Band surgery trial re­verses type 2 di­a­betes

Surgery is rarely of­fered as a treat­ment for di­a­betes, but that may soon change, writes Health ed­i­tor Adam Cress­well

The Weekend Australian - Travel - - Health -

PRISON offier Domenic Mer­curi was cer­tainly on the heavy side when his doc­tor told him he had type 2 di­a­betes: car­ry­ing just over 100kg on a 1.73 me­tre (5ft 7in) frame put him well into the obese cat­e­gory.

Bat­tling symp­toms in­clud­ing dizzi­ness and high blood pres­sure, he’d re­alised he wasn’t in top form. But it still came as a shock to hear in early 2004 that his blood glu­cose level was 20 mil­limoles per litre (mmol/L) — more than twice the healthy limit.

Drugs pre­scribed by his GP quickly brought that down to 9mmol/L, the up­per end of the healthy range. But Mer­curi, now 51, was still feel­ing out of sorts. So when he saw an ad­ver­tise­ment seek­ing par­tic­i­pants for a trial to test the ef­fec­tive­ness of surgery in obese pa­tients with type 2 di­a­betes, he jumped at it.

The 60 obese pa­tients on the trial, con­ducted by Monash Univer­sity’s Cen­tre for Obe­sity Re­search and Ed­u­ca­tion, were di­vided into two groups: one group re­ceived usual di­a­betes care, namely anti-di­a­betes drugs such as met­formin which in­creases sen­si­tiv­ity to in­sulin, as well as diet and lifestyle ad­vice.

The other group — into which Mer­curi was ran­domly as­signed — re­ceived ad­justable gas­tric band­ing surgery. In this pro­ce­dure, a band is placed around the top part of the stom­ach, slow­ing the rate at which food can pass into the main part of the stom­ach and caus­ing the pa­tient to feel ‘‘ full’’ much sooner.

The trial recorded some dra­matic find­ings last week af­ter fol­low­ing the pa­tients for over two years. Pa­tients given the gas­tric band lost an av­er­age of 20 per cent of their weight, com­pared to a 1.4 per cent weight loss in the nor­mal care group. The surgery pa­tients also cut their blood sugar by 80 per cent, com­pared to 20 per cent of the nor­mal-care pa­tients; and the surgery pa­tients also en­joyed a big­ger cut to their blood pres­sure and use of drugs.

Per­haps most dra­matic of all, 22 of the 30 surgery pa­tients (73 per cent) shed their di­a­betes al­to­gether, com­pared to just four (13 per cent) of the 30 in the nor­mal-care group — mean­ing surgery led to a five times greater rate of re­mis­sion from the dis­ease than con­ven­tional treat­ments.

About 14 months af­ter the trial ended, Mer­curi is a changed man. He now weighs just over 70kg in­stead of 100kg; he is no longer di­a­betic; he no longer has to take drugs for di­a­betes or high blood pres­sure; and he feels more fit and en­er­getic.

‘‘ The pain as­so­ci­ated with the surgery is min­i­mal,’’ he says. ‘‘ With what it has done for my health, I would do it again, and I have rec­om­mended it to quite a num­ber of peo­ple.’’

The study find­ings, pub­lished in the Jour­nal of the Amer­i­can Med­i­cal As­so­ci­a­tion (2008;299(3):316-23), have made a con­sid­er­able splash, par­tic­u­larly in the US which is fac­ing an obe­sity epi­demic even worse than Aus­tralia’s.

In an ac­com­pa­ny­ing edi­to­rial in the jour­nal, two ex­perts from the Univer­sity of Wash­ing­ton in Seat­tle de­scribed the find­ings as ‘‘ clear and strik­ing’’ and to­gether with other re­cent find­ings pro­vided ‘‘ in­sights . . . (that) may be the most pro­found since the dis­cov­ery of in­sulin’’.

As a re­sult, they said doc­tors and med­i­cal Monash Univer­sity’s Cen­tre for Bari­atric or­gan­i­sa­tions ‘‘ should re­con­sider the role of Surgery, says that while re­mis­sion of di­a­betes surgery to treat di­a­betes’’. ‘‘ It is time for a has been ob­served pre­vi­ously, the new study ma­jor shift in the way the health care — be­ing a ran­domised con­trolled trial, com­mu­nity con­sid­ers di­a­betes treat­ment con­sid­ered the gold stan­dard for med­i­cal goals,’’ they wrote in the edi­to­rial ev­i­dence — is one of the first to pro­vide (2008;299(3):341-3). con­fir­ma­tion that weight loss it­self can bring

Bari­atric (obe­sity) surgery cov­ers a num­ber this about. of pro­ce­dures, of which la­paras­copic (keyhole) It also shows the scale of the in­creased ad­justible gas­tric band­ing surgery is just one. weight loss that surgery can bring about.

While it is still in­va­sive, and does have some ‘‘ The cost of treat­ing some­one with risks and side ef­fects, it is gen­er­ally much di­a­betes (on ex­ist­ing ther­a­pies) is very high — safer, quicker and less painful than some older on av­er­age it’s prob­a­bly in ex­cess of $10,000 forms of gas­tric surgery, such as sta­pling and a year,’’ O’Brien says. gas­tric by­pass. ‘‘ The cost of gas­tric band­ing surgery in a

Con­trary to com­mon be­lief, gas­tric band­ing pub­lic hospi­tal is likely to be about $5000 to does not squash the stom­ach into a smaller $8000 in to­tal. What you are buy­ing for that vol­ume. In­stead, a hollow band is placed cost is a ma­jor like­li­hood of the dis­ease go­ing around the top part of the stom­ach, which can into re­mis­sion . . . This (surgery) sounds to be be in­flated to the de­sired ten­sion by in­fus­ing a pretty good ther­a­peu­tic path­way.’’ saline or other so­lu­tion. How­ever, surgery is not be­ing pre­sented as

It cre­ates a pocket at the top of the stom­ach, a treat­ment for ev­ery­one with di­a­betes. which fills quickly as food is eaten, and slows O’Brien stresses that the ben­e­fi­cial ef­fects the rate at which this food can progress into were recorded in obese (not just over­weight) the main part of the stom­ach. pa­tients with type 2 di­a­betes, all of whom

While it used to be thought that a feel­ing of en­tered the trial with a body mass in­dex of ‘‘ full­ness’’ was trig­gered by the re­lease of be­tween 30 and 40 — well above the healthy hor­mones af­ter a meal, it is now thought this up­per limit of 25. may be trig­gered by nerve sig­nals — and that They were also all at rel­a­tively early stages the gas­tric band­ing sends th­ese sig­nals to the of the dis­ease, and none needed to take brain, even though the stom­ach con­tains lit­tle in­sulin. or no food. ‘‘ If we see some­one at 10 years with this

‘‘ You can go through a day with­out feel­ing dis­ease, and they are on in­sulin, the like­li­hood hun­gry,’’ says Mer­curi, who says he would is we are not go­ing to put them into take 30 min­utes to eat an en­tree-sized meal. re­mis­sion,’’ O’Brien says. ‘‘ In this study we

Co-au­thor pro­fes­sor Paul O’Brien, head of only ac­cepted peo­ple who had been di­ag­nosed for two years. It’s a strong mes­sage to the doc­tors who treat di­a­bet­ics: they don’t only have to think about surgery, but think about surgery early in that per­son’s dis­ease.’’

Al­though fol­low-up in the study was lim­ited to two years, ev­i­dence from pre­vi­ous re­search shows re­mis­sion from di­a­betes can be main­tained be­yond 10 years, he says.

The study’s find­ings raise the ques­tion of whether there should be a much wider use of surgery in obese pa­tients who also have type 2 di­a­betes than cur­rently hap­pens.

While there are cur­rently about 8000 gas­tric band­ing op­er­a­tions a year in Aus­tralia — a fig­ure O’Brien says is ‘‘ in­creas­ing all the time’’ — this is a tiny fig­ure in pop­u­la­tion terms.

Surgery has tra­di­tion­ally not been con­sid­ered as a treat­ment for di­a­betes. It is not gen­er­ally funded through pub­lic hos­pi­tals.

Melbourne’s Austin Health is one that does al­low gas­tric band­ing — but the num­bers are lim­ited to just 12 pa­tients per year.

Pro­fes­sor Joe Proi­etto, an Austin en­docri­nol­o­gist and pro­fes­sor of medicine at the Univer­sity of Melbourne, says even then pa­tients can only qual­ify if they have failed on other ther­a­pies.

A co-au­thor of the study, Proi­etto says that while there has been a strong pref­er­ence for non-sur­gi­cal ther­a­pies for obe­sity, the short­term suc­cess of th­ese treat­ments tended to fade over the longer term.

Con­trary to old-fash­ioned stereo­types that obese peo­ple lack willpower, Proi­etto says there are ‘‘ good bi­o­log­i­cal rea­sons’’ why peo­ple find it hard to re­duce their weight and then keep their new, lower weight.

This is be­cause the body em­ploys a num­ber of tricks in an at­tempt to re­gain what it thinks is the ‘‘ right’’ weight. The meta­bolic rate drops; the lev­els of lep­tin, a hor­mone that helps reg­u­late food in­take, also falls by about half. Lev­els of an­other hor­mone, ghre­lin, which stim­u­lates food in­take, rise.

The gas­tric band, which makes the brain think the stom­ach is full, short-cir­cuits th­ese de­fen­sive sys­tems and al­lows peo­ple to cut their food in­take much more eas­ily.

‘‘ Th­ese phys­i­o­log­i­cal adap­ta­tions ex­plain the per­plex­ing and mys­te­ri­ous data about why peo­ple can’t keep weight off,’’ Proi­etto says.

‘‘ It also shows it’s go­ing to be ter­ri­bly dif­fi­cult to con­trol obe­sity with pub­lic health mea­sures. There haven’t been any pub­lic health mea­sures that have shown any im­pact (on obe­sity), up to now.’’

Like Proi­etto — who says gas­tric band­ing ap­pears to be ‘‘ very cost-ef­fec­tive’’ — O’Brien re­jects the idea that obe­sity is the re­sult of peo­ple show­ing in­suf­fi­cient willpower over their lifestyle.

‘‘ Th­ese peo­ple are des­per­ately keen to lose weight, and try harder than most peo­ple,’’ he says. ‘‘ But they have a set point to their weight that’s too high. Gen­er­ally they can give more than a 20-year his­tory (of weight loss at­tempts).

‘‘ Rather than blame them, we should face up to the fact that as a com­mu­nity, if we can help peo­ple, we should help them. There are so many peo­ple who have this prob­lem who could be helped.’’

Pic­ture: David Crosling

Band aid: Pro­fes­sor Paul O’Brien says surgery can bring about weight loss and put type 2 di­a­betes into re­mis­sion

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