A Message from Dr. Walter J. Pories
Co-Author: Dr. Konstantinos Spaniolas
Walter J. Pories, MD, FACS, Colonel, USA (Ret.), is Professor of Surgery, Biochemistry and Kinesiology, Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina. Konstantinos Spaniolas, MD, FACS, Assistant Professor of Surgery and Interim Chief of Bariatric and Minimally Invasive Surgery, Brody School of Medicine, East Carolina University.
Dear Friends and Readers:
The biggest contribution of “bariatric” surgery is the change in our understanding of metabolic disease. Weight loss, it turns out, is not the only effect. The operations also reverse a variety of diseases previously considered separate illnesses, including diabetes, hypertension, and hyperlipidemias among others. These three illnesses along with central obesity were previously lumped into a “metabolic syndrome,” but even that entity has now been expanded to a much longer list that includes nonalcoholic steatohepatitis (NASH), polycystic ovary syndrome (PCOS), infertility, and gastroesophageal reflux disease (GERD), which also improve when patients undergo bariatric surgery. Even more surprising is the return of pancreatic islet function, relief of renal failure, and repair of cirrhosis following surgical intervention.
These diseases have another common property: They are all associated with high insulin levels indicating a common cellular metabolic defect, perhaps at the level of the tricarboxylic acid (TCA) cycle in the mitochondria.
Given these new observations, we need to reconsider our approaches to this complex disease. We don’t even have a good name for the entity. “Metabolic Syndrome” does not reflect the seriousness of this group of diseases that account for our greatest healthcare costs as the primary causes of renal failure, blindness, amputation, heart attacks, and strokes. One approach to this semantic challenge is use a term like metabolic health and describe metabolic illness as metabolic disease and, if progressed, metabolic failure.
More important than the names, however, is the approach to treatment. If diabetes, hypertension, and PCOS are expressions of the same metabolic defects, then patients with these conditions might be better served in interdisciplinary clinics that facilitate communications and shared opinions regarding therapies.
Our colleagues in oncology already have such a model. They have Cancer Centers that are built with the goal of facilitating optimum care for patients and families. Related specialists see patients in the same clinics, imaging and laboratory resources are easily accessible, and medical records are shared promptly. Consultation is just a few steps away. Access to a pharmacy and needed supplies is convenient. Social services are just a floor level away. Clinical trials are a matter of course. We can learn from this model.
It’s time to explore the creation of “Metabolic Centers” with the same goal: providing the best care for patients with metabolic disease. The designs of the space may have to be different to accommodate the special needs of the patients and various specialties. Of particular importance is the organization of a “Metabolic Board,” an entity similar to a tumor board in cancer centers, where complex cases are seen simultaneously by endocrinologists, primary care physicians, surgeons, nutritionists, social workers, and other essential providers.
Yes, I know it’s a new idea and I am certain that there will be objections about costs, organizational hurdles, and other problems. However, those were the same objections raised with the first cancer centers, trauma centers, and clinics for women and children. As we seek to provide better care for our patients, this idea at least deserves serious consideration.
Walter J. Pories, MD, FACS, and Konstantinos Spaniolas, MD, FACS
1. Kelly CT, Mansoor J, Dohm GL, Chapman WH 3rd, Pender JR 4th, Pories WJ. Hyperinsulinemic syndrome: the metabolic syndrome is broader than you think. Surgery. 2014;156(2):405–411.
2. Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. Chronic Diseases: The Leading Causes of Death and Disability in the United States. August 25, 2015.