NEJMx2

NEJMx2

Dear Bariatric Times Editor:

In March, the New England Journal of Medicine published two important, prospective, randomized, and controlled series[1,2] that compared the outcomes of patients with type 2 diabetes (T2DM) treated with intensive medical therapy versus a similar cohort treated with bariatric surgery. Schauer et al[1] reported a series of 150 patients randomized to three equal groups: 1) medical therapy, 2) gastric bypass, and 3) gastric sleeve. Of the 150 patients, 93 percent completed 12 months of follow up. Full resolution was achieved in 12 percent (5 of 41 patients) in the medical therapy group versus 42 percent (21 of 50 patients) in the gastric bypass group (p<0.002) and 37 percent (18 of 49 patients) in the gastric sleeve group (p<0.008). They concluded that “in obese patients with uncontrolled type 2 diabetes, 12 months of medical therapy plus bariatric surgery achieved glycemic control in significantly more patients than medical therapy alone.”

The other paper by Mingrone et al[2] described a controlled trial involving 60 patients with body mass indices (BMIs) of 35kg/m2 or more and advanced T2DM—a diabetes history of at least five years and a glycated hemoglobin level of 7.0% or more. These patients were randomly assigned to receive conventional medical therapy or undergo either gastric bypass or biliopancreatic diversion (BPD). At two years postoperative, diabetes remission had occurred in no patients in the medical-therapy group versus 75 percent in the gastric bypass group and 95 percent in the BPD group (P<0.001 for both comparisons).

The importance of these two papers cannot be overstated. Since 1980, in the 32 years since we first reported the rapid and full remission of T2DM, there have been an overwhelming series of reports that have documented that the gastric bypass produces durable and full remission not only of T2DM, but also of severe obesity, sleep apnea, pseudotumor cerebri, hyperlipidemias, hypertension, nonalcoholic steatohepatitis (NASH), and gastroesophageal reflux disease (GERD). Further, the decrease in weight and inflammation allows patients previously crippled by arthritis to resume activity. Quality of life improves almost uniformly. Finally, multiple reports also document that the surgery, if performed in bariatric Centers of Excellence, is as safe as a routine cholecystectomy with sharp savings in cost.[3]

It is difficult to think of any medical intervention with a greater record of success. Even so, today, a full generation later, less than one percent of those who could be helped by bariatric surgery have access. The reasons are, admittedly, complex. Some patients do not want surgery; some fail to admit the dangers of T2DM and the associated comorbidities; and some are unwilling to try what they still consider experimental surgery. However, the biggest reason is that our colleagues and, indeed, the insurance carriers, did not believe us. After a presentation I gave with other colleagues during a recent medical meeting, an endocrinologist summarized his feelings harshly to us saying, “Seems to me it’s just a bunch of surgeons reporting the success of their work. Like they’re selling cars. I just don’t believe it and I won’t believe it until we see some randomized, prospective studies.”
Well, we’ve met the test. The controlled, randomized, prospective studies have now been done, documenting that T2DM is no longer a hopeless disease and that surgical therapies now offer relief to a degree previously deemed impossible. Now, in turn, it’s time for our colleagues to get on board and to offer patients the most effective therapy.

One might ask, “Why has it taken so long?” Actually, and surprisingly, in terms of other surgical advances, it’s about par for the course. The medical community has, fortunately, always been slow to accept new discoveries. Even though Alexis Carrel (1873–1944) won the Nobel Prize in 1912 for his discoveries in vascular surgery, transplantation, and tissue culture, none of these advances entered medical practice until the 1960s. Similarly, although Jacobeus of Sweden reported the first laparoscopic operation in humans in 1910 and Semm of Germany published over 1,000 papers on the subject by 1985, Eddie Joe Reddick encountered major resistance during his introduction of laparoscopic cholecystectomy in the 1980s. Max Planck, the Nobel Laureate who discovered the quantum theory, may have devised the best explanation: “A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.”

By the way, Planck was far more than a remarkable physicist, He openly opposed Nazi persecutions and intervened on behalf of Jewish scientists and even met with Hitler to stop the persecution. In 1944, his second son was executed for involvement in a plot to assassinate Hitler.

So, what now? How should we proceed so that our rapidly growing population of citizens with T2DM is made aware that their disease is reversible through safe and effective surgery?

Maybe it’s time to consider a motto, and what better way to summarize our frustrations and celebrate our victory than to display “NEJMx2” at every opportunity. I’d bet that those shirts would sell.

An original cartoon by Walter J. Pories, MD, FACS

References
1.    Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012; 366:1567–1576. 2.
2.    Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012;366:1577–1585.
3.    Buchwald H, Cowan Jr G, Pories W. Surgical Management of Obesity, 1e. Philadelphia, PA: Saunders;2006

With regards,

Walter J. Pories, MD, FACS
Professor of Surgery, Biochemistry, Sport and Exercise Science
Brody School of Medicine
East Carolina University
Greenville, North Carolina

G. Lynis Dohm, PhD
Professor of Surgery, Biochemistry, Sport and Exercise Science
Brody School of Medicine
East Carolina University
Greenville, North Carolina

Category: Letters to the Editor, Past Articles