Surgical Treatment of Diabetes
As a specific type of surgery can lead to complete remission of diabetes, the surgical treatment of diabetes is emerging as a field in itself.
The number of people living with diabetes is growing globally. In urban regions, more than 10% of the population is living with diabetes, and another 30% is living with pre-diabetes. These figures are alarming, as it means that diabetes will continue to rise in the visible future.
Diabetes kills slowly and is associated with numerous severe health conditions like chronic kidney disease, increased risk of cardiovascular events, limb amputation, retinopathy, and much more.
Diabetes is managed with great success with the help of medications, especially type 2 diabetes (more than 90% cases). However, a large number of cases are not able to achieve adequate glycemic control. Such individuals continue to develop various diabetes-related complications. Moreover, taking multiple tablets daily or insulin pricks is not comfortable at all.
Wouldn’t it be wonderful if some surgical procedures could treat diabetes?
Surgery that helps in diabetes
It is difficult to believe, but researchers first noticed the benefit of some surgeries in diabetes almost 100 years back. First reports of diabetes remission after stomach surgery came in the 1920s. Such stories became more frequent with the introduction of bariatric surgery (weight loss surgery) in 1955.
Bariatric surgery not only helps lose body weight, but it leads to diabetes remission in the majority of cases. Science now knows that a reduction in body weight is just one of the factors for such a phenomenon. Bariatric surgery causes changes in gut hormones, bile acid movement, gut microbiota, and nutrient sensing by the gut. All this leads to diabetes remission. Science has not fully understood all the reasons behind such a remission.
During the last 40 years, there has been lots of systematic research into the subject. And now science knows for sure that more than 80% of patients undergoing bariatric surgery can expect complete remission in diabetes or significant improvement.
Surgery for diabetes also has additional benefits like the remission of hypertension, improved lipid profile, and thus considerably reduced risk of heart attack or stroke.
Candidate for surgery for diabetes
These are the good times for some individuals to consider surgical treatment of diabetes, as the safety of such procedures has improved a lot. According to the American Diabetes Association (ADA), the following individuals should consider surgery for diabetes 4:
- Severely obese people with BMI >40 (for Asians recommendations are BMI>37.5). Individuals with BMI above 35 can also discuss surgical options if they fail to control blood glucose with medications well (BMI>32.5 for Asians).
- Individuals above BMI 27.5 may also consider going for surgery if they are, by no means, able to control blood glucose (failure of intensive drug therapy or severe insulin resistance).
International diabetes organizations support the above recommendations5.
What surgery to choose from?
Nowadays, there are many surgical options, and not all are equally effective for reversing diabetes. While choosing a particular type of weight loss surgery, one should weigh the risks and benefits.
There are two kinds of weight loss surgeries:
- Gastric restrictive surgery – It is less invasive and frequently done with the use of laparoscopy. Other methods are sleeve gastrectomy and vertical gastroplasty. These surgeries involve reducing stomach volume by banding or other means. The benefit of these kinds of operations is the extremely high safety level. On the downside, only about half of the patients can expect diabetes remission, and that too occurs after some time and is proportional to the weight loss. There are ~50% chances of hypertension remission and correction of hyperlipidemia.
- Intestinal bypass surgery – It involves not only reducing the size of the stomach, but the intestine is shortened too. Roux-en-Y and biliopancreatic diversion are standard procedures. This kind of surgery produces faster results as it not only limits calorie intake but also alters working of the intestine, reduces the absorption of fat and calories. These are highly effective in treating diabetes with a remission rate anywhere between 82%-99%. Moreover, diabetes remission may occur even without weight loss. Additionally, more than 80% of individuals can expect the reduction of hypertension, hyperlipidemia, and thus considerably reduced risk of cardiovascular diseases.
Researchers are unsure about such a fantastic benefit from these surgical procedures. However, they think that it occurs due to many reasons like improved insulin sensitivity, and reduced body weight, lipotoxicity, inflammation. There is also strong evidence that these procedures alter gut hormones3.
Future perspectives of surgical treatment of diabetes
Medications can control blood glucose in most. Nonetheless, many fail to gain adequate control. Additionally, taking pills daily, is not an easy task.
This raises a question that wouldn’t it be good if more people were recommended surgical treatment? Or, are their surgical options for those with normal body weight who would like to get rid of daily pills/diabetes?
The answer to the question is “yes.” Although such surgeries are still not widely accepted as a standard treatment, however, many organizations are studying the surgical treatment of diabetes. Such procedures are specifically for the treatment of diabetes and not for weight loss.
At present, science is studying two surgical procedures for curing diabetes that is an ileal transposition and duodenal-jejunal bypass2.
Duodenal-jejunal bypass does not involve cutting or stapling the stomach; it just tries to bypass the small proximal part of the intestine. The initial results of clinical trials are encouraging.
Ileal transposition involves cutting the small distal part of the intestine along with its blood vessels and nerves and then attaching it to the proximal portion of the intestine.
After both these surgeries, there are significant changes in gut hormones, which results in not only diabetes remission, but drastically improved metabolism.
As the risk of such surgeries will close down to nil, they would be more widely used to treat diabetes. At present, surgical treatment is a good option for those failing to control body weight, having high cholesterol and hypertension, and inadequate response to drug therapy.