Category Archives: Diabetes & Bariatrics

It’s not vanity and it’s not easy: NHS agrees

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As reported on Sky News and the New York Times, there has been a radical turn around regarding the use of bariatric surgery to prevent/ control and even “cure” diabetes.

vanity

Not a vanity procedure

Once relegated to the category of a” vanity” procedure, bariatric surgery has emerged as a legitimate,  life-saving intervention which has been scientifically proven to have multiple major health benefits.

For years, patients have had to jump numerous hurdles to be considered for this procedure.  One of the biggest hurdles was often that patients were not considered fat enough to qualify for this procedure.  The traditional guidelines restricted surgery to morbidly obese people, and then required these patients to perform numerous tasks to be considered eligible candidates of surgery such as attaining a diagnosis of “carbohydrate addiction” and losing weight prior to surgery as a sign of “commitment” to weight loss.  This was in addition to several months of therapy with nutritionists and counselors.

hoops

A punitive process

While including this ancillary education may have assisted patients post-operatively, it also felt punitive to people who were seeking medical help.  No one forces lung cancer patients to attend smoking cessation courses or counselling before having their cancer treatment nor do we require several sessions of pre-operative classes prior to a bowel resection.

No, not this kind of scale

New guidelines – perform surgery earlier (2012)

But as the data started to emerge that showed long-lasting health benefits of surgery-assisted weight loss, debates raged between International and American physicians.  Several years ago, several international organizations such as the International Diabetes Federation began to recommend lowering the eligibility criteria for bariatric surgery – particularly for patients with documented complications of obesity present (diabetes, coronary artery disease, severe orthopedic injuries).  But these recommendations were ignored by American medical societies and many physicians including the doctors responsible for initiating referrals to bariatric surgery programs.  Americans. it seemed were reserving the the more effective treatments (like gastric bypass or gastric sleeve) for the super-obese, and the prototypical 600 pound patients.

Obese patients who did not meet these rigid guidelines were often sent for less effective procedures like lap-band or balloon placement.  Insurance companies often denied payment stating that surgery in these patients were ‘not medically necessary’  and thus it was considered a ‘vanity’ procedure.  Additionally, in most cases, the procedures failed to produce meaningful or long-lasting results.

Adding stigma and shame to a medical condition

Patients who were overweight  and seeking definitive treatment were often made to feel “lazy” for being unable to lose weight without surgical assistance.  They were also told to return only if they continued to fail (or gain weight).

The Diabetes Pandemic

But as the obesity pandemic continued to escalate at breakneck speed along with obesity-related complications (and healthcare costs skyrocketed), the evidence began to become too overwhelming to ignore.

New guidelines were passed for eligibility criteria for gastric bypass procedures.  These guidelines reduced the necessary BMI to qualify for surgery, especially in patients with co-morbidities such as diabetes.  But it still ignored a large segment of people; non-morbidly overweight people with early diabetes – the very group that was most likely to have a high rate of success and immediate normalization of blood sugars*.

But now the government of the United Kingdom and the National Health Service (NHS) have adopted some of the most progressive recommendations world-wide; aimed at stemming the tide of diabetes and diabetes-related complications such as heart attacks, strokes, renal failure, non-alcoholic fatty liver disease (NASH) and limb ischemia leading to amputation.

The NHS should be commended for their early adoption of eligibility criteria that lowers the BMI requirement to 30 in diabetic individuals and eliminates this requirement entirely in diabetes of Asian descent**. Conservative estimates believe that this change will make an additional one million British citizens eligible for bariatric surgery.

* As a ‘cure’ for diabetes, gastric bypass is most successful in people who have had the disease for less than eight years.

Surge of patients but few surgeries

But can supply keep up with demand?  Last year, according to the our source article (NYT), only 9,000 bariatric procedures were performed in the UK.

**Diabetics of Asian and East Indian  heritage (India, Bangladesh, Pakistan) often develop a more severe, aggressive, rapidly progressive form of diabetes which is independent of BMI or obesity.

More from the Diabetes & Bariatric Archive:

Life after bariatric surgery

Bariatric surgery and the family

Bariatric surgery and CV risk reduction

The Diabetes Pandemic

Part II

Diabetes as a surgical disease

Gastric bypass as a cure for diabetes

New recommendations on the bariatric surgery and diabetes

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New recommendations out of a recent conference in Austria as reported by the Heart.org.  This comes on the heels of the most recent changes in BMI recommendations, as we reported last month.

As reported by Steve Stiles over at the Heart.org,  in”Case made for metabolic bariatric-surgery eligibility criteria,”  new evidence and recommendations suggest that surgery should be done earlier in the course of the disease process (diabetes) in patients with lower BMIs.  Currently the BMI restriction criteria enforced in North America and Europe prevent the majority of diabetic patients from receiving gastric bypass surgery, which is the only proven ‘cure’ for diabetes.  That’s because the majority of type II diabetic patients are  overweight but not morbidly obese.

As reported previously on this site, Latin American bariatric surgeons have been at the forefront of the surgical treatment of diabetes.  Many of the surgeons previously interviewed for numerous projects here at Cartagena Surgery were involved in several early studies on the effects of surgery in moderate overweight patients with diabetes.

More interestingly, researchers at the conference are also suggesting possible gastric bypass procedures for patients with ‘pre-diabetes’ or patients with an hemoglobin A1c greater than 5.7 % but less than 6.5% (6.5% is the cut off for diagnosis of diabetes.)

This is wonderful news – it means committees and such are finally getting around to following all of the research that has been published and presented over the last ten years..  But then it just one more important step…

Call it by its name

So I have my own suggestion to doctors and researchers – and it’s one that I’ve made been – a nomenclature change.  We need to stop calling it “pre-diabetes”, because the name is a falsehood – and leads everyone (patients, nurses and doctors astray.)

– Greater than 95% of patients with ‘pre-diabetes’ will develop diabetes – so without a drastic intervention (far beyond diet and exercise)  it’s pretty much a certainty.

– Many of the devastating complications of diabetes develop during this so-called pre-diabetic period.

– Doctors are now recommending surgical treatment to cure this “pre” disease state.

So….  

if almost everyone who has ‘pre-diabetes’ gets diabetes, and it’s already causing damage PLUS we now recommend a pretty radical lifestyle change (surgical removal of most of the stomach) —> that sounds like a disease to me.  Call it early diabetes, call it diabetes with minimal elevation of lab values, but call it what it is….Diabetes..

This is critical because without this firm diagnosis:

– insurance won’t pay for glucometers, medications, diabetic education, dietary counseling (or surgery for that matter).  That’s a lot of out-of-pocket expenses for our patients to bear, for something that is treated like a ‘maybe’.

– patients (and healthcare providers) alike won’t take it seriously..  Patients won’t understand how crucial it is to take firm control of glucose management, patients won’t be started on preventative regimens to prevent the related complications like renal failure, heart disease and limb ischemia.

– Patients may not receive important screening to prevent these complications – and we already know that at the time for formal diagnosis (usually SEVEN years after initial glucose derangements are seen) – these patients will already have proteinuria (a sign of kidney disease), retinopathies, vasculopathies and neuropathies..

I work with providers every day, and the sad fact is that too many of them (us) shrug their shoulders and say – yeah – he /she should eat better, get more exercise, shrug.. But they don’t treat the disease – they don’t start checking the glucose more often, they don’t start statin drugs, the don’t screen for heart disease and they don’t consult the specialists – the diabetic educators, the nutritionists, the endocrinologists – and yes, the bariatric surgeons…

Chances are if your doctors and your nurses don’t take it seriously; and don’t make a big deal out of it – and don’t talk to you, at length about what “pre-diabetes” IS and what it really means for your life and your health –

then neither will you.

For related content:  see the Diabetes & Bariatric tab

the Weight of a Nation: the obesity epidemic

Bariatric surgery and non-alcoholic fatty liver disease

The Pros & Cons of Bariatric Surgery

Gastric bypass to ‘cure’ diabetes goes mainstream

Talking with Dr. Jhon Jairo Berrio about vascular disease and Prostaglandin E1

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XXIX Congreso Latinoamericano de cirugia vascular y angiologia

Santa Cruz de la Sierra, Bolivia

Dr. Berrio, Vascular Surgeon, Tulua, Colombia

Dr. Jhon Jairo Berrio is  the Chief of Vascular Surgery at the Clinica San Francisco, Tulua, Colombia, which is a small community outside of Cali.  He attended medical school in Colombia, completing his general surgery residency at Hospital clinics for Carlos.  He completed additional training at New York University and he completed his vascular surgery residency in Bogota at the Hospital de Kennedy  and trained under the instruction of Dr. Albert Munoz, the current president of the Association of Latin American Vascular Surgery and Angiography (ALCVA) .  He does a range of vascular procedures such as aortic aneurysm repair, fistula creation as well as endovascular surgery but his favorite procedures are limb salvage procedures such as aorto-femoral bypass, femoral-popliteal bypass and other treatments designed to prevent amputation.

He is here in Bolivia giving a presentation on the use of Prostaglandin E1 for critical ischemia / and last chance limb salvage.

Today we are talking to Dr. Berrio about the use of prostaglandin E1 (Iloprost/ iprostadil) for peripheral vascular disease (PAD).  In the past, we have used a myriad of treatments including statins, pentoxifylline, clopidogrel and even quinine for the prevention and relief of claudication symptoms.  However, all of these previous agents are designed for early PAD and are only minimally effective at treating later stages of disease.  Treatment of severe disease (rest pain or ulceration/ ischemia wounds) has been limited to stenting (angioplasty) and surgical revascularization – but this strategy often fails for patients with microvascular disease (or disease that affects vessels that can not be operated on.)

Last effort at Limb Salvage in critical ischemia

No – Prostaglandin E is not some magic ‘panacea’ for peripheral vascular disease.  There is no such thing – but it is a medication in the treatment arsenal for vascular surgeons – and it has shown some promising results particularly in treating limb-threatening ischemia.  In fact, the data goes back over 20 years – even though most people in the United States have never heard of it.  That’s because prostaglandin E1 is more commonly used for other reasons in the USA.  It is a potent vasodilator, and in the US, this medication is often used in a different (aerosolized form) for primary pulmonary hypertension.  It is also used for erectile dysfunction.  Despite a wealth of literature supporting its use for critical ischemia it is not currently marketed for such use in the United States – and thus – must be individually compounded in a hospital pharmacy for IV use.  Supplies of this medication in this form are often limited and costly.

Intravenous Prostaglandin E1

This medication offers a desparately needed strategy for patients with critical ischemia who (for multiple reasons) may not be surgical candidates for revascularization and is a last-ditch attempt to treat ‘dry’ gangrene and prevent amputation and limb loss.  Since more than 25% of all diabetes will undergo amputation due to this condition – this is a critical development that potentially affects millions of people.  (Amputations also lead to high mortality for a variety of reasons not discussed here.)

What is Prostaglandin E1?

As mentioned above, prostaglandin E1 is a potent vasodilator – meaning it opens up blood vessels by forced the vessels to dilate.  This brings much-needed blood to ischemia tissue (areas of tissue dying due to lack of blood.)

Treatment details:

A full course of treatment is 28 days.  Patients receive 60 micrograms per day by IV.

Patients must be admitted to the hospital for observation for the first intravenous administration of prostaglandin E1.  While side effects such as allergic reactions, rash or tachycardia are rare – since this medication is given as an IV infusion, doctors will want to observe you for the first few treatments. The most common side effect is IV irritation.  If this occurs the doctors will stop the infusion and dilute it further to prevent discomfort.  Once your treatment has been established, doctors may arrange for you to have either out-patient therapy at an infusion center, or home health – where a nurse comes to your house to give you the medication.

The surgeons will evaluate your legs before, during and after treatment.  If the ischemia or rest pain are not improving, or worsen during treatment – doctors may discontinue therapy.

Prostaglandin E1 therapy is compatible with other medications for PAD such as clopidogrel, aspirin, pentoxifylline and statins, so you can continue your other medications for PAD while receiving this treatment.  However, if you are taking nitrates such as nitroglycerin, (Nitro-dur, Nitropaste) or medications for pulmonary hypertension or erectile dysfunction – please tell your surgeon.

In Colombia, the average cost of the entire course of treatment (4 weeks of daily therapy) is 12 million Colombian pesos.  At today’s exchange rate – that is  a little under $ 7000.00  (seven thousand dollars, USD).

While this is a hefty price tag – it beats amputation.  In some cases, arrangements can be made with insurance companies to cover some of the costs.  (Insurance companies know that amputation-related costs are higher over the long run, since amputation often leads to a lot of other problems due to decreased mobility).

Additional Information about Dr. Berrio:

Dr. Jhon Jairo Berrio, MD

Vascular surgeon

Calle 414 – 30

Buga, Colombia

Tele: 236 9449

Email: vascular@colombia.com

Speaks fluent English, Espanol.

References/ Additional information about peripheral arterial disease (PAD) and prostaglandin e1

Pharmacotherapy for critical limb ischemia  Journal of Vascular Surgery, Volume 31, Issue 1, Supplement 1, January 2000, Pages S197-S203

de Donato G, Gussoni G, de Donato G, Andreozzi GM, Bonizzoni E, Mazzone A, Odero A, Paroni G, Setacci C, Settembrini P, Veglia F, Martini R, Setacci F, Palombo D. (2006).  The ILAILL study: iloprost as adjuvant to surgery for acute ischemia of lower limbs: a randomized, placebo-controlled, double-blind study by the italian society for vascular and endovascular surgery.  Ann Surg. 2006 Aug;244(2):185-93.  An excellent read – even for novices.

S Duthois, N Cailleux, B Benosman, H Lévesque (2003).   Tolerance of Iloprost and results of treatment of chronic severe lower limb ischaemia in diabetic patients. A retrospective study of 64 consecutive cases .  Diabetes & Metabolism, Volume 29, Issue 1, February 2003, Pages 36-43

Katziioannou A, Dalakidis A, Katsenis K, Koutoulidis V, Mourikis D. (2012).  Intra-arterial prostaglandin e(1) infusion in patients with rest pain: short-term results.  Scientific World Journal. 2012;2012:803678. Epub 2012 Mar 12.e Note extremely small study size (ten patients).

Strecker EP, Ostheim-Dzerowycz W, Boos IB. (1998).  Intraarterial infusion therapy via a subcutaneous port for limb-threatening ischemia: a pilot study.  Cardiovasc Intervent Radiol. 1998 Mar-Apr;21(2):109-15.

Ruffolo AJ, Romano M, Ciapponi A. (2010).  Prostanoids for critical limb ischaemia.  Cochrane Database Syst Rev. 2010 Jan 20;(1):CD006544.

Volteas N, Leon M, Labropoulos N, Christopoulos D, Boxer D, Nicolaides A. (1993).  The effect of iloprost in patients with rest pain.  Eur J Vasc Surg. 1993 Nov;7(6):654-8.

New NAFLD (nonalcoholic fatty liver disease) resources from Medscape

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On the heels of a previous post about NAFLD/ NASH (nonalcoholic liver disease) – Medscape just published new treatment guidelines along was part of an on-going series of articles on  fatty liver disease.

While Medscape is free – it does require a subscription to view, so I’ve re-posted the articles (as downloadable pdfs) here for interested readers.  I would also like to encourage people to sign up with Medscape.com on-line.

Guidelines:

Diagnosis and Management of NAFLD: New Guidelines – David A. Johnson

Summary of new guidelines for treatment of fatty liver disease  – Laurie Barclay

However, there are some concerns related to these new guidelines – primarily the recommendations for Vitamin E and other supplements for biopsy-proven NAFLD.  The biggest concerns relate to the availability and purity of these products.  Caution is advised in the use of unregulated over-the-counter supplements since the purity and efficacy of these products may vary widely.

In the ‘Ask the Experts’ readers ask Dr. William F. Balistreri, MD – Is the Prevalence of NASH Really Rising?   In another article, Dr. Balistreri addresses, How Can I Convince My Patients That NASH Is Serious?

As we’ve discussed before, the incidence of fatty liver disease is on par with the expanding obesity epidemic – and histological evidence of liver disease is apparent in over 70% of bariatric surgery patients (at the time of surgery.)

Now doctors are seeing in younger patients – as the more and more kids become obese. In the article [below] by Helwick,  10% of all adolescents in the USA are estimated to have fatty liver disease.

A Fat Kid With a Fatty Liver: Case Challenge – Valerio Nobili, MD; Massimiliano Raponi, MD

Prevalence of NAFLD Increasing Among American Adolescents -Caroline Helwick

Of course, some of this is old news to long-time readers, who read Charlotte Rabl and Guilherme M. Campos’ article, The Impact of Bariatric Surgery on Nonalcoholic Steatohepatitis here at Cartagena Surgery, way back in April 2012 as part of our on-going discussions on bariatric surgery.

This article was just this beginning; with another article published just a few weeks later by Sindu Stephen; Ancha Baranova and Zobair M Younossi.  Their article, Nonalcoholic Fatty Liver Disease and Bariatric Surgery reinforced the idea of bariatric surgery as a reasonable option for obese patients with liver disease.

For everyone looking for information on fatty liver disease, I hope these articles get you started.. Then head over to Medscape for the full library of resources.

Dr. Marco Sarinana and Dr. Joel Ramos,Bariatric surgeons

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Busy day yesterday – spent the morning shift with Jose Luis Barron over at Mexicali General..  Then raced over to Hospital de la Familia for a couple of general and bariatric cases.

The first case was with the ever charming Drs. Horatio Ham, and Rafael Abril (who we’ve talked about before.)  with the always competent Dr. Campa as the anesthesiologist.   (Seriously – Dr. Campa always does an excellent job.)

Then as we prepared to enter the second case – the director of the hospital asked if I would like to meet Dr. Marco Sarinana G. and his partner, Dr. Joel Ramos..  well, of course.. (Dr. Sarinana’s name has a tilde over the first n – but try coaxing that out this antique keyboard..)

So off to the operating room with these three fellows.  (This isn’t my usual protocol for interviewing surgeons, etc. but sometimes it works out this way.)  Their practice is called Mexicali Obesity Solutions.

Dr. Marco Sarinana and Dr. Joel Ramos, Bariatric surgeons

Dr. Alejandro Ballesteros was the anesthesiologist for the case – and everything proceeded nicely.

After that – it was evening, and time to write everything down!

Today should be another great day – heading to IMSS with Dr. Gabriel Ramos for a big case..

Coffee as a superfood round-up

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Update:  New article published on MSNBC –  25 May –underscores health benefits of coffee –  and further proves premise of optimal coffee ingestion at five to six cups.  (Previous studies showed the majority of benefits at five cups/ day.)

Posting this for a friend, who wasn’t quite convinced by my arguments for coffee..  Added the video just for a light-hearted touch..and who doesn’t like David Bowie..

Happily,  the majority of people have gotten away from the incorrect notion that coffee is somehow harmful, the “I gave up cigarettes and coffee” mentality.. It always irks me a bit when coffee drinking is lumped into a group of unhealthy behaviors….Stay away from coffee… and crack cocaine, people… But seriously, this is one beverage that has been mislabeled over the years – undeservedly.

With so many honest – to-  goodness harmful food additives,  fast food and other ‘junk‘ we put in our bodies – misidentifying coffee is a tragedy (albeit, a small one.)  Admittedly, it is hard on my dental enamel – but otherwise, it is a welcome part of my daily routine.

So today, we are going to review some of our previous posts and the latest published information on coffee and it’s health effects..

For starters, we are going back to a post dated March 2011 – where I first reviewed my love of the hot, rich beverage, along with a summary of health benefits..

We talked about preliminary research suggesting coffee may be protective against strokes.. An additional study on this was actually just published last month, as reported in Medscape.com, Moderate coffee intake protects against stroke, (11 May, 2012) on a meta-analysis presented at the European Society of Hypertension (ESH) European Meeting on Hypertension 2012 by Dr Lanfranco D’Elia. 

Then – a year ago (May 2011) we brought you more information about coffee as a potent anti-oxidant, and potential implications for preventing cancer (and refuting claims that it caused cancer.)

Following that – in July of 2011 – we went as far as proclaiming ‘superfood status’ when preliminary research suggested coffee ingesters were less likely to have MRSA colonization.

We haven’t even touched on the diabetes, and pancreatic cancer angle today, but suffice to say that research shows that the pancreas has a definite affinity for coffee..

Now, on the heels of reports of the underdiagnosis and increasing incidence of fatty liver disease – comes a study in the Annals of Hepatology entitled, “High coffee intake is associated with lower grade nonalcoholic fatty liver disease: the role of peripheral antioxidant activity.”  Translated for readers, this small study by Gutierrez – Grobe, et. al (2012) suggests that high coffee intake is actual beneficial and may have a protective effect on the liver.  Now – don’t get too excited – since it was just a very small study, of 130 subjects – coffee and noncoffee drinkers, 73 without liver disease and 57 with liver disease.  So clearly, we need to look at this more closely..

But in the meantime, you can keep drinking your coffee.

Back in the OR with Drs. Ham & Abril, bariatric and general surgeons

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My first case this morning with another surgeon was cancelled – which was disappointing, but I still had a great day in the operating room with Dr.  Ham and Dr. Abril.  This time I was able to witness a bariatric surgery, so I could report back to all of you.

Dr. Ham (left) and Dr. Abril

I really enjoy their relaxed but detail oriented style – it makes for a very enjoyable case.  Today they performed a sleeve gastrectomy** so I am able to report – that they (Dr. Ham) oversewed the staple line (quite nicely, I might add).  If you’ve read any of the previous books, then you know that this is an important step to prevent suture line dehiscence leading to leakage of stomach contents into the abdomen (which can cause very serious complications.)  As I said – it’s an important step – but not one that every doctor I’ve witnessed always performed.   So I was a pleased as punch to see that these surgeons are as world-class and upstanding as everything I’d seen already suggested..

** as long time readers know, I am a devoted fan of the Roux-en-Y, but recent literature suggests that the sleeve gastrectomy is equally effective in the treatment of diabetes.. Of course – we’ll be watching the research for more information on this topic of debate. I hope further studies confirm these results since the sleeve gives patients just a little less of a drastic lifestyle change.. (still drastic but not shot glass sized drastic.)

Dr. Ham

They invited me to the show this evening – they are having several clowns (that are doctors, sort of Patch Adams types) on the show to talk about the health benefits of laughter.  Sounds like a lot of fun – but I thought I better catch up on my writing..

I’ll be back in the OR with Los Doctores again tomorrow..

Speaking of which – I wanted to pass along some information on the anesthesiologist for Dr. Molina’s cases since he did such a nice job with the conscious sedation yesterday.  (I’ve only watched him just yesterday – so I will need a few more encounters, but I wanted to mention Dr. Andres Garcia Gutierrez all the same.

the Weight of a Nation: the obesity epidemic

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There’s a new series on HBO that is a collaboration between the Institute of Medicine, the CDC and the National Institute of Health (NIH) that begins airing tomorrow night.  This is a huge undertaking that took over three years to bring to the screen.

As many of you know – Obesity, diabetes and bariatric surgery are some of the topics that have been covered fairly extensively here at Cartagena Surgery.  In fact – it’s the heart of Cartagena Surgery – since the very first surgeon interview I ever performed back in 2010 was Dr. Francisco Holguin Rueda, MD, FACS, the renown Colombia bariatric surgeon.  (Shortly after that first leap – came Drs. Barbosa and Gutierrez – which is how we ended up here today.)

I’ve also been spending time, both last week and this week in the company of several bariatric surgeons here in Mexicali. MX and plan to go to several surgeries this week – so it seemed only appropriate to publish a few articles on the topic.

Talking with Dr. Horacio Ham – Bariatric surgeon, part 1

Talking with Dr. Ham, part 2

(I’m still transcribing notes from another one of my recent interviews – with Dr. Jose Durazo Madrid, MD, FACS).

I’d also like to encourage readers to take a look at HBO’s new mini-series (four episodes over Monday and Tuesday).

In the OR with Los Doctores, Dr. Ham & Dr. Abril

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Haven’t had time to sit down and write about my trip to the operating room with Dr. Horacio Ham and Dr. Rafael Abril until now, but that’s okay because I am going back again on Saturday for a longer case at a different facility.  Nice surprise to find out that Dr. Octavio Campa was scheduled for anesthesia.  Both Dr. Ham and Dr. Abril told me that Dr. Campa is one their ‘short list’ of three or four preferred anesthesiologists.  That confirms my own impressions and observations and what several other surgeons have told me.

campa

Dr. Campa (left) and another anesthesiologist at Hispano Americano

That evening we were at Hispano – Americano which is a private hospital that happens to be located across the street from the private clinic offices of several of the doctors I have interviewed.  It was just a quick short case (like most laparoscopy cases) – but everything went beautifully.

As I’ve said before, Dr. Campa is an excellent anesthesiologist so he doesn’t tolerate any hemodynamic instability, or any of the other conditions that make me concerned about patients during surgery.

Dr. Ham  and Dr. Abril work well together – everything was according to protocols – patient sterilely prepped and draped, etc..

laparoscopy

laparoscopy with Dr. Ham & Dr. Abril

I really enjoy talking with the docs, who are both fluent in English – but I won’t get more of an interview with Dr. Abril until Saturday.

w/ Dr. Ham

with Dr. Horacio Ham in the operating room after the conclusion of a successful case

Then – on Wednesday night – I got to see another side of the Doctors Ham & Abril on the set of their radio show, Los Doctores.  They were interviewing the ‘good doctor’ on sympathetectomies for hyperhidrosis – so he invited me to come along.

Los Doctores invited me to participate in the show – but with my Spanish (everyone remembers the ‘pajina’ mispronunciation episode in Bogotá, right?)  I thought it was better if I stay on the sidelines instead of risking offending all of Mexicali..

Los Doctores

on the set of Los Doctores; left to right: Dr. Rafael Abril, Dr. Carlos Ochoa, Dr. Mario Bojorquez and Dr. Horacio Ham

It really wasn’t much like I expected; maybe because all of the doctors know each other pretty well, so it was a lot more relaxed, and fun than I expected.  Dr. Abril is the main host of the show, and he’s definitely got the pattern down; charming, witty and relaxed, but interesting and involved too.. (my Spanish surprises me at times – I understood most of his jokes…)  It’s an audience participation type show – so listeners email / text their questions during the show, which makes it interesting but prevents any break in the format, which is nice.  (Though I suppose a few crazy callers now and then would be entertaining.)

Dr. Ochoa did a great talk about sympathectomy and how life changing it can be for patients after surgery, and took several questions.  After meeting several patients pre and post-operatively for hyperhidrosis, I’d have to say that it’s true.  It’s one of those conditions (excessive palmar and underarm sweating) that you don’t think about if you don’t have – but certainly negatively affects sufferers.  I remember an English speaking patient in Colombia telling me about how embarrassing it was to shake hands -(she was a salesperson) and how offended people would get as she wiped off her hands before doing so.  She also had to wear old-fashioned dress shields so she wouldn’t have big underarm stains all the time..  This was in Bogota (not steamy hot Cartagena), which is known for it’s year-round fall like temperatures and incredibly stylish women so you can imagine a degree of her embarrassment.

It (bilateral sympathectomy) is also one of those procedures that hasn’t really caught on in the USA – I knew a couple people in Flagstaff who told me they had to travel to Houston (or was it Dallas?) to find a surgeon who performed the procedure..  So expect a more detailed article in the future for readers who want to know more.

Tomorrow, (technically later today) I head back to San Luis with the good doctor in the morning to see a couple of patients – then back to the hospital.. and then an interview with a general surgeon.. So it should be an interesting and fun day.

Dr. Horacio Ham, and Los Doctores

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Just finished interviewing Dr. Horacio Ham, a bariatric surgeon with the DOCS (Diabetes & Obesity Control Surgery) Center here in Mexicali.  Later this evening, we’ll be heading off to surgery, so I can see what he does first-hand.

Tomorrow sounds like a jam-packed day for the young doctor, he’s being interviewed for a University television series on Obesity in addition to his normal activities (surgery, patients) and of course, the radio show.  Turns out his guest doctor tomorrow evening is none other my professor, the ‘good doctor.’

Sounds like a great show – so if you are interested it’s on 104.9 FM (and has internet streaming) at 8 pm tomorrow night..

I’ll report back on the OR in my next post..

Bariatric surgery and non-alcoholic fatty liver disease

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Interesting article over at Medscape on the role of bariatric surgery in the treatment of non-alcoholic fatty liver disease (NAFLD) and (NASH).

For the uninitiated, non-alcoholic fatty liver disease is a serious condition where functional tissue of the liver (used to metabolize and detoxify everything we ingest including medications) is replaced with fat tissue, and eventually fibrosis.  As more and more healthy tissue becomes fatty & fibrotic, the liver function deteriorates until it progresses to cirrhosis and eventual liver failure.

Currently, the only treatment for cirrhosis and liver failure is liver transplantation (which is still only a temporary measure, even in the best case scenarios*.)

But why is the happening?  and who does it affect?  Obesity and obese patients.

To better understand what’s going on – we need to review some basic pathophysiology:

First, lets look at food.  Not in cultural or psychosocial way, or even in food preferences, but food as the body sees it: Fuel for all of our cellular functions.  Just as we run our houses, appliances and cars on different types of fuel – gasoline, natural gas, electricity etc.  our body runs on different types of fuels (proteins, fats, sugars) that all get broken down to serve as energy.  Like fossil fuels – the metabolism of each of these fuels requires different mechanisms (ie. gas-powered versus electric cars) and creates different by-products.

Now I want you to think of a scale.

No, not this kind of scale

No – I want you to think of a scale, as in a delicate balance between differing metabolisms for different fuels.

Think of a multi-tiered scale, where a delicate balance between the types of metabolism and waste products is required for continued good health – anything that upsets the balance such as diabetes – throws everything out of whack.

Normally, as fuel (food) in consumed – the body uses insulin to transport the fuel into the cell for processing (metabolism), so think of insulin as a wheelbarrow carrying in complex carbohydrates (sugars) into the cell.

Now, in a person with obesity & diabetes – two things are occurring – too much fuel and not enough wheelbarrows**.  These means that:

1.  Excess fuel is converted into fat (adipose tissue – which we are all familiar with).

2.  Without the wheelbarrows, the body has to find another way to break down the fuel.  This other pathway – for fat metabolism has a lot of by-products  – namely free fatty acids (cholesterol and triglycerides.)  This leads to numerous problems (hypercholesterolemia and cardiovascular disease for one), and fatty liver disease.

(This is a gross oversimplification of a series of very complex mechanisms, but for today’s discussion – it is sufficient.)

Just as the rates of obesity, and diabesity (diabetes caused by obesity) have skyrocketed, so has cardiovascular disease (which we’ve talked about before) and the prevalence of non-alcoholic liver disease. In fact, the authors of the study below found that 70% of the people with a BMI greater than 35 have some degree of non-alcoholic liver disease, and over 30% have the more severe form – NASH.

The article by Rabl & Campos (2012) looks at the literature on the outcomes (progression or regression of disease) after bariatric surgery in patients previously diagnosed with NAFLD.  (I’ve linked a pdf version of the entire article under the full reference.)

They looked at the current bariatric procedures including the ever popular lap-band procedure and it’s effectiveness in treating NAFLD. What they found was that in the majority of cases – with certain procedures (formal gastric bypass surgery aka Roux en Y, and biliopancreatic diversion procedures) the disease process was not only halted, but regressed as a result of both weight loss, and a reversal of altered metabolism.  They also found that as a result of a reduced stomach surface area (in comparison to lap-band procedures where the stomach remains intact) – reduced ghrelin leads to increased weight loss.

(If you don’t know about ghrelin – think of it as an evil gremlin (the one that makes you want cookies when you know you are about to eat dinner) – since it is a potent appetite stimulant produced by the stomach.  The larger the stomach – the more ghrelin released – so the surgical procedures such as gastric bypass where a portion of the stomach is actually surgical removed are significantly more effective overall that lap-banding procedures.)

This is a significant advancement for medicine and the treatment of obesity related disease – since as we suggested above, multiple authors including Burianesi et. al (2008) suggest that the true prevalence of non-alcoholic fatty liver disease is much higher than we realize, (thus affecting a lot more people.)

Notes

* There is a tendency in American society to ‘gloss over’ many of life’s harsh realities, and no where is this more evidence than in the public perceptions of organ transplantation as a ‘cure’ or permanent solution for organ failure.  Transplanted organs do not have the same life expectancy as native organs (even in the best case scenarios) – and for most people who need non-kidney transplants – they get one opportunity, not multiple.  Transplanted organs last ten years – maybe fifteen at the outside – so this is not a cure (particularly in young patients).  Transplantation also carries a whole host of other problems with it – such as the development of opportunistic infections and cancer from the drugs used to prevent rejection, or rejection itself.  The very drugs used to prevent rejection of some organs may cause failure of others – so relying on transplantation as a ‘cure’ for a disease that is becoming more and more prevalent is a pretty poor strategy.

** This balance between mechanisms can be upset in other ways – by starvation, for example, when the body starts catabolizing proteins..  Catabolizing – think cannibalism – as the body consumes it’s own muscle tissue because there is nothing left for it to eat, after it has exhausted all other sources of fuel.

References and Resources

Rabl, C. & Campos, G. M. (2012)  The Impact of Bariatric Surgery on Nonalcoholic Steatohepatitis. Semin Liver Dis. 2012;32(1):80-91 [Article under discussion above].

Body Mass Index calculator – West Virginia Dietetic Association.

Bugianesi et. al. (2008).  Clinical update on non-alcoholic fatty liver disease and steatohepatitis. Annals of hepatology, 2008; 7 (2): April – June 157-160.  The authors ask, “What is the real prevalence of disease?”

Goldstein, B. J. (2001) Insulin Resistance: Implications for Metabolic and Cardiovascular Diseases.  This is a good presentation that explains how alterations in glucose metabolism (from diabetes) affects fat metabolism.

Overview of NASH/ NAFLD with classifications, diagnostics, prognostics : University of California, San Diego – Dan Lawson, 2010 [notes]. Good reference for medical students, health care professionals wanting a brief review.

Salt, W. B. (2004).  Nonalcoholic fatty liver disease (NAFLD): A comprehensive review.  J Insur Med, 2004; 36: 27 -41.

For more about Bariatric surgery – including the Pros & Cons

The Pros & Cons of Bariatric Surgery

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As my loyal readers know, I do my best to try to give fair and balanced depictions of surgical procedures, as well as reviews of medical and surgical news and research.  Over at Medscape.com – there is a new video discussion by Dr. Anne Peters, MD.  Dr. Peters is an endocrinologist and a certified diabetic education.  In this video – she talks about the realities of bariatric surgery, and these are things I think that people need to hear.

For more on Bariatric surgery – see my other posts

One of the points that she makes, is (in my opinion) critical.  While bariatric surgery has been shown to cure diabetes in many individuals – there is no medical/ surgical or other treatment to cure much of the pathology related to the development of obesity in the first place.  Obesity is more than poor dietary and exercise habits – it is a psycho-social and cultural phenomenon as well.

For people who don’t want to go to the Medscape site – I have re-posted a transcript of the video from Medscape.com below.

Bariatric Surgery a ‘Magic Bullet’ for Diabetes?

Anne L. Peters, MD, CDE

Transcript
Hi. I’m Dr. Anne Peters from the University of Southern California. Today I’m going to talk about the role of bariatric surgery in the treatment of type 2 diabetes.

There have been a number of recent studies that show just how good bariatric surgery can be for patients with type 2 diabetes.[1,2] In many cases, it seems to cure type 2 diabetes (at least for now), and I think it is an important tool for treating patients with obesity and diabetes.

However, I also have concerns about bariatric surgery, concerns that go back for years as I watched its increased use. When I was a Fellow, I developed a sense of the benefit of extreme caloric restriction for the treatment of type 2 diabetes. I will never forget the first patient I had, an extremely obese man with type 2 diabetes who was on 200 units of insulin per day. His blood sugar levels remained high no matter what we did. He was a significant challenge in terms of management.

One day, he got sick. I don’t remember how or why he got sick, but he ended up in the hospital and I thought that his management would continue to be incredibly difficult. In fact, it was miraculously easy. Within 2 days, he was completely off of insulin and his blood glucose levels remained normal for the entire time he was in the hospital.

This was only a short-lived benefit, however. After he was discharged, he went back to his old habits. He started eating normally, regained the weight, and went back on several hundred units of insulin per day. But it really impressed me how acute severe caloric restriction could, in essence, treat type 2 diabetes.

I have seen many overweight and obese patients with diabetes over the years, and I have seen the frustration as patients go on drugs (such as insulin) that are weight-gain drugs, and they keep gaining more weight. Although I am a big advocate for lifestyle change, many patients can’t do much better. They can’t lose appropriate amounts of weight by their own will or through weight loss programs, or increase their exercise. Therefore, bariatric surgery remains a reasonable option.

For many of my patients who have a body mass index > 35 and type 2 diabetes, I recommend that they at least consider bariatric surgery. Interestingly, very few of my patients actually go for the procedure and I ponder why this is. In part, I think it’s because of the initial evaluation, when you are told what bariatric surgery is like and how much you have to change your habits after the procedure. Before surgery, you are eating however you want to eat and, although you may be trying to diet, there is no enforcement of that diet. After surgery, you have to change how you eat, the portions you eat, and when you eat. I know that people feel fuller, and this is a lot more than just changing one’s anatomy. I think there are significant changes in gut hormones that regulate appetite and satiety. Nonetheless, it is a big change, and many people don’t want to change their habits that much. I know I would be somewhat leery if I were to undergo a surgical procedure that would change my whole way of being. For lots of people, food has many different associations. It’s not just caloric intake; it’s festival, it’s party, it’s joy, it’s sadness. It’s something people like to do, and it hasn’t a lot to do with just maintaining a positive or neutral caloric balance.

I find that people are reluctant to change, and that is understandable. We also don’t know the long-term complications of the procedure. As an endocrinologist, I see 2 things. First, I tend to get sicker patients, so my patients who are on insulin when they undergo bariatric surgery may not get off insulin entirely. They become very disappointed because they think that bariatric surgery will cure them of their diabetes. I also see patients who are too thin, who are nutritionally deficient, who have severe hypoglycemia, or who have significant issues from the surgery itself. In some cases, these patients have needed a takedown of the surgical procedure, restoring them back to their native anatomy.

I think of bariatric surgery as a tool. It is one of many ways to treat our patients with type 2 diabetes. I am a little concerned because we don’t have long-term follow-up data. I think that all bariatric surgery programs, in addition to doing a very thorough preoperative evaluation and counseling, need to do long-term, lifelong follow-up of these patients to see how they do, to see if their obesity returns. In many cases, this does happen. [Patients need to be followed up] to see what happens to their lipids, their blood pressure, and their blood sugar levels over time, and to monitor for other complications.

I think [bariatric surgery] is something that we need to recommend to our patients, and for those in whom it’s appropriate, it is a reasonable step. This has been Dr. Anne Peters for Medscape.

 References
  1. Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012 Mar 26. [Epub ahead of print]
  2. Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012; Mar 26. [Epub ahead of print]

Life after Bariatric Surgery

There is also an excellent article by two nurse practitioners about the long-term interventions and health monitoring needed for wellness promotion and health maintenance after bariatric surgery.  While this article is written for other health care providers – it gives an excellent look at life after bariatric surgery, as well as an overview of the surgical techniques, pre-operative evaluation and anticipated post-operative outcomes.

Thomas, C. M. & Morritt Taub, L. F. (2011).  Monitoring and preventing the long-term sequelae of bariatric surgery.  J of the American Academy of Nurse Practitioners, 2011, 23 (9).

Metformin and Cancer

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The news about Metformin as a possible ally in the fight against cancer has finally taken wings.   (This was first reported in the literature several years ago.)

 As we’ve spoken about in the past – these discoveries about the ‘side benefits’ of this powerful oral anti-glycemic are finally getting some well-deserved press.  As a drug that’s often been shunted aside despite it’s low cost, and impressive safety profile for the more pricey and flashy (but less clinically-proven) alternatives (Yes, Byetta, I am talking about you) this could serve as a boon to consumers..

The other thing we should take from this research is that it remains critical to aggressively control diabetes – for more than just the usual cardiovascular risks – but to reduce the risk of our patients developing cancer.  While insulin is a godsend to patients with uncontrolled glucose – metformin should remain on the menu even after the initiation of insulin therapies.  Too often, metformin falls off the roster.  We also need to impress upon our patients to potent nature of this innoculous sounding medication.  Frequently patients inform me that they have abandoned metformin for various reasons in favor of the more pricey, and heavily advertised medications.  Unfortunately, they are really just short-changing themselves: both their wallets and their health.

Coming soon – more about the ‘magic bullet’ of Aspirin – as both a cancer-fighter and an essential element for cardiovascular health.

Unleash Metformin: Reconsideration of the Contraindication in Patients with Renal Impairment – Wenya R. Lu, PharmD.