Although, in the end I spent less than 24 hrs in the Emirates, one of the highlights of attending the 1st International Abu Dhabi Diabetes Conference, was the opportunity to once again hear David Cummings (Seattle) speak about how bariatric surgery can lead to the remission of type 2 diabetes. Cummings’ talk certainly provided plenty of food for thought on my long flight back to Canada.

As outlined in a newly released Diabetes Surgery Position Statement published in the latest issue of the Annals of Surgery, surgical approaches may well prove to be the treatment of choice in carefully selected patients with poorly controlled type 2 diabetes and a BMI greater than 30.

While the authors of the Statement emphasize the need for more clinical trials to investigate the future role of surgery in diabetes treatment, they also call for further investigations on the mechanisms of surgical control of diabetes (which are far from being fully understood).

Although weight loss itself clearly plays a significant role in the reversal of diabetes generally seen with bariatric surgery, with gastric bypass surgery, this reversal of diabetes often precedes the weight loss and there are likely neuroendocrine consequences to allowing food to bypass the duodenum that may substantially affect glucose metabolism (including regeneration of pancreatic beta-cells).

Thus, a better understanding of exactly how gastrointestinal surgery “cures” diabetes, will hopefully also open new avenues for pharmacological treatments that can mimic the effects of surgery in these patients.

Indeed, certain gut-hormones, which are known to be dramatically affected by gastric bypass surgery (e.g. GLP-1), have already been shown to have a beneficial effect both on diabetes and weight management (e.g. liraglutide).

Health professionals who want to learn more about this topic should consider attending the upcoming First Canadian Summit Metabolic Surgery for Type 2 Diabetes to be held in partnership with the Canadian Obesity Network and the Canadian Diabetes Association at the Hôtel Le Centre Sheraton, Montréal, May 6-7, 2010.

To watch a recent episode of 60 Minutes on CBS, which features interviews with Cummings and others discussing the surgical approach to type 2 diabetes, click here.

Very much appreciate hearing from my readers on their thoughts regarding whether or not diabetes surgery (vs. lifelong medications or injections) will significantly change how we treat diabetes in the future.

AMS
Edmonton, Alberta

This week, I am in Guadalajara, Mexico, to speak at the Congreso Hospitales Civiles 2010.

Mexico, as does most of North America, has a burgeoning obesity crisis, where the number of people struggling with excess weight far outweighs the ability of the health care system to provide even just a “band-aid” solution to the problem.

As in Canada, treatments for people struggling with severe obesity is limited and offered by only a handful of surgical centres - mostly to people who can afford it.

While in Canada, the public healthcare system is only gradually beginning to tackle the issue of providing adequate access to bariatric surgery, most of the bariatric surgery in Canada is in fact delivered in the private setting.

Thus, an increasing number of private centres across Canada are providing laparoscopic adjustable gastric banding (LABG), a procedure that is not covered by the public health care system in most provinces.

The fact that this procedure can indeed be provided safely in a non-hospital setting is now documented in a paper by Chris Cobourn and colleagues from the Surgical Weight Loss Centre just published in Obesity Surgery.

In this paper, Cobourne report on the perioperative complications (30 days) in a retrospective analysis of 1,641 consecutive patients who underwent outpatient LAGB, beginning with their initial experience in February 2005 and continuing to July 2009.

The average presurgical body mass index was 46.7, of whom around 60% had at least one weight-related chronic disease.

Fifteen patients (~1%) experienced minor complications during or within 30 days of surgery (dysphagia, n = 5; wound infection, n = 3; port infection, n = 2; all other complications occurred in one patient each). Four patients required transfer to hospital from the clinic on the day of surgery, and three were admitted. Apparently, none of the complications were serious and all were resolved. The device was explanted in two patients.

Notably, the average time from sedation to discharge was less than 4 hours.

While this study does not report on the long-term outcomes of these patient, and 30 days is of course only a tiny window in what is a lifelong disorder, the paper does clearly show that LAGB can indeed be safely performed in a non-hospital outpatient setting.

Although LABG may not be the “gold standard” for bariatric surgery, it certainly is a technique that is surgically quick and easy. This, however, should not distract from the fact, that long-term success with any form of bariatric surgery is anything but quick or easy - rather, as I have blogged before, to succeed with bariatric surgery patients have to make extensive and persistent lifestyle changes and will often require long-term medical and psychosocial support.

Among all of the various bariatric surgical techniques, LABG is certainly the one that is most dependent on patient’s ability to change their dietary behaviours and of course, the bands do require periodic readjustment in order to continue to be effective.

We certainly look forward to seeing the long-term results in these patients before accepting that quick and safe also translates into best.

If you perform, look after patients who’ve had, or have had this surgery yourself, I’d love to hear from you.

AMS
Guadalajara, Mexico

Anyone dealing with pediatric obesity knows that there is now an increasing number of massively obese kids for whom behavioural and/or medical weight management will simply not cut it. It is therefore no surprise that an increasing number of kids and their families are now looking to surgeons for help.

To address this demand, Toronto’s Hospital for Sick Children last week announced the creation of a centre for pediatric and adolescent bariatric surgery (see report on CTV).

While to some readers this may seem shocking, extreme, drastic, and will likely provoke much head shaking amongst people who simply do not get that calling for more prevention efforts will be of no benefit to these kids, the reported outcomes for pediatric obesity surgery (at least in the short term) are actually quite good.

Thus, Ai Xuan Holterman and colleagues from Rush University, Chicago, IL, recently reported their experience with bariatric surgery in morbidly obese adolescents in the Journal of Pediatric Surgery.

This looked at the more than one year outcomes in twenty 14-17 year olds undergoing plaparoscopic adjustable gastric banding (LAGB). BMI at baseline was around 50 and was associated with hypertension (45%), dyslipidemia (80%), insulin resistance (90%), metabolic syndrome (95%), and biopsy-proven nonalcoholic steatohepatitis (88%).

At mean follow-up of 26 months, mean excess weight loss was around 30% and the metabolic syndrome was resolved in 63% and 82% of the patients at 12 and 18 months, respectively. Hypertension normalized in all patients, along with improvement in lipid abnormalities and quality of life scores.

LABG is relatively safe with few perioperative complications. Nevertheless, long-term complications including band slippage, erosions, and other problems remain a concern. Furthermore, LABG patients have to follow stringent dietary regimens to be successful. Despite these reservations, LABG certainly currently appears to be the procedure of choice both because it is theoretically reversible and has such low perioperative complication rates.

While we of course all wish that there was no need to reach for such drastic treatments in kids, the reality is that an increasing number of severely obese adolescents and kids will no doubt benefit and will get a real chance at regaining control over their weight and lives.

I predict that Toronto’s Sick Kids is very unlikely to remain the only place in Canada that performs pediatric bariatric surgery for long.

AMS
Edmonton, Alberta

To anyone regularly dealing with overweight and obese patients, the frequent association between excess weight and chronic musculoskeletal pain is no secret.

This association is particularly true for the rather enigmatic syndrome of fibromyalgia, characterised by the presence of generalized pain in muscle and joints, often associated with fatigue, poor sleep, and depression. Patients typically present with exquisite tenderness over discrete anatomical points, commonly referred to as tender points.  While there is still much debate around the exact etiology or even the exact diagnostic criteria (e.g. number of tender points) for fibromyalgia, there is no doubt that the presence of this syndrome can prove a major barrier to weight management.

Indeed, it is not at all clear whether there may in fact be an etiological link between fibromyalgia and obesity. As outlined in a paper by Akiko Okifuji and colleagues from Salt Lake City, UT, published last year in Clinical Rheumatology, 70% of fibromyalgia patients in their study were overweight or obese and presented with elevated levels of IL-6, catecholamines, cortisol, and CRP, all of which are common findings in obese patients. Furthermore, the patients with fibromyalgia, as do obese patients, presented with reduced sleep duration and efficiency. Based on these commonalities, Okifuji and colleagues concluded that excess weight and obesity may well play a role in fibromyalgia and related dysfunction. 

Interestingly, in 2008, Alan Saber and colleagues published an article in Obesity Surgery describing a significant improvement in pain score and points of tenderness in patients with fibromyalgia who underwent laparoscopic Roux-en-Y gastric bypass surgery. Based on these findings, the authors suggested that weight loss may be an important treatment modality for severely obese patients with this syndrome.

Whether or not less drastic approaches to weight management can provide benefits remains to be seen. Nevertheless, there have been reports of limited response to education, exercise, and psychological interventions. Thus, currently accepted non-pharmacological treatments for fibromyalgia remain rather limited.

Recently, a Cochrane review concluded that duloxetine is efficacious for treating pain in fibromyalgia and another systematic review found evidence that gabapentin and pregabalin can also reduce pain in these patients. 

Nevertheless, fibromyalgia continues to be a common but largely undertreated problem in overweight and obese patients and can often pose a significant barrier to increasing physical activity or modifying ingestive behaviour. 

As blogged before, assessment for muskuloskeletal pain should be a regular and essential feature of any assessment for overweight and obesity. 

I very much look forward to comments from any readers struggling with fibromyalgia or from colleagues on how they manage this debilitating syndrome.

AMS
Edmonton, Alberta

All current guidelines highlight the need for mental health assessments in individuals considering bariatric surgery.

But what exactly should be assessed, how important is mental health as a predictor of outcomes and what is the risk for exacerbation of mental health problems after surgery (remember: bariatric surgery has been reported to substantially increase the risk of suicides and accidental deaths).

These questions are now addressed in a review paper by Charles Pull from the Centre de Recherche Public de la Santé, Luxembourg, just published in Current Opinions in Psychiatry.

The review summarizes findings from previous review articles and new research findings published between August 2006 and August 2009.

According to Pull’s review, although the value of psychopathological factors for predicting weight loss and mental health after surgery remains controversial, the presence of psychopathology should be taken into account both in the presurgical and postsurgical management of patients undergoing bariatric surgery.

Not only is morbid obesity associated with higher rates of psychopathology, including depression, anxiety, eating disorders, abnormal personality traits and personality disorders, there is also clear evidence for poorer postsurgery outcome in individuals with significant presurgery psychopathology (although mental health may improve in a significant number of patients after surgery).

There is a clear need for more substantial information with regard to reliable psychological predictors of weight loss and mental health after surgery.

Importantly, Pull concludes, “whatever the predictive value of psychopathology prior to surgery, it is essential to detect patients in need of psychiatric and/or psychological support after surgery”.

I could not agree more.

AMS
Sapporo, Japan