Diabetic Surgery


Obesity & Diabetes Doctor: A weight loss and Diabetes Surgery centre, helps to reduce the excess weight and nearly normalise the uncontrolled blood sugar after all initial modalities fails. Centre is having most experienced and super-specialist laparoscopic Gastrointestinal surgeon along with team of physician, diabetologists, intensivist, dietician and specialized physiotherapist to take care of all & high-risk obese person. This centre is equipped with all latest facilities to deliver world class treatment.



Type of Diabetes

The classification of diabetes includes four clinical classes

  •   Type 1 diabetes (results from B-cell destruction, usually leading to absolute insulin deficiency)
  •   Type 2 diabetes (results from a progressive insulin secretary defect on the background of insulin resistance)
  •   Gestational diabetes mellitus (diabetes diagnosed during pregnancy)
  •   Specific types of diabetes due to other causes, e.g., genetic defects in B-cell function, genetic defects in insulin action, diseases of the exocrine pan-creas (such as cystic fibrosis), and drug-or chemical-induced (such as in the treatment of AIDS or after organ trans-plantation)

Diabetes is greatest public health threat of the 21st century

Dr Avinash Tank Super-specialist For Metabolic Surgery in Ahmedabad, Diabetes Surgery in Ahmedabad, Sleeve gastrectomy in Ahmedabad, Gastric bypass in Ahmedabad, Banded bypass in Ahmedabad, Mini-bypass in Ahmedabad, Bilio-pancreatic diversion in Ahmedabad, Metabolic surgery in Ahmedabad, Metabolic Surgeon in Ahmedabad, Diabetes Surgeon in Ahmedabad, Obesity Surgeon in Ahmedabad, Bariatric Surgeon in Ahmedabad, Diabetes Hospital in Ahmedabad. Metabolic Surgery in India, Diabetes Surgery in India, Sleeve gastrectomy in India, Gastric bypass in India, Banded bypass in India, Mini-bypass in India, Bilio-pancreatic diversion in India, Metabolic surgery in India, Metabolic Surgeon in India, Diabetes Surgeon in India, Obesity Surgeon in India, Bariatric Surgeon in India, Diabetes Hospital in India

The world wide cases of Type 2 diabetes are rising dramatically, secondary to increasing sedentary behaviour and easier access to attractive calorie-dense foods. The most recent global predictions by the International Diabetes Federation (IDF) suggest that there are 285 million people with diabetes currently worldwide. This is set to escalate to 438 million by 2030, with a further half billion at high risk.Dr Avinash Tank for Diabetes Surgeon in India, Diabetes Surgeon in Gujarat, Diabetes Surgeon in Ahmedabad.

Diabetes is the risk factor for disease of Heart, Eye, Kidney, Nerve & limb vessels

Type 2 diabetes is a risk factor for vascular damage: affecting small blood vessels (eye; kidney and nerve) and large blood vessels (premature and more extensive heart, brain and limb blood vessels). Early death and damage to organs in diabetes result from such complications. The disease results from inadequate insulin (hormone that keeps sugar under control) production and action and results in hyperglycaemia (high sugar in blood). In addition, obesity, by itself, generates similar cardio-metabolic dysfunction.

Obesity is the risk factor for Type 2 diabetes

Obesity is considered the primary risk factor for diabetes. It has been estimated that the risk of developing Type 2 diabetes is increased 93-fold in women and 42-fold in men who are severely obese rather than of healthy weight.

Need of Diabetes Surgery

Limitation of Medical treatment in Obese

Though lifestyle interventions along with medical treatment options are initial line of treatment for any diabetic patient, but they have very limited success in controlling blood glucose levels amongst the severely obese, with many of these patients not achieving targets.

There is strong evidence that significant weight loss achieved by using lifestyle and medical methods by obese, particularly severely obese, people is modest and rarely sustained, particularly in the severely obese.

A number of these medications used for treating Type 2 diabetes, including insulin, themselves can result in weight gain.

There are now few medications approved for weight loss with recent withdrawals associated with adverse events.

Diabetic Surgery has sustainable effect on sugar control

Almost all severely obese patients are unsuccessful in their efforts to achieve sustained and significant weight loss and there is evidence that weight loss induced by Gastro-intestinal (bariatric) surgery can lead to remission of high blood sugar in the majority of patients with diabetes. Earlier treatment increases the likelihood of remission. In the remaining patients, residual hyper-glycaemia is easier to manage following surgery. It can therefore be suggested that Gastro-intestinal (bariatric) surgery for the morbidly (severely) obese with Type 2 diabetes should be considered early as an option for eligible patients, rather than being held back as a last resort.

Decrease the risk of death by diabetes and related complications:

In addition to weight loss by Gastro-intestinal (Bariatric) surgery, has been shown to substantially improve hypertension, high cholesterol and sleep apnoea and several reports have documented an improvement of overall survival and specific reduction in diabetes-related mortality.

International Diabetic Federation: 2011

IDF Taskforce on Epidemiology & Prevention of Diabetes
Appropriate role of Surgery and other Gastrointestinal Interventions in the Treatment and Prevention of Type 2 Diabetes

Introduction:

The International Diabetes Federation (IDF) is an umbrella organization of over 200 national diabetes associations in over 160 countries. The Federation has been leading the global diabetes community since 1950. IDF€™s mission is to promote diabetes care, prevention and a cure worldwide. The Federation€™s activities aim to influence policy, increase public awareness and encourage health improvement, promote the exchange of high-quality information about diabetes, and provide education for people with diabetes and their healthcare providers. IDF is associated with the Department of Public Information of the United Nations and is in official relations with the World Health Organization (WHO) and the Pan American Health Organization (PAHO).

The International Diabetes Federation Taskforce on Epidemiology and Prevention of Diabetes convened a consensus working group of diabetologists, endocrinologists, surgeons and public health experts to review the appropriate role of surgery and other gastrointestinal interventions in the treatment and prevention of Type 2 diabetes and published in Diabetic Medicine 2011.

Summary of Recommendation:

Gastro-Intestinal surgery is an appropriate treatment for people with Type 2 diabetes and obesity not achieving recommended treatment targets with medical therapies, especially when there are other major co-morbidities.

  1. Gastro-Intestinal Surgery should be an accepted option in people who have Type 2 diabetes and a BMI of 35 kg„ m2 or more.
  2. Gastro-Intestinal Surgery should be considered as an alternative treatment option in patients with a BMI between 30 and 35 kg„ m2 when diabetes cannot be adequately controlled by optimal medical regimen, especially in the presence of other major cardiovascular disease risk factors.
  3. In Asian, and some other ethnicities of increased risk, BMI action points may be reduced by 2.5 kg„m2.

The morbidity and mortality associated with surgery is generally low and similar to that of well-accepted procedures such as elective gall bladder or gallstone surgery.

Gastro-Intestinal surgery in severely obese patients with Type 2 diabetes has a range of health benefits, including a reduction in all-cause mortality.

Available evidence indicates that bariatric surgery for obese patients with Type 2 diabetes is cost-effective.

Clinically severe obesity is a complex and chronic medical condition. Societal prejudices about severe obesity, which also exist within the healthcare system, should not act as a barrier to the provision of clinically effective and cost-effective treatment options.

Strategies to prioritize access to surgery may be required to ensure that the procedures are available to those most likely to benefit.

In order to optimize the future use of Gastro-Intestinal surgery as a therapeutic modality for Type 2 diabetes, further research is required.

American Diabetic Association: 2009

Standards of Medical Care in Diabetes
Diabetic Care 2009

Introduction:

The American Diabetes Association (ADA) is a United States-based association working to fight the consequences of diabetes and to help those affected by diabetes. The Association funds research to manage, cure and prevent diabetes (including type 1 diabetes, type 2 diabetes, gestational diabetes, and pre-diabetes); delivers services to hundreds of communities; provides information for both patients and health care professionals; and advocates on behalf of people denied their rights because of diabetes.

Summary of Recommendation:

Gastro-Intestinal (Bariatric) surgery should be considered for adults with BMI 35 kg/m2 and type 2 diabetes, especially if the diabetes is difficult to control with lifestyle and pharmacologic therapy. (B)

Patients with type 2 diabetes who have undergone Gastro-Intestinal (Bariatric) surgery need life-long lifestyle support and medical monitoring. (E)

Although small trials have shown glycemic benefit of Gastro-Intestinal (Bariatric) surgery in patients with type 2 diabetes and BMI of 30€“35 kg/m 2, there is currently insufficient evidence to generally recommend surgery in patients with BMI 35kg/m2 outside of a research protocol. (E)

The long-term benefits, cost-effectiveness, and risks of Gastro-Intestinal (Bariatric) surgery in individuals with type 2 diabetes should be studied in well-designed ran-domized controlled trials with optimal medical and lifestyle therapy as the comparator. (E)

Level of Evidence Description

A: Clear evidence from well-conducted, generalizable, randomized controlled trials
B: Supportive evidence from well-conducted cohort studies
C: Supportive evidence from poorly controlled or uncontrolled studies
E: Expert consensus or Clinical experience

Diabetic Surgery Summit Consensus Conference: 2008

1st International Conference on Gastrointestinal Surgery to Treat Type 2 Diabetes, Rome 2007
1st World Congress on Interventional Therapies for T2 Diabetes Mallitus, New York, 2008
Recommendations for the Evaluation and Use of Gastrointestinal Surgery to Treat Type 2 Diabetes Mellitus

Introduction:

This statement is generated by 50 world class experts (endocrinologists, gastroenterologists, diabetologists, surgeons & basic science investigators) and endorsed by 21 diverse professional and scientific organizations like American Diabetes Association, American Society for Metabolic and Bariatric Surgery, American Gastroenterological Association, Diabetes United Kingdom, European Association for the Study of Diabetes, European Association for the Study of Obesity, International Federation for the Surgery of Obesity and Metabolic diseases, Italian Society of Diabetology, Society of American Gastrointestinal and Endoscopic Surgeons, Society for Surgery of the Alimentary Tract, are few of them.

Summary of Recommendation:

Gastro-Intestinal (G.I.) Surgery (ie, RYGB, LAGB, or BPD) should be considered for the treatment of T2DM in acceptable surgical candidates with BMI 35kg/m2who are inadequately controlled by lifestyle and medical therapy (A).*

Although novel GI surgical techniques (eg, duodenal-jejunal bypass, ileal interposition, sleeve gastrectomy, endoluminal sleeves) show promising results for the treatment of T2DM in early clinical studies, they should currently be used only in the context of IRB-approved and registered trials (A).

To improve quality of medical evidence, the development of standards for measuring clinical and physiological outcomes of surgical treatment for T2DM is a high priority (A).

Randomized controlled trials are strongly encouraged to assess the utility of GI surgery to treat T2DM (A). In patients with BMI35 kg/m2, determining the appropriate use of GI surgery for the treatment of T2DM is an important research priority (A). Controlled clinical trials in these patients should be performed to determine the safety and efficacy of GI metabolic surgery (A) as well as to identify parameters other than BMI as criteria for appropriate patient selection (A). Development of a standard registry/database is a high priority for research in this area (A).

In addition to clinical trials, animal studies can provide useful information about the efficacy and mechanisms of GI metabolic surgery to treat T2DM (A).

The study of GI metabolic surgery provides valuable, new opportunities for investigating contributions of the GI tract to glucose homeostasis and the pathophysiological mechanisms of T2DM (A). Available data from animal and clinical studies suggest that weight loss alone explains diabetes control after LAGB (A). In contrast, intestinal bypass procedures such as RYGB, BPD, and duodenal-jejunal bypass appear to engage additional anti-diabetes mechanisms beyond those related to reduced food intake and body weight (A). Furthermore, anatomic modifications of various regions of the GI tract ameliorate T2DM through distinct physiological mechanisms (B).

Collaboration among endocrinologists, surgeons, and basic scientists should be encouraged to facilitate greater understanding of GI mechanisms of metabolic regulation and to allow use of these insights to improve the treatment of T2DM (A).

The establishment of a multidisciplinary taskforce to guide the study and development of diabetes surgery is a high priority. This taskforce should include endocrinologists, surgeons, clinical and basic investigators, and bioethicists, among others (A).

*Capital letters in parentheses indicate the levels of consensus for individual statements, defined as follows: Grade (67%-77% agreement), Grade (78-89% agreement), and Grade (90-100% agreement).

Diabetic Surgery Symposium: Rome 2007

1st International Conference on Gastrointestinal Surgery to Treat Type 2 Diabetes, Rome 2007
1st World Congress on Interventional Therapies for T2 Diabetes Mallitus, New York, 2008
Recommendations for the Evaluation and Use of Gastrointestinal Surgery to Treat Type 2 Diabetes Mellitus

Introduction:

This statement is generated by 50 world class experts (endocrinologists, gastroenterologists, diabetologists, surgeons & basic science investigators) and endorsed by 21 diverse professional and scientific organizations like American Diabetes Association, American Society for Metabolic and Bariatric Surgery, American Gastroenterological Association, Diabetes United Kingdom, European Association for the Study of Diabetes, European Association for the Study of Obesity, International Federation for the Surgery of Obesity and Metabolic diseases, Italian Society of Diabetology, Society of American Gastrointestinal and Endoscopic Surgeons, Society for Surgery of the Alimentary Tract, are few of them.

Summary of Recommendation:

Gastro-Intestinal (G.I.) Surgery (ie, RYGB, LAGB, or BPD) should be considered for the treatment of T2DM in acceptable surgical candidates with BMI 35kg/m2who are inadequately controlled by lifestyle and medical therapy (A).*

A surgical approach may also be appropriate as a non-primary alternative to treat inadequately controlled T2DM in suitable surgical candidates with mild-to-moderate obesity (BMI 30-35 kg/m2) (B). RYGB may be an appropriate surgical option for diabetes treatment in this patient population (C).

Although novel GI surgical techniques (eg, duodenal-jejunal bypass, ileal interposition, sleeve gastrectomy, endoluminal sleeves) show promising results for the treatment of T2DM in early clinical studies, they should currently be used only in the context of IRB-approved and registered trials (A).

To improve quality of medical evidence, the development of standards for measuring clinical and physiological outcomes of surgical treatment for T2DM is a high priority (A).

Randomized controlled trials are strongly encouraged to assess the utility of GI surgery to treat T2DM (A). In patients with BMI35 kg/m2, determining the appropriate use of GI surgery for the treatment of T2DM is an important research priority (A). Controlled clinical trials in these patients should be performed to determine the safety and efficacy of GI metabolic surgery (A) as well as to identify parameters other than BMI as criteria for appropriate patient selection (A). Development of a standard registry/database is a high priority for research in this area (A).

In addition to clinical trials, animal studies can provide useful information about the efficacy and mechanisms of GI metabolic surgery to treat T2DM (A).

The study of GI metabolic surgery provides valuable, new opportunities for investigating contributions of the GI tract to glucose homeostasis and the pathophysiological mechanisms of T2DM (A). Available data from animal and clinical studies suggest that weight loss alone explains diabetes control after LAGB (A). In contrast, intestinal bypass procedures such as RYGB, BPD, and duodenal-jejunal bypass appear to engage additional anti-diabetes mechanisms beyond those related to reduced food intake and body weight (A). Furthermore, anatomic modifications of various regions of the GI tract ameliorate T2DM through distinct physiological mechanisms (B).

Collaboration among endocrinologists, surgeons, and basic scientists should be encouraged to facilitate greater understanding of GI mechanisms of metabolic regulation and to allow use of these insights to improve the treatment of T2DM (A).

The establishment of a multidisciplinary taskforce to guide the study and development of diabetes surgery is a high priority. This taskforce should include endocrinologists, surgeons, clinical and basic investigators, and bioethicists, among others (A).

*Capital letters in parentheses indicate the levels of consensus for individual statements, defined as follows: Grade (67%-77% agreement), Grade (78%-89% agreement), and Grade (90%-100% agreement).

Recommendation for Children

Long-term whole-of-family lifestyle change, with high-quality medical management, is the mainstay of paediatric obesity treatment. However, the growing prevalence of severe obesity in children and adolescents demonstrates a need for additional therapy.

Bariatric surgery is only considered suitable for adolescents of developmental and physical maturity.

Australian and New Zealand Colleges for paediatric physicians and surgeons and the Obesity Surgery Society of Australia and New Zealand has recommended that surgery be considered

  1. If adolescents had BMI > 40 kg,m2
  2. > 35 kg,m2with severe co-morbidities (including Type 2 diabetes)
  3. Aged 15 years or more
  4. Tanner pubertal stage 4 or 5 and skeletal maturity
  5. Can give informed consent
  6. Potential candidates should have failed a multidisciplinary programme of lifestyle & pharmacotherapy for 6 months
  7. Patient & his family must be motivated and understand the need to participate in post-surgical therapy and follow-up
Basic of Diabetes Surgery

Gastro-intestinal surgery is known to be the most effective and long lasting treatment for morbid obesity and many related conditions, but now mounting evidence suggests it may be among the most effective treatments for metabolic syndrome and conditions including type 2 diabetes, hypertension, high cholesterol, non-alcoholic fatty liver disease and obstructive sleep apnea.

New research indicates that Gastro-Intestinal surgery may improve insulin resistance and secretion by mechanisms independent of weight loss €“ most likely involving changes in gastrointestinal hormones. Many patients with type 2 diabetes experience complete remission within days of surgery, long before significant weight comes off. This has led to new thinking that Gastro-intestinal metabolic surgery may also be appropriate for diabetic individuals who are of normal weight or only slightly overweight.

Established Procedure (Diabetes Surgery Procedure)

Roux-en-Y Gastric Bypass


Laparoscopic Adjustable Gastric Banding


Roux-en-Y Gastric Bypass

A Surgical stapler to create a small and vertically oriented gastric pouch and its volume is usually<30 cc. The upper pouch is completely divided from the gastric remnant and is anastomosed to the jejunum (30“75 cm from the ligament of Treitz) through a narrow gastro-jejunal anastomosis. Bowel continuity is restored by an entero-entero anastomosis between the excluded bil-iopancreatic limb and the alimentary limb. This anastomosis is usually performed 75-100 cm distal to the gastro-jejunostomy. although it has also been performed at 100-250 cm in patients with BMI>50 kg/m2. As this is a restrictive as well as malabsorpative procedure, diabetes control is moderate and acepatable and easily manageable mal-absorption related deficiencies.


Laparoscopic Adjustable Gastric Banding

Laparoscopic adjustable gastric banding (LAGB) is a restrictive procedure that involves encircling the upper part of the stom-ach with a band-like, saline-filled tube. The band is wrapped around the superior portion of the stomach, just distal to the gastroesophageal junction. The amount of restriction can be adjusted by injecting or withdrawing saline solution from the hollow core of the band through a subcutaneous port. Being a purely restrictive procedure, diabetes control correlates with corresponding weight loss. As it does not affect gastro-intestinal hormonal milieu, diabetes control is mild.

Biliopancreatic Diversion

The operation consists of a distal, horizontal gastrectomy that leaves behind upper stomach 200-500 ml in size. This remnant stomach is anastomosed to the distal 250 cm of small intestine (alimen-tary limb). The excluded small intestine (including the duodenum, the jejunum, and part of the proximal ileum) carries bile and pancreatic secretions (biliopancreatic limb), and it is connected to the alimentary channel 50 cm proximal to the ileocecal valve. The 50-cm common limb is the only segment of small bowel where digestive secretions and nutrients mix.

Biliopancreatic Diversion with Duodenal Switch

The biliopancreatic diversion with duodenal switch (BPD-DS) includes a sleeve vertical gastrectomy (rather than a horizontal version, as in Scopinaro™s original procedure), which leaves a 150“200-ml gastric reservoir. The duodenum is closedˆ¼2 cm distal to the pylorus, and a duodeno-ileal anastomosis is performed. Bowel continuity is restored, as in BPD; however, the entero-entero anastomosis is performed more proximally on the alimentary limb, leaving a longer common channel of ˆ¼100 cm, as opposed to 50 cm in Scopinaro™s original procedure. As this is also restrictive as well as mal-absorptive procedure, but it induced greatest mal-absorption. Thus diabetes control is greatest with this procedure and also associated with maximum deficiency of nutrients. That led some researchers to raise concern in the long term safety of this procedure.


Biliopancreatic Diversion


Biliopancreatic Diversion with Duodenal Switch

Noval Procedure (Diabetes Surgery Procedure)

Sleeve gastrectomy


duodenal-jejunal bypass


Sleeve gastrectomy (SG)

To shorten the duration of the laparoscopic BPD-DS in high-risk patients, the originator of this operation, proposed a two-stage approach in which SG is performed first, with the duodeno-ileostomy and ileo-ileostomy as a second stage a few months later. This approach resulted in reduced surgical morbidity and mortality compared to the traditional one-stage approach in super-superobese patients (BMI>60 kg/m2). Unexpectedly, patients achieved re-markable weight loss after the first stage of this approach, and SG is now being proposed as an independent anti-obesity operation by some authors. In addition to reducing the functional capacity of the stomach, this procedure eliminates the ghrelin-rich gastric fundus, which may play a role in its mechanism of action. SG has also been shown to improve diabetes in severely obese patients. The short term results are encouraging. The long-term efficacy of the procedure is pending.


DJB:duodenal-jejunal bypass

DJB is a stomach-sparing bypass of a short portion of proximal intestine, comparable to the segment excluded in a standard RYGB (Figure 2a). Variants of this experimental procedure include techniques that preserve the pylorus (duodeno-jejunal anastomosis) or do not (gastro-jejunal anasto-mosis). DJB has now been performed in several centers worldwide to treat T2DM in non-obese patients, and short term results are encouraging and long-term follow-up clinical data are pending.

Ileal Interposition (IT)

This operation involves the surgical insertion of a small segment of ileum, with its neurovascular supply intact, into the proximal intestine, increasing its exposure to ingested nutrients that leads to increased level of glucagon-like peptide-1 (GLP-1) and peptide-YY. These hormonal changes, in the absence of gastric restriction or malabsorption, are associated with reductions in food intake and body weight & improvement in glucose levels. This procedure, alone or in combination with SG, has been used in lean diabetic patients. The short term results are encouraging. The late metabolic sequalae are therefore unknown, and long-term safety is still to be evaluated.




Endoluminal duodenal-jejunal sleeve (ELS)

The ELS is a flexible plastic sleeve, placed in stomach using endoscope. This sleeve extends for distal stomach to duodenum and proximal jejunum, thus disrupting absorption of nutrients. Studies to determine the safety and efficacy of long-term ELS placement in humans are under way.

Result

Most studies show prevention, improvement or remission of type 2 diabetes after surgery with a relatively low rate of risk in appropriate patients. The extent of remission of Type 2 diabetes is influenced by the extent of weight loss, weight regain, duration of diabetes, the pre-surgery hypoglycaemic therapy requirements, and the choice of gastro-intestinal procedure. In addition, each patient™s commitment to modifying their diet and levels of exercise within a framework of ongoing multidisciplinary care will influence outcomes.

Supportive Evidence:

1.2004: According to a landmark study published in the Journal of the American Medical Association (JAMA) in 2004, Gastro-intestinal (bariatric) surgery patients showed improvements in the following metabolic conditions:

  1. Type 2 diabetes remission in 76.8% and significantly improved in 86% of patients
  2. Hypertension eliminated in 61.7% and significantly improved in 78.5% of patients
  3. High cholesterol reduced in more than 70% of patients
  4. Sleep apnea was eliminated 85.7% of patient™s.
  5. Joint disease, asthma and infertility were also dramatically improved or resolved.
  6. The study showed that surgery patients lost between 62 and 75 percent of excess weight.

2009: The Swedish Obese Subjects study clearly demonstrated the prevention and sustained remission of Type 2 diabetes in a group of 2037 severely obese patients electing to have bariatric surgery when compared with well-matched controls at 2 and 10 years follow-up (Sjostrom L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C,Carlsson Bet al.Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351: 2683-2693)

2008: There is a well designed prospective randomized control trial (RCT) that compared bariatric surgery (compared laparoscopic adjustable gastric banding) to conventional diabetes therapy with a focus on weight loss by diet and exercise. After 2 years, remission of diabetes was significantly more common in those who had received surgery (73 vs. 13%) (Dixon JB et al. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. J Am Med Assoc 2008;299: 316-323)

2009: Cochrane review including patients with and without diabetes concluded that bariatric surgery resulted in greater weight loss than conventional treatment in obese class I (BMI>30kg m2) as well as severe obesity, accompanied by improvements in co-morbidities such as Type 2 diabetes, hypertension and improvements in health-related quality of life. (Colquitt JL et al. Surgery for obesity. Cochrane Database Syst Rev2009; CD003641)

2009: A systematic review and meta-analysis of 621 studies which included approximately 135 000 patients identified 103 studies reporting on the remission of the clinical and or laboratory manifestations of diabetes. Overall, 78.1% of patients had ˜remission™ of diabetes following surgery. Among patients with diabetes at baseline, 62% remained in remission more than 2 years after surgery. (Buchwald H et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med 2009;122: 248-256)

Benefits

Untreated Obesity & Diabetes increase the chances of early death:

Severe obesity is associated with a large number of health problems in addition to Type 2 diabetes. A review of more than 1.4 million participants in prospective studies largely from North America, Europe and Australia show a consistent progressive rise in the mortality hazard ratios with increasing BMI. (Berrington de et al. Body mass index and mortality among 1.46 million white adults. N Engl J Med 2010; 363:2211-2219)

A similar analysis by the Prospective Studies Collaboration found the risk of diabetes-related death was quadrupled for morbidly obese individuals (Whitlock G et al. Body mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet 2009;373: 1083-1096)

Obesity & Diabetes Surgery prolong overall survival:

Follow-up of participants in the Swedish Obese Subjects Study after an average of 11 years found that bariatric surgery was associated with a 29% reduction in all-cause mortality after accounting for sex, age and risk factors in this severely obese group. (Sjostrom L et al. Effects of bariatric surgery on mortality in Swedish obese subjects.N Engl J Med2007;357: 741-752)

Another study also has confirmed this mortality advantage when compared with community matched control subjects. (Adams TD et al. Long-term mortality after gastric bypass surgery. N Engl J Med2007;357: 753-761)

Specific mortality reductions in the operated group were 56% for coronary artery disease, 92% for diabetes and 60% for cancer when compared with matched controls. Bariatric surgery also led to a specific reduction in cancer incidence in women. (Sjostrom L et al. Effects of bariatric surgery on cancer incidence in obese patients in Sweden. Swedish Obese Subjects Study. Prospective, controlled intervention trial. Lancet Oncol 2009; 10:653-662)

Surgery improves overall quality of life:

Many studies have demonstrated major improvements in health-related quality of life following surgery using both generic and obesity-specific quality-of-life instruments. (Kolotkin RL. Two-year changes in health-related quality of life in gastric bypass patients compared with severely obese controls. Surg Obes Relat Dis2009;5: 250-256)

Risk of Surgery

There are risks that go with any type of medical procedure and surgery is no longer an exception. Success of surgery depends upon 3 factors: type of disease/surgery, experience of surgeon and overall health of patients. The risks of each procedure need to be considered in the light of potential reductions in mortality, morbidity or co-morbidity, quality of life and productivity.

  1. The most common complications of Gastro-intestinal (bariatric) surgery include anastomotic and staple-line leaks (3.1%), wound infections (2.3%), pulmonary events (2.2%) and haemorrhage (1.7%). Morbidity rates are lower after laparoscopic procedures, which constitute a steadily increasing proportion of bariatric operations. (Nguyen NT et al. Use and outcomes of laparoscopic versus open gastric bypass at academic medical centers.J Am Coll Surg2007;205: 248-255).
  2. Early post-operative morbidity and mortality are related to the complexity of the surgery. The US Bariatric Outcomes Longitudinal Database (BOLD) reviewed over 57 000 consecutive procedures and reported one or more complication at 1-year rates of 4.6, 10.8, 14.9 and 25.7% following laparoscopic adjustable gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass and bilio-pancreatic diversion, respectively. (DeMaria EJ. Baseline data from American Society for Metabolic and Bariatric Surgery-designated Bariatric Surgery Centers of Excellence using the Bariatric Out-comes Longitudinal Database.Surg Obes Relat Dis2010;6: 347-355)
  3. The 30-day mortality associated with Gastro-intestinal (bariatric) surgery is estimated at 0.1-0.3%, a rate lower / similar to that for laparoscopic cholecystectomy & described as ‘low’. Thirty-day post-surgical mortality is 0.1% for laparoscopic adjustable gastric band, 0.5% for Roux-en-Y gastric bypass and 1.1 for bilio-pancreatic diversion. (Buchwald H et al. Trends in mortality in bariatric surgery: a systematic review and meta-analysis. Surgery 2007;142: 621-632).
  4. Long-term concerns, especially with Roux-en-Y gastric bypass and bilio-pancreatic diversion, include vitamin and mineral deficiencies, osteoporosis and, rarely, Wernicke’s encephalopathy and severe hypoglycaemia from insulin hypersecretion.
Cost Effective Treatment

The costs of Type 2 diabetes are substantial: In the USA, the lifetime cost has been estimated at $US 172 000 for a person diagnosed at the age of 50 years and $US 305 000 if diagnosed at the age of 30 years. The estimate included both the direct medical costs of diabetes and its complications and indirect costs caused by work absence, reduced productivity at work, disability and premature death. Over 60% of the medical cost was incurred within 10 years of diagnosis. (Zhuo X. Life-time cost of type 2 diabetes in the US. Presented at the American Diabetes Association meeting, 25–29 June 2010, Orlando, FL, USA. Abstract 0434-PP)

Diabetic Surgery & Weight loss Surgery is the cost saving tool: Surgery for severe obesity, regardless of diabetes status, has been assessed as cost-effective and, in some analyses, cost saving.

  1. Picot J et al. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation.Health Technol Assess 2009.
  2. Salem L, Devlin A, Sullivan SD, Flum DR. Cost-effectiveness analysis of laparoscopic gastric bypass, adjustable gastric banding, and nonoperative weight loss interventions. Surg Obes Related Dis 2008.
  3. Cremieux PY et al. A study on the economic impact of bariatric surgery. Am J Manag Care 2008.
  4. Ackroyd R, Mouiel J, Chevallier JM, Daoud F. Cost-effectiveness and budget impact of obesity surgery in patients with type-2 diabetes in three European countries. Obes Surg 2006.
  5. van Mastrigt GA. One-year cost-effectiveness of surgical treatment of morbid obesity: vertical banded gastroplasty versus Lap-Band.[erratum appears in Obes Surg. 2006 May;16(5):682]. Obes Surg 2006.

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