If I were a diabetic, would I go for a surgery that promises to halt the disease even for a few years and lasts
an hour with a hospital stay of one day? A surgery that would leave four tiny scars on my belly andallow me to eat grilled fish?
Well I don’t know and I am not a diabetic. But I have always judged a procedure by asking myself one question, which is, would I recommend it for my own kin. If the answer is yes, then I wouldn’t hesitate to suggest the procedure to my patients. Now let’s evaluate this fascinating claim that a surgery can reverse a disease so far thought to be irreversible.
Diabetes is a disease of absolute or relative insulin deficiency. Insulin is required by the body to push in glucose from the blood to the cells. In type 1 diabetes, insulin itself is deficient and in type 2, it is present but unable to work. The net result is the same where the body cells are starved and undergo progressive degeneration. Eventually, a patient with chronic diabetics may incur multiple organ damage that includes the eyes, heart, kidneys, liver, nerves, blood vessels, etc. Diabetic patients frequently have to undergo eye surgery, heart stenting, kidney dialysis, nerve vitamin supplementation and leg and feet amputations.
In the last three decades there has been evidence that indicates that the reason why insulin doesn’t work in type 2 diabetics is because they have chemicals in the blood that inhibits its action. They are called anti-incretins. It is further known that a certain part of the gut is responsible for liberating it. So if we were to bypass the food from entering this part of the gut, it would lead to amelioration of diabetes. This has been adequately exemplified in rat models and it is this knowledge that is fundamentalto the concept of diabetes surgery.
The fat cells in the body which were earlier thought to be an inactive body tissue is now known to liberate chemicals- adipokines that have been shown to be pro-diabetic. This comes as no surprise since it was common knowledge that diabetes affected the obese more than leaner individuals and weight loss is instrumental for diabetes control.
More research to excavate the cause of diabetes has revealed the role of liver and bile salts. The liver when laden with fatis also unable to perform its function of reducing blood glucose.
Bile salts which are secreted by the liver and absorbed in the gut via receptors have been shown to be instrumental in keeping the blood glucose at optimal levels. It has been demonstrated that these bile salt receptors in the gut go haywire in diabetes.
Metabolic or diabetes surgery - the gastric bypass in particular - has profound effects on all these aspects of diabetes. They are listed below –
1. Calorie restriction—By reducing the food intake and hopefully the carbohydrate intake ina sensible compliant patient, the glucose load is decreased, thereby allowing insulin to breathe easy.
2. Duodenal bypass—This arguably reduces the anti-incretins and allows the insulin to perform. It is therefore no surprise that gastric bypass-conventional or mini gastric bypass-works better in diabetes than procedures like sleeve.
3. Adipolysis—Fat melting is the biggest boon after the metabolic surgery - in the eyes of most patients - and helps in reducing the adipokines which are the chemicals liberated by fat cells. This leads to improved insulin function and normalisation of blood glucose.
4. Resolution of fatty liver (NASH) — The liver post-surgery becomes less fatty. This translates into better liver function and diabetes resolution.
5. Alteration of bile salt pool—This has become an area of active research in recent times. It is known that the gastric bypass especially the MGB has pronounced actionon them.
So what am I suggesting to my readers? Am I recommending diabetes surgery? Well I put the evidence as it is but the patient should always have the last word. However, if I were a diabetic and obese with high blood fat, I would
consider a surgery. I would definitely go for surgery if medicines were failing to control diabetes. I wouldn’t accept the risk related to the damage to eye, heart, kidney, nerves and vulnerability to infections. Accepting to eat moderately and sensibly and taking vitamins daily sounds like a good trade-off for diabetes in that situation, especially if it promises to halt the disease progression
— The writer is Surgical Gastroenterologist Digestive Surgery Clinic, Belle Vue Hospital, Kolkata, India