Is gastric bypass surgery a godsend to overweight people – and a possible cure for type 2 diabetes – or is it a dangerous procedure that can kill you before it cures you?
The operation is highly controversial, and here are two anecdotes that reflect the continuum of the debate.
1) A friend of mine, quite overweight, decided to have gastric bypass surgery last year; the procedure makes the stomach smaller and allows food to bypass part of the small intestine. Within a month or so of her surgery, the pounds began to melt away, and this continued over time. But more striking than her gradual weight loss was her behavior. I now saw her jogging or walking, either outside or at the gym. She kept losing weight, she kept exercising, and it was clear that she was just motivated. It was a classic example of a phenomenon in behavior psychology – motivation follows action, not vice versa. In this case, the gastric bypass was the action that inspired her motivation. As far as I know, she experienced no serious complications, save one brief emergency room visit when she ate some acidic fruit.
2) In June of 2002, Charlie Weiss, offensive coordinator for the New England Patriots, underwent gastric bypass. He feared that his weight – about 350 pounds – could cause him to drop dead; he also thought it was hurting his chances of becoming a head coach. But after the procedure, he bled internally for 30 hours; a priest visited his bedside to deliver what he thought were his Last Rites.
Weiss survived, lost some weight (though he’s still hefty), and is now the head football coach of Notre Dame. But he sued his surgeons at Massachusetts General Hospital for unspecified damages, and this week he testified in court to what he claims have been the long-term complications of the operation. “I don’t understand why I can’t walk on the boardwalk with my wife,” he said. “I don’t understand why I can’t play with my kids. I don’t understand why I can’t run out on the field when our football team runs out at the start of the game.”
The surgeons deny any wrongdoing.
A wide range of experiences, to be sure. What’s clear is that bariatric surgery is becoming more popular. From 1998 to 2004, the total number of these operations increased by nine fold, from 13,386 to 121,055, according to the Healthcare Cost and Utilization Project, and we know that by last year, the number performed exceeded well over 200,000. (Women account for 82 percent of all such surgeries.) While the number of patients who died from the surgery, on percentage basis, is quite small – less than 0.2 percent – there are still risks: In 2004, 230 patients died in hospital stays during which bariatric surgery was performed.
The diabetes community is keenly interested in gastric bypass surgery, for obvious reasons. Any treatment that causes safe weight loss could have a profound impact on type 2 diabetes. A JAMA article in 2004 (H. Buchwald, et al, 292, no. 14) found that, according to a meta analysis, 62 to 70 percent of excess weight was lost following gastric bypass, and following successful weight loss, diabetes was “completely resolved” in 76.8 percent of patients. As we reported in last October’s Diabetes Close Up, another interesting calculation by Dr. Henry Buchwald (one of the pioneers of bariatric surgery): because it resolves so many comorbitidies, surgery actually becomes cost-effective at 3.7 years after the surgery. Dr. Buchwald opined that the reason payors remain reluctant to reimburse is that they can’t hold their customers that long to reap the benefits. Probably true: we’re quite familiar with the similar lack of interest in prevention programs in diabetes – a shortsighted approach that simply means all insurers will eventually end up with obese or overweight patients on their logs.
Beyond weight loss, gastric bypass surgery appears to have remarkable metabolic effects. For reasons not entirely understood, the procedure eliminates type 2 diabetes in some patients before they lose any weight. It seems that many of the gut hormones – ghrelin, CCK1, PPY, GLP-1, leptin, alpha-MSH, and others – change dramatically after the surgery, generating positive effects that include reductions in insulin resistance as measured by HOMA-IR. Last year, at the annual meeting for the North American Association for the Study of Obesity, we heard Francesco Rubino, of the University of Strasbourg, France, report that some patients are effectively cured of type 2 diabetes immediately after the surgery – not in conjunction with weight loss. “I don’t know if this is a cure,” he said, “but if it’s not, it looks very close to that kind of concept.” (See diaTribe #1 for more about this meeting – www.diatribe.us).
We don’t know if it’s a cure either, but we know that gastric bypass will become increasingly popular, if only because the pool of obese candidates grows every day. We hope that additional research is done on the metabolic impact of the surgery, but we also hope that it’s the procedure of last resort – only used after lifestyle changes and pharmacotherapy have been exhausted. Even then, we remain skeptical about its efficacy (let alone its safety) unless the patient commits to a diet and exercise regimen.
In short, we’d rather see more people like my dedicated friend, jogging around the track, than people like Charlie Weiss, confined to his scooter on the sidelines.
James S. Hirsch