Going Under the Knife

Health Care System and Professor of Endocrinology and Nutrition, University of Washington. An active member of American Diabetes Association (ADA), Dr Cummins is collaborating with bariatric surgeons Dr Shashank Shah and Dr Jayashree Todkar for clinical trials in India to investigate the role of bariatric surgery in controlling diabetes.

This means, to put it simply, that bariatric surgery is doing something more to the body than merely helping people lose weight. It is triggering some sort of change in the body's metabolism. "In many cases, patients are able to discontinue their diabetes medication within days after the operation, well before the actual weight loss happens," explains Dr David Cummins, a Physician at Seattle V A Puget Sound and obese people are predisposed to suffer from type II diabetes. However, sustainable weight loss among patients suffering from type II diabetes, can enable reversal of their condition. A recent randomised clinical trial (RCT), termed as "Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial", published in New England Journal of Medicine (NEJM) earlier this year, established that "in severely obese patients with type 2 diabetes, bariatric surgery resulted in better glucose control than did medical therapy. Preoperative BMI and weight loss did not predict the improvement in hyperglycemia after these procedures."

Let us go through that once again, one bit at a time:

• "In severely obese patients with type 2 diabetes" – this was the group under focus.

• "bariatric surgery resulted in better glucose control than did medical therapy" so when you operate a patient for obesity, better glucose control is a pleasant side effect. Now, given the famous association between diabetes and obesity, you'd think that losing weight after surgery would naturally help control blood glucose levels, right? But read on… "Preoperative BMI and weight loss did not predict the improvement in hyperglycemia after these procedures." – this means that while one is more likely to have good glycaemic control after bariatric surgery, how well you perform is not a function of how much weight you lost.

Beyond Obesity

Their research is not just relevant for people with type 2 diabetes who are morbidly obese by present standards. At present, this surgery is only performed on people with a set minimum BMI, but that could change – Gastric bypass surgery may at some point be an option for treatment of diabetes. "If someone does not have a very high BMI, but stands benefit from surgery in terms of glycaemic control, should we make the option available to them, or do we wait for them to put on more weight and worsen their condition before we can help?" argues Dr Cummins.

Indians happen to have greater abdominal fat concentration in body at lower BMI than their European counterparts – which puts us at higher risk for heart diseases. The work done by Dr Cummins, Dr Shah & Dr Todkar may bring new hope to many of these cases, especially where conventional therapy has been unable to prevent complications, or where for any reason, lifestyle intervention is difficult or impossible.

Are we there yet?

But the million buck question remains – is this a cure? Dr Cummins chooses to be non-committal, it may be too early to say something as preposterous. "It's a bit like Cancer," he sadly notes, – you're never fully convinced it is gone. However, in the real scientific world, this is as close as we've got to a cure as of today. Unless you're counting on some magic juice.

• Pancreatic transplant

• Foot surgery/amputation

• Cardiac surgery

Extremities through diabetes complications and their treatment is in itself a subject too vast for us to address in this context. While basic care prior to, during and after surgery is similar to that explained above, someone who has had to resort to surgery owing to a complication of diabetes is not very likely to have good glycaemic control. If the surgery can be planned well ahead, it is always safer to first work on bringing the blood glucose levels to a healthy range through aggressive management.

Surgery as cure for diabetes?

Now comes the interesting part. To begin with, one is always a bit wary of talking about a cure for diabetes – the disease runs in this author's family, and one has heard enough claims of magical wild berry juice guaranteed to cure diabetes, and variants of it, to compile in a cautionary manual for all diabetics. Scientifically speaking, diabetes cannot be cured today. But researchers are always on the trail of something or the other that might just work. In our October 2011 issue, we explored the various avenues researchers are exploring to find the elusive cure for Diabetes. One unexpected and possible solution comes from surgery originally conceived for a close cousin of Diabetes – obesity.

Gastric bypass surgery has been around for quite some time as an option for treating morbid obesity. We know that Diabetes and obesity have been found to be inter-linked Once you have been living with Diabetes for some years, you get used to factoring it into everything you do and every decision you make. This could includes your food, your daily routine, your working hours, travel plans, and almost everything in between. So when it comes to an important medical procedure such as surgery, your Diabetes is bound to provide some additional homework to you and your medical team. Especially considering that Diabetes may be the very reason you need that surgery in the first place, via a plethora of direct and indirect complications.

Once you have been living with Diabetes for some years, you get used to factoring it into everything you do and every decision you make. This could includes your food, your daily routine, your working hours, travel plans, and almost everything in between. So when it comes to an important medical procedure such as surgery, your Diabetes is bound to provide some additional homework to you and your medical team. Especially considering that Diabetes may be the very reason you need that surgery in the first place, via a plethora of direct and indirect complications.

Here we take a look at various kinds of surgery and the implication it may have on your Diabetes, as well as vice versa. In course, we'll also take a look at a particular kind of surgery that may perhaps provide hope for a permanent cure for Diabetes! But before we get there, first the basics.

Surgery despite diabetes

Just because you have diabetes, does not mean you should hesitate to get that troublesome hernia removed. Before going for any kind of surgery make sure the attending medical team knows about it, as well as all your medication. The physician, surgeon and anaesthetist can assess the case in detail before surgery. This would include knowing the duration of the disease, checking for any diabetic complication, or any associated conditions that may increase surgical risk, especially presence of cardiac autonomic neuropathy. Your medical team will decide the best course for you – whether and how long you need to be admitted to a hospital and monitored before surgery, and how your medication and insulin doses may need to be modified, etc. The kind of surgery – whether it is major, minor, or very urgent… also needs to be considered. Good glycaemic control before surgery will make everyone's job a lot easier!

As far as possible, you should be closely monitored prior to surgery – although this may get difficult in case of an emergency. Some points to discuss with your medical team:

• Any alteration in medication prior to surgery or on the day of surgery

• Any changes in insulin dose or type of insulin

• Would it be possible to schedule the surgery early in the morning?

• Will you need any external insulin or glucose during the operation?

After surgery, you'll be administered glucose and insulin until you can start eating normally. Till you resume your regular diet, your medicinal routine might be changed. You may get back to your normal diet and medication, once your blood glucose level is under control.

Remember, this information is to help you understand and know what to expect – your physician is the best person to prescribe the proper course for you. Follow their advise very carefully. With the right kind of care and advice, your diabetes should not affect the safety and outcome of surgery.

Surgery because of diabetes

What about surgery for, say, transplanting a donor kidney in place of a kidney damaged because of diabetes? Poorly controlled Diabetes may lead to complications that, beyond a point, only a surgeon can address. Some common examples are:

Cataract removal Kidney transplant