Dr Gert Du Toit explains the numerous health benefits metabolic surgery has for obese patients.
Many people have the misconception that metabolic surgery (bariatric surgery) is done to achieve weight loss for purely cosmetic reasons. In fact, metabolic surgery shows a high-degree of success in assisting to resolve the medical conditions commonly associated with obesity, including impaired glucose tolerance and Type 2 diabetes.
Although many patients appreciate the cosmetic aspects of metabolic surgery, and the fact that it is effective in assisting them to shed the unhealthy kilograms and keep them off, it is important to note that this treatment is always undertaken for the health benefits it affords patients, rather than for cosmetic purposes.
The health risks associated with obesity
Obesity is associated with a variety of related health conditions, such as metabolic syndrome – a cluster of conditions occurring together including high blood sugar levels and high blood pressure (hypertension); ischaemic heart disease; sleep apnoea; certain kinds of cancers; osteoarthritis, and mobility problems.
One of the most common health risks associated with obesity, and particularly an excess of fat around the abdomen, is Type 2 diabetes. This can cause a variety of severe and even life-threatening complications if it is not properly managed.
There is a strong correlation between the rise in obesity and the explosion in Type 2 diabetes and other lifestyle related chronic health conditions that are currently being experienced not only in South Africa but throughout the world.
Approximately 425 million people globally, and 1,8 million in South Africa, are suffering from diabetes; while one in every two cases have not even been diagnosed, according to the International Diabetes Federation.1 This highlights the magnitude of the global health challenge posed by the deadly combination of obesity and diabetes.
Metabolic surgical approach
Where patients are treated and properly supported pre- and post-operatively by a multi-disciplinary team of medical and other healthcare practitioners at a South African Society for Surgery, Obesity and Metabolism (SASSO) accredited metabolic surgery centre, metabolic surgery presents a safe and viable treatment option for obese individuals, offering real hope of substantially improved health and quality of life.
The surgical approach not only achieves outstanding weight loss results, but also a high degree of success in resolving conditions associated with obesity, including metabolic syndrome, impaired glucose tolerance, as well as Type 2 diabetes.
Three surgical options are available at SASSO-accredited centres to assist obese South Africans who are having difficulties in achieving and maintaining weight loss. The patient is carefully assessed beforehand to ascertain their suitability for surgery, and to establish which kind of metabolic surgery approach will be the most effective in addressing their specific healthcare issue.
The three types of metabolic surgery all minimally invasive and are undertaken lapascopically through small incisions in the skin. They include restrictive procedures, such as gastric banding and sleeve gastrectomy; procedures with gastric restriction (i.e. Roux-en-Y gastric bypass), which alter gastro-intesinal peptides; and malabsorptive procedures, which involve bypassing a portion of the intestine.
Treatment for diabetes
So successful has metabolic surgery proved in either assisting to prevent, control or even completely resolve Type 2 diabetes, that in 2015 the Second Diabetes Surgery Summit (DSS-II) included metabolic surgery in its global clinical practice guidelines as a standard treatment option for certain categories of people with Type 2 diabetes.2
In addition, the American Diabetes Association (ADA), one of the organisers of DSS-II Summit, has noted that: “Many people who undergo metabolic surgery experience major improvements in glycemia, as well as a reduction in cardiovascular risk factors, making it a highly effective treatment for Type 2 diabetes and a highly effective means of diabetes prevention.”3
As the ADA statement suggests, metabolic surgery can play an important role in diabetes prevention and management. Early surgical intervention shows outstanding potential in preventing the obese patient from proceeding from impaired glucose tolerance (pre-diabetes) to full-blown Type 2 diabetes, and improves outcomes.
Metabolic surgery often achieves a complete remission in diabetes but this depends on how long the patient has had the disease. In international and in our local experience, the best outcomes are achieved in patients who have not had diabetes for more than five years, so early diagnosis is important.
A recent US study4 points out that metabolic surgery in Type 2 diabetes patients results in:
- Better glyceamic control.
- Decreased medication use.
- Reduction in cardiovascular disease risk, heart attack, stroke, cancers and in overall mortality rates.
- Improved weight loss and quality of life.
The STAMPEDE trial’s (a randomised trial) results were published in the New England Journal of Medicine, and reported similar findings, suggesting that gastric bypass and sleeve gastrectomy, were superior to intensive medical therapy for Type 2 diabetes alone, achieving excellent glycaemic control.5,6
Funding the treatment
Recognising the advantages of early intervention, South Africa’s largest medical scheme, Discovery, revised its funding requirements for metabolic surgery for 2018, reducing the patient body mass index (BMI) requirement from 35 to 30.
This is a significant development and a recognition of the important preventative role that metabolic surgery can play, particularly with regard to pre-diabetes and Type 2 diabetes, which can cause irreversible damage to blood vessels and organs if it is not properly controlled.
This decision, which was made following negotiations with endocrinologist and SASSO chair, Professor Tess van der Merwe, highlights the fact that the metabolic surgery treatment also makes economic sense for many patients, and we expect that other medical schemes will follow Discovery’s lead in covering metabolic procedures in future.
Who will benefit from metabolic surgery?
As there can be numerous highly complex physiological and psychological causes of obesity, and each person has a completely different constitution and metabolic makeup, every case is different and not everyone can have, or will respond well, to the treatment.
Before the decision is taken to recommend metabolic surgery, SASSO-accredited facilities insist that the prospective patient undergoes a thorough physiological and psychological evaluation to ascertain their suitability for the treatment.
The prospective patient needs to demonstrate a commitment to weight loss and long-term follow-up. Those who are abusing drugs or alcohol, or have an uncontrolled psychiatric illness, are precluded from the treatment.
Overweight patients with Type 1 diabetes may qualify for the surgery but it should be noted that, unlike Type 2, it does not assist in managing this form of the disease, but the treatment may have other weight loss related health benefits for them.
All three types of metabolic procedures that are available not only limit how much the patient can eat but also reduce the absorption of nutrients by the digestive system. The individual consequently feels satiated after consuming smaller portions of food.
In the great majority of cases, where patients are treated and properly supported before and after surgery by a multi-disciplinary team, including a psychologist and dietitian, the metabolic surgery approach is safe, achieves outstanding results and is completely life-changing for patients.
One patient who has undergone metabolic surgery is Sr Charmaine Thamotharan, a 44-year-old nursing sister who manages the intensive care unit (ICU) at Netcare St Augustine’s Hospital, one of the busiest units of its kind in KwaZulu-Natal.
Her experience of metabolic surgery is typical of most our patients at the Durban Metabolic Surgery Centre based at the hospital, where more than 400 of these procedures have been completed to date.
Weighing 113kg, Sr Thamotharan had reached a stage where she even struggled to climb a flight of stairs without becoming breathless, and her weight was impacting her ability to do her work effectively. She was also pre-diabetic, suffered leg and knee pain, polycystic ovaries, high blood pressure, and high cholesterol levels.
Encouraged by a colleague and the good outcomes that were being achieved at the Netcare St Augustine’s Hospital centre, she decided to investigate the metabolic surgery option. After a thorough physical and psychological assessment at the centre, she finally underwent the surgery in August 2016.
“Since the surgery, my life has changed and I have never looked back,” Sr Thamotharan said. “I have lost 38 kilograms, but more important than that, I have more energy and confidence than ever.”
In consultation with her doctors, Sr Thamotharan was also able to stop her blood pressure, asthma and other medications, and the pre-diabetes and other medical conditions she suffered while she was obese, have been completely resolved. She observed that the procedure itself was quick and painless: it was over within an hour and she suffered little post-operative pain. She was back at work just two days after the operation.
It is strongly recommended that metabolic surgery be undertaken at a SASSO-accredited metabolic surgery centre, which must at all times adhere to the strict protocols and guidelines of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO).
There are currently 11 centres of excellence for metabolic medicine and surgery in South Africa, six of which are situated at Netcare hospitals, including the unit at Netcare St Augustine’s Hospital. These centres are designed to create a safe and supportive environment for obese patients, who are treated with the highest levels of empathy and care.
Over and above the laparoscopic surgeons, the multi-disciplinary teams at SASSO centres must include highly experienced endocrinologists, physicians, dietitians, psychiatrists and/or psychologists, and biokineticists. Such a team is able to take a comprehensive and holistic approach to weight loss, and determine the most practical solutions for each individual patient.
Not a quick-fix
It should be understood that metabolic surgery is no quick-fix solution for obesity. It requires a long-term commitment to a proper post-surgery diet and on-going follow-ups. However, in appropriate patients who have struggled to lose weight and regain their health for years, such a holistic treatment approach is usually nothing short of life-changing.
Professor Tess van der Merwe who, as director of the Centres of Excellence for Metabolic Medicine and Surgery of South Africa (CEMMS)(SA), oversees the work of the local metabolic surgery centres.
To ensure compliance with stringent international standards, these centres must maintain a comprehensive patient database with statistics on each patient. In addition, strict rules and regulations are in place regarding patients’ dietary environment, as well as care in ICU and wards. Training facilities with specialised technology and equipment are also required.
High-degree of disease resolution
In conclusion, a high-degree of disease resolution and very low complication rates are achieved at dedicated multi-disciplinary metabolic surgical centres. For those who qualify for this treatment, metabolic surgery is a tried and proven option.
- International Diabetes Federation: http://www.diabetesatlas.org/across-the-globe.html.
- Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations: http://care.diabetesjournals.org/content/39/6/861.
- Consensus from Diabetes Organizations Worldwide: Metabolic Surgery Recognized as a Standard Treatment Option for Type 2 Diabetes: http://www.diabetes.org/newsroom/press-releases/2016/consensus-from-diabetes-organizations-worldwide-metabolic-surgery-recognized-as-a-standard-treatment-option-for-type-2-diabetes.html.
- Metabolic Surgery for Tackling Type II Diabetes Epidemic: https://biomedres.us/pdfs/BJSTR.MS.ID.000401.pdf.
- The New England Journal of Medicine, http://www.nejm.org/doi/10.1056/NEJMoa1200225.
- The New England Journal of Medicine, http://www.nejm.org/doi/full/10.1056/NEJMoa1600869.