No-Surgery Bariatric Procedures: An Expert Interview With Joseph Colella, MD

Carol Peckham; Joseph Colella, MD


April 25, 2013

Editor's Note:
According to a Centers for Disease Control and Prevention report, 35.8% of US men and women were overweight in 2011, and 27.8% were obese. Only 34.5% were normal weight, and 1.8% were below.[1] Obesity with its accompanying risks for diabetes, cardiovascular disease, and cancer not only continues to be a national epidemic but is fast becoming a global one with very few treatment options. One bright note is bariatric surgery, with many studies now supporting its use in stopping the progression of diabetes in many patients. Recently, some nonsurgical procedures have been touted by their developers as being effective for weight loss and viable alternatives to surgery. Medscape interviewed Joseph Colella, MD, Director of Robotic Surgery at Magee Women's Hospital, University of Pittsburgh Medical Center, and Assistant Professor of Surgery, University of Pittsburgh Medical School, in Pittsburgh, Pennsylvania. He is also a founding member of the Board of the Clinical Robotic Surgery Association, an international association of the world's premier robotic surgeons.

Medscape: Bariatric surgery has been shown to slow progression of diabetes, and in one meta-analysis it resolved it in 77% of cases.[2] Resolution of diabetes has been observed after bariatric surgery even regardless of weight loss. Can you describe the physiologic mechanisms that might explain these results?

Dr. Colella: The results that we see from bariatric surgery in people with diabetes are commonly observed with many of the procedures that we do. The duodenal switch operation is probably the best option for diabetes resolution, although not substantially better than a bypass or sleeve, but the complications are relatively high so it is not as commonly done as the other 3 major bariatric procedures -- gastric bypass, sleeve gastrectomy, and gastric banding.

There are 3 mechanisms with gastric bypass that likely affect reductions in diabetes: changes in secretion of certain gut hormones, a decrease in ghrelin and in other chemicals that affect appetite, and an increase in insulin sensitivity; all play some part. Food is also rerouted past the pancreas and liver, which changes the way it is metabolized.[3] Another factor in the effect of gastric bypass on diabetes is a dramatic reduction in sugar intake after the procedure.

Medscape: Bariatric surgery is also proving to reduce risk for heart disease,[4] and a recent study in the Southern Medical Journal[5] estimated that costs for bariatric surgery were recouped in 4 years when taking into consideration medical and pharmaceutical claims in patients who did not have surgery. Given these findings, do you think current recommendations for surgical candidates are too restrictive?

Dr. Colella: There has been a recent push on 2 levels to open up the indications for bariatric surgery. In 2011, the US Food and Drug Administration (FDA) approved the adjustable gastric band for patients with a body mass index (BMI) between 30 and 34 who also have an existing medical condition related to their obesity.[6] Another push comes from numerous studies showing type 2 diabetes resolution in patients with a BMI between 30 and 35.[7,8,9,10,11,12] Both of these events open up indications for surgery in non-morbidly obese diabetics.

The lynch pin is access; insurance coverage is certainly an issue. Some people have coverage for bariatric surgery, some do not -- even those with so called "good insurance." People should find out if they have coverage early in the process, when they are first investigating bariatric surgery.

The real barriers, however, often come from the patients themselves -- their fear of surgery and the fact that they don't realize their need for these procedures. That's the fault of the medical profession -- not getting the information out on the benefits of bariatric surgery: the increase in life span, reduction in comorbidities, and cancer risk reduction. These should be addressed directly by the clinician.

Medscape: You mentioned that bariatric procedures might reduce cancer. Could you expand a bit on that?

Dr. Colella: Cancers associated with obesity are probably related to an increased inflammatory response from high glucose levels and a cancer-promoting hormonal milieu. Specific cancers related to obesity are breast, endometrial, and ovarian, some colorectal cancers, and possibly even pancreatic cancer.

Medscape: There's some evidence that surgery is more effective in white patients than in black patients. Has that been your experience?[13]

Dr. Colella: It has not been my experience, and I don't know the ultimate answers. We need more studies on that question. More women than men are having this surgery, but we don't have enough knowledge on race and ethnicity. However, in my personal experience, I see the same resolutions regardless of race.

Medscape: What's your view of bariatric surgery in obese adolescents?

Dr. Colella: The whole question of bariatric surgery -- the Rosetta stone -- is who should not be having it, even adults who pass all the criteria, including weight, risks, comorbidities, and so on. So if this is a problem with adults, extrapolate it to the adolescent population, and the question of who will fail becomes even more of a gamble. However, there is an appropriate role for surgery in adolescents, and as they reach late teens the role becomes stronger. The complication rates are just about the same as in adults -- some better and some worse. In fact, overall, it's a little safer in younger people. If I had a morbidly obese adolescent who had gone through all of the nonsurgical options, I wouldn't hesitate to recommend surgery for my teenager. The procedure should be more available to kids, but you would really need to screen extensively. The long-term risks are less associated with medical complications than with failure to maintain the weight. So many more factors have an impact on the outcome.

Medscape: Are you finding any complications of bariatric surgery that are of concern?

Dr. Colella: Sleeve gastrectomy and gastric bypass mortality rates are approximately 0.3%, and rates for other significant complications are less than 5%. Reoperation rates with lap band, however, can be as high as 30%-50% within the first 5 years. Being male and having higher BMIs are independently predictive of complications.

The long-term complications, which are predominantly nutritional issues, have really dissipated. In patients who follow up routinely, they are now mostly anecdotal and uncommon. Patients who haven't seen their surgeon in years, however, are still at risk.

Medscape: Some new procedures are being developed that are being touted as a potential replacement for bariatric surgery. One is a duodenal-jejunal bypass liner that can be implanted endoscopically. It's temporary and is removed after a year. It was presented at the European Association for the Study of Diabetes meeting last October.[14] What's your view of this procedure?

Dr. Colella: There is no point in having an immediate miraculous response with a device if it's not sustained with lifestyle changes. If you don't still have success after 5 years, then you don't have success. And all procedures have complications. If this liner has a role at all, it would be in preparing super obese patients for a secondary bariatric procedure. Then it could be beneficial, but as a stand-alone procedure, this is not a long-term solution.

Medscape: More extreme is the AspireAssist™ stomach pump that aspirates food out through a tube and into the toilet.[15] Could you provide some insight into this product and if you think it has a chance at FDA approval?

Dr. Colella: This seems like the surgical equivalent to bulimia, and I know it has to be talked about because it's out there. This device is like handing a 5-year-old the keys to a Ferrari. Bulimia is an infrequent problem because it requires self-induced vomiting, which is not an easy thing to do. Now with this pump, you're essentially giving obese patients the ability to induce vomiting without nausea. You're giving them a borderline solution and letting them control it at home. For those with a psychiatric issue, this is unbelievable. All those nutritional complications from bariatric surgery will run amuck. But the real problem is the one that has always bedeviled those taking diet pills, which is that anything that allows you to control your weight without watching what you eat is doomed to make you sicker. So, if I have my self-vomiting stomach tube, I can eat 8 pounds of French fries without gaining weight, but it won't keep my body from absorbing those trans-fatty acids and toxic chemicals.

This is a surgical procedure, and it still has to go through FDA approval. I wouldn't think it will meet approval, but they approved those weight loss pills this year, so, given the national obesity epidemic, I wouldn't bet on them not approving this procedure.

Medscape: The Swedish Obese Subjects study found that about half of patients with diabetes in remission following bariatric surgery relapsed during 10 years of follow-up. This is still better than with standard lifestyle weight loss measures, but can anything be done to improve these rates?

Dr. Colella: Those numbers are pretty accurate and will be the same at the end of the day. Only better patient follow-up by bariatric surgeons, and also by primary care physicians or endocrinologists, will improve these numbers. I can't make this statement strong enough. Surgeons need to be accountable to patients and patients to their surgeons. Patients should follow up with their surgeons every year. Anything less than that and they are at higher risk for weight loss failure and nutritional complications. We have mandates and guidelines, but there is less than adequate follow-up even among surgeons. We're trying, but we are not as successful as we would like. And patients should be advised that if a surgeon doesn't follow up, then they should look for one who does. And that's hard to do.

So, no matter how obesity is treated -- whether with medication, devices, surgery, or education -- if there are no lifestyle changes enhanced by clinician follow-up, then nothing will work. These treatments should be considered nothing more than tools to facilitate a lifestyle change.