The Role, Merits and Demerits of Bariatric Surgery - Literature review Example

?The Role, Merits and Demerits of Bariatric Surgery in the Treatment of Type 2 Diabetes Mellitus in Overweight and Obese Adults Introduction New and innovative recommendations for the treatment of Type 2 Diabetes Mellitus (DM) in overweight and obese adults keep surfacing now and then given the increasing incidence of this particular disease over the past some years. Given the fact that type 2 DM has rapidly taken the form of a full blown epidemic, it is important to contemplate all the possible options in context of treatment. It is stressed that such type 2 diabetes therapies are highly needed which “provide adequate glycemic control without causing hypoglycemia and weight gain which are associated with increases in cardiovascular risk” (Goldenberg, 2011, p. 518). Type 2 DM particularly affects overweight or obese adults who also suffer from any form of cardiovascular disease and the incidence of this disease particularly increases in patients over 45 years of age. “Diabetes affects approximately 285 million persons worldwide, with type 2 diabetes comprising 90% of diagnoses” (International Diabetes Federation, cited in Goldenberg, 2011, p. 518). Given such a high incidence, multiple research studies are done to analyze the effectiveness of bariatric surgery in treatment of type 2 DM. One research in particular focuses on the role played by bariatric surgical procedures on the insulin action and beta-cell function in diabetic patients. It suggests that in contrast to other treatment modalities which have failed repeatedly, a systematic review of the English literature based on more than 22000 patients revealed that bariatric surgery resulted in complete regression of type 2 diabetes in 77% patients in terms of normal blood glucose levels and discontinuation of diabetic medications (Ferrannini and Mingrone, 2009, p. 515). The basic purpose of this literature review is to identify and contemplate the role, benefits, and adverse effects of Bariatric Surgery for medical treatment of type 2 DM in overweight and obese adults. Given the fact that majority of people have very scarce information regarding the latest scientific discoveries and innovations made for preventing the occurrence or recurrence of this type of diabetes, discussing something as interesting as bariatric surgery is a worthwhile attempt at increasing public awareness. Bariatric operations are basically grouped into totally restrictive, mostly restrictive, and mostly malabsorptive procedures (Ferrannini and Mingrone, 2009, p. 516) but the most common surgery performed is Roux-en-Y gastric bypass through which “between 33 and 77% of excess weight can be lost” (Buchwald et al., 2004, p. 1730). General consensus among clinicians is that the bariatric operations have proved to be particularly appreciative medical treatment for diabetes associated with obesity and cardiovascular diseases. Also research has it that all these surgical options are potentially capable of helping the diabetic patients in terms of fast recovery, weight adjustment, cardiovascular risk factors management, and significant reduction in mortality of 23% from a troubling 40% (Robinson, 2009, p. 521). Evidence about the role, credibility, and shortcomings of bariatric surgery as a thriving treatment option for type 2 DM is gathered through reviewing credible scientific journals and findings are discussed and scrutinized in this paper as an attempt to compare and contrast what different researchers have said on this subject so far. Literature Review For people having a BMI of at least 35 with significant comorbidities like diabetes, bariatric surgery is ruled out as a safe and healthy recommendation by the health care professionals as this is considered a wise decision with great payoffs (Robinson, 2009, p. 520). In a research study involving as many as 232 obese patients with type 2 DM from 1979 to 1994, it is claimed by MacDonald et al. (1997) that 154 out of them underwent gastric bypass operation and had their small intestines resected while the rest did not give consent for surgical treatment either due to minimal awareness or no insurance. After the two groups were examined in terms of chances of survival and the need for medical treatment for their non-insulin dependent DM, it was revealed that the mean glucose levels in the surgical group showed significant improvement along with the mean length of follow-up period. Before undergoing gastric bypass operation, patients in the surgical group were admitted with mean glucose levels of 187mg/dl which fell to 140mg/dl and consistently remained less than that level postoperatively. In contrast, patients in the control group which refused to undergo any surgery exhibited very different results in terms of mean glucose level and follow-up period length. Same research reports that the mean length of follow-up remained 6.2 years among those 78 obese patients with type 2 DM while the mean glucose levels remained significantly higher than normal though they continued to be treated with oral hypoglycemics and insulin. The percentage of patients in the surgical group also fell from a preoperative 31.8% to 8.6% at last contact while that of control group subjects in stark contrast rose from 56.4% to 87.5% at last contact. Mismanaged cardiovascular risk factors directly relate to type 2 DM (Goran, Ball, and Cruz, 2003, p. 1417). Considering this, the mortality rate in the surgical subjects showed phenomenal changes largely due to a decrease in the number of deaths related to aggravated cardiovascular issues. Research has it that “the mortality rate in the control group was 28% compared to 9% in the surgical group” (MacDonald et al.,1997, p. 213) and after that for every year during follow-up, “patients in the control group had a 4.5% chance of dying vs. a 1.0% chance for those in the surgical group” (MacDonald et al.,1997, p. 213). Another credible source supporting the fact that gastric bypass surgery is capable of plummeting down mortality in obese adults with type 2 DM is based on research carried out by Dixon, Zimmet, Alberti, and Rubino (2011). This research cites the position statement from the International Diabetes Federation Taskforce on Epidemiology and Prevention according to which surgery and other gastrointestinal interventions play an appropriate role for effective treatment of type 2 DM and correlated diseases. A large group of practicing endocrinologists, diabetologists, and surgeons supported this position statement and together claimed that barriers to surgical access like less awareness and insurance problems should be removed as fast as possible as “bariatric surgery can significantly improve glycaemic control in severely obese patients with Type 2 diabetes” (Dixon et al., 2011, p. 628). Research on cost-effectiveness of bariatric surgery for severely obese diabetic patients stresses that bariatric surgical procedures not only could be considered safe but they “provide a cost-effective method of reducing mortality and diabetes complications in severely obese adults with diabetes” (Hoerger et al., 2010, p. 1938). In context of cost-effectiveness of gastric bypass, results derived from complete economic analysis in another study suggested cost effectiveness to be “greater for women and those with higher pre-surgery BMI” (Craig and Tseng, 2002, p. 495). Literature on the type of role played by bariatric surgery between 1991 and 2010 suggests that “bariatric surgery in severely obese patients with Type 2 diabetes has a range of health benefits, including a reduction in all-cause mortality” (Dixon et al., 2011, p. 629). Many gastrointestinal operations originally intended to cause weight loss in severely obese adults have also shown “dramatic improvement of Type 2 diabetes and can effectively prevent progression from impaired glucose tolerance to diabetes” (Dixon et al., 2011, p. 631). Such literary evidence sufficiently supports the positive natured role played by bariatric surgery in treating obese adults with type 2 DM. However, this research lacks evidence regarding which patients can gain maximum advantage from which clinical procedures. Also, minimal evidence is presented to establish criteria other than BMI to validate benefits of bariatric surgery by Dixon et al. (2011). According to one latest report issued by American Diabetes Association, the role of bariatric surgery to cure type 2 DM along with obesity is now better understood than ever as “University of Maryland researchers are closer to understanding how surgery cures diabetes and are looking for drug to mimic benefits” (Cohn, 2012). It is identified in the report how initially this surgical intervention was only used to cure overly obese patients but now this is increasingly being used to specifically address the national epidemic of type 2 diabetes. In contrast to research findings by Ferrannini and Mingrone (2009) which suggested resolved type 2 diabetes in 77% cases, another systematic review and meta-analysis reveals that “Type 2 diabetes was resolved in 78% and resolved or improved in 87% of patients undergoing bariatric surgery” (Buchwald et al., 2009, p. 249). The overall mortality for all bariatric operations is 0.28% which places these procedures in the lowest class of operative mortality of operations performed in America (Dimick, Welch, and Birkmeyer, 2004, p. 848). The specialty of report analyzed by Cohn (2012) is that it explains how diabetes costs the American nation alone about $116 billion each year in direct medical costs and how gastric bypass is able to treat more than 78% diabetic patients even before significant weight loss occurs. It is further identified that “a hormone called glucagon-like peptide-1, or GLP-1, has been suspected to play a role for about a decade” (Cohn, 2012) and gastric bypass is directly involved in increasing GLP-1 levels. However, one shortcoming of this research could be related to the fact that no evidence is presented regarding the nature of role played by bariatric surgical procedures in the progressive loss of beta-cell function which is characteristic in patients with type 2 DM. It is not discussed at length if bariatric surgery prevents or merely slows the progressive loss of beta-cell function and more research-based studies are needed to establish this particular role. Risk of developing type 2 DM is largely related to weight gain (Levy, Fried, Santini, and Finer, 2007, p. 1248) which is why it should be deemed important that societal prejudices about severe obesity do not become a barrier in the way of providing cost-effective and clinically effective treatment options (Dixon et al., 2011) like gastric bypass. Sustained weight loss and improvement in diabetes are the principal advantages of bariatric surgery for the management of type 2 diabetes (Lau, 2011, p. 86). Patients should be more motivated to undergo surgeries which focus at weight loss when oral medical treatment fails to achieve desired health targets and weight gain remains persistent because research has it that “relative risk for type 2 diabetes is reduced to 0.13 for weight loss >20 kg” (Levy et al., 2007, p. 1249). It is suggested that along with gastric bypass, other malabsorptive procedures like biliopancreatic diversion also remain widely helpful when addressing both obesity and type 2 DM (Marinari, 2006) at the same time instead of using restrictive procedures like gastroplasty and gastric banding which focus more on slowing the rate at which food is consumed by the stomach. In context of what kind of health circumstances a person is subjected to face about 10 years after bariatric surgery, the discussion is furthered by the claim that though weight loss is a wise technique which helps in preventing myriad metabolic and cardiovascular risk factors, “but whether these benefits persist over time is unknown” (Sjostrom et al., 2004). This calls in question the long-term effectiveness of bariatric surgery to cure type 2 DM. In an attempt to analyze the long-term effects of gastric surgeries performed to cure both obesity and diabetes, the Swedish Obese Subjects (SOS) Study was performed which analyzed and compared changes in risk factors over follow-up periods of 2 and 10 years in patients who were surgically treated with control subjects who did not undergo any surgery and were conventionally treated. Changes in physical activity were also compared in addition to cardiovascular risk factors. Results revealed that “the surgically treated subjects in this study had greater weight loss, more physical activity, and lower energy intake than the control subjects over a 10-year period” (Sjostrom et al., 2004, p. 2690). In support of the already mentioned feature that gastric bypass is more effective than gastric banding for addressing both type 2 DM and correlated obesity, this research also stresses that “the mean changes in weight and risk factors were more favorable among the subjects treated by gastric bypass than among those treated by banding or vertical banded gastroplasty” (Sjostrom et al., 2004, p. 2690). More weight loss after gastric bypass could be related to “altered gut-to-brain signaling” (Cummings et al., cited in Sjostrom et al., 2004, p. 2690). Although curing diabetes cannot yet be considered an objective of bariatric surgery, evidence for the use of this surgical treatment modality with positive results is increasing. Still in context of adverse effects, researchers in a study based on assessing the impact of bariatric operations on obese adults with type 2 DM concluded that nutritional deficiencies leading to metabolic disorders are common after bariatric surgery and “long-term follow-up is mandatory for surveillance of metabolic status” (Kashyap, Gatmaitan, Brethauer, and Schauer, 2010, p. 467). Despite other sources claiming that bariatric surgical interventions have proved to be more helpful and effective than oral or restrictive medical treatment on grounds of observational studies comparing surgical groups vs. control groups, it is argued that such observational studies lack appropriate control groups which is why “relative benefit of bariatric surgery vs aggressive medical antidiabetic therapy is not yet known” (Kashyap, Gatmaitan, Brethauer, and Schauer, 2010, p. 467). In another research based on 2522 former obese and diabetic patients on whom bariatric surgery had been performed, 21.9% risk of complications was displayed by the research’s surgical subjects during the initial hospital stay alone and that was followed by a total of 40% risk of complications in the follow-up based on six months (Encinosa, Bernard, Chen, and Steiner, 2006). It is stressed in the study that though bariatric surgery is one of the fastest growing hospital procedures to specifically address diabetes, it is also important to analyze the trends towards safety outcomes and resource utilization following surgery. A nationwide, population-based sample was used for this study conducted by Encinosa et al. (2006) according to which negative trend was noticed more in those patients who were over 40 at that time which led to more costly health care expenditures. In order of frequency of occurrence of surgical complications, gastric dumping syndrome stood first with 20%, then leaks at the surgical site with 12%, hernia was observed by 7%, infections by 6%, and pneumonia by 4%. It is further claimed in the research that “in contrast to current bariatric studies, which report a 20% in-hospital complication rate, we find a significantly higher complication rate over the 6 months after surgery” (Encinosa et al., 2006). More risks of bariatric operations in particular Roux-en-Y gastric bypass which develop as late complications include “ulcer or stricture formation at the gastrojejunostomy site occuring in 5% to 10% of cases” (Kashyap et al., 2010, p. 474). Literature based on postsurgical outcomes of gastric bypass surgery in specific enumerate that often reduced calcium absorption is noticed in surgical patients which leads to the complication of metabolic bone diseases leading to increased bone fracture while those patients are reported to be specially at high risk of developing severe nutritional deficiencies who lose more than 10% of their body weight by 1 month (Davies, Baxter, and Baxter, 2007, p. 1153). Nutritional dysfunctions prompted by decreased serum levels of micronutrients are claimed to be common specifically after malabsorptive bariatric surgeries. It is also suggested that though renal function visibly improves following surgery but “adverse effects like oxalate nephropathy can lead to chronic kidney disease or end-stage renal disease” (Chauhan et al., 2010, p. 775). Conclusion The purpose of this review was to enumerate and discuss the literature on the subject of the role played by bariatric surgery in treating type 2 DM in overweight or obese patients in addition to analyzing the benefits and adverse effects associated with it. Surgery is repeatedly claimed to be an effective early intervention for diabetes by different researchers. Much research has been done on the subject of effectiveness of bariatric surgery in weight loss and diabetes-related outcomes in the obese adults. Weight reduction is the first most strategy which should be considered by the diabetic patients as the progression rate of diabetes heavily relates to the obesity rate. A reduction in all-cause mortality is stressed in the literature on bariatric surgery and its implications because the surgical interventions largely aim at decreasing the weight as obesity in itself is a potential driver of many cardiovascular and metabolic dysfunctions. The charm of bariatric surgical interventions like gastric bypass surgery is that they are performed to achieve multiple targets and may or may not include weight loss depending on the situation. This means that diabetic patients of think physique can also go through bariatric surgery to have their diabetes treated only. However different sources cite that complications resulting from weight loss surgery vary and are frequent including nutritional deficiencies, kidney issues, bone fracture risks, postprandial diarrhea, and other metabolic bones diseases. Among the postsurgical complications, gastric dumping syndrome which involves bloating and diarrhea after meals forms the commonest complication of bariatric surgery performed to treat type 2 DM in overweight or obese adult patients. In context of research recommendations so as to further advance the discussion on this subject in the future, criteria other than BMI that is stronger and denser needs to be established for analyzing the benefits offered by bariatric surgery. Also more research based studies are needed to establish which kind of patients benefit most from which type of surgical or nonsurgical procedures. Conducting such studies should be deemed highly important as not all patients respond in the same way to any particular clinical treatment procedure rather some adapt more to one while rest may respond more favorably towards any other treatment option which is why finding out which patients benefit most from which treatment choices is a matter of critical nature. Also more research should be done on the subject of effectiveness of bariatric surgery in patients with type 2 DM but who show no incidence of obesity. There is ample amount of studies and literature available on the role played by surgery in obese adults to treat diabetes by reducing weight through either gastric bypass or biliopancreatic diversion but there is not much to say in comparison on the subject of what kind of role bariatric surgery is capable of playing to treat diabetes in already wasted patients. More studies are needed to document the probable duration of the effects or benefits of bariatric surgery to establish how long different effects like weight loss and normal glucose levels last. 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