Questions remain about weight-loss surgery for diabetes

A pair of landmark studies demonstrated that weight-loss surgery may be the best solution for Type 2 diabetics with poor control over their blood sugar. So, now what?

Experts say that diabetes care is likely to undergo a profound shift. But before diabetics get in line for space on the operating table, a lot of questions need to be answered.

Not least of those, say clinicians, is who will do those operations, how well and for how much.

Bariatric surgery has exploded in recent years, and with that growth have come concerns about quality of care and patient safety. While rates of post-operative complications and mortality are lowest at bariatric “centers of excellence,” those remain few and far between. HealthGrades, which produced a comprehensive look at bariatric surgery and its costs and quality, says that of 468 hospitals providing bariatric surgery that it evaluated, 107 ranked “best performers” and 100 were rated as “poor.”

At between $10,000 and $42,000 per procedure, it’s also not clear that the cost of bariatric surgery will be less than that of medications. At a time when the cost of healthcare is undergoing increasing scrutiny, being clinically better may not be good enough.

“It becomes a resource allocation question,” said University of Colorado at Denver endocrinologist Daniel Bessesen. “What we do about that is a huge public healthcare challenge. This is a place where scientific data is almost ahead of coverage and policy decisions that have many, many implications.”

At the intersection of cost and patient care is the issue of what happens to patients whose diabetes may go into remission after bariatric surgery, Bessesen added.

“Primary-care docs may or may not know how to take care of people who’ve had this surgery,” Bessesen said. Bariatric surgery patients need special guidance to maintain their bone health and nutritional needs, since critical vitamins and minerals will not be as readily absorbed through a small intestine shortened by surgery. Over time, many patients also experience creeping weight gain, and primary-care doctors will need to know how to respond.

And eventually, experts say, even bariatric surgery may not provide more than a temporary respite from diabetes, as gradual insulin insensitivity may once more drive down the pancreas’ ability to produce insulin. Those who conducted the studies published this week hope that having had such a “diabetes vacation” will lower a patient’s risk for stroke and heart disease over the long run, but that’s a hope that research will need to bear out.

Finally, the studies are also likely to shift the focus of some efforts to gain pharmacological traction on the nation’s twin epidemics of obesity and diabetes.

Diabetes medications are rife with problems. Even as they control blood sugar, some cause weight gain, exacerbating the condition they are meant to treat. Others are linked to redistribution of fat in ways that make cardiovascular disease more likely. And the track record of successful weight-loss drugs has been a disheartening disappointment.

The success of gastric bypass, however, offers pharmacologists a new approach to treating both obesity and the insulin insensitivity that so often accompanies it. If researchers can zero in on the hormonal and other changes that make bariatric surgery such a successful treatment, pharmaceutical researchers can then look for ways to effect those same changes sans surgery.

Finding the “gastric bypass pill” may be the next big quest. And, given the price tag and risks of bariatric surgery, such a pill need not be cheap or free of side effects to gain a following.