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The Metabolic and Bariatric Surgery Program at Mount Sinai is an innovative, multidisciplinary program designed to treat obesity and the numerous health problems that accompany conditions associated with it, such as Type 2 diabetes. The Mount Sinai Metabolic and Bariatric Program offers both established and advanced procedures to its patients. Gastric Bypass: An established operation that has been used to treat obesity for more than 40 years, the gastric bypass entails creating a small stomach pouch and bypassing three to five feet of intestine.
Adjustable Gastric Band (LAP-BANDa„?): The adjustable gastric band is wrapped around the upper stomach, restricting the stomach's food capacity.
Sleeve Gastrectomy: During this procedure, the left side of the stomach is removed, leaving a stomach roughly the size and shape of a banana. Biliopancreatic Diversion with Duodenal Switch (BPD-DS): A sleeve Gastrectomy is performed and a large amount of small intestine is bypassed, resulting is decreased absorption of nutrients.
In addition to the established procedures, Mount Sinai Metabolic is evaluating several investigational operations to treat diabetes and obesity. To learn more, please contact us at 212-824-2350 to learn about our program and the operations we offer. FDA Advisory Panel votes 8-2 in favor of an insulin dosing label update for Dexcom's G5 CGM!
Kelly: Some researchers call gastric bypass surgery the most reliable cure for type 2 diabetes. Jessica: On that note, which diabetes patients have the most success with metabolic surgery? I think that this perspective has enormous significance on populations of people who get diabetes at lower BMI levels, such as Asians and Asian Indians.
Jessica: In order for us to have a better understanding of metabolic surgery, can you discuss the risks of having the surgery? But for pulmonary emboli, there are baseline characteristics that put a patient at greater risk for getting a blood clot. Although I’m not an expert for young patients, I know that many of us are concerned that the operation could cause the malabsorption of micronutrients like vitamins. Jessica: Could you describe the different kinds of bariatric surgery and which would be best for a particular patient? Our mission is to help individuals better understand their diabetes and to make our readers happier & healthier. Our mission is to help individuals better understand their diabetes and to make our readers happier and healthier.
People who have diabetes and are severely overweight are deciding more and more often that bariatric surgery is just the thing for them. Some people, including a couple of my friends, have had wonderful results from bariatric surgery.
A study presented yesterday at the annual meeting of the American Society for Metabolic and Bariatric Surgery can help you decide. Roux-en-Y is the name of the most commonly performed bariatric surgery in the United States.
People who weren’t using insulin and whose pancreatic beta cells were working better were much more likely to get remission of their diabetes. They measured how well the beta cells were working by using something they call the “glucose disposition index.” If the patients had a GDI of 30 percent of normal or less, they were less likely to achieve remission.
What didn’t make a difference in remission rates was how much the patient weighed before surgery and whether they had lost any weight after six weeks or after one year. What the study does make clear is that if you are going to have bariatric surgery, it’s better not to wait until your diabetes has become completely unmanageable. While Roux-en-Y gastric bypass is the most common bariatric surgery, different hospitals use different techniques, including less invasive laparoscopic surgery. Generally, about 2.5 percent of people who have bariatric surgery have serious complications, according to a study last year in Annals of Surgery. A recent and comprehensive review in The New England Journal of Medicine shows somewhat worse statistics. Whenever people have asked me about bariatric surgery for weight loss, I have always suggested that they consider it only as a last resort. While lifestyle changes like following a very low-carb diet can put diabetes into remission for some of us, others can’t afford to wait to lose weight without surgery.
Last observation, I know a couple of ladies that have had this procedure and I don’t see where their quality of life has been improved. The network of interactions between obesity, cardiac and renal impairment comprises a complex multisystemic dialogue including neurohormonal, endocrine, paracrine and inflammatory signalling.


New research suggests that both diabetes and obesity may in fact be diseases of the gastrointestinal tract.
Established minimally invasive operations such as gastric bypass, sleeve gastrectomy, adjustable gastric banding, and duodenal switch, are available for patients with a body mass index (BMI) of 35 or more. To determine which surgery is most appropriate, it is necessary to evaluate each patient's height, weight, and medical problems, while also taking into consideration his or her lifestyle. The amount of restriction is adjusted by injecting saline solution into a small access port located under the skin. Weight loss is similar to gastric bypass, and Type 2 diabetes resolves in 60 percent of patients. Weight loss is typically slightly better than gastric bypass, and Type 2 diabetes resolves in over 90 percent.
Additionally, we are studying established procedures in patient populations that have not traditionally qualified for bariatric surgery operations. We also offer, free of charge, a series of online seminars to improve your understanding of bariatric surgery. David Cummings, a highly respected researcher from the University of Washington, Seattle, talked to us about the evolving field of metabolic surgery for type 2 diabetes. What is the rationale behind the shift towards using the term “metabolic surgery” instead of “bariatric surgery”? Cummings: I think there has been a shift in mindset about the reasons for seeking out surgery. Cummings: If you have type 2 diabetes and have gastric bypass, you enjoy complete remission in about 80% of cases. But for people with prediabetes, what are the odds for delaying or preventing diabetes onset? National guidelines tell healthcare providers to use BMI to select candidates, but we have heard that BMI is not the best predictor of success.
This is a very small number of the population, but anyone who has a history of hypercoagulability would be of special concern. While children and adolescents are getting taller, epiphyseal plates, the cartilage at the ends of their bones, are open and allow for growth. The new connection bypasses the remaining stomach pouch below, though both pouches are still connected to the small intestine. Although it is expensive and like any surgery it can have complications, the amount of weight that they lose is usually dramatic and their diabetes often completely disappears. Perugini and his colleagues studied what happened to 139 consecutive people with type 2 diabetes who had the Roux-en-Y operation.
The study found that overall 67 percent of these gastric bypass patients achieved remission one year after surgery, but that number grew to 96 percent when they weren’t on insulin and didn’t have severely reduced pancreatic function. Perugini’s remark about diabetes progression relates to the old strategy of countering the typical high-carbohydrate diet with more and more diabetes drugs culminating in insulin. Even then,  you need to consider the many different types of bariatric surgery, where to have the surgery, the possible complications, and how much it costs.
Other common procedures include gastric banding, one of the least invasive surgeries, and the relatively new sleeve gastrectomy. Hospitals and individual surgeons who have more experience with bariatric surgery do better, according to an Agency for Healthcare Research and Quality study. It covers new articles and columns that I have written and important developments in diabetes generally that you may have missed.
Metabolic surgery can reverse systemic hypertension, improve systolic and diastolic function and precipitate reverse cardiac remodelling leading to improvement of obesity-associated cardiomyopathy. Surgical modification of the stomach and intestines, such as bariatric surgery, may result in substantial improvements in both these conditions. Patients suffering from diabetes and milder obesity, with a BMI of 30-35, may qualify for one of several investigational procedures currently being performed under a research protocol. Remission means that, for at least a period of time, you’ll come off all your diabetes medications, including insulin, if you used to be on it, and have non-diabetic glucose levels (an A1c below 6.5%). According to the SOS Trial, which is probably the best dataset in the field, the factors that actually predicted the benefits of surgery were high fasting glucose levels and high fasting insulin levels. Leaks can occur when the new junctions of the gastrointestinal tract are not connected well during surgery. People who have had pulmonary emboli or deep venous thrombosis, or any family history of hypercoagulability, such as Factor V Leiden, should have second thoughts about whether the surgery is for them.
Then at some point, the cartilage becomes bone, the plates close off, and they cannot grow any further.


Keep in mind, that the safety of gastric bypass is somewhere in the same range as having your gallbladder removed. The probability of patients dying of their disease – diabetes, hypertension, cholesterol, or any other obesity-related complication – has repeatedly been shown to be higher than the probability of dying from surgery. We greatly appreciate and admire the work that he does for patients and we look forward to continuing to learn from his research on metabolic surgery. The researchers particularly wanted to find out who experienced remission of their diabetes. It’s getting a little less expensive, but the mean cost to all payers in 2004 was $10,385, the Agency for Healthcare Research and Quality says.
The proportion of people whose diabetes goes into remission after this surgery is impressive, particularly when people with diabetes don’t wait until they have only a few working beta cells.
But bariatric surgery is for people who can’t lose weight, not that they have to lose weight first. By modulating the entero-cardiac axis, metabolic surgery might also improve cardiac function via the actions of hormones such as GLP-1 and ghrelin and the adipokines leptin and adiponectin.
Coordinated by the Division of Metabolic, Endocrine and Minimally Invasive Surgery, the Program includes a tightly integrated group of advanced laparoscopic and minimally invasive endocrine surgeons, working in conjunction with internal medicine specialists, endocrinologists, cardiologists, diabetologists, psychiatrists, nurse practitioners, and nutritionists. Lena Carlsson’s 2012 New England Journal of Medicine paper on the Swedish Obese Subjects (SOS) trial: surgery reduced the probability of developing diabetes by 80% over 15 years. What is clear to me is that people who are more insulin-resistant benefit the most from surgery on many outcomes including the prevention of diabetes, heart attacks, strokes, and overall risk of dying. I don’t know of a good way to predict whether that will happen in one patient versus another so it’s a low probability concern that applies to everyone.
Most of us in the field think a conservative practice would be to wait until the epiphyseal plates have closed and linear growth has ended because the surgery might put patients at risk of a vitamin D deficiency.
We just don’t have anywhere near the richness of data for its long-term efficacy and safety as we do with bypass.
The abstract of the study, “Predictors for Remission of Type 2 Diabetes Mellitus Following Roux En Y Gastric Bypass,” is online.
Using insulin therapy as a surrogate for the degree of diabetes control makes sense some of the time — but not always.
Sustained weight loss after surgery may reduce glomerular hyperfiltration, reduce albuminuria and improve renal function. This distinguished team provides a broad spectrum of both traditional and advanced procedures to treat diabetes and obesity. He has spent the past 20 years specializing in gastrointestinal surgery, studying its effects on diabetes remission (please see the Metabolic Surgery Primer at the end of the article for specific definitions), and the mechanisms for how body weight, glucose, and appetite are controlled.
But it’s very well established that about 80% of patients will undergo remission as defined above.
The press got a hold of the paper, and they spun it as saying lots of people with diabetes who have remission get diabetes again, implying that if your diabetes is only going to be temporarily remitted, you shouldn’t have surgery. Excessive weight loss, gross malabsorption, under nutrition, and protein calorie malabsorption are not gastric bypass complications. If we were talking about biliopancreatic diversion, that’s a bigger deal, and it carries a significant risk, perhaps more than 1%, of death in operation. In comparison, the chance of dying within 30 days after gallbladder removal is 0.3% in the US. Furthermore, resolution of type 2 diabetes mellitus and systemic hypertension might reduce progression or even reverse chronic kidney disease.
It also poses a significant risk of complications such as malnourishment, and excessive weight loss.
Bush presented him with the US Presidential Early Career Award for Scientists and Engineers – the highest award given to young researchers by the US government.
Patients who have surgery will need to take post-operative iron and vitamin B12 supplements. The fear of bariatric surgery comes from attention bias – it’s the bad cases that get press and stick in your memory. We’ve been lucky to follow his work at multiple scientific meetings over the last several years. It does seem to work pretty well, but we don’t know why it works and we’re waiting for a longer-term data.



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