Diabetes And Metabolic Surgery | Healios

Diabetes and Metabolic Surgery

Diabetes and Metabolic Surgery

Obesity and Diabetes are frequently associated with each other.  “Diabesity “ is the terminology used for Diabetes in association with Obesity. Long standing  diabetes can result in microangiopathy and macroangiopathy. Microangiopathy is usually in the form of retinopathy , nephropathy and neuropathy. Diabetic  Macroangiopathy  may lead to coronary artery disease , peripheral vascular disease and cerebrovascular disease .  Long standing diabetes may also affect the gastrointestinal tract causing gastroparesis.

GUIDELINES FOR METABOLIC SURGERY

  1. If you have type 2 diabetes and are morbidly obese with BMI >35 Kg/m2, there is no question that one should consider metabolic surgery. It is expected to achieve 86% remission of diabetes and reduce the 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 associated with any of the long-term complications of type 2 diabetes such as eye (retinopathy) or kidney (renal insufficiency) problems, one should seriously consider metabolic surgery . It is expected to achieve at least 78% chance of diabetes cured/improved.
  3. If you are of Asian origin and have a BMI > 27.5 Kg/m2, you should strongly consider metabolic surgery

RECENT  EVIDENCE ABOUT  BARIATRIC / METABOLIC SURGERY

(Medical societies including the ADA, AHA, IDF, AACE & the Endocrine Society)

  • Helped Type 2 diabetic patients achieve glycemic control more effectively than intensive medical therapy within 1 year (STAMPEDE & Mingrone)
  • Resolved or improved Type 2 diabetes and other obesity-related Cardio vascular co morbidities for up to 5 years (STAMPEDE, Buchwald, Klein and Bolen)
  • Reduced medication use for Type 2 diabetes and other Cardio vascular comorbidities for up to 3 years (STAMPEDE, AHRQ/Segal and Klein)
  • Was more efficient than usual care for the prevention of Type 2 diabetes in persons with obesity at 15 years (Carlsson)
  • Reduced the risk of cardiovascular death (myocardial infarction or stroke) compared to customary intervention at 15 years (Sjostrom)
  • Resulted in morbidity / mortality rates similar to well-established general surgery procedures such as gallbladder surgery and hysterectomy (CMS)
  • Is viewed an acceptable treatment option for obese patients with T2DM

HOW DOES BARIATRIC – METABOLIC SURGERY HELPS TO CURE DIABETES

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• Intestinal Malabsorption
– Weight loss reduces insulin resistance
– Glucose malabsoprtion reduces stress on islet cells
– Fat malabsorption reduces circulating free fatty acids and improves insulin sensitivity

• Hormonal Changes

Re-routing of food alters the dynamic of gut-hormone secretion
• Increased levels of glucagon-like peptide 1 (GLP-1) increases insulin production
• Decrease in plasma levels of leptin & insulin
• Increased levels of adiponectin & peptide YY restore beta cell function and improves insulin sensitivity

• Rearrangement of GI anatomy
– “Hindgut hypothesis”
– “Foregut hypothesis”

• The Foregut Theory
Exclusion of the duodenum results in inhibition of a “putative”signal that is responsible for
insulin resistance and/or abnormal glycemic control (T2DM)

• The Hindgut Theory
The more rapid delivery of undigested nutrients to the distal bowel upregulates the          production of L-cell derivatives like GLP-1

GROWING CONSENSUS FAVOURS BARIATRIC / METABOLIC SURGERY

“Bariatric surgery should be considered for adults with BMI ≥ 35 kg/m2 and type 2 diabetes, especially if the diabetes is difficult to control with lifestyle and pharmacologic therapy.”
– American Diabetes Association (2009)

“When indicated, surgical intervention leads to significant improvements in decreasing excess weight and co-morbidities that can be maintained over time.”
– American Heart Association (2011)

“Bariatric surgery is an appropriate treatment for people with type 2 diabetes and obesity not achieving recommended treatment targets with medical therapies”
– International Diabetes Federation (2011)

“The beneficial effect of surgery on reversal of existing DM and prevention of its development has been confirmed in a number of studies”
– American Association of Clinical Endocrinologists (2011)

The Endocrine Society recommends that practitioners consider several factors in recommending surgery for their obese patients with type 2 diabetes, including patient’s BMI and age, the number of years of diabetes and the assessment of the (patient’s) ability to comply with the long-term lifestyle changes that are required to maximize success of surgery and minimize complications.”

“… remission of diabetes, even if temporary, will still lead to a reduction in the progression to secondary complications of diabetes (such as retinopathy, neuropathy and nephropathy), which would be an important outcome of … surgery.”
– The Endocrine Society (March 2012)

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