The Case for Bariatric Surgery as an Initial Treatment Option
Doron Schneider, MD and Jack Leahy, MD discuss the effectiveness and challenges of bariatric surgery. (7:18)
Dr. Doron Schneider (DS): Hello, my name is Doron Schneider, and I’m a practicing internist at Abington Memorial Hospital in Philadelphia, and today I’m joined by Dr. Jack Leahy [endocrinologist, University of Vermont] to discuss a case that is as follows:
38-year-old Caucasian male who presents to his primary care doctor, not having seen the doctor for over 10 years. He presents with fatigue, thirst and has had some recent weight loss. He has an elevated BMI of 36, his blood pressure’s found to be elevated, 150/96, and he reports a family history of cardiovascular disease, The initial exam is otherwise unrevealing, but blood work does show an A1C of 8.6, cholesterol level up at 130, triglycerides are at 350 and after that encounter we diagnosed him with Type 2 diabetes, hyperlipidemia, and hypertension. This patient does have insurance coverage and is started on hydrochlorothiazide and lisinopril for his blood pressure, atorvastatin for his hyperlipidemia, and now remains how to deal with his A1C which is found at 8.6. First step was counseling and lifestyle modification and with a brief office-based counseling send him on his way to follow up in approximately 8 weeks. Three months later he does show up, and his A1C is down to 8.2 and having had the trial of lifestyle therapy, the next step is to decide how best to manage his Type 2 diabetes.
We’re presented in this case with three possible options. One is monotherapy with metformin. The other is combination therapy, and number three is bariatric surgery. So, Dr. Leahy—maybe a few words about bariatric surgery. This clearly is new on the scene—last ten years or so—increasing in popularity, increasing as an option. How do you think about bariatric surgery as it relates to this patient and maybe more broadly in diabetes in general?
JL: I think this is a very difficult conversation because actually when you read commentaries about bariatric surgery they’re often starting with saying it’s very much an institution variation or even a geographical variation in terms of how active weight reduction programs are, what the collaboration is between the surgeons and maybe a diabetes clinics in a university and on and on and on. So we’re probably not as clean in our thought process in terms of who should go for that kind of surgery as it ought to be, and that probably needs to evolve with time so we have a much better understanding of, you know, criteria, who’s best and how that information should be presented to patients generally across the country plus specifically institution specific.
So now that I’ve said that, I think here's sort of the thought process: It is a common experience of all of us, of people we have taken care of for years and years who struggle with diabetes care, who struggle with obesity, who struggle with hypertension, and who struggle with lipid control, and it just never seems to get better despite adding drug after drug after drug after drug over many years. And I think now that we have this other option, which is a surgical approach, we’re learning that in fact people fairly early in the course of diabetes with significant obesity and other cardiovascular risk factors, that weight reduction surgery can be incredibly effective. And all of the studies that have recently come out in several New England Journal papers in the last year that show about an 80 percent reduction in risk of diabetes after Roux-En-Y gastric bypass surgery; it shows much, much better long-term efficacy in terms of diabetes control or even essential removal of all diabetes treatment agents, and the patients chose weight reduction surgery as opposed to standard medical therapy. Big improvement in cardiovascular risk factors with the surgical approach as opposed to standard medical therapy, and over the long term the Swedish obesity studies showed less cardiovascular disease in patients who had had gastric bypass surgery as opposed to medical therapy.
So it’s clearly, I think, in most patients an effective therapy. The problem is the obvious, which is it's a major surgical approach. It is scary as all get-out to many providers and patients, and because of that it’s still a limited therapy in many institutions, not used probably as much as it should be if we didn’t have all of these negatives attached to it. Specifically, for my institution, the working relationship between us and the surgeons is pretty good, and I think essentially when we see people who are the classic patient of a BMI with 35 and above who have diabetes and especially with other cardiovascular risk factors, at least part of the initial conversation we have with them is that weight reduction surgery is there. It is effective. It would require them to have full consultations and probably a lengthy pre-operative time with these services, that they work hard on a multitude of evaluations before one finally gets surgery, but at least we have the conversation that this, you know, therapy exists, and if people have an interest then we’ll help them go to the appropriate people and learn more about it.
DS: Well, I do believe also that bariatric surgery is going to continue its evolution just as diabetes pharmacologic therapies have in the past 20, 30 years. We continue to see the evolution of bariatric surgery to more, or less invasive options, if you will, that will continue to drive the cost down and to make these more accessible. And for now, your point is well taken to know your own local options, know the complication rates, know the surgeons, know the approaches, and it's that type of knowledge is going to need to be factored into your decision making then you would present to your patients very similar to that kind of knowledge that’s required when you offer pharmaco therapy.
So with that I would like to extend my sincere gratitude to you, Dr. Leahy, for joining me in a discussion of this fascinating case, and we look forward to the next opportunity to get together. Thank you.
JL: Thanks a lot.
DS: This case and others can be found at betacellsindiabetes.org. Please visit the site regularly at as we continue to enhance it, add additional cases, and provide content as it appears in the news, in the literature and around the world.