Surgical options in diabetes mellitus: A ray of hope.

Diabetes, a slowly progressive disease, with the number of complications involved, is undoubtedly, the uncrowned “king” of epidemics of modern era. Morbidity associated with diabetes makes quality of life of the patient very poor. The cost of treatment is ever escalating. The problem is compounded by co-morbid conditions of obesity, hyperlipidemia and hypertension. With long term diabetes, both micro- and macrovascular complications are commonly seen. In long standing cases, the requirement of daily insulin shots or the compulsion of taking plethora of oral medicines itself start evoking irritating emotions; seriously denting the psyche of the patient.

In such a scenario, the surgical options of “Bariatric Surgery” may provide a ray of hope for obese diabetic patients, having uncontrolled glucose levels with or without medications and failed exercise and diet regimen. Bariatric surgery is otherwise a commonly used procedure for attempting weight-loss in obese patients having body mass index (BMI) ≥40 kg/m2 who started but failed an exercise and diet program (with or without drugs) with co-morbid conditions like hypertension, dyslipidemia etc.[1] Bariatric procedures can be categorized in to three main categories - predominantly malabsorptive procedures, predominantly restrictive procedures, and mixed procedures.[2] A recent position statement issued by the International Diabetes Federation has advocated that the Bariatric surgery should be an accepted option in obese diabetic patients having BMI > 35 kg/m2 and an alternative treatment option in obese diabetic patients having BMI 30-35 kg/m2, especially if HbA1c > 7.5 despite fully optimized conventional therapy, especially if weight is increasing, or other weight responsive co-morbidities not achieving targets on conventional therapies like blood pressure, dyslipidemia and obstructive sleep apnoea. It is suggested that for Asian, and some other ethnicities of increased risk, BMI action points may be reduced by 2.5 kg/m2.[3]

The surgical options being tried in diabetic obese patients include, among others, sleeve gastrectomy and Roux-en-Y gastric bypass. The former is a mixed procedure while the later is a predominantly restrictive procedure. With the lowering of the BMI limit for performing these surgical procedures in obese diabetic patients and with the reported 5 years-remission rates of up to 85-90%, the procedures have brought a ray of hope of obese patients with uncontrolled diabetes despite exercise and diet, and having co-morbid conditions.[45]

In order to evaluate the duration of type 2 diabetes as prognostic factor for remission after sleeve gastrectomy, a study was conducted in which Group A consisted of 16 patients who had lived with type 2 diabetes mellitus (T2DM) for > 10 years and Group B included 40 obese patients who had lived with T2DM for < 10 years. It was observed that the diabetes remission rate in all 56 patients was 80.3%. However, in group B, the resolution rate was 100%, but in group A, the resolution rate was 31%. Thus, it was concluded that the duration of T2DM was of paramount importance as a prognostic factor, with 10 years representing a cutoff between a 100% rate of remission and significantly lower rates of remission.[6] Another study confirmed the efficacy of sleeve gastrectomy in the treatment of non-morbidly obese T2DM patients, with a remission rate of 88.8% without undesirable excessive weight loss.[7]

A recent prospective study evaluated the long-term results of laparoscopic Roux-en-Y gastric bypass on excess weight loss, remission of the metabolic syndrome, and complications in Indian patients with uncontrolled type 2 diabetes mellitus (T2DM) with a body mass index of 30-35 kg/m2, with follow-up of 5 years. The results of the study are encouraging. The median percentage of excess weight loss was 72.2% at 1 year and 67.8% at 5 years. Of the 52 patients, 84.6% had achieved euglycemia and 73.1% had achieved complete remission, 23.1% partial remission, and 3.84% no remission at 1 year. Weight regain occurred in 8 patients. They required antihypertensive drugs and statins, decreasing the complete remission rate to 57.7% and partial remission rate to 38.5% at 5 years. However, 96.2% improvement in metabolic status was found at the end of 5 years. Authors concluded that Laparoscopic Roux-en-Y gastric bypass is a safe, efficacious, and cost-effective treatment for uncontrolled T2DM in patients with a BMI of 30-35 kg/m2, and the improvement after surgery in hyperglycemia, hypertension, and dyslipidemia could help in controlling the occurrence of micro- and macrovascular complications and decrease the morbidity and mortality associated with T2DM.[8]

As is evident, the long term results of surgical options are encouraging; and they are likely to become a viable option in obese diabetic patients with BMI > 30 kg/m2, with uncontrolled glucose levels and having co-morbid conditions; thus helping not only in weight loss, but also in controlling glucose levels, without the pain of daily insulin shots.