Diabetic Surgery

What is Metabolic/Diabetic Surgery?

In 2009 the American Society for Bariatric Surgery (ASBS) changed its name to the American Society for Metabolic and Bariatric Surgery (ASMBS) to promote information on the beneficial effects of surgeries for weight loss in treating metabolic diseases, especially Type 2 Diabetes Mellitus (T2DM).

Today, the term Metabolic Surgery is used to describe surgical procedures to treat metabolic diseases, especially, type 2 diabetes.

METABOLIC SURGERY FOR TYPE 2 DIABETES

In this form of diabetes, the body does not produce enough of the insulin, or the cells in the body do not use insulin properly. Insulin is necessary for the body to be able to use blood sugar for energy. As a result, glucose builds up in the blood, instead of going into cells. Type 2 diabetes is the form of the disease most closely linked to obesity and the name Diabesity has been used to describe this association.

HOW TYPE 2 DIABETES IS MEDICALLY TREATED?

Traditional 1st line treatment includes losing excess weight, eating a healthful diet and engaging in regular exercise. When these modifications do not make enough control in the disease, medications can be prescribed. Some medications help the pancreas produce more insulin; while others help the body to use the insulin that was produced efficiently. If these drugs don’t work, a person needs to take insulin.
Often these traditional treatments for diabetes do not work and patients run the risks of long-term complications.

Even with good medical control diabetes, some patients still go on dialysis, lose limbs, and have significant heart attacks, drug reactions, and other complications. The notion that medical therapy is without risk is absolutely incorrect.

Does Metabolic Surgery “Cure” Diabetes?

Till date, diabetes is poorly understood and medical treatment cannot claim a “Cure”. The aim is to put it in remission, defined as normal blood sugar levels and no need for diabetes medication. This means bringing glucose to normal levels and arresting the progression of the diabetic complications, thus giving the body a chance to repair the damage.

In 2004, study in Journal of the American Medical Association (JAMA) of more than 22,000 people who underwent bariatric surgery showed the following:

  1. Diabetes was completely resolved or improved in 86% of patients.
  2. High blood lipids improved in 70% or more of patients.
  3. High blood pressure was resolved or improved in 78% of patients.

How Does Metabolic Surgery “Cure” Type 2 Diabetes?

After Metabolic surgery, remission is observed in the days to weeks before any substantial weight loss has occurred.  Metabolic surgery cures Type 2 diabetes by causing calorie restriction, hormonal changes such as reduced Ghrelin, increased GLP1 and peptide YY. These hormones stimulate beta cells in pancreas to stimulate increased secretion of insulin, provided enough beta cell mass is still present in pancreas. Persistent increased GLP-1 secretion increases beta cell mass in the long term.

Before recommending any patient for metabolic surgery, evaluation of pancreatic Beta cell function is done to access Insulin secretion, Insulin Sensitivity and Insulin resistance. Type of Metabolic procedure is chosen depending on the duration of diabetes, dosage and duration of Insulin therapy, pancreatic Beta cell function, Insulin sensitivity and Insulin resistance.

Type of Metabolic procedure is chosen depending on the duration of diabetes, dosage and duration of Insulin therapy, pancreatic Beta-cell function, Insulin sensitivity and Insulin resistance.

How about metabolic surgery in type 2 diabetic patients who are not morbidly obese?

Actually, 2/3 of the world’s type 2 diabetics are not morbidly obese. They are however, overweight with BMI range 27-35Kg/m2. According to IDF guidelines for Asians, most of metabolic surgeons will accept patients with type 2 diabetes and BMI of 27.5Kg/m2 or greater for metabolic surgery.

It is possible that metabolic surgery may benefit even person with diabetes who are not overweight or obese.

International Diabetes Federation – 2011 Position Statement for Bariatric Surgery

  • Obesity and type 2 diabetes are serious chronic diseases associated with complex metabolic dysfunctions that increase the risk for morbidity and mortality.
  • The dramatic rise in the prevalence of obesity and diabetes has become a major global public health issue and demands urgent attention from governments, health care systems and the medical community.
  • Bariatric surgery is an appropriate treatment for people with type 2 diabetes and obesity not achieving recommended treatment targets with medical therapies, especially when there are other major co-morbidities.
  • Surgery should be an accepted option in people who have type 2 diabetes and a BMI of 35 or more.
  • Surgery should be considered as an alternative treatment option in patients with a BMI between 30 and 35 when diabetes cannot be adequately controlled by optimal medical regimen, especially in the presence of other major cardiovascular disease risk factors.
  • In Asian, and some other ethnicities of increased risk, BMI action points may be reduced by 2.5 kg/m2.
  • The morbidity and mortality associated with bariatric surgery is generally low, and similar to that of well-accepted procedures such as elective gall bladder or gall stone surgery. Bariatric surgery for type 2 diabetes must be performed within accepted international and national guidelines. This requires appropriate assessment for the procedure and comprehensive and ongoing multidisciplinary care, patient education, follow-up and clinical audit, as well as safe and effective surgical procedures.

FREQUENTLY ASKED QUESTIONS

Should I have metabolic surgery for my Type 2 diabetes?
  1. If you have type 2 diabetes and are morbidly obese with BMI >35 Kg/m2, you must consider metabolic surgery. You should expect to achieve 86% remission* of your diabetes and reduce your risk of death by as much as 89%.
  2. If you have type 2 diabetes and are overweight with BMI 30-35 Kg/m2, and especially if you have any of the long-term complications of type 2 diabetes such as eye (retinopathy) or kidney (renal insufficiency) problems, you should seriously consider metabolic surgery. You stand at least 78% chance to have your diabetes cured/improved.
SURGICAL TREATMENT
Weight loss surgeries or bariatric surgeries are the conventionally used surgical methods used for managing diabetes.
Who are eligible to undergo Metabolic Surgery?
1. Patients aged between 30 to 65 years, with diabetes> 3 years, not losing weight in the past 1 year, on stable insulin or oral hypoglycemic agents requirement in the past 3 months, post prandial serum C – peptide levels > 0.9 ng/ml
2. BMI ≥ 27.5 kg/mt2 with uncontolled type 2 diabetes