Wednesday, January 23, 2008

Surgery for Type 2 Diabetes with Obesity?

For inquiries: Contact Form

Schedule of the free no-obligation educational seminars

Who would have thought that the most effective available treatment of a metabolic medical disease (that is, type 2 diabetes) could be a surgical solution? A new study in JAMA showed that patients who have type 2 diabetes and who are obese, were far more able to come off their diabetic medications than those who were treated by non-surgical means.

From Melbourne, Australia, an article titled "Adjustable Gastric Banding and Conventional Therapy for Type 2 Diabetes - A Randomized Controlled Trial" is published in the January 23, 2008 of the Journal of the American Medical Association (JAMA). The aim of the study is to determine if weight loss surgery resulted in better control of type 2 diabetes than medical (non-surgical) approaches to weight loss and diabetes control. Among 55 patients who completed the follow-up (out of 60 patients), remission of type 2 diabetes was achieved by 73% in the surgical group and 13% in the non-surgical group. In this study, the surgical procedure was laparoscopic adjustable gastric banding (Lap Band). Remission meant being able to keep normal diabetic blood tests while not taking diabetes medications anymore. Please notice that the participants' BMI was more than 30 and less than 40. So, the surgeons accepted lower BMI than the usual cut-off of BMI of 35 that is mostly recommended. Furthermore, the study excluded BMI above 40.

This study adds to other pointers from previous research. Dr. Henry Buchwald in his frequently quoted study: "Bariatric Surgery: A Systematic Review and Meta-analysis" reported that weight loss surgery resulted in complete resolution of type 2 diabetes in 76.8% of patients. To my knowledge, not a single conventional non-surgical treatment of diabetes reported anything even close.

Diabetes treated by surgery? Well, this is not a new concept. Actually, in 1992, an article was published under the provocatrive title: "Is type II diabetes mellitus (NIDDM) a surgical disease?". This is one reason why the professional organization for bariatric surgeons in North America changed its name from the "American Society for Bariatric Surgery" (ASBS) to the "American Society for Metabolic and Bariatric Surgery" (ASMBS)

The authors of the reference article, John B. Dixon, MBBS, PhD; Paul E. O’Brien, MD; Julie Playfair, RN; Leon Chapman, MBBS; Linda M. Schachter, MBBS, PhD; Stewart Skinner, MBBS, PhD are from the Centre for Obesity Research and Education (CORE), Monash University, Melbourne, Australia


Dixon JB, O'Brien PE, Playfair J, Chapman L, Schachter LM, Skinner S, Proietto J, Bailey M, Anderson M. Adjustable Gastric Banding and Conventional Therapy for Type 2 Diabetes: A Randomized Controlled Trial. JAMA. 2008 Jan 23;299(3):316-323 (Abstract)

Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004 Oct 13;292(14):1724-37. PMID: 15479938 (Full Text)

Dixon JB, Pories WJ, O'Brien PE, Schauer PR, Zimmet P.Surgery as an effective early intervention for diabesity: why the reluctance? Diabetes Care. 2005 Feb;28(2):472-4. PMID: 15677819 (Full Text)

Pories WJ, MacDonald KG Jr, Flickinger EG, Dohm GL, Sinha MK, Barakat HA, May HJ, Khazanie P, Swanson MS, Morgan E, et al. Is type II diabetes mellitus (NIDDM) a surgical disease? Ann Surg. 1992 Jun;215(6):633-42; PMID: 1632685 (Full Text)

Saturday, January 12, 2008

Abdominal Pain after Gastric Bypass

Let's start with a bottom-line statement: Abdominal pain after gastric bypass (other than the early postoperative recovery) is not normal. You are not expected to have on and off severe pains, nausea or vomiting. Chronic abdominal pain is debilitating and may lead to avoiding eating, and, therefore, unnecessary malnutrition.

Here are some causes of pain after gastric bypass:

1. Bowel obstruction from internal herniation. This condition can be very serious, and may lead to loss of bowel or life. A loop of small bowel glides (herniates) into a defect inside the peritoneal cavity, then becomes trapped. The herniated loop may become strangulated, cutting off the blood supply, which could lead to death of that part of the bowel. I placed this as #1 not because it is common, but because it is probably the most serious and dreaded of all causes of later pain after abdominal surgery.

2. An ulcer, either in the pouch, on the anastomosis, or in the bypassed stomach or duodenum. Ulcers can cause not only severe pain, debilitation and malnutrition, but also may lead to bleeding. An ulcer may even perforate, causing peritonitis. Smoking and chronic intake of non-steroidal anti-inflammatory medications (NSAIDs) are risk factors for the development of ulcers.

3. Gallstones and gallbladder disease.

4. Abdominal wall hernia (incisional hernia, also called ventral hernia) my entrap a loop of bowel causing severe pain. When a hernia does not reduce itself, it is called "incarcerated". An incarcerated hernia may become strangulated, cutting off the blood supply to that loop of intestine. Incisional hernias can occur after any abdominal surgery, and bariatric surgery is no exception.

It is important to not accept pain after gastric bypass surgery as a normal sequence. Make sure that you seek expert help.

Hair Loss after Weight Loss Surgery

Here is a common question: Will I lose all my hair after gastric bypass? How do I keep my hair from falling out? The reality is that hair loss after bariatric surgery is common. But patients do not lose all their hair. In the most severe cases, patients may find clumps of hair in their hair brushes, or in the shower drain. However the hair loss normally corrects itself. The most accepted explanation is inadequate protein intake. Hair loss tends to start about three to five months after surgery. The best way to prevent hair loss is to make sure that you take your proteins first, with each meal.

Hair loss after bariatric surgery is considered a type of Telogen Effluvium. To explain, we need to talk a little bit about the normal phases of the cycle of hair development. Each strand of hair goes through three stages of development. These stages are Anagen – the growing phase, Catagen – the intermediate or transitional phase, and Telogen – the resting phase.

Anagen (The Growth Phase): Lasts 2-6 years. About 85% of all the hairs are in the growth phase at any given period of time.

Catagen (The Transitional Phase): The outer root sheath of the hair follicle shrinks and stops producing hair. The catagen phase usually lasts 2-3 weeks.

Telogen (The Resting Phase) The hair does not grow at all. This phase lasts about 3 months (100 days). An average of 5-15% of all hair is in the resting phase at any given period of time. At the end of this phase, the hair follicle starts a new Anagen phase. The resting (telogen) hair remains in the follicle until it is pushed out by growth of a new anagen hair, unless it was shed earlier. There is some recent evidence suggesting that shedding of a telogen hair might be an active process, independent of an emerging anagen hair.

Telogen effluvium occurs when an event prematurely terminates anagen and causes an abnormally high number of normal hairs to enter the resting, or telogen phase. Not all hair enters the telogen phase, but the percentage is much higher than normal. The hairs that are shed due to telogen effluvium are in the telogen phase. Examples of such events include childbirth, gastric bypass surgery, crash diets with inadequate protein intake, acute blood loss, and high fever. Notice that the follicle is not diseased. Simply, the hair follicle’s biologic clock has been reset. On the average, telogen hair loss occurs 3 months after the event.

For the record, this is very different from another type of hair loss called "Anagen Effluvium". The latter is abrupt loss of hair in the anagen phase, which may be caused by cancer chemotherapy and irradiation therapy. This is very different from telogen effluvium.

In conclusion, hair loss after bariatric surgery (a form of acute telogen effluvium) is fully reversible. Patients never completely lose all their scalp hair, although the hair can be very thin. The hair follicles are not irreversibly affected. With restoration of the nutritional balance, helped by increasing the intake of proteins, hair regrowth is expected within 3 - 6 months.