I want to say a few words about surgery for weight reduction. Surgery is used in the most severe and resistant cases of obesity. It has impressive effects, such as correction of high glucose and reduction or discontinuation of glucose-lowering drugs. Results are so successful in some patients that some surgeons consider type 2 diabetes to be a surgical disease. That, I believe, is a little extreme.
Some of the reasons for considering surgery include i You have a body mass index (see Chapter 7) that is greater than 40. i You have an obesity-related physical problem, such as inability to walk. i You have a high-risk obesity-related health problem like heart disease.
Formerly, the best surgical treatment for obesity was the vertical banded gas-troplasty, where the upper stomach is stapled to create a small, thumb-sized pouch above, a narrow opening, and a larger pouch below. Because the upper pouch is small, you have a feeling of early fullness, and you tend to eat less. The upper pouch is connected to the small intestine so that the lower stomach is bypassed. Patients are forced to eat very small portions and can't eat sugar and other carbohydrates, which cause dizziness and other symptoms. Most of the weight is lost in the first year.
More recently, the laparoscopic gastric banding procedure has been used. A constricting band containing an inflatable balloon is placed around the upper end of the stomach to create a small upper pouch and a larger lower pouch. It can be inflated or deflated to control the size of the upper stomach. The usual weight loss is two-thirds of the excess within two years. By removing the band, the procedure can be reversed. This is a simpler operation than gastric bypass and is less likely to result in a surgical complication.
Some of the problems of gastric banding include the following:
i The pouch may stretch. i The band may slip.
i The reservoir in the constricting band that permits inflation may leak.
1 Weight loss may not occur (if the patient chooses to overeat).
1 The patient may experience acid reflux from the stomach into the esophagus.
When you have surgery for obesity, you must be committed to lifelong medical follow-up. You must be willing to give up large meals and be determined to lose weight. There is no question that severely obese patients with type 2 diabetes do well with surgery. As they lose weight, their blood glucose falls, their cholesterol falls, and their blood pressure improves. They sleep better and are less depressed.
As for liposuction and its possible role in the treatment of type 2 diabetes, there are few studies on the subject and they are short-term, but early reports showed some promise. For example, a report in the Annals of Plastic Surgery in January 2004 showed a fall in glucose, cholesterol, and insulin secretion after liposuction, but this was only at three weeks after surgery. A report from the New England Journal of Medicine later that year in June showed that liposuction did not significantly improve obesity-associated metabolic abnormalities after three months of observation.
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