Bariatric surgery and diabetes.

Abstract

As this year's review indicates, we now have ample level 1 evidence, from prospective randomized clinical trials in our most respected journals, that surgery produces significantly better outcomes than even the most intensive medical therapies—that is, the ideal that is clearly not feasible in daily medical practice. The operations are as safe as routine cholecystectomies with 90-day mortality rates of 0.3% with lengths of stay of 1–2 days. As in other operations, there are variations in outcomes such as weight loss and rates of remission with gender, age, duration of disease, use of insulin, and other factors. In the NIH-funded study, the Longitudinal Assessment of Bariatric Surgery (LABS) (7), none of the patients returned to their original weight in 3 years and only 2.1% of the cohort fell in the quartile that lost the least weight. Bariatric surgery, again, similar to other operations, has its share of late complications, including marginal ulcers, episodic hypoglycemic attacks, neuropathies, and emotional issues. However, even these compare well to strokes associated with type 2 diabetes. Given this evidence, how can we explain the leveling of bariatric surgery at about 200,000 per year, about 1% of the population who would benefit from the operations? If there were a pill that could produce full and durable remission of type 2 diabetes in four out of five patients, with significant improvement in the rest and a reduction in mortality of 83%, would we have the same response or would the demand outstrip our ability to produce it? History suggests that delays in the adoption of new approaches in medicine are not new. Even though Sir Humphry Davy noted in 1799 that “as nitrous oxide in its extensive operation appears capable of destroying physical pain, it may probably be used with advantage during surgical operations in which no great effusion of blood takes place,” anesthesia was not adopted until after the demonstration by William T.G. Morton in 1846, a delay of 47 years. Alexis Carrel described the principles of vascular suture in 1894, transplantation of organs in 1905, placement of a carotid venous patch in 1906, tissue culture in 1912, and a cardiac perfusion pump in 1935, and even though these advances were described in the best journals and he was awarded the Nobel Prize, introduction into medical practice was very slow. The first repair of an aortic aneurysm at the University of Rochester was performed in 1961 (a delay of 67 years), the first kidney transplant by Joseph Murray was reported in 1954 (a delay of 49 years), Charles Rob published the first carotid endarterectomy in 1954 (a delay of 49 years), and John Gibbon carried out the first open-heart operation in a woman in 1943 (a delay of 8 years). Nor are these delays limited to medicine. The Chinese invented black powder in the ninth century; Nobel patented dynamite in 1867. Einstein introduced his formula E=MC2 in 1905; it took the pressure of a world war and 40 years to discover atomic fusion. Turing invented the first real computer in 1936; Gates founded Microsoft in 1976. On the other hand, the adoption of flight progressed much more rapidly. The first successful flight by the Wright brothers was in 1903; the first airline was founded by Thomas Henry David in 1916. In summary, for the first time, we have a safe, effective, and durable treatment for diabetes and the other expressions of the metabolic syndrome. Only time will tell whether there will be wider application of these operative procedures or whether better medications make the surgery obsolete. In the meantime, bariatric surgery offers remarkable new approaches for research, the study of patients first with diabetes and then without it that, hopefully, will allow us to conquer this costly and cruel disease.