Can diabetes surgery save lives – and money?
Francesco Rubino still remembers the day he realised that surgery could cure diabetes type 2. ‘It was July 3rd 1999,’ he recalls. ‘When I saw that surgery could put the disease into remission – despite the consensus at the time that it was progressive, irreversible and incurable – I knew our generation had an opportunity that could not be missed.’
The possibilities were so exciting that Rubino didn’t sleep that night. A great deal of work lay ahead: he would have to show that surgery was an effective therapeutic option; to win over sceptics in the medical establishment and the public; and to study whether it would deliver value for money.
Now, the jury is in. Almost two decades after Rubino’s ‘Eureka moment’, he is a professor at King’s College London and has co-authored landmark guidelines which recommend bariatric surgery as a treatment for diabetes type 2.
From theory to practice
With the backing of professional societies from around the world, the next task is to oversee the implementation of guidelines that would make surgery a mainstream option for large numbers of people with diabetes.
This, says Rubino, will have two major implications. The first is the possibility of containing the public health and economic impact of a disease which might otherwise threaten the sustainability of health systems. The other is that as growing numbers of diabetes patients are treated with gastric surgery, scientists may learn more about the underlying cause of the disease – potentially leading to better preventative strategies.
The biggest barrier to rapid adoption of the guidelines is misconceptions surrounding the disease. ‘In the past, bariatric surgery for diabetes has been seen as an extension of obesity treatment,’ he says. ‘It is an entirely different concept if we think of it as a treatment for diabetes itself. Once you accept that people with diabetes need treatment and we want the most effective and cost-effective option, then you have to consider surgery.’
In theory, up to 60% of people with diabetes type 2 could be candidates for surgery, based on their body mass index and other criteria. However, not all will have the procedure. ‘In reality, the number of patients prioritised for surgery would be much less than 60%,’ says Rubino. ‘It always depends on the individual patient, their willingness to undergo surgery, and the effectiveness of alternative therapies.’
Endocrinologists – specialists with a key role in managing diabetes patients – are coming on board the surgical revolution. ‘I think it’s a game-changer,’ says Carel le Roux, Co-Director of the Metabolic Medicine Group at University College Dublin. ‘Over the past 20 years we’ve seen the development of some impressive treatments that can control blood sugar, blood pressure and lipids but there is still a significant number whose diabetes is not under control. Gastric bypass surgery is probably the most effective treatment for them.’
Le Roux says surgery offers the chance to reverse the relentless advance of diabetes, giving many patients a chance to control their condition using lower doses of medication: ‘Surgery allow us to lower the dose of medicines to a level where we get the benefit of controlling the disease and reducing complications, while sparing the patient the side-effects of long-term high-dose medication.’
With strong evidence from clinical trials showing the clinical benefit of gastric bypass surgery, attention will turn to the costs of investing in surgery. Implementing the new guidelines will require a considerable scaling up of surgical capacity and a commitment to spend money today in order to save over the longer term. Politicians will need persuading.
‘For someone with type 2 diabetes who may be on expensive – but excellent – medication, the costs can easily run to €4,000 per year,’ says le Roux. ‘If an operation costs, let’s say, €8,000 and means we can use cheap, low-dose drugs from now on, the health system gets its money back in a couple of years.’
That back-of-the-envelope calculation becomes stronger still if indirect costs are considered. The ability to work and pay tax, and reduced demand on social insurance systems, promises even greater impact.
The economic case will continue to grow as more cases are done on large groups of patients with type 2 diabetes (rather than on cohorts with a mix of obese patients with and without diabetes). The big question for the future appears to be how quickly health systems can deliver the operating theatres and surgeons to meet demand – and how willing the public is to rethink its view of gastric surgery.
ABOUT PROFESSOR FRANCESCO RUBINO
Professor Francesco Rubino is Chair of Metabolic and Bariatric Surgery at King's College London and Honorary Consultant at King's College Hospital. He is internationally recognised as one of the world's leaders in research, teaching and practice of metabolic and weight loss surgery. Professor Rubino's research showed that the anti-diabetes effect of certain bariatric procedures, particularly gastric bypass surgery, result from mechanisms beyond weight loss. This evidence provided scientific rationale for surgical treatment of type 2 diabetes including in less obese patients. His research findings and theories also points to a role of the gastrointestinal tract in the pathophysiology of diabetes and obesity. Professor Rubino received his MD in general surgery at the Catholic University / Policlinico Gemelli in Rome and he completed fellowships at the European Institute of Telesurgery in Strasbourg; MountSinai Medical Centre in New York and the Cleveland Clinic. Professor Rubino is the recipient of numerous awards and has given hundreds of presentations throughout the world. He is the author of over 100 articles in peer reviewed journals and book chapters. For several consecutive years Professor Rubino was selected by both US News & World Report and Castle Conolly as one of "America's Top Doctors".
ABOUT CAREL LE ROUX
Carel le Roux graduated at the University of Pretoria, South Africa and completed his postgraduate clinical training at St Bartholomew’s Hospital and Imperial College London. He was awarded a Wellcome Fellowship for his PhD and worked in Prof Steve Bloom’s laboratory. His work on appetite regulation lead to a postdoctoral Clinician Scientist’s award by the Department of Health in the UK.
He is a Reader in Metabolic Medicine and currently heads the Obesity working group at Imperial College London. His work is focused on understanding the mechanisms by which bariatric surgery affects energy balance.