Type 2 diabetes is a very common and
serious disease that in many cases can
lead to serious complications including
heart attacks and strokes, and reduced
life expectancy.
Conventionally type 2
diabetes is being treated by the use of
insulin and oral drugs but unfortunately
up to fifty percent of patients who
take medications, especially patients
with associated obesity, are not able to
achieve adequate control of their blood
sugar levels. For many of those patients
metabolic surgery could be an excellent
treatment option, and in fact in many of
them, if not most. Surgery achieves
adequate control of blood sugar levels
and in some cases - I would say many cases -
even a complete disease remission.
In 1999 I was a junior surgeon in training in
New York. I knew a little bit about
diabetes but enough to know that it is
a disease that is not supposed to go away,
so I was surprised to see that patients
who had bariatric surgery, within days
from the operation could see their
symptoms - diabetes symptoms - completely
resolved. I wondered whether there was
something that made surgery so effective,
and that something could be because surgery
changes the anatomy of the stomach and
intestine and this organ, the
gastrointestinal tract, is so important
for glucose regulation, for sugar
regulation. And so we set up some
experiments that did investigate the
hypothesis and found that in fact when you
change the anatomy of the intestine,
particularly the upper portion called
the duodenum, but also the stomach and
also other portions of the
gastrointestinal tract, you immediately and
powerfully change the way blood sugar
levels are regulated. On the back of
those findings we became convinced that
surgery could be used as a legitimate
treatment for type 2 diabetes.
Bariatric surgery was developed in the
1950s as a surgical approach to reduce
the size of the stomach or to bypass a
segment of intestine, and in doing so
reducing the absorption of nutrients and
causing weight loss. We now know that
this mechanical idea behind bariatric
surgery is actually wrong. In fact when
you change the anatomy of the gut or
reduce the size of the stomach you're
basically changing the physiology that
regulates body weight. So patients
reduce their weight not because they
have a small stomach and they cannot eat
but because they simply feel less urge
to eat, they feel more satiety, they feel
less hungry and also their metabolism is
much more efficient, it's made more
efficient by the changes in gastrointestinal
physiology. This is an excellent
physiologic way to tackle obesity - severe
obesity - it's not mechanical as we first
thought. And so because of that we now
understand better the proper indications
for bariatric surgery and the best type
of procedures in individual patients.
There's a number of procedures that can
be offered for the treatment of severe
obesity or type 2 diabetes. Those
include gastric bypass, sleeve gastrectomy,
bilio-pancreatic diversion, gastric banding
and also novel procedures that can be
performed endoscopically. All these
operations can be offered by a minimally
invasive approach or laparoscopic
approach which reduces post-operative
pain and allows an early recovery and
return to daily activities. These
procedures can now be performed with the
same safety as many other common
operations such as gall bladder procedure
or hysterectomy.
The important thing is that we now know
how these procedures work and we know
that each operation has a distinct
mechanism of action, and therefore it is
important to decide the choice of the
surgical procedure based on individual
patient's needs - there is no one
procedure that fits all. But there are
different procedures with different
mechanisms of action and different effects
that might suit different types of
patients. So our job is to identify the
patient's characteristics which would
indicate one or another type of operation.