Walter M. Bortz II


Diabetes Wellness News
Volume 14, Number 7
Diabetes and Surgery

As I write this column, I prepare to write a similar letter the editor of Science, the house publication of the American Association for the Advancement of Science (AAAS) on the same topic. Science and its British counterpart, Nature, are the two leading scientific journals in the world. Any academic who has an article in press in either of these journals is the apple in the eye of all colleagues on campus. Such publications not only bring prestige, but are sturdy credentials for academic advancement and receipt of further research grants, which are the lifeblood of all scientific researchers.

The title of the key article is "Bypassing Medicine to Treat Diabetes," authored by Jennifer Couzin of their editorial staff. The history of this operation goes back 50 years to when stomach surgery was widely prescribed for ulcers and cancer. Often, coincidentally, weight loss and reversed diabetes were noted.

In 1980, Dr. Walter Pories of Greenville, North Carolina took up the cause. His key paper published in 1995 in the Archives of Surgery showed that of the 146 persons with diabetes on whom he operated in the prior 14 years, 121 -- or 83 percent -- became diabetes-free. The word spread rapidly.

Last year there were 120,000 patients operated on by our surgeons for gastric recircuiting. Different types of surgery are available, but the most common consists of creating a short circuit of the upper part of the small intestine plus a shrinking down of the stomach volume to 25 percent of its original capacity.

The really interesting part of the results of the diabetes reversal seems to be independent of the weight loss that accompanies the surgery. A further explanation is sought. In this it is suggested that several hormones from the stomach and small intestine are altered by this procedure, among them GHERLIN [words missing].

It has long been recognized that excessive fat causes the pancreas to work especially hard to make insulin, and somehow this surgery seems to make the higher insulin levels more effective. In my mind, whenever smart people get too smart by messing with the wonderful balance between the body's humours - they are courting unforeseen consequences.

Post-op mortality remains a problem. I have had a family member die after such surgery. To me, invoking a surgical solution to a behavioral problem smacks to immorality. The Diabetes Prevention Program (DPP) unequivocally showed that behavioral intervention strategies work: 58 percent of their cases in the important DPP trial.

Cynics say "You can't get people to lose weight. It is impossible," and therefore, we default to this huge operation of uncertain long-term effects.

However, the National Weight Control Registry-started by doctors Wing and Hill of Brown University and the University of Colorado respectively - involves 5,000 obese individuals. They have reported on the results: 2,700 of the participants have kept off at least 30 pounds for over one year; weight losses range from 30 to 300 pounds - the average weight loss being 66 pounds over five years. Their strategy is behavior modification with dietary restraint and increased exercise. I personally have monitored a 512-pound weight loss in one personal with behavior modification alone. That was largely maintained over the subsequent 25 years. So we have shown that weight loss via behavior change can happen, but is too easily subverted by the lure of a quick fix.

This article follows shortly after a major conference at Stanford, where our new chief of [word missing] surgery described his early results. Similarly, when he was asked in his presentation whether the treatment was appropriate for diabetes he glowingly announced - "absolutely."

But let's think of the numbers for a moment. There are 20 to 30 million persons with diabetes already diagnosed, and maybe another 30 million waiting in the wings, bringing the potential patient population to 50 million in America alone. If our surgeons did five of these operations daily for 200 days a year, that means a thousand operations per surgeon per year - divided into 16 million potential subjects - it would require 60,000 surgeons to address this demand. In 2007, they only did 120,000 - 2 percent of the potential.

The medical system is certainly going to have to get on the stick if they think that this is the solution that we have all been waiting for. This entire scenario personally bothers me a great dealů that this radical approach to a behavioral problem is being so widely utilized and endorsed. To me it is a severe indictment of our medical ethics and needs stern re-examination.

Copyright 2006-20172019 Walter M. Bortz II, M.D.