KOCHI: Diabetes is a global epidemic affecting millions of people across the world, around 347 million people worldwide have diabetes. In 2012 diabetes was the direct cause of 1.5 million deaths. More than 80% of diabetes deaths occur in low and middle - income countries. Type-2 diabetes results from the body’s ineffective use of insulin. Type-2 diabetics comprises 90% of people with diabetes around the world, and is largely the result of excess body weight and physical inactivity.
Metabolic syndrome is a condition in which excess body fat is accumulated to such an extent that health may be negatively affected and the life span is shortened. It is a group of diseases where increased abdominal girth more than 90 cm in males and more than 80 cm in females generally associated with increased BMI, diabetes, dyslipidemia, hypertension, polycystic ovarian disease, sleep apnoea, non-alcoholic steato hepatitis. Treatment of diabetes involves lowering blood glucose and the levels of other known risk factors that damage blood vessels. Only 33% get full control (HbA1c) of diabetes with Oral drugs and insulin. Every one point increase in HbA1c will increase the risk of complications upto 30%. In this context, surgical option to cure Type 2 diabetes is emerging. There are various procedures to reduce excess body weight thereby reducing the insulin resistance.
NON-SURGICAL TREATMENT :Intragastric Balloon (IGB)
It is placing a deflated balloon in the stomach using endoscope and then filling it to decrease the amount of intragastric space. It can be left in the stomach for a maximum period of six months. It results in average weight loss of 10 to 15 kg. It may be used in patients with overweight who are not suitable for Metabolic Surgery.
SURGICAL TREATMENT (METABOLIC SURGERY):
Open approach: Involves long incision and resultant problem for the patient. It is extremely difficult for the procedure to be completed in morbidly obese patients.
Laparoscopic approach : This approach is comfortable both for the patient and surgeon. It is highly effective and safe to perform with least of problems. It has the advantage of minimal blood loss, minimal post operative pain, fewer wound infections, very few incisional hernias, very fast recovery and early return to presurgical activity level.
Lap. Gastric banding: Effects are moderate with some undesirable effects and hence not preferred.
Bypass procedures : These procedures are malabsorbtive. There is good weight loss and resolution of metabolic syndrome to great extend. Less preferred due to shunting of food (dumping syndrome) and some vitamin deficiency.
Laparoscopic Sleeve Gastrectomy (more than 30 BMI patients) – The portion of stomach which secretes Ghrelin and acid in excess is removed. This leads to reduction in food intake and also alteration in hormonal milieu which leads to usage of stored fat for caloric requirement. This has got very good results without significant nutritional deficiency and hence most preferred.
Modified Sleeve Gastrectomy with Ileal Interposition ( BMI 25 – 30) : In this after a modified sleeve gastrectomy ileum is brought near the stomach by interposing proximally. The jejunum is connected after ileum. This ensures early entry of food to ileum but jejunum is not kept out of its route. There is significant increase in GLP1 hormone and resultant increase in timely secretion of insulin. There is no dumping or vitamin deficiency in contrast to Bypass procedures.
Around 85 to 90 % of diabetes patients treated by these surgeries get complete resolution of diabetes. Whereas the result of them get significant control of diabetes with reduced dose of medication. In addition to diabetic control the other benefits are loss of excess weight and control of triglyceride levels. Sleep apnoea, arthritis, cardiac episodes, kidney disorders and cancers are also reduced significantly. There is very good improvement in fertility which is also a welcome thing for those who are infertile due to insulin resistance.
The SOS study with 15 year of followup has also concluded that bariatric surgery patients have better type 2 diabetic remission and fewer complications than the medically treated patients.
Metabolic surgery has emerged as the most preferred, highly effective and safer means to achieve long term resolution of type 2 diabetes.
The author is a Specialist in Laparoscopy at KIMS Hospital, Kochi
The views expressed by the author are his own.