Can A Gastric Bypass Procedure Have A Positive Impact On Diabetes?

By Chad Friedman, DPM, and Doug Pacaccio, DPM

   The complications stemming from obesity have been well documented. In recent years, the popularity of the gastric bypass procedure has increased as a method of combating obesity. As the literature shows, gastric bypass has a positive effect on diabetes itself as well as diabetic neuropathy. However, the surgery is not without its risks and the entire health care team must be aware of both the benefits and downsides.

   According to data from the 1999-2000 National Health and Nutrition Examination Survey, two-thirds of the United States population is overweight and 30.5 percent of people are obese.1 This may lead to other commonly prevalent dilemmas including hypertension, heart disease and type 2 diabetes. This becomes a difficult task with the morbidly obese patients with diabetes who present with foot ulcers and have other foot deformities such as a Charcot foot.

   When it comes to people who are overweight, the body mass index (BMI) may range between 25.0 to 29.9 kg/m2. For those who are obese, the BMI is greater than or equal to 30.0 kg/m2. These numbers are for adults who are age 20 and over. Among people diagnosed with type 2 diabetes, 67 percent have a BMI greater than 27 and 46 percent have a BMI greater than 30.2 An estimated 70 percent of diabetes risk in the U.S. can be attributed to excess weight.2

Should You Refer A Patient For Gastric Bypass?

   Given that podiatrists may treat lower extremity dilemmas in obese patients with diabetes, some patients may warrant an appropriate referral for a gastric bypass procedure.

   In 1991, the National Institute of Health (NIH) consensus conference established guidelines and indications for surgical management of severe obesity.3,4 These include:

   • a BMI equal to or greater than 40 kg/m2 or a BMI equal to or greater than 35 kg/m2 with significant comorbidities; and
   • patients must have demonstrated previous dietary attempts at weight loss that have been ineffective.3

   Also keep in mind that various multidisciplinary consults usually precede a patient undergoing a gastric bypass procedure. This multidisciplinary team may include a nutritionist, psychiatrist/psychologist, internist, cardiologist and various support groups.

How The Gastric Bypass Procedure Has Evolved Over The Years

   At the end of the 1800s and early 1900s, surgeons performed bypass on patients with peptic ulcers and also utilized the procedure as a treatment for stomach cancer. Obesity surgery began in 1954 at the University of Minnesota with the empiric use of intestinal bypass.3,5 Complications of intestinal bypass led to overgrowth of bacteria in the bypassed area of the bowel, kidney stone formation and cirrhosis. In 1966, researchers introduced gastric bypass at the University of Iowa with the belief that this surgery would restrict the intake of food without creating the complications of malabsorption that surgeons had observed with intestinal bypass.3

   Today, the most frequent gastric bypass operation in the U.S. is the Roux en-Y gastric bypass, which Giffen introduced in 1977.3,5 Alkaline gastritis from early gastric bypass led to the Roux en-Y reconstruction. Other gastric bypass or bariatric bypass procedures are the vertical banded gastroplasty, the biliopancreatic diversion and the Lap-Band. Over the last decade, the popularity of gastric bypass has greatly increased since Wittgrove and Clark introduced laparoscopic techniques in 1994.3,7

   The Roux en-Y procedure is a combination of a restrictive and a malabsorptive procedure. The malabsorptive aspect decreases the amount of calories absorbed and accordingly leads to weight loss while the restrictive aspect reduces the size of the stomach. Current restrictive procedures provide a very limited gastric reservoir that fills rapidly, leading to early satiety.3

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