“Diabetes can be treated with surgical method!”
You feel pain and burning in your feet in every morning and you feel chronically tired and exhausted at day time. You are started on insulin, even if you take handful of pills. Your blood glucose is fluctuating despite all measures and treatments. How can you solve this problem?
Many patients with diabetes mellitus experience those signs and symptoms, soon or late, at early stage of the condition. While some patients are diagnosed with diabetes at very late age, others require learning to live with diabetes at early stages of life and at young ages. Well then, what is diabetes mellitus and how does it influence our life that much?
High blood glucose or diabetes in medical terms is a chronic condition, which is manifested by high blood glucose level. High blood glucose is, unfortunately, destructive and lethal for all body cells, especially blood vessels. In other words, unregulated blood glucose kills cells and shortens our lifetime. Moreover, our quality of life is substantially reduced and it leads to medical conditions and even crisis, which can be hardly managed, due to various organ damages. Examples include patients with renal failure, who require dialysis to manage this condition. Heart attacks, strokes and vascular disorders – leading to even amputation of legs – are common medical conditions, which we frequently observed in many diabetic patients.
Alteration of Lifestyle is the principal treatment!
The principal treatment of diabetes is to make patients adapt their life to diabetes. This approach requires adopting some specific principles. Briefly, we should make a room for exercise in our life again. In other words, patients with Type 2 diabetes should jog regularly every day. In addition, they should eat as small portions at frequent intervals and foods with heavy sugar and starch content should be avoided.
Less than 10% of all diabetic patients can efficiently regulate blood glucose.
Most of these patients cannot achieve regulation of blood glucose with lifestyle modification alone. Therefore, almost all patients are started on blood glucose lowering pills. These treatment modalities are started as mono-agent medication therapy, but since it fails in most patients, multi-agent therapies and insulin are added to the management in the course of time.
Diabetes mellitus is a very complex medical condition. Therefore, multiple agents with different mechanism of action are used in management of diabetes mellitus.
Diabetes mellitus follows various courses based on many different mechanisms. It leads to condition, which increases blood glucose using different mechanisms in different organs. Therefore, multiple anti-diabetic agents are added to medication therapy in time in order to exert different effects on different pathways. Undoubtedly, patients are started on other classes of medicaments, when other diabetes-related conditions emerge, including but not limited to heart failure, vascular disease, hypertension, hypercholesterolemia and renal protein loss.
Management of diabetes mellitus with medication(s) and lifestyle modifications is the gold standard. However, compliance to treatment is mostly poor. Long-term studies demonstrate that organ damage cannot be reduced to zero percent even if insulin is used.
Diabetic surgery ensures long-term regulation in diabetes mellitus!
In fact, diabetic surgery is not a recent concept. We know that various bariatric surgeries, which have been performed for 30 to 40 years, correct or regulate diabetes at higher success rates. Introduction of “ileal interposition” – a very important novelty – caused this field of surgery is re-designated as “Diabetes Surgery” especially in last decade. This type of surgery, which is colloquially known as Diabetes Mellitus Surgery, reveals out its advantage, since it is a safe surgery also for non-obese diabetic patients and it does not lead to absorption disorder. In other words, it is the only metabolic surgery method that can be also used for lean diabetic patients.
Non-obese patients or patients with normal body weight can also undergo Diabetic Surgery.
Basically, ileal interposition is an example of good engineering that is designed for lean or mildly overweight diabetic patients. Why is it so? As we mentioned above, it has a very special design, which prevents synthesis of glucose, caused by diabetes mellitus based on different mechanisms, by influencing different organ systems.
Ileal interposition is completely performed with laparoscopic, in other words, closed method.
Ileal interposition is completely performed with closed method. We perform the whole operation using 6 pen-thick holes (ports) on abdominal wall. This is what we call Laparoscopic Method. Thus, patients can be mobilized several hours after surgery, and thus, re-activation of intestinal peristalsis is achieved within shortest time possible in postoperative period.
This operation involves a transposition in digestive tract. We transpose most distal part of small intestine, which we want to meet it with foods at early phase, to proximal part of small intestine immediately posterior to stomach. We do not cause a substantially significant and efficient absorption disorder. Therefore, our patients face no deficiency problem at any time of life in postoperative period. They do not need a medication starting at postoperative Month 5 or 6.
Diabetic Surgery restores homeostasis of hormones.
Diabetic Surgery exerts an effect, which is totally based on elimination of insulin resistance. In fact, this effect regulates and corrects mode of operation of hormones, which we calls as “Endocrine Surgery”.
Pancreas is untouched.
Ileal interposition is completely performed in small intestines. It boosts bioavailability of insulin, which is secreted from pancreas, even if pancreas works at idle capacity. Type 2 Diabetes Mellitus is in fact a state of “Insulin Inflation”. Or, insulin level is high in body, but function is insufficient or absent. Ileal Interposition ensures that higher amount of blood glucose is regulated with less insulin. Thus, value of insulin is increased.
All Patients With Type 2 Diabetes Who Cannot Precisely Regulate Blood Glucose are Candidate to This Surgery.
This surgery is useless for patients with pediatric diabetes, or Type 1 Diabetes Mellitus. Because, insulin is not synthesized or synthesized at very low amount in patients with Type 1 Diabetes Mellitus.
Ileal Interposition is reserved for patients with Adulthood Diabetes Mellitus or Type 2 Diabetes Mellitus. However, patients with Type 2 Diabetes Mellitus are not always eligible for this surgery. Therefore, patients should have a series of tests and examinations regarding insulin synthesis capacity and insulin sensitivity. These tests clearly indicate response of the patient to the surgery at a very high prediction rate. Patients will preoperatively know this estimated benefit level or rate, and final decision is made by the patients, if they believe that this operation is appropriate for them.
There is inter-patient variation regarding postoperative benefit.
Characteristics of diabetes, age, body weight, time since diagnosis of diabetes and actual organ damages vary. Level of pancreatic exhaustion is also closely related with those factors. All factors should be specifically evaluated in each patient and it is necessary to inform patient about specific benefit rate. Margin of error is <5% in this estimation. Accordingly, patient will preoperatively know whether medications will be partially maintained in postoperative period.
Patients who can hardly regulate blood glucose will have medical benefit before organ damage(s) progress.
Some patients ask “Is operation the last option?” Our answer is, in fact, very clear; it is neither too early nor too late. In other words, we do not recommend surgery to patients, who are recently diagnosed with diabetes, have not tried other therapeutic options and will possibly benefit from other modalities. Or, on the contrary, we do not also recommend operation for patients, who had poorly regulated diabetes for a very long time and show signs and symptoms of severe organ damages. The best example is a diabetic patient with chronic renal failure, who requires dialysis. Operation makes not contribution to comfort of life or even, it may worsen quality of life for these patients. We can generate benefit to patients, who had lived with diabetes, made efforts to adapt, could not efficiently regulate blood glucose despite compliance to treatment and face or candidate to face organ damages. In those patients, we can eliminate anti-diabetic agents by >90% and assure a very efficient regulation of blood glucose – a very positive outcome regarding long-term organ damage. Those positive outcomes can substantially increase overall quality of life even at early postoperative period. Patients start feeling energetic and fresh. They are much more involved in social life.
Ileal Interposition offers a comfortable life without leaving initiative to patient.
Diabetes is a chronic metabolic condition, which lasts lifelong and severely deteriorates quality of life by absolutely leading to organ damages. The most principal underlying cause of organ damages and deaths is critical fluctuations of blood glucose at day time. Unfortunately, conventional medications and insulin therapy are insufficient to efficiently eliminate them. Ileal Interposition is a therapeutic option, which is most efficiently regulate blood glucose based on instant insulin adjustment in a natural way, since no medication is required and conserved reserves are activated. It can be considered as an assurance for and future investment to quality of life and avoidance from long-term organ damage.
Tuğrul DEMİREL, M.D.
Bariatric and Metabolic Surgeon