If I were a diabetic, often I ask myself- Would I take a surgery that promises to halt the disease even for a few years- and lasts an hour with a hospital stay of one day and that would leave me 4 tiny scars on my belly and would make me satisfied after eating a grilled fish? Well I don't know. I am not a diabetic and I am not an expert in mind reading either. But I have always judged a procedure by asking myself one question- would I recommend it for my own kin, if yes then I wouldn't hesitate to offer it to my patients.
Now let's evaluate this fascinating and awesomest claim that a surgery can reverse a disease so far thought to be irreversible. Diabetes per se is a disease of absolute or relative insulin deficiency. Insulin is required by the body to push in glucose from the blood to all the cells in the body. In type 1 diabetes insulin itself is deficient and in type 2 it is there but unable to work. The net result is same- the body cells are starved and undergo progressive degeneration. Ultimately a diabetic therefore has multiple organ damage including the eyes, heart, kidneys , liver, nerves, blood vessels, etc.
It is no surprise therefore that diabetic patients frequently have to undergo eye surgery, heart stenting, kidney dialysis, nerve vitamin supplementation and leg and feet amputations. In the last 3 decades there has been evidence that the reason why insulin doesn't work in type 2 diabetics is because they have chemicals in the blood that inhibits it's 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 (Rubino et al) and it is this knowledge that is fundamental to the concept of diabetes surgery. But there is a lot more than this.
The fat cells in the body 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 the 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 fat is also unable to perform its function of reducing blood glucose. Bile salts- 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 - have profound effects on all these aspects of diabetes. To enumerate once more they are:
1. Calorie restriction - obviously by reducing the food intake and hopefully the carb intake in a 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 insulin to perform. It is therefore no surprise that gastric bypass- conventional or mini gastric bypass- works better in diabetes than procedures like sleeve (Stampede trial)
3. Adipolysis - fat melting is the biggest boon after the metabolic surgery - in the eyes of most patients - and helps in reducing the adipokines - chemicals liberated by fat cells. Yes they are not as innocent as you might think. 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 resolution5. 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 action on them.Phew! That's a lot to digest. So what am I suggesting to my readers - the diabetics more so? Am I recommending diabetes surgery. Well I put the evidence as it is - plain and simple- without resorting to gobbledygook. The patient should always have the last word.
However if I were a diabetic and obese with blood fat also high, I would consider a surgery. I would definitely go for surgery if medicines were failing to control diabetes. I wouldn't accept the risks of damage to eye, heart, kidney, nerves and vulnerability to infections lying down. 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. Yes, I would take it.