Bariatric Surgery Without the Surgery?

New Laparoscopic Procedure May Achieve Glycemic Benefits in Nonobese

Leszek Czupryniak, MD, PhD; Dimitri J. Pournaras, PhD, MRCS


October 25, 2012

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Leszek Czupryniak, MD, PhD: Hello. My name is Leszek Czupryniak. I am here in Berlin for the 48th annual meeting of the European Association for the Study of Diabetes (EASD). Today we have a guest surgeon, Dr. Dimitri Pournaras, from the United Kingdom.

Dimitri J. Pournaras, PhD, MRCS: Hello. I am Dimitri Pournaras, a surgical trainee in the east of England in the United Kingdom. I did most of my research at the Imperial College London.

Dr. Czupryniak: You are here because you have just presented a very interesting set of data[1] on the new method used in bariatric surgery. This is one of the hottest topics in diabetes care in recent years. What about this topic is so interesting that it was selected for an oral presentation during this meeting?

Dr. Pournaras: We are trying to achieve the outcomes of weight-loss surgery without the surgery. This is a new device. It is an endoscopic procedure, called a duodenal-jejunal bypass liner. It is a 60-cm-long tube and is impermeable. The idea is that it is placed endoscopically, just distally to the pylorus, and you have no contact of nutrients with the mucosa of the duodenum and the proximal gut. At the same time, bile and pancreatic juices are in direct contact with the duodenum and proximal gut in undiluted form, which is highly unphysiologic. The idea is that we mimic part of the gastric bypass procedure.

The glycemic outcomes are promising. We demonstrated a reduction in A1c very early on. These were patients with a body mass index (BMI) of 25-35 kg/m2, so they did not qualify for weight-loss surgery and their weight loss was minimal. In fact, at 1 week, there was no weight loss at all, but even by then, we saw a change in the insulin resistance, and it cannot be explained by weight loss.

Dr. Czupryniak: How can it be explained? Was the endocrine system affected by this device or is something else happening that we don't yet know about?

Dr. Pournaras: This is a burning question. We did not show a change in insulin production. After undergoing gastric bypass, you get a dramatically enhanced insulin production, but that does not occur with the duodenal-jejunal bypass liner. The GLP-1 change is dramatic after bypass, but it does not seem to happen with this procedure. Yet there is a change in insulin resistance. The explanation remains to be determined.

Dr. Czupryniak: Do you think that this device is the future -- bariatric surgery without surgery or bariatric endoscopic surgery?

Dr. Pournaras: It definitely has a place in the present and in the future as a new method. We need to identify the patients who will benefit most from it. In this study, we looked at patients who did not qualify for surgery. We cannot do weight-loss surgery on everyone, no matter how much I would like to do that. There are patients who could benefit from these devices. We just need to identify who benefits most. It is definitely going to be there in the future. We just need to establish the role of this new device in the treatment algorithm of type 2 diabetes.

Dr. Czupryniak: The question that comes to mind is, how long can you keep the barrier in the body? You probably can't keep it forever, so what is your experience?

Dr. Pournaras: It stays in for 12 months; it is licensed for 12 months. We are analyzing some pilot data at the moment to see what happens afterwards. There seems to be an increase in A1c, but not quite to the preimplantation level and not immediately after the device is explanted, so we need to investigate this further. Probably next year we will have some more data on this, but it can be removed. It has to be removed at 12 months and it can be repeated, so you can do it again. It can be done more than once.

Dr. Czupryniak: Let's talk in a more general way on bariatric surgery. You have been involved in the studies in the last several years. You had several significant publications, so you are one of the few surgeons very close to diabetologists who can see how the area develops and how it will develop in the future.

What do you think is the position of bariatric surgery now in diabetes care? Who could be recommended to have this surgery, without any hesitation? For whom is it not the best way to treat diabetes now?

Dr. Pournaras: For patients with a BMI more than 35 kg/m2 and who have type 2 diabetes, the guidelines are clear. Patients do benefit. This year, we had very good studies in the New England Journal of Medicine[2,3] saying that bariatric surgery is better than medical treatment. We also have data to show that there is a reduction in cardiovascular risk in patients with type 2 diabetes. That is also very important.

We can identify the patients who will benefit most with future studies, but for the time being, it is the patients with type 2 diabetes and a BMI more than 35 kg/m2. I have no hesitation in saying that, with no contraindications and a thorough workup by the primary care physician, diabetologist, anesthetist, and surgeon, in a multidisciplinary environment, and performed safely in a center that performs this procedure with high frequency, this is the way forward for these patients.

Dr. Czupryniak: What about the less obese patients? That is a controversial area -- whether we should recommend bariatric surgery for those whose BMI is 25-35 kg/m2. What is your opinion?

Dr. Pournaras: We need definitive data on this. Patients from this group who receive surgery need to be in a clinical trial so they can at least contribute to the evidence base for this population. At the moment, we do not have high-quality studies to give us a definitive answer. The data that we have seen are promising, and it is worth exploring further. At the moment, we are still collecting the data to support this treatment.

Dr. Czupryniak: So that is the direction for future studies? Using it in slimmer patients?

Dr. Pournaras: Definitely.

Dr. Czupryniak: Thank you. We have been talking with Dr. Pournaras, from Berlin from the 48th meeting of the EASD.