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Minimally Invasive Surgery for Treating Type 2 Diabetes

Online Health Chat with Dr. Stacy Brethauer

February 28, 2011


Introduction

Cleveland_Clinic_Host: If you struggle with diabetes and are overweight, you are not alone. More than half of Americans are overweight, and roughly 12 million have severe obesity. Obesity is one of the most important factors for the development of type 2 diabetes. Studies have shown that bariatric surgery (also known as gastric bypass or weight-loss surgery) is not only an effective tool for treating obesity, but also for preventing, treating, and even resolving diabetes in some cases.

The Cleveland Clinic Bariatric and Metabolic Institute works closely with Cleveland Clinic endocrinologists to treat patients with diabetes and to develop a program tailored to suit their needs. Our endocrinology program is ranked in the top 10 nationally by U.S. News & World Report.

Dr.  Stacy Brethauer, is an associate staff physician in the Bariatric & Metabolic Institute at Cleveland Clinic. He attended medical school at Uniformed Services University of Health Sciences – F. Edward Hebert School of Medicine, in Bethesda, MD, and received his medical degree in 1993. Dr. Brethauer then served for three years as an air wing flight surgeon aboard aircraft carriers based in California. He completed a general surgery residency at the Naval Medical Center in San Diego, CA, in 2001.

Following his residency, Dr Brethauer was assigned as a staff general surgeon in Okinawa, Japan, and at the Naval Medical Center in San Diego, and was deployed with the 1st Marine Expeditionary Force to Taqaddum, Iraq, in 2004. Dr. Brethauer completed a research fellowship and a clinical fellowship in laparoscopic bariatric surgery at Cleveland Clinic and joined the staff in 2007. His clinical interests include bariatric surgery, laparoscopic surgery, gastrointestinal surgery, hernia repair, and endoscopy.

To make an appointment with Dr. Brethauer or any of the other specialists in the Bariatric & Metabolic Institute at Cleveland Clinic, please call 216.445.2224 or call toll-free at 800.223.2273, ext. 52224. You can also visit us online at www.clevelandclinic.org/bariatric.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Stacy Brethauer. We are thrilled to have him here today for this chat. Let’s begin with the questions.


Bariatric Surgery

cabriojag: What is this surgery?

Dr__Stacy_Brethauer: Minimally invasive bariatric procedures are surgeries designed to achieve weight loss and improvement in obesity-related medical problems. They involve various types of surgery on the stomach and intestine. Please see our website -- clevelandclinicweightloss.com -- which has more details and diagrams.

cheri0901: What are the main symptoms of Type 2 Diabetes?

Dr__Stacy_Brethauer: Excessive thirst, urination, and fatigue are the most common symptoms of type 2 diabetes.

janKL: What differentiates Cleveland Clinic’s bariatric surgery program from other hospitals in the area?

Dr__Stacy_Brethauer: Cleveland Clinic has a high volume bariatric surgery practice, with more than 700 cases performed last year. We also have great expertise in managing complex and high-risk patients.

cabriojag: I have additional health issues other than diabetes. The medications I take all have the side-effect of weight gain. Would a bariatric procedure help me?

Dr__Stacy_Brethauer: It should help you, but specific medications would need to be discussed at your consultation to see how they may affect your weight loss.

wileycoyote: What are the mortality statistics for these procedures?

Dr__Stacy_Brethauer: The average mortality rate after gastric bypass is 0.3% based on large national studies. This is the same as the mortality rate in the Cleveland Clinic program. Of course, individual risk depends on many things, including age, BMI, and medical co-morbidities. To put this number in perspective, the mortality rates after a common procedure -- such as gallbladder removal or hip replacement -- are also 0.3%.

cuttin_it: Can I lose more weight by having the surgery? Which way is healthier – surgery or diet?

Dr__Stacy_Brethauer: After gastric bypass, patients lose two thirds of their excess weight, which is about one third of their total weight. This is more than most people can achieve with a diet. It is durable weight loss for the rest of your life, if you make the necessary changes in your lifestyle and diet. As you probably know, most people regain weight after diet within a year.

I_didn't_know: If I decide to have the surgery, what should I expect? I mean, what is the process before and after surgery?

Dr__Stacy_Brethauer: Before the surgery, you will need to have a medical, psychological, and nutritional evaluation in our program. These are required by insurance companies and can take anywhere from one to six months, depending on your issues. After the surgery, there are regular follow-up appointments, and we recommend one month off of work after gastric bypass.

caterer: How painful is this procedure?

Dr__Stacy_Brethauer: The laparoscopic approach is far less painful than an open surgery. The small incisions will hurt for several days, but most people return to normal activities after one week. They are usually off pain medication after a few days.

cheri0901: I often find myself tired and short of breath, and I really don't sleep well. Will bariatric surgery lessen or negate these conditions?

Dr__Stacy_Brethauer: If those symptoms are related to sleep apnea, than there is a lot of evidence that those issues will resolve after surgical weight loss. There may be other reasons for these symptoms that we can pursue before surgery. Most people find that their energy increases tremendously after the weight starts to come off.

Kat799: I have diabetes and am overweight. I also have high blood pressure. Would bariatric surgery have a positive effect on my high blood pressure?

Dr__Stacy_Brethauer: Yes. After gastric bypass, more than 75% of people have improvement in their blood pressure.


Diabetes and Weight

Sammie11: My doctor told me that my weight may begin to play a role in developing diabetes? Why does this happen, and how can I prevent it from developing? I find it difficult to lose weight through diet and exercise.

Dr__Stacy_Brethauer: It happens because, as your weight goes up, your body uses insulin less effectively (insulin resistance), and that leads to high glucose levels. The only effective way to reverse insulin resistance is weight loss. Unfortunately, many diabetes medications can cause weight gain.

Vinnie: I have a BMI of 38 and have type 2 diabetes. If I were to have bariatric surgery, how quickly will the weight come off? How long will it take for my diabetes to resolve?

Dr__Stacy_Brethauer: It depends on the procedure you have done (lap band, gastric bypass, or vertical sleeve gastrectomy), but with gastric bypass the weight loss will occur very rapidly in the first 6 to 12 months. Your BMI should decrease to approximately mid to high 20s. Your chance of diabetes remission is around 80% in the first year.

Nattiesue: I thought once you have diabetes you always have it. How does bariatric surgery cure diabetes? Can it come back?

Dr__Stacy_Brethauer: Gastric bypass changes the way the gut and pancreas communicate, causing the pancreas to produce insulin more effectively. Also, as weight loss occurs, insulin resistance improves, so that more than 80% of type 2 diabetics will be off their medication with normal glucose levels around one year after surgery. These changes occur less rapidly with the band, but can occur. We refer to it as remission as opposed to cure because it can come back in certain instances if weight is regained. Patients who are requiring insulin at the time of surgery are less likely to have a full recovery of their pancreas function after surgery.

wileycoyote: I have read various articles that state this surgery seems to eliminate diabetes almost immediately. Do you find this to be true?

Dr__Stacy_Brethauer: Overall, one third of patients require no medication after gastric bypass. Most of these individuals are early diabetics taking only oral medications. The reference ‘early diabetes’ would mean less than five years.

camimor: I am a 58-year-old woman and have struggled with weight my entire life. It has taken me almost three years to reduce my BMI from 34 to 27 and I struggle to get it lower. I am now on Metformin 2g/d to assist in weight loss and blood sugar control, although classified as pre-diabetic/metabolic syndrome, mild hypertension. My family history has much obesity/type 2 diabetes/hypertension. I have requested bariatric surgery as a preventive measure and solution to the weight/insulin/hypertension issue, but have been told by my endocrinologist that I do not qualify. Is there any way I could qualify based on my description?

Dr__Stacy_Brethauer: We understand how difficult it is to manage both diabetes and your weight. However, a BMI of 27 is below the current criteria, even for somebody with metabolic syndrome. There may be research studies in our program for which you might qualify. Please call Chytaine Hall, study coordinator at 216.445.3983.


Qualification

Slyjon: Do you offer minimally invasive bariatric surgery? Is it common to qualify for this type of procedure?

Dr__Stacy_Brethauer: Yes. All of the procedures are done laparoscopically. Qualifying depends on medical insurance, BMI, and medical co-morbidities.

Ken10: What type of criteria do I have to meet to qualify for weight loss surgery? What is the first step to have surgery?

Dr__Stacy_Brethauer: Criteria includes: body mass index (BMI) over 40, or 35 or higher with obesity-related co-morbidities. Start by checking if this benefit is offered by your insurance company. Go to www.clevelandclinicweightloss.com and select the Pathway to Surgery section, which includes demographic information and a health questionnaire.

sallysue: I have had prior abdominal surgeries and probably have scar tissue. Would I still be a candidate for the minimally invasive surgery?

Dr__Stacy_Brethauer: Yes. We do many patients with the laparoscopic approach that have had abdominal surgery in the past. This may add some time to the procedure, but rarely requires the need for an open procedure.


Life After Surgery

cheri0901: Once you have the surgery, how can you expect your eating and  lifestyle to change?

Dr__Stacy_Brethauer: It dramatically changes the way you eat in terms of portion size. Having the surgery requires a long-term commitment to changing your eating behavior. The program has nutritionists that will help you post-operatively. Most people are able to eat regular food at meal times, but in smaller amounts over the long term. It is important to avoid junk food and to incorporate exercise into your routine. That will determine your success.

allie: How long does it typically take to recover from this procedure?

Dr__Stacy_Brethauer: After gastric bypass, the average hospital stay is three days. Most people are back to normal activity within one week. We recommend one month off of work to adjust to the new way of eating. After having the gastric band procedure, the recovery times are less, around half as long.

DJ: After gastric bypass and excess weight has been lost, what can you eat? What foods are prohibited two to three or more years after surgery?

Dr__Stacy_Brethauer: The normal healthy diet is tolerated by the vast majority of patients after gastric bypass. Soft and liquid calories and junk food will overpower the effects of the surgery and will cause weight to be regained.


Research Studies

larryfun: I read that Cleveland Clinic has a research study for people interested in bariatric surgery to help treat diabetes. Can I join the study? What should I do to get involved?

Dr__Stacy_Brethauer: One study was just completed and another is just about ready to begin. The study is called STAMPEDE II. To see if you qualify for the study, please contact Chytaine Hall, study coordinator, at 216.445.3983.

cabriojag: How does one get in a study?

Dr__Stacy_Brethauer: There may be research studies that you could qualify for in our program. Please call Chytaine Hall, study coordinator at 216-445-3983.

love_me: Are there studies as to the health/eating issues 5-10-15 years after gastric bypass, especially if partial or more weight has been regained?

Dr__Stacy_Brethauer: The most common long term complications after gastric bypass are iron deficiency and osteoporosis. These result from inadequate supplementation. In our program, we make it clear what supplements are required and we check patients’ vitamin levels annually. Weight regained is a potential problem after any of these operations. Most commonly this occurs when people discontinue their lifestyle changes after surgery.


Insurance Cost

flowers22: Are insurance companies more apt to cover this procedure if you have diabetes? What's the easiest way to find out if my insurance covers this? Are there other options if they don't cover it? Thanks.

Dr__Stacy_Brethauer: It helps support your case if your body mass index, your BMI, is 35 to 40. Otherwise, it is not a major concern for qualification. You should contact your insurance company directly to find out if bariatric surgery is covered under your plan. There are other financial options and self-pay options available. That information is also located on the website under Insurance and Financial information.

wileycoyote: Are insurance companies beginning to cover this type of surgery to eliminate diabetes?

Dr__Stacy_Brethauer: Most insurance companies do cover bariatric surgery, although the criteria may differ between insurance policies. Make sure to check with your insurance company to determine if the benefit is covered under your policy.

keep_going: I have had no success getting Medicaid to cover bariatric surgery, what options would I have in terms of financing?

Dr__Stacy_Brethauer: There are financing and self-pay options. More information can be found on our website at www.clevelandclinicweightloss.com.

sophia1: How much upfront money will be required for employees with Antares insurance in order to have the surgery?

Dr__Stacy_Brethauer: Co-pay is $2750. Of that, $250 is due before surgery. After 18 months, it is incrementally repaid if you meet your follow-up requirements.


General Questions

cabriojag: How do I calculate my BMI?

Dr__Stacy_Brethauer: Go to www.clevelandclinicweightloss.com and we have a BMI calculator on the website. Then go to the Am I a Candidate for Weight Loss Surgery tab on the left hand side of the screen.

so_cold: I watched a documentary on bariatric surgery. Scientists have discovered a link between the gut and the brain. Does cutting the nerves in the stomach correct the brain (meaning neurotransmitters) and the way one thinks?

Dr__Stacy_Brethauer: There is no direct effect on the brain. There are, however, changes that occur in the gut that alter the signals to the brain, and affect how people perceive hunger and satiety.

tadada: Is there a support group meeting, pre-op or post-op?

Dr__Stacy_Brethauer: Yes. We provide support groups for both pre- and post-op patients. There is a complete list of these support groups on our website.

fallin: Why does the bypass stomach have to be made so small?

Dr__Stacy_Brethauer: It comprises the restrictive part of the surgery, which is an important factor in your hunger and portion control long term. Larger pouches will stretch over time and you may lose some of this effect.

jengirl: I live far from Cleveland, would I still be able to have my surgery at Cleveland Clinic?

Dr__Stacy_Brethauer: Yes. We are happy to take care of patients who come from far distances and will try to consolidate their appointments as much as possible. We do ask that patients remain in the area for one week before returning home.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Stacy Brethauer is now over. Thank you again for taking the time to answer our questions about Minimally Invasive Surgery for Treating Type 2 Diabetes.

Dr__Stacy_Brethauer: These were great questions. Thank you for your interest.


More Information
  • To make an appointment with Dr. Brethauer or any of the other specialists in the Bariatric & Metabolic Institute at Cleveland Clinic, please call 216.445.2224 or call toll-free at 800.223.2273, ext. 52224. You can also visit us online at www.clevelandclinic.org/bariatric.
  • A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.eclevelandclinic.org/myConsult
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