Surgery News - March 2008 - (Page 15) MARCH 2008 • SURGERY NEWS GENERAL SURGERY 15 Gastric Banding Yielded 76% Diabetes Remission Rate B Y M A RY A N N M O O N Else vier Global Medical Ne ws aparoscopic adjustable gastric banding produced a 76% remission rate in the first randomized trial to compare the surgery against conventional treatment in obese patients with recent-onset type 2 diabetes. “After 2 years, the surgical group displayed a 5 times higher remission rate and a 4 times greater reduction in [hemoglobin A1c] values than the conventional-therapy group,” John B. Dixon, Ph.D., of Monash University, Melbourne, and his associates reported in JAMA. The surgical group also showed greater resolution of features of the metabolic syndrome and greater improvements in insulin sensitivity, lipid profiles, and hypertension, allowing for significant reduction in their use of medications for these conditions as well as their use of drugs for glycemic control. L The investigators attributed the procedure’s benefits principally to its great effectiveness in inducing weight loss, rather than to other antidiabetes effects, such as those reported with the Roux-en-Y gastric bypass procedure that is more common in the United States. In the study, patients diagnosed as having type 2 diabetes within the preceding 2 years and having a body mass index of 30-40 were randomly assigned to receive conventional medical and behavioral therapy either alone (26 subjects) or in addition to laparoscopic adjustable gastric banding (LAGB) via the pars flaccida technique (29 subjects). All subjects met with at least one member of a treatment team—which included a general physician, a dietitian, a nurse, and a diabetes educator—every 6 weeks for the duration of the 2-year follow-up. The mean surgical time was 54 minutes, and 80% of patients were discharged after only 1 day of hospitalization. The surgery group achieved a mean weight loss of 20.7%, compared with 1.4% for the conventional therapy group. Complete remission of diabetes occurred in 76% of the surgery group, compared with 15% of the controls, Dr. Dixon and his associates said ( JAMA 2008:299:316-23). There were no surgical complications. The rate of postoperative wound infection was under 2%, and 5% of subjects had a reoperation to enlarge the gastric pouch. In an editorial comment, Dr. David E. Cummings and Dr. David R. Flum of the University of Washington, Seattle, said these “clear and striking” results should lead clinicians and professional societies to reconsider the role of surgery in treating diabetes. At present, “despite hundreds of observational studies demonstrating benefits of surgical weight loss on diabetes, the American Diabetes Association and similar international and pediatric societies have yet to Pouch Band before inflation Gastric Band EMILY BRANNAN, ILLUSTRATION Stomach Band inflated by saline Sources: Brigham and Women’s Hospital, Laparoscopic Association of San Francisco Port (Used to adjust saline levels that control the gastric band) highlight surgery as an important treatment option,” they wrote. More than 90% of obese diabetic patients considered eligible for gastric bypass procedures do not undergo them, mostly because they are never referred for surgical evaluation or informed of surgical options, noted Dr. Cummings and Dr. Flum, an ACS Fellow ( JAMA 2008;299:341-3). They added that the general applicability of the study findings is not yet known. “The authors’ bariatric surgical team in Melbourne is among the most experienced groups in the world using LAGB, and their excellent results may not be readily reproducible elsewhere,” they said. ■ Alternative to Transplantation Resection • from page 1 anatomy. Four patients had both EHBR and hepatectomy. Results were similar to those of 73 patients treated with EHBR alone. After a median follow-up period of 10 years, EHBR patients had an overall survival of about 60%, which is “comparable” to liver transplantation, he said. Significantly fewer patients who underwent EHBR had cirrhosis (5 of 77) than did those who underwent LT (30 of 49). The EHBR patients with cirrhosis had significantly higher mortality than the LT patients. A stratified analysis showed that cir- Previous studies of EHBR have had relatively small sample sizes and short median survival, “which is especially important in a disease that is characterized by such a long natural history.” The idiopathic, chronic cholestatic disease process of primary sclerosing cholangitis results in fibrosis of both the intraand extrahepatic biliary tree and is associated with a higher risk of cholangiocarcinoma in up to 8%-30% of patients. The extent of the disease and how far along the patient is in the disease process influence the treatment options, which include medical therapy, endoscopic and percutaneous biliary dilatation and stenting, liver transplantation, and surgical resection. Dr. Pawlik reviewed the results of 77 patients who underwent EHBR and 49 who underwent liver transplantation (LT) at three major hepatobiliary centers during 1981-2006. The patients had to have cholangiographic findings consistent with PSC and histologic confirmation. Most patients who went on to undergo EHBR were indicated for resection because of a dominant stricture where cholangiocarcinoma could not be ruled out, Dr. Pawlik said. But PSC patients without cholangiocarcinoma at the time of surgery were excluded. About 80% of the entire sample had a prior history of hospitalizations, mostly for biliary procedures. Perioperative mortality was similar for EHBR (3 of 77) and LT (5 of 49), but perioperative morbidity was significantly higher among EHBR patients than LT patients (34% vs. 23%), primarily because of cholangitis. EHBR procedures were performed in conjunction with reconstruction, which usually involved hepaticojejunostomy through both hepatic ducts or multiple hepaticojejunostomies, depending on the rhosis was associated with a seven-fold higher risk of death. At 3 years after surgery, 60% of patients with cirrhosis were still alive, but only 12% survived at 10 years. Patients with bilirubin levels of greater than 2 mg/dL at 2 months after surgery had more than a 10-fold higher risk of death than did those with lower levels. Another stratified analysis of patients according to their bilirubin levels 2 months after surgery showed that of those with bilirubin levels greater than 4 mg/dL, 60% survived at 3 years, whereas none survived at 10 years. Patients with bilirubin levels of 2 mg/dL or less at 3 years had 97% survival, compared with 69% at 10 years. None of the patients who underwent EHBR developed cholangiocarcinoma during follow-up. At 1 year after surgery, 81% had not required hospital readmission for reasons related to PSC, while the remaining 19% were readmitted one to three times. After 3 years, 57% still had not been readmitted for PSC-related reasons, but 27% had needed one to three readmissions. The results suggest that, “[liver] transplantation can potentially be delayed or even avoided in very-well-selected patients with PSC. Transplantation therefore should be reserved for those patients with associated hepatic dysfunction or cirrhosis,” Dr. Pawlik said. ■ http://www.nashvillesurg.com http://www.nashvillesurg.com
For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.