Diabetes mellitus is rapidly increasing in numbers worldwide with over 77 million Indians affected by this disease in 20191. Despite awareness campaigns, lifestyle changes and availability of various pharmaceutical products, almost 77.6% of them have remained uncontrolled(HbA1c>7).2
Patients with uncontrolled diabetes are at a higher risk of various vascular complications broadly classified as
- Macrovascular – mostly cardiovascular – resulting in myocardial infarction(heart attack), brain stroke etc
- Micro-vascular – peripheral neuropathy(sensory loss requiring amputations in few), nephropathy etc
It is estimated that besides shortened lifespan, 1,000,000 Indians lose their life directly related to diabetes related causes.3
- Pradeep R, Mohan V. Epidemiology of type 2 diabetes in India. Indian J Ophthalmol. 2021 Nov;69(11):2932-2938. doi: 10.4103/ijo.IJO_1627_21. PMID: 34708726; PMCID: PMC8725109.
- Borgharkar SS, Das SS. Real-world evidence of glycemic control among patients with type 2 diabetes mellitus in India: the TIGHT study. BMJ Open Diabetes Research Care 2019;7:e000654
- International Diabetes Federation. IDF Diabetes Atlas. 9th ed. Brussels, Belgium: International Diabetes Federation 2019.
It has been shown that over 80%1 of surgical patients have glycemic resolution(normal blood sugars and stoppage of medicine) at 12-18 months and 36%2 continue to be off diabetes medicines even 10 years after surgery.
Maintenance of normal blood sugar has shown remarkable effect on reduction of diabetes complications at 5 years3 after diabetes(metabolic) surgery –
- 1/3rd reduction of diabetic retinopathy(eye problems)
- 50% reduction of diabetic kidney disease
- 2/3rd reduction of diabetic nerve problems
- 40% reduction in diabetes related heart attacks & deaths
Glycemic control and avoidance of complications have shown to result in an increased lifespan of 9.3 years4 in diabetes surgery patients.
- Sjostrom L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery.N Engl J Med.2004 Dec 23;351(26):2683–93
- Adams TD, Pendleton RC, Strong MB, Kolotkin RL, Walker JM, SEL, et al. Health Outcomes of Gastric Bypass Patients Compared to Nonsurgical, Non-intervened Severely Obese.Obesity (Silver Spring)2010 Jan;18(1):121–30
- Rebecca O Brein et al. Micro-vascular outcomes in patients with diabetes after bariatric surgery versus usual care – A matched cohort study. Annals. Surg. August 2018
- Nicholas L Syn, David E Cummings, Louis Z Wang et al, Association of metabolic–bariatric surgery with long-term survival in adults with and without diabetes: a one-stage meta-analysis of matched cohort and prospective controlled studies with 174 772 participants ; www.thelancet.com https://doi.org/10.1016/S0140-6736(21)00591-29
Surgery for treatment of diabetes is also called metabolic surgery in scientific terms. These surgeries involve laparoscopic(keyhole) stomach size reduction &/or intestinal re-routing. Commonly performed metabolic surgeries in India include gastric bypass and sleeve gastrectomy. Earlier these surgeries were done for weight loss alone, but with changed guidelines they can now be offered in >27.5 BMI patients with uncontrolled diabetes, despite best medical management.
These surgeries changes gut hormones(GLP-1, PYY, GIP, Amylin), gut bacteria and limits food intake with resultant improvement of insulin sensitivity(reduced insulin resistant), enhanced insulin secretion and better glycemic control.
Person considering metabolic surgery option should meet all of the following criterion –
- >18 years age
- Type 2 Diabetes
- HbA1c > 7 even after optimal diabetes medication
- BMI >27.51,2,3,4,5(approx. 8-10 kgs overweight)
Patients meeting abovementioned will require individual assessment for pancreatic function, associated co-morbidities and anaesthetic suitability.
Usual surgical time is ~1 hour, patients are allowed to drink water & walk within 6-8 hours and usual hospital stay is 24-48 hours. The blood sugar levels start improving within 24-48 hours and in most patients injectable insulin is likely to be stopped within 2-7 days of surgery.
Risks associated with metabolic surgeries are considered significantly less than a gall bladder6 or hip replacement surgery. However individual risk assessment and optimization is necessary in each patient. It has also been established that the risk is lower in experienced hands at high volume centers.7
Metabolic surgeries are covered under medical insurance policies for >35 BMI patients with uncontrolled type 2 diabetes.
- Dan Eisenberg, Scott A.Shikora, EdoAarts, AliAminian et al. 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery. SOARD; vol 18, issue 12,December 2022, Pages 1345-1356
- Bhasker AG, Prasad A, Raj PP, Wadhawan R, Khaitan M,et al. OSSI (Obesity and Metabolic Surgery Society of India) Guidelines for Patient and Procedure Selection for Bariatric and Metabolic Surgery. Obes Surg. 2020 Jun;30(6):2362-2368
- American Diabetes Association; 8. Obesity Management for the Treatment of Type 2 Diabetes:Standards of Medical Care in Diabetes—2021.Diabetes Care1 January 2021; 44 (Supplement_1): S100–S110
- Dixon JB, Zimmet P, Alberti KG, Rubino F; International Diabetes Federation Taskforce on Epidemiology and Prevention. Bariatric surgery: an IDF statement for obese Type 2 diabetes. Diabet Med. 2011 Jun;28(6):628-42
- Rubino F, Nathan DM, Eckel RH, Schauer PR, Alberti KG, Zimmet PZ, Del Prato S, Ji L, Sadikot SM, Herman WH, Amiel SA, Kaplan LM, Taroncher-Oldenburg G, Cummings DE; Delegates of the 2nd Diabetes Surgery Summit. Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations. Diabetes Care. 2016 Jun;39(6):861-77.
- Buchwald H et al. Trends in mortality in bariatric surgery. A systematic review and meta analysis. Surgery 2007
- Flum DR et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009
- Really a nice way to get rid of diabetes immediately - Shridhar Pai https://youtu.be/6IvTqx4NAiM
- I am off diabetes medicines & regained energy after diabetes surgery https://youtu.be/EDCMYklZBy8
- I did not require insulin after surgery – Ms Karangutkar https://youtu.be/UxYF8WPPpwQ
- Ms Shardul got relief from years of insulin injections https://youtu.be/nOZhDFwlM8s
- Diabetes control after bariatric surgery https://youtu.be/R6P97c1ELZQ
- Darr ke aage jeet ho gayee meri - Manorama https://youtu.be/D57ot0a44DM
Dr Ramen Goel’s Presentations
- Is surgery the most effective therapy for diabetes? https://www.youtube.com/watch?v=7xNFoDAcNUc
- Lokmat news channel interview https://youtu.be/_hXLN4wN5_U
- Navbharat Times(Hindi) news coverage https://navbharattimes.indiatimes.com/lifestyle/health/keyhole-surgery-can-control-sugar-by-getting-rid-of-medicines/articleshow/99146084.cms?upcache=2