Bariatric Surgery for the Treatment of Type 2 Diabetes in Patients With Lower Body Mass Index—Are We There Yet?

Dear Readers:

Welcome to the March issue of Bariatric Times.

We start this issue with an excellent evidence-based review article on prevention of anastomotic leaks by Drs. Pooli and Phillips from the Center for Minimally Invasive Surgery, Cedars-Sinai Medical Center, in Los Angeles, California. The authors performed a very comprehensive data search and describe and discuss pre-, intra-, and postoperative interventions that can possibly decrease leak rate. The authors also provide the level of evidence for each described intervention. The question that remains to be answered despite this excellent review is, “Can we really prevent leaks from happening?” The answer is no. Despite excellent technique and experience, the most relevant articles in the bariatric literature report a leak rate below one percent. The most important message when it comes to management of anastomotic leaks is that we must concentrate our efforts on early detection and drainage. As Bob Marema used to say in lectures on management of anastomotic leaks, “the most important step is drainage, drainage, and drainage.”

As you know, use of bariatric surgery to treat type 2 diabetes (T2D) in patients with a body mass index (BMI) less than 35kg/m[2] continues to be a subject of major controversy as an effective and accepted tool. Procedure type, mechanism of action, morbidity, and mortality remain to be defined before we have the green light from the Centers for Medicare and Medicaid Services (CMS) to operate in this patient population. In this issue, we are pleased to have the opportunity to interview Dr. Jaime Ponce, world renowned for his extensive experience with the use of laparoscopic adjustable banding procedure. Though controversial in patients with high BMI, the adjustable gastric band has provided the only scientific evidence that surgically managed weight loss is more effective than medical treatment when it comes to the treatment of type 2 diabetes mellitus in low BMI patients.

Following this, Ms. Lucy Jones, a registered dietitian from The Whittington Hospital in London, describes a rare but significant syndrome in post-bariatric surgery patients: refeeding syndrome. Ms. Jones summarizes the pathology and management of refeeding syndrome, referring to appropriate guidelines available, and then discusses the cases reported in the literature, making recommendations for the future. Refeeding syndrome is a well described entity in those that are subjected to long periods of starvation. I loved Lucy’s article explaining the pathophysiology of this syndrome.

Finally, Dr. Adrienne Youdim (Medical Director, Comprehensive Weight Loss Center, Cedars Sinai Medical Center, Los Angeles, California and Assistant Clinical Professor of Medicine, David Geffen School of Medicine, University of California Los Angeles, California) describes the studies supporting the role of strict long-term glycemic control, as reflected by HbA1c, in reducing postoperative complications, emphasizing the importance of good glycemic control in preoperative bariatric surgery patients. According to the evidence, a reasonable goal for preoperative glycemic control is a HbA1c of 7.0 or less.

We hope you enjoy these excellent contributions. We also hope to see you at the upcoming World Congress Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons April 14–17 in Landover, Maryland. Make sure to stop by the Bariatric Times booth. We would love to meet you and hear your feedback and suggestions for the journal.

Sincerely,

Raul J. Rosenthal, MD, FACS
Editor, Bariatric Times

Tags: Dr. Raul Rosenthal

Category: Editorial Message, Past Articles