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Metabolic Surgery


Laparoscopic Surgery for Type 2 Diabetes

Are you thinking of Permanent cure to type 2 Diabetes? Then you should read this

In addition to weight loss, Bariatric surgery results in resolution of co-morbid conditions like type 2 diabetes, hypertension, obstructive sleep apnea, hyperlipidemias in significant number of patients. These co-morbid conditions along with central obesity constitute metabolic syndrome.
This resolution is more after restrictive + mal-absorptive operations and mostly mal-absorptive operations compared to purely restrictive operations. Reason behind this resolution is thought to be due to the alteration of gut hormones that control insulin production and action, in addition to weight loss and calorie restriction. Due to the positive effect of bariatric surgery on type 2 diabetes, exclusive laparoscopic metabolic surgery is developed. Laparoscopic Sleeve Gastrectomy with Duodenoileal Interposition (Laparoscopic Diverted Sleeve Gastrectomy with Ileal Interposition), Laparoscopic Sleeve Gastrectomy with Duodenojejunal Bypass and Laparoscopic Sleeve Gastrectomy with Jejunoileal Interposition (Laparoscopic Sleeve Gastrectomy with Ileal Interposition) are the metabolic surgeries. These operations result in resolution of type 2 diabetes in obese patients and even in patients with normal BMI.

How Type 2 Diabetes is Cured by Metabolic Surgery?
Insulin is a chemical which keeps the blood sugar under control. In metabolic surgery we remove part of stomach (sleeve gastrectomy) and rearrange small bowel. This leads to changes in several gut hormones that control release of insulin and its action. Metabolic surgery cures type 2 diabetes as a result of several factors. Some of them are increased incretins, reduced anti incretins, reduced ghrelin, increased action of leptin, rapid emptying of stomach, calorie restriction and weight loss.

What are Incretins?
These are gut chemicals which greatly increase insulin release in the presence of glucose. Most important incretin is GLP1 (Glucogon like Peptide 1). This is produced from the last part of small bowel (ileum) when this part of the bowel comes in contact with nutrients in food. As we rearrange small bowel in metabolic surgery, food reaches ileum rapidly resulting in early production of GLP 1. GLP 1 increases the number of insulin producing cells (beta cells in pancreas) and the size of those cells (hypertrophy). This results in increased production of insulin. This chemical also increases the insulin action by increasing the number of insulin receptors.

What are Anti-incretins?
Theses are chemicals produced in first part of small bowel (duodenum) when duodenum comes in contact with food. They have negative effect on insulin and increase blood sugar. In metabolic surgery duodenum is bypassed so food will not enter the duodenum and the production of antiincretins is reduced. Thus results in loss of negative effect on insulin.

What is Ghrelin?
This is a chemical produced mainly in the upper part of stomach (fundus). This increases the appetite. It also has negative effect on insulin. Sleeve gastrectomy is a part of metabolic surgery. And fundus is removed in sleeve gastrectomy. So ghrelin production is reduced. This results in loss of negative effect on insulin.

What is the Role of Increased Gastric Emptying?
Sleeve gastrectomy results in increased emptying of stomach. This has positive effect on normalization of glucose levels. This helps in rapid entry of nutrients into small bowel. This also compensates for the reduced gastric emptying effect of GLP 1.

What is the Role of Calorie Restriction?
Sleeve gastrectomy is done as a part of metabolic surgery. This results in reduced intake of calories. Reduced calorie intake increases number of insulin receptors on the cells (so insulin sensitivity is increased). Therefore blood glucose levels become normalized. In diabetics with normal weight sleeve gastrectomy is done in such a way that calorie restriction is not much so that they don’t lose much weight. In obese diabetics we fashion sleeve gastrectomy in such a way that they have more calorie restriction so that they shed excess weight, in addition.

What is the Role of Weight Loss?
Sleeve gastrectomy results in calorie restriction and weight loss. Weight loss has positive impact on maintaining normal glucose levels in blood. Weight loss increases insulin action, reduces damage to beta cells in pancreas. Weight loss is not much or will not be there if surgery is performed on normal weight diabetic patients.

What are the Types of Laparoscopic Metabolic Surgery?
Practically all bariatric surgeries are metabolic surgeries as they result in resolution of co-morbid medical conditions including diabetes in significant number of patients. There are operations specifically designed for type 2 diabetes. These can be performed both in obese as well as non obese diabetics. Most popular among them are Laparoscopic Sleeve Gastrectomy with Duodenoileal Interposition (Laparoscopic Diverted Sleeve Gastrectomy with Ileal Interposition), Laparoscopic Sleeve Gastrectomy with Duodenojejunal Bypass, and Laparoscopic Sleeve Gastrectomy with Jejunoileal Interposition (Laparoscopic Sleeve Gastrectomy with Ileal Interposition).

Who are eligible to undergo Metabolic Surgery?
Patients suffering from type 2 diabetes who are fit, aged between 18 to 65 years, duration of diabetes > 3 years and < 20 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 are eligible for metabolic surgery. Obese Indians with BMI ≥ 30 kg/m2 and type 2 diabetes we recommend metabolic surgery if they are fit. In these patients surgery results in resolution of type 2 diabetes and weight loss. For obese Indians with BMI ≥ 25 kg/m2 and < 30kg/m2, non obese Indians (Normal weight – BMI < 23 kg/m2, Overweight – BMI ≥ 23 kg/m2 and < 25 kg/m2) we do metabolic surgery after taking detailed informed consent and taking ethical committee approval. Even in such individuals the resolution of diabetes is high.

Who are not eligible?
Patients with type 1 diabetes, those suffering from other endocrine problems, those with severe cardio-respiratory diseases who are unfit for surgery are not eligible. As insulin secretion is very less or absent in type 1 diabetes, metabolic surgery is not helpful. There is a specific subgroup of type 1 diabetics in whom onset is late and progression is slow. This group is called LADA (Latent Autoimmune Diabetes of Adults). As their diabetes is detected in adulthood they may wrongly be considered as type 2 diabetics. In such individuals metabolic surgery is harmful. We exclude these patients by performing specific tests before surgery. In long standing diabetics the beta cell mass in pancreas (cells producing insulin) reduces and this affect the cure rate. It is better to perform the surgery in the early stage itself. Beta cell mass is indirectly indicated by the serum C – peptide levels. C – peptide is produced by the beta cells along with insulin. For each molecule of insulin that is produced, one molecule of C – peptide is also released. So C – peptide levels indirectly indicate the amount of insulin that is produced, and the beta cell mass.

What are the Results of Metabolic Surgery?
This results in resolution of diabetes in over 95% of patients. In more than 65% patients HbA1C becomes < 6% and in 30% of remaining patients HbA1C level between 6 and 7 % is achieved. Patients are off insulin and tablets.

What factors affect the Cure of Type 2 Diabetes?
Duration of diabetes, insulin requirement before surgery, age of the patient, amount of insulin produced in body at the time of surgery (beta cell mass) affects the resolution rate.

What are the Investigations needed before Metabolic Surgery?
We perform complete patient evaluation including his/her cardiac and respiratory status. We perform fasting and post prandial blood glucose levels, HbA1c, post prandial C – peptide and Anti GAD antibody levels. We evaluate patient’s renal function. We perform detailed eye examination.

What are the Complications of Metabolic Surgery?
Complications are very less. Life risk almost nil. Some problems are leak from staple edges, postoperative requirement of assisted ventilation, lung infections after surgery, risk of heart attack if patient is old and already has heart problem, formation of blood clots in legs, intestinal obstruction, inability to pass urine in the immediate postoperative period etc. All these problems are rare and can be managed effectively. Compared to the risk of diabetes and the resulting medical problems, complications of surgery are very less.

What is the effect of Metabolic Surgery on Macrovascular Complications?
Diabetes results in narrowing of blood vessels in several parts of body. Blood supply to several parts of the body (including heart, brain, legs, penis in males) is reduced resulting in heart attack, stroke (paralysis), gangrene and ulcers in legs, erectile dysfunction in males. If surgery is performed before the development of these problems then occurrence of these problems can be avoided or delayed by several years. Even if the patient had these problems already, further progression is prevented and in some improvement in the blood flow and reversal of the problems can be seen.

What is the effect of Metabolic Surgery on Microvascular Complications?
Increased blood glucose levels and fluctuations in blood glucose levels affects function of several parts of body like kidney, eye (a layer in eye called retina). This can result in kidney failure and loss of vision respectively. Metabolic surgery results in normalization of blood glucose levels and prevents fluctuations in blood glucose levels. If these problems are not present at the time of surgery then their occurrence is prevented or delayed for several years. Even if these problems are present already their progression is prevented and in some patients improvement in kidney function and vision can occur.

What is the Cost of Metabolic Surgery?
Bariatric and metabolic surgeries are expensive. Main cost is due to usage of staplers. Patient needs to be in ICU for 1 to 3 days on average and sometimes on ventilator after operation. These result in increased cost. Given the excellent results of metabolic surgeries, these costs should be considered as an investment for future healthy life. If diabetes is left untreated, then overall cost to treat its co-morbid medical conditions and their complications is lot more than the cost of metabolic surgery. This expenditure will be saved, as metabolic surgery results in resolution of diabetes and co-morbid conditions in significant number of patients.

Please see the sections below for the surgery details