Metabolic (Bariatric and Nonbariatric) Surgery for Type 2 Diabetes: A Personal Perspective Review

Abstract

Metabolic surgery can cause amelioration, resolution, and possible cure of type 2 diabetes. Bariatric surgery is metabolic surgery. In the future, there will be metabolic surgery operations to treat type 2 diabetes that are not focused on weight loss. These procedures will rely on neurohormonal modulation related to the gut as well as outside the peritoneal cavity. Metabolic procedures are and will always be in flux as surgeons seek the safest and most effective operative modality; there is no enduring gold standard operation. Metabolic bariatric surgery for type 2 diabetes is more than part of the clinical armamentarium, it is an invitation to perform basic research and to achieve fundamental scientific knowledge. And the Lord God caused a deep sleep to fall upon Adam, and he slept; and he took one of his ribs, and closed up the flesh instead thereof, and the rib which the Lord had taken from man, made he a woman.. .. dGenesis 2:21-22 METABOLIC SURGERY In 1978, in the foreword to the book Metabolic Surgery (1), by author H.B. and Richard L. Varco, we defined the discipline of metabolic surgery "as the operative manipulation of a normal organ or organ system to achieve a biological result for a potential health gain." The procedure described in Genesis was an "operative manipulation" under general anesthesia on a "normal organ" to achieve a "biological result"; it was metabolic surgery. As early as 1896, bilateral oophorectomy was used to cause temporary regression of breast cancer metastases (2). The 100-year heyday of peptic, primarily duodenal, ulcer surgery, from the late 19th century to the discovery of Helicobacter pylori, involved operating on normal stomachs and vagus nerves to cure the pathologic lesion, a distal ulcer left untouched by the surgeon. This was metabolic surgery, as was the partial ileal bypass (Fig. 1) for the treatment of hypercholesterolemia, introduced in 1962 and 1963 (3,4). The partial ileal bypass was used as the intervention modality in the Program on the Surgical Control of the Hyperlipidemias (POSCH) (5-8), the first randomized controlled trial to use metabolic surgery. POSCH was the first study definitively to demonstrate the benefits of marked cholesterol lowering in preventing myocardial infarctions, peripheral vascular disease, and the need for coronary artery

Standardization of Bariatric Metabolic Procedures: World Consensus Meeting Statement

“…Obesity is both a serious disease and a symptom of other metabolic diseases and one of the top 3 health burdens created by human beings after smoking and violence [5]. More than 50 distinct operations have been implemented by bariatric surgeons to manage the critical global threat of obesity and the metabolic syndrome [3,7]. By recent count, 579,517 bariatric metabolic operations and 14,725 endoluminal procedures are performed annually worldwide [8].…”

Bariatric/Metabolic Surgery for Diabetes: Lessons From the Past and Present

“…As obesity rates have risen, so has our understanding of the importance of excess fat storage in expression of insulin resistance and type 2 diabetes. In this issue of Diabetes Care , Buchwald and Buchwald ( 2 ) chronicle the history of surgical approaches to weight loss in patients with obesity and the subsequent, often dramatic improvement in hyperglycemia and type 2 diabetes these patients experience. In highlighting those surgeons whose key innovations led to today’s effective procedures, they can make it seem, in retrospect, that these innovations occurred in an orderly fashion.…”

“…However, the medical community has historically been wary of bariatric/metabolic approaches to diabetes management, citing a lack of high-quality evidence (e.g., randomized controlled trials) and failure to properly define the mechanisms of diabetes improvement. Buchwald and Buchwald ( 2 ) nicely chronicle the initial observational studies from single sites, followed by large prospective cohort studies and the now more than 10 randomized controlled trials that have 3- to 5-year follow-up data consistently showing superior weight loss and diabetes control, or equivalent control with far less diabetes medication use, following bariatric/metabolic procedures compared with intensive medical diabetes management. Counterarguments are given, though, that if patients lose weight through other means, they will achieve the same result.…”

“…Not covered in the review ( 2 ) are several areas of common ground shared by bariatric/metabolic surgery and medical management. For example, microvascular and macrovascular complications of diabetes have been shown to improve with medical management ( 11 , 12 ) as well as bariatric/metabolic surgeries ( 13 ), and reductions in cardiovascular events and total mortality have been noted with both ( 14 – 18 ).…”

“…The review by Buchwald and Buchwald ( 2 ) tends to pass lightly over the complications of bariatric/metabolic procedures, giving the impression that they were anticipated or have been resolved. Not mentioned is a major surgical innovation that led to dramatically improved patient safety, which was the widespread adoption of minimally invasive (laparoscopic) techniques in the 1990s ( 30 ).…”