Bariatric/Metabolic Surgery for Diabetes: Lessons From the Past and Present.

Abstract

One of the most important breakthroughs in diabetes was announced in 1921 by a surgeon-led team working on the gastrointestinal tract. Frederick Banting, a general surgeon in Canada, partnered with a physiologist, John Macleod, and others to purify insulin from pancreatic extracts and demonstrated that this gut hormone could treat diabetes. Eighty years later, more than 30 gut-derived hormones have been described (1), many of which have also been shown to influence glucose as well as lipid metabolism, appetite control, and energy expenditure. And these are just the ones we know about. Despite its gastrointestinal origins, research into the mechanisms of insulin’s action and its use for the treatment of diabetes became the domain of endocrinologists, who to this day, it may be argued, have otherwise ignored the largest endocrine organ in the body to focus on the five or six hypothalamic-pituitary axes. As a result of these efforts, diabetes is now understood to be a chronic disease that manifests when too little insulin is secreted by pancreatic islets in response to the body’s needs: an absolute deficiency in the case of type 1 diabetes and a relative insulin deficiency in type 2 diabetes. It is frustrating that, despite nearly 100 years of research since insulin’s discovery, the specific causes of insulin resistance and impaired insulin secretion that lead to diabetes remain largely elusive. Enter the surgeons again. Starting in the latter half of the last century, obesity became an increasingly prevalent medical problem in the U.S. and other developed nations. As obesity rates have risen, so has our understanding of the importance of excess fat storage in expression of …