Ed Mason at Large—July 2012

This ongoing column is dedicated to sharing with readers the life and experiences of Dr. Edward Mason.

Column Editor: Tracy Martinez, RN, BSN, CBN
Ms. Martinez is the Program Director for Wittgrove Bariatric Center in La Jolla, California.

Dr. Mason, with all the patients you have seen and all the trends in bariatric surgery you have witnessed, what do you believe is the best option for a revision of a Roux-en-Y gastric bypass patient experiencing weight regain? What is your opinion regarding placing an adjustable gastric band over the bypass?
-David Dyer, MD
Nashville, TN
Dr. Mason: If the operation appears to meet the standards for Roux-en-Y gastric bypass (RYGB), I would not revise or convert. I would recommend a search for adverse childhood events (ACE).[1] Half of our patients whose operations had failed to achieve the expected weight control had a history of adverse childhood events. Vincent Felitti, author of “The relationship of adult health status to childhood abuse and household dysfunction,”[1] told me that there were two questions that helped to determine ACE: 1) When did you become obese? 2) Why did it occur at that time? The treatment is counseling. It requires experienced counselors. Some of my answers to the other questions below may help in answering this question. So much depends upon the patient and the many variables involved in his or her care.

The gastric band has risks peculiar to foreign material in the abdomen, especially when close to the digestive tract. These relate to the reactions of scar formation and rejection. The risks of complications over the patient’s remaining life would be increased. Bands must be removed if there is infection or erosion.

What do you think about American Society for Metabolic and Bariatric Surgery and American College of Surgeons providing accreditation together? What are the major advances in weight loss surgery?
-Daniel Jones, MD
Boston, Massuchusetts
Dr. Mason: The American Society for Metabolic and Bariatric Surgery (ASMBS)/American College of Surgeons (ACS) cooperative effort should eliminate duplication and increase cooperation. In addition to accreditation, it could provide longer and more complete follow up. Of course, success will require cooperation of patients. Patients should be made aware of the importance of their continuing participation in this national effort. Let’s encourage them to stay aboard this vehicle of search for truth, Our World.

The one greatest advance in WLS remains the discovery of the missing hormone in type-2 diabetes mellitus by JJ Holst et al in their study of intestinal bypass and their recent study of gastric bypass.[2,3] My “aha” came in 1998 when intestinal bypass operations were reported as stimulating secretion of the missing hormone, GLP-1.[4] The common denominator between resolution of T2DM by intestinal and gastric bypass is GLP-1, and the mechanism for gastric bypass is exposure of distal bowel to glucose, bile acid, and other stimulants of L cell secretion. The ultimate goal of surgeons as physicians should be the elimination of the need for any operation. That is now within reach for many patients, like me, with T2DM who are not severely obese.

If you have not done so, I encourage every reader to review the references in the May 2012 installment of my column in Bariatric Times, where I provide my interpretation of the two studies published in the New England Journal of Medicine comparing bypass surgery with more intensive medical treatment. The operations, which were so strikingly superior, assured that those patients received treatment with their own GLP-1. GLP-1 is available in T2DM. Secretion only requires stimulation. As I mentioned in May’s column, GLP-1 mimetics are available and in use, and a glucose mimetic is effective and in use as a sweetener but is not approved as a neutraceutical or pharmaceutical.

In the beginning, barbers performed surgery because they had the instruments. Today, surgeons have endoscopes and robots but we are much more than physicians who cut. We have the privilege of the most penetrating study of certain diseases and their treatment. We are not really minimally invasive. It just looks that way. GLP-1 causes some weight loss and may decrease the need for operations when a patient’s body mass index (BMI) is 30 to 45kg/m2. GLP-1 type medical treatment for T2DM can reduce the need for surgery and make room on the operating schedule for more severely obese patients who have no other choice. We are discovering how our surgical operations make use of hormones to treat obesity. Maybe someday obesity surgery can be bypassed. Figure how much money and effort that could save our world.

The epidemics continue to overwhelm our healthcare system. Who would have thought this?  Many surgeons, after 1954 for intestinal bypass and after 1966 for gastric bypass, became aware of the immediate benefit of these operations for non-insulin dependent T2DM. In retrospect, Billroth II gastrectomy has prevented and resolved T2DM since 1885, even before we had a name for the disease.

Dr. Mason, in your opinion, what is the future of obesity treatment: medicine or surgery? What about the future of treating type 2 diabetes mellitus with surgery?
-Shashank Shah, MD
Mumbai, India
Dr. Mason: Arthur Steindler, my professor of orthopedics in medical school, taught that there were no bad operations (or treatments). Each use had to match the patient’s requirements. What is best for a patient depends upon what is available, what is approved, and what that patient understands and accepts. Surgery should remain a last resort. Now that we know GLP-1 is the missing hormone, such medication can be provided. This should open a way to treat millions of patients whose BMIs are less than 40kg/m2 and probably many with BMI of 40kg/m2 and greater.

Surgeons will continue to treat obesity and T2DM with GLP-1 stimulating surgery when the BMI is 40kg/m2 or higher. Patients with a BMI less than 40kg/m2 should, in my opinion, be treated with GLP-1 mimetics or dipeptidyl peptidase blocking agents. If and when glucose mimetics are approved they may be low enough in cost to treat the T2DM epidemic. Treatment is most likely to be effective if begun early, whether GLP-1 stimulation is medical or surgical, maybe before it is diagnosable (in central obesity).

Failure of intensive medical treatment with insulin for T2DM should not be accepted as an indication for surgery. GLP-1 is needed for T2DM. Insulin is required only for type 1 diabetes. Some patients have both type-1 and type-2 diabetes if you can find them. If we don’t look we will not find these patients. They are the only patients who need both insulin and GLP-1. We may have missed them because of the treatment of T2DM with insulin instead of with GLP-1 mimetics and DPP4 blocking agents.

Bypass surgery is a way of exposing distal bowel to glucose and other stimulants of secretion of GLP-1, the hormone that is missing in T2DM and that decreases insulin resistance. Pure restriction operations like LAGB do not stimulate GLP-1 secretion. The only way banding helps is through weight loss and maintenance of that loss.

Most surgical endocrinologists have not become bariatric surgeons. The importance of hormones in control of both body weight and T2DM has been revealed. The word metabolic was added to the name of our society (ASMBS). We must study and participate in the science of GLP-1 dependent diabetes. I hope that surgeons and endocrinologists will share in resolving the two epidemics by working together in patient care. The references provided in this column, such as the articles by JJ Holst et al, can open doors to much more as some of you know.

References
1.    Felitti VJ, Anda RF, Nordenberg D, et al. The relationship of adult health status to childhood abuse and household dysfunction. American J Preventive Medicine. 1998;14:245–258.
2.    Näslund E, Blackman L, Holst JJ, et al. Importance of small bowel peptides for the improved glucose metabolism 20 years after jejunoileal bypass for obesity. Obes Surg. 1998;8:253–260.
3.    Falken Y, Hellstrom PM, Holst JJ, Näslund E. Changes in glucose homeostasis after Roux-en-Y gastric bypass surgery for obesity at day three, two months, and one year after surgery: role of gut peptides. J Clin Endocrinol Metab. 2011;96(7):2227–2235. Epub 2011 May 4.
4.    Mason EE. Ileal transposition and enteroglucagon/GLP-1 in obesity (and diabetic?) surgery. Obes Surg. 1999; 9:223–228.

Category: Ed Mason at Large, Past Articles