In recent years, medical institutions carrying out diabetes surgery have sprung up in China, and there have also been chaotic situations such as blind surgery leading to poor outcomes and even patient deaths. In a recent summit forum on obesity and diabetes surgery held in Changsha, Hunan Province, experts from the field of diabetes surgery in China appealed that diabetes surgery must be strictly controlled in all aspects such as indications, surgical methods and post-operative follow-up, and take the road of standardization and standardization, otherwise it will cause unnecessary harm to patients.
Safety and effectiveness are recognized
The main mechanism of surgical treatment of diabetes is to surgically “short-circuit” the structure of the gastrointestinal tract, thereby limiting food intake and absorption and reducing the load of food on the islet cells; in addition, due to changes in the path of food entering the gastrointestinal tract, causing a series of changes in the level of hormones in the digestive tract, thereby increasing insulin secretion.
”The use of surgery to treat diabetes, a traditional medical disease, is an important medical advance in recent years.” A retrospective analysis by researchers of a total of 22,094 patients in 136 papers published between 1990 and 2003 on the surgical treatment of type 2 diabetes found that 76.8 percent of type 2 diabetes patients who underwent gastric bypass surgery had normalized blood glucose targets and 86 percent had significant improvements, said a professor of general surgery at Shengjing Hospital of China Medical University.
A randomized controlled study published in the New England Journal of Medicine in March 2012 found that both procedures reduced blood glucose levels by 30 percent in patients with type 2 diabetes. Another article published in the same issue showed that surgical control of blood glucose was significantly better than drug therapy.
In terms of surgical safety, short-term complications of diabetic surgery include anastomotic stricture, leakage and bleeding, diarrhea, pulmonary embolism or respiratory failure; long-term complications include anemia, incisional hernia, vitamin deficiency, intestinal obstruction and gastric ulcers. “Overall, there are no additional complications associated with diabetic surgery compared to other surgical procedures. Some foreign studies have shown that minimally invasive surgical procedures for diabetes are similar in risk to laparoscopic cholecystectomy surgery.”
The study shows that while surgical treatment of diabetes inevitably involves surgical risks, in the long run it can reduce long-term mortality and improve the quality of survival for patients. A 15-year long-term follow-up of patients with type 2 diabetes after surgical treatment from the New England Journal of Medicine showed that gastric bypass surgery had a perioperative mortality rate of 0.2 percent but reduced long-term mortality in patients by 50 percent.
Safety hazards hidden in the “blossoming” market
It is understood that more than 60 medical institutions in China have already carried out surgery to treat diabetes, and more hospitals are trying to do so. The “blossoming” has also led to increased post-operative complications, poor outcomes and other worrisome issues.
”The irregularity of medical practice will make the efficacy and safety of the surgery greatly reduced.” Strict grasp of surgical indications, standardized preoperative examination, patient perioperative evaluation, surgical operation and postoperative complication management are the guarantee of the safety and effectiveness of surgical treatment of diabetes, said.
The lack of strict control over the indications for surgery is the most worrying point for the participating experts. Not long ago, a diabetic patient from Changchun City came to Shenyang City to seek treatment. The patient had previously undergone diabetes surgery in other hospitals with little success. “We received the examination and found that this was in fact a type 1 diabetic patient who was not suitable for surgery at all.”
Experts pointed out that surgery for diabetes is not suitable for all diabetic patients. 2011 International Diabetes Federation Guidelines for the Surgical Treatment of Diabetes specially launched in Asia states that for patients with type 2 diabetes with BMI (body mass index) ≥ 32.5, surgery is recommended as the first choice; patients with BMI between 27.5 and 32.5 and whose condition cannot be effectively controlled by optimal drug therapy are recommended to opt for surgery treatment. In China, the expert consensus on diabetes treatment launched by the Chinese Medical Association Diabetes Branch and the Chinese Medical Association Surgery Branch clearly puts forward six indications for surgery, such as type 2 diabetes with BMI ≥ 32.5, and type 1 diabetes as a contraindication to surgery.
The variety of surgical procedures and random “improvements” is another prominent problem. For example, in gastric bypass surgery, a small gastric capsule needs to be left to anastomose with the small intestine, and the current international standard is that the volume of the preserved stomach should be less than 30 ml, but in clinical treatment, some doctors expand the volume of the preserved small gastric capsule several times. The larger the preserved gastric bursa, the easier it is to anastomose with the small intestine and facilitate the operation, but this “technical improvement” will have a negative impact on the long-term results of the operation. The vice president of the First Affiliated Hospital of Jinan University, Prof. said that it is extremely unscientific for a few doctors to “improve” and simplify the classic surgery because they cannot master it well.
In addition, surgical treatment of diabetes requires multidisciplinary collaboration among endocrinology, nutrition, anesthesia and psychology. For example, patients with diabetes combined with obesity are prone to poor respiratory and cardiac function, which requires the intervention of respiratory medicine and cardiology during the perioperative period; due to structural changes in the digestive tract, patients may suffer from nutritional deficiencies after surgery and need long-term vitamin supplementation, which requires the intervention of the nutrition department for long-term follow-up. A few hospitals, however, only care about opening the surgery and do not think about multidisciplinary collaboration and postoperative supportive treatment, which also causes an increase in postoperative complications for patients.
It is believed that the emergence of various misconducts in the field of diabetes surgery treatment is due to the influence of professional factors such as the lack of widespread professional equipment in China, inadequate professional training of surgeons, and the lack of unified norms for large-scale evidence-based medical support in China; on the other hand, the phenomenon of improper medical practices occurring due to the drive of economic interests should not be ignored.
It is understood that, at present, there are about 92.4 million diabetic patients in China, more than 90% of them are type 2 diabetic patients, and the cost of one case of gastric bypass surgery is about 40,000 yuan. Faced with the temptation of huge economic gains, some medical institutions blindly launch new technologies without mature technical conditions and arbitrarily expand the scope of surgical indications.
There is still a lot to do to achieve standardization
”Make surgical treatment of diabetes on the right track, increase the standardization of training is a top priority.” The other identity of the Chinese physicians association of surgeons branch of obesity and diabetes surgeon committee chairman, he told reporters, the committee since its official establishment last year, will focus on promoting the standardization of diabetes surgery training, has been in Shanghai, Shenyang City, the establishment of two training bases, training the personnel of 40 hospitals. The training includes the selection of indications, standardized surgical operation, and preoperative and postoperative management, etc. “The training is not just for surgeons, but for the entire medical team.”
On the grasp of surgical indications, Chengzhu Zheng, professor of general surgery at Changhai Hospital of the Second Military Medical University, emphasized that BMI-only criteria for selecting indications are undesirable. He suggested that BMI is an important reference indicator, but it cannot be the only indicator, and doctors should also consider the patient’s islet function, age, medical history and other factors comprehensively.
To provide clinical practice with a higher level of diagnosis and treatment norms, is also an important issue facing the field of surgical treatment of diabetes in China at present. “There are no accurate data and more definitive medium- and long-term follow-up data from China for the surgical treatment of diabetes.” The experts pointed out that for the surgical treatment of diabetes, China has launched an expert consensus, but the main content or reference to foreign countries, to come up with the “Chinese version” of the surgical treatment of diabetes industry norms, clinical guidelines, clinical pathways, as well as the evaluation of the long-term clinical efficacy of this approach, but also need to carry out large-scale basic and clinical research.