Surgery to cure obesity and diabetes

Question 1

Describe the broad categories of obesity management

Answer 1

Obesity management may be thought of as being surgical, or medical.
Surgical refers to bariatric surgery.
Medical refers to GLP1 receptor agonists.

Question 2

List and describe the types of bariatric surgery

Answer 2

Types of bariatric surgery
- gastric banding
- has fallen out of favour; needs a lot of attention post-op
- takes a restrictive approach
- sleeve gastrectomy
- takes a restrictive approach
- also removes most of fundus where ghrelin is produced [[Gastroenterology - Lecture 18]]
- roux-en-Y
- takes a restrictive approach
- bile drains into jejunum, limits absorption
- also limits absorption by making duodenum useless
- Biliopancreatic diversion with Duodenal Switch
- bile and pancreatic juices avoid jejunum, limits absorption
- stomach directly connected to ilium, limits absorption
- also restrictive approach

• more extensive surgeries have greater risk of mortality, although overall 1/1000
  
  • and risk of complications e.g. BP and biliary, anastomotic leaks

mort has significantly improved

Question 3

Describe the therapeutic benefits of surgery

Answer 3

Mingrone NEJM 2012
- bariatric surgery vs conventional medical therapy for T2D, RCT
- crucially before the ‘tides’ and metformin
- glycated Hb significantly reduced with surgery compared with medical therapy
- virtually cured T2D with BPD (<5.7%)
Wilding et al., 2021
- semaglutide on adults with overweight or obesity
- wildly effective compared with placebo
- similar results with tirzepatide, (Jastreboff et al., 2022); also maintained loss after x years
- usually in patients who have not progressed, islets still intact mostly

Is this reproducible?
- Yes

Does it last?
- Yes; some surgeries better than others e.g. BPD re: weight reduction and % remission, reduction % glycated Hb

Is it safe?
- Mortality (see above)
- Lazzati Surgery 2016; 159:467-474

Does it reduce the comorbidities?
- Yes
- Hatoum JAMA Surg 2016; 151:130-137; retrospective data n=33718

A big takeaway:

Bariatric Surgery cures DMII independent of obesity

Doctors have since developed algorithms to assess which T2DM patients are suitable for surgery i.e. Class I obesity with poor glycaemic control, Class III, or Class II with poor control or significant comorbidity as obese but otherwise healthy individuals

Question 4

Describe the role of lifestyle interventions and potential issues

Answer 4

A consideration
- insulin resistance may be protective in T2D for insulin sensitive tissues such as heart
- treating with high insulin to try to overcome this resistance risks collateral organ damage (steatosis in heart)
- GLPs, lifestyle intervention and surgery aka nutrient off-loading

Intensive lifestyle intervention
- 2018 Lancet study
- intervention group had 46% remission, proportional relationship to weight loss
- early in diabetes, middle age
- very intensive from HCW and patient perspective

Question 5

Describe the role of pharmacotherapy

Answer 5

• Dahl et al SURPASS-5
  
  • tirzepatide vs insulin glargine - tirzepatide comes on top
  • T2D
  • 61y, 13 years of obesity, 8.3% HbA1c
  • GI adv events, but overall not many