The biggest winners? Weight-loss surgery and diabetes

A few days after Mike Pezzano had gastric-bypass surgery, his diabetes disappeared.

By the time he went home from Crozer-Chester Medical Center, the Folsom resident was off the four medications he had used for a decade to control his blood sugar.

"When I left the hospital, they said, 'Monitor your blood sugar for a few days,' " recalls Pezzano, 53, who has shed more than 100 pounds in the year since his operation and is approaching his target weight of 200. "The readings were all normal."

Gastric bypass and the other common bariatric surgery - gastric banding - dramatically reduce stomach size, so patients feel full after eating tiny amounts and sick if they eat more.

Developed about 40 years ago, weight-loss surgery has exploded in popularity in Philadelphia and across the nation, reflecting the obesity epidemic, surgical advances, and studies showing that the radical procedure extends lives.

The surprising thing is that for Type 2 diabetics, surgery confers benefits independent of weight loss, and that's especially true of gastric bypass, which bypasses part of the small intestine, as well as much of the stomach. Studies show about 84 percent of bypass patients have a total remission of diabetes, sometimes within days or weeks, just like Pezzano.

This is not to minimize the costs - $20,000 to $35,000 for the surgery - or the hazards of reducing the stomach to the size of an egg. Patients can develop infections, blood clots, ulcers, hernias and problems with excess skin. Adjustable gastric bands that shrink the stomach can slip, break or cut into the organ. Long-term risks include vitamin deficiencies, osteoporosis and the rare but severe problem of low blood sugar.

Nor does the weight-loss battle end. On average, patients shed 62 percent of their excess weight with bypass, 48 percent with banding - and most eventually regain some.

The ultimate peril - dying - has fallen to about 0.3 percent, but that's averaging all patients. For "super-obese" patients (more than 175 pounds overweight) and those with severe heart or lung disease, mortality rates were 6 percent and 10 percent respectively, in a study of veterans published last month.

Still, nothing has proved better than surgery at treating Type 2 diabetes, long viewed as chronic, progressive and incurable.

That's why some leading bariatric surgeons say it's time to rethink the mysterious disorder. Even though its characteristic feature is insensitivity to insulin, the hormone made by the pancreas to control blood sugar, perhaps diabetes is an intestinal disease that can be treated by changing anatomy.

Among the skeptics is Baylor University endocrinologist Alan J. Garber, chief editor of the journal Endocrine Today. It is not yet clear, he said, that remission lasts indefinitely. And although he is impressed that sugar metabolism improves right after bypass surgery, he suggests a simple reason. "After surgery, you stop eating," he said. "So for a day or two, your blood sugar falls. This may be nothing more than the effect of not eating."

Still, if the intestines do play a crucial role, it suggests that people with poorly controlled diabetes could benefit from gastric bypass even if they aren't greatly obese.

In Latin America and Europe, such patients are being allowed to have surgery. In the United States, by contrast, doctors and insurers stick to 1991 guidelines set by the National Institutes of Health: Candidates should have a body-mass index of at least 40 (about 100 pounds overweight), or a BMI of at least 35 (75 pounds overweight), along with weight-related problems such as diabetes and heart disease.

"Those guidelines need to be updated. There is no science behind" them, said Francesco Rubino, chief of metabolic surgery at Weill Cornell Medical College and a pioneer in the emerging field of diabetes surgery.

About 5 percent of Americans now fit the NIH criteria, which is why obesity surgery is growing even faster than the nation's girth. Consider the Philadelphia region. An Inquirer analysis of billing records shows that in 1998, about 140 people - 10 percent of them diabetics - underwent bariatric surgery at the three hospitals then offering it.

By 2007, 16 hospitals did the surgery on 2,500 patients, a third of them diabetics.

The counts keep rising. Last month, Bryn Mawr Hospital opened a bariatric center.

Succeeding where pills, insulin shots and glucose monitoring fail is a vindication for surgeons, said Ramsey Dallal, chief of bariatric surgery at Albert Einstein Healthcare Network. Forty percent of its obesity-surgery patients are diabetic.

"There's a general bias in medicine and in society against people who are overweight. It's assumed that they lack willpower and that surgeons who operate on them are doing so foolishly," Dallal said. Acceptance from specialists has "taken a long time."

One indicator of changing attitudes: In January, the American Diabetes Association for the first time added bariatric surgery to its recommended treatment options for Type 2 patients who meet NIH criteria.

Of the two common surgeries, gastric bypass works better and faster, but banding is reversible.

The two leading theories of why bypass is better focus on changes in hormones and food absorption in the small intestine, said Leon Katz, director of minimally invasive and bariatric surgery at Crozer-Chester Medical Center.

"Either it's the exposure of food to the more distant portion of the small intestine much earlier than normal," he explained, "or the exclusion of food" from the bypassed part of the intestine.

Despite some breathless media reports, bypass is not a "cure" for diabetes - at least, not yet. Patients with diabetes for a decade or more, or those on large amounts of insulin, are less likely to have a complete remission.

Bill Jacobson, 57, of North Wales, is a case in point. A diabetic for about 25 years, he was able to cut way back - but not quit - insulin, blood-pressure medicine and a cholesterol-lowering drug after his 2007 gastric-bypass surgery at Penn Presbyterian Medical Center.

Not that he's dissatisfied.

Jacobson, who oversees trials of obesity and diabetes drugs for a clinical-trials company, now carries 155 pounds, down from 235, on his 5-foot-6 frame. His sleep apnea is gone, his chance of an imminent heart attack has fallen from 96 percent to 2 percent - and it's far easier for him to put on socks.

He has had no complications, other than two episodes of "dumping" - the sudden cramping triggered by food that is too rich or too much to digest.

But he works hard, both mentally and physically, to stay healthy. He eats "smaller and smarter," attends support-group meetings, and works out daily on a treadmill, even when traveling.

"Surgery is nothing more than a tool," he said. "You can subvert it. But I'm motivated."

Contact staff writer Marie McCullough at 215-854-2720 or mmccullough@phillynews.com.