Surgery News - April 2008 - (Page 12)

OPINION EDITORIAL SURGERY NEWS • A P R I L 2 0 0 8 Fighting Fat: Blade or Pill? I t is a well-established fact that operative understand and manage the basic physicorrection of morbid obesity signifi- ology of weight control. And when that cantly reduces long-term mortality, par- happens, it will have a major impact on ticularly from diabetes, heart disease, and general surgery, because bariatric procecancer (N. Engl. J. Med. 2007;357:741-52 dures are the mainstay of many practices. In the long run, surgery will and 753-61). Now we need to not likely be considered the pay more attention to the globanswer to the problem anyal epidemic of obesity. way, given the premium on Although famine is still a cost-effectiveness and the imdevastating problem, the numense number of potential tritional consequence of globcandidates. alization is an abundant supply The ability to store fat is a of sugared drinks; corn, soy, survival necessity, but we know and other vegetable oils; and much less about its regulation animal-source foods that are than we do about the mainteexpanding waistlines at an unBY LAZAR J. precedented rate around the GREENFIELD, M.D., FACS nance of fluids and electrolytes, temperature, or blood presworld. In fact, the current population of overnourished individuals ex- sure. The value of fat from a Darwinian ceeds the hungry by several hundred mil- survival standpoint favors relevant genes that support its thriftiest management. lion (Sci. Am. 2007;297:54-7). The economic consequences of diseases But until recently the tilt toward obesity associated with obesity are significant, but has been hard to identify. We now know about the FTO gene, no country in modern times has been able to reduce obesity in its population. whose variation carriers were heavier and The promise of a safe weight-loss drug has more likely to become obese in a worlda potential market exceeding 1 billion wide study of 40,000 subjects (Sci. Am. adults, so there is even more incentive to 2007;297:72-81). But just how that gene affects weight regulation is unknown. We are more familiar with the loss-of-function mutation in the leptin gene that leads to early-onset obesity. A better understanding of leptin-type signaling between fat cells and the arcuate nucleus of the hypothalamus has been facilitated by the identification of other related neuropeptides, but most obese patients have no genetic mutations and their leptin levels are higher than those of lean individuals. So leptin’s signal that fat stores are sufficient did not register with regulatory pathways. This leptin resistance has been attributed to two proteins, SOCS3 and PTP1B, which can be reduced in mice and which make them resistant to obesity (Sci. Am. 2007;297:78). But it remains to be seen whether this approach would lend itself to treatment in humans. The search for an obesity pill continues to be elusive; currently, only two drugs are approved. Sibutramine reduces appetite by facilitating central effects of norepinephrine and serotonin, but elevates blood pressure and heart rate. Orlistat reduces fat absorption, but has such a dubious record of effectiveness that it is sold without prescription. Rimonabant, a drug used in Europe, acts on a central receptor. But this drug lacks Food and Drug Administration approval because it is associated with depression and anxiety. Among the known pathways for regulating weight, potential approaches include inhibitors of appetite-stimulators ghrelin, melanin-concentrating hormone (MCH) and neuropeptide Y (NPY), and mimics of suppressors PYY, melanocortin 4, and some serotonin receptors. It should also be possible to block fat storage, increase the rate at which fat cells release energy, and block the body’s tendency to compensate for fat loss by conserving energy. Given the large number of laboratories working on the problem, and the economic rewards of success, it seems only a matter of time before customized drugs for obesity become available. Bariatric surgeons, take heed: Trauma is a problem of human behavior much less likely to be solved. DR. GREENFIELD is editor in chief of SURGERY NEWS. GUEST EDITORIAL Metabolic Surgery Holds Hope for Patients With Diabetes significantly improve immediately after bariatric surgery, even before weight loss occurs, it is possible that improved insulin glycemic agents for his diabetes and is on resistance might be independent of weight a low-salt diet for mild hypertension. He loss and could result from changes in gashas had an appendectomy and hernia re- trointestinal hormones and regulatory pair in the past. His body mass index is 32 peptides. The gastrointestinal tract plays a critikg/m2. He is here to see you for treatment of his diabetes—specifically, for bariatric cal role in the regulation of blood sugar levels and fat metabolism, and surgery. the operations used to treat Sound absurd? Perhaps not, morbid obesity, which engenconsidering the data indicatder changes in the gastroining that surgery is a superb testinal anatomy, might also treatment for diabetes, better treat diabetes and other metaeven than medical therapy (N. bolic disorders through direct Engl. J. Med. 2007;357:741-52 mechanisms. Although the exand 753-61). Bariatric surgery is act mechanism is as yet unwell known as an effective known, the data suggest that treatment for morbid obesity, metabolic surgery, regardless but new data suggest that it BY MYRIAM J. CURET, of weight loss, can effectively might be the most effective M.D., FACS treat type 2 diabetes. treatment for metabolic disThe idea that diabetes is a surgical diseases such as diabetes and hypertension: hence, the emergence of “metabolic ease was first proposed in a landmark paper by Dr. Walter Pories (Ann. Surg. 1992; surgery.” According to the American Diabetes 215:633-42). A more recent study demonAssociation, nearly 21 million people in strated the superior effects of laparoscopthe United States have type 2 diabetes, a ic adjustable gastric banding on type 2 didisease not presently curable by medi- abetes compared with medical therapy, cine. The prevalence of insulin resistance with complete remission in 73% of surgically treated patients versus 13% for those is growing worldwide. It is well known that obesity increases managed medically ( JAMA 2008;299:316the risk for metabolic diseases, at least par- 23). These and other data call into question tially through increased insulin resistance. Metabolic surgery might improve insulin the National Institutes of Health guideline resistance. In fact, the level of improve- stating that a BMI of 35 is a lower limit for ment seen with surgery cannot be ap- bariatric surgery. Last year, the American Diabetes Assoproximated with nonoperative manageciation endorsed the Diabetes Surgery ment. Given that many patients with diabetes Summit, which brought together 150 a new patient comes to your clinic: a with newImagine that42-year-old maleoral hypoonset diabetes. He is taking medical professionals and other concerned individuals—including surgeons, endocrinologists, and experts in gastrointestinal physiology—to develop a consensus statement on metabolic surgery. The initial statement indicates that gastrointestinal surgery “may be appropriate for the treatment of type 2 diabetes in patients who are appropriate surgical candidates with BMI of 30-35 who are inadequately controlled by lifestyle and medical therapy.” Eighty-two percent of voting members agreed with this statement. It might make sense to use surgery explicitly to treat diabetes. Also last year, the American Society for Bariatric Surgery changed its name to the American Society for Metabolic and Bariatric Surgery in order to reflect this new era of metabolic surgery. New York– Correction In “Tourniquet Control Improves Varicose Vein Stripping” (SURGERY NEWS, February 2008, p. 17), there is a statement indicating that the minimally invasive venous ablation procedure was developed at VeinSolutions, a nationwide practice specializing in cosmetic and therapeutic vein care. In fact, the procedure was not developed there. A 2001 paper in the Journal of Vascular Surgery cites the long-term experience of Dr. J. Leonel Villavicencio, an ACS Fellow and Distinguished Professor of Surgery at Uniformed Services University of the Health Sciences in Bethesda, Md., and his colleagues, in the use of Presbyterian Hospital made a recent announcement that it was establishing a gastrointestinal metabolic surgery section, becoming the first academic medical center to offer “a dedicated and highly specialized approach to surgical treatment of type 2 diabetes” as well as other metabolic diseases and conditions seen with severe obesity. The possibility that surgery may be the best approach for diseases that traditionally have been treated medically is an exciting concept for surgeons. Although the data are preliminary, we may be seeing patients, like the one described above, who seek surgical cures for their diseases. DR. CURET is professor of surgery at Stanford (Calif.) University. the tourniquet in complex venous surgery ( J. Vasc. Surg. 2001;34:947-51). The error was introduced during the editing process and was not the result of faulty reporting. Clarification In “Colorectal Cancer Prognosis Tied to Neurogenesis” (SURGERY NEWS, March 2008, p. 1), Dr. Jonathan Wilks was listed as the lead author of the study, which he presented at the Academic Surgical Congress. The article did not mention that the principal investigator of the study was Dr. Daniel Albo, associate professor of surgery at Baylor College of Medicine, Houston. http://www.nxtbook.com/nxtbooks/elsevier/sn0208/index.php?startid=16 http://www.nxtbook.com/nxtbooks/elsevier/sn0208/index.php?startid=16 http://www.nxtbook.com/nxtbooks/elsevier/sn0308/index.php?startid=1 http://www.nxtbook.com/nxtbooks/elsevier/sn0308/index.php?startid=1

Table of Contents Feed for the Digital Edition of Surgery News - April 2008

Surgery News - April 2008 Contents Comorbidities Sway Bariatric Outcomes Database Finds Gap in Dissection For Melanoma Future Surgeon Shortage Predicted Dexterity Demo Best for Bile? Health Policy Scan Plan

Surgery News - April 2008

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