless.

SCHAUER: (Turns to assistant) Stitch!

Schauer finishes up and says her outlook is good.

SCHAUER: We expect her diabetes to improve, probably even tonight, before she’s lost a single ounce of weight. I wouldn’t be surprised by the time she leaves the hospital that her diabetes will be in full remission.

(Sounds of OR fade out)

Physicians are not entirely sure why some patients see their diabetes improve almost immediately after the surgery.

But theories point to the intestine.

Hormones there change with the bypass.

The effect is like jumper cables for the pancreas; it stimulates the organ to pump insulin, which keeps blood sugar in check. Which improves diabetes.

Right now bariatric surgery isn’t widely used to treat diabetes; clinical guidelines recommend it only as an option for those who are also severely obese.

Diet, exercise and meds are the go-to therapy; but Schauer says they aren’t cutting it.

SCHAUER: It’s true—we always want to do the lowest risk, least invasive therapy, right. But we want something that works.

He calls surgery a powerful tool that should be utilized more often, and in some cases, sooner…that is, when diabetics are merely overweight, instead of waiting till they’ve become very obese.

His confidence is based on a study his team did showing that surgery worked better than medical therapy for putting uncontrolled diabetics into remission.

It was published in The New England Journal of Medicine last April.

It involved 150 patients over one year.

A later multi-site study that looked at how patients fared years after the surgery found that the disease came back, for about a third of the people whom it initially worked.

Practitioners have had different reactions to the research.

Dr. James Salem, an endocrinologist at Summa Health System in Akron, says the later study doesn’t discount the benefits of surgery to a diabetic.

SALEM: If you give someone eight years where you define them as not having diabetes, that’s eight years of them not being subject to the complications of the disease—that’s a big deal. Also, even if the patient doesn’t go into remission, you’re making the diabetes easier to treat.

For Dr. Gregg Faiman at University Hospitals the jury is still out on when bariatric surgery should be used to control diabetes.

FAIMAN: I think it’s an evolving landscape.

Faiman says the risks have to be weighed against the benefits.

FAIMAN: When they quote 1 out of 200 people not getting off the table, not surviving the surgery, that’s, to me, that’s a significant risk, in addition to some of the other things with recovery.

There can be a lot of complications.

Debbie Wagner, the patient whose surgery I watched, had some rough going.

I called her a month after.

WAGNER: I had a little bit of a setback. I was rushed back to the emergency room, couldn’t hold anything down and everything you know was coming up.

Wagner says she’s getting stronger now and would still recommend the surgery to others.

Her blood sugar returned to normal and she hasn’t had to give herself an insulin shot since she left the hospital.

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