Diabetes and Bariatric Surgery
- February 14, 2022
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Recently, doctors have been exploring different treatments for type 2 diabetes. One option for patients, besides medication, is surgery. Studies have shown that weight loss surgery (or bariatric surgery), commonly associated with obesity, has also been effective in the treatment of diabetes. One study involving 400 people tracked their journey with the condition. It showed that six years after weight loss surgery, 62% showed no signs of the condition and had better cholesterol levels, blood pressure, and triglyceride levels. This is compared to the 8% of people who were treated with medicine in the same time frame.
Therefore, more and more people are looking to the option of surgery to treat their diabetes. However, the question is: what times of surgeries for type 2 diabetes are there, and which one is right for you?
What is Diabetes?
Diabetes is a chronic disease that can either be inherited or developed in the body over the years. Basically, diabetes affects the process of turning food into energy that can be used by the body.
When food enters the body, it breaks down into glucose (sugar), which is the main energy source for the body. The sugar is then released into the bloodstream. When a person’s blood sugar levels elevate, the body gives a signal to the pancreas. The pancreas produces enzymes that break down things like sugar, and it releases a hormone called insulin. Insulin is extremely important because it lets glucose enter the body’s cells to be used to give us energy.
Diabetes, however, inhibits this process. This is because of one of three reasons. The body:
- cannot produce the necessary amount of insulin to go through this process
- does not produce insulin at all
- does not use insulin efficiently, meaning that the body cannot break down glucose well
This then causes the blood glucose levels in the body to rise, resulting in hyperglycemia. If the glucose levels in the body remain high over a long period of time, this can result in damage to one’s body. It can also lead to many serious health problems, such as:
- heart disease
- vision loss
- nerve damage
- kidney disease
Type 2 Diabetes
Type 2 is when the body does not have the ability to use or produce insulin well. This means that the person’s body will not be able to keep their blood glucose levels under control. This form of diabetes is the most common form, affecting almost 90% of people diagnosed with the condition. Type 2 diabetes is usually diagnosed in older people. However, today it is being seen more and more in children, adolescents, and young adults. Obesity is a common contributor to developing type 2 diabetes.
Obesity and Type 2 Diabetes
There is a clear relationship between type 2 diabetes and obesity, one often being the reason for the other. People who are obese even have a higher chance of developing diabetes – about 10 times higher than usual. This is because both issues are related to the body’s metabolism (the rate at which your body burns calories).
Obesity is an excess in the amount of fat present in the body. Foods high in fats and carbohydrates, causing excess fat, also increase the levels of fatty acids in the blood. They also increase fat build-up in the liver. This then affects the body’s insulin, making the pancreas decrease insulin production over time.
So, since the two issues are often intertwined, it makes sense that weight loss surgeries that are primarily used to treat obesity could also be effective in the treatment of type 2 diabetes. Solving one issue helps indirectly solve the other.
How can weight loss surgery help Type 2 Diabetes?
First and foremost, weight loss surgery helps patients with type 2 diabetes by regulating their sugar levels. The changes in blood sugar levels can even be seen before any weight is lost. Through bariatric surgery, diabetics regain their ability to use glucose in a healthy way. This is because these surgeries change a person’s metabolism which can affect the hormones that are in charge of regulating blood sugar. This lowers blood glucose levels, resulting in the reduction of diabetes medication, and, over time, remission.
Weight loss surgery also helps with reducing hunger. This also decreases the amount of food that you need to feel satisfied after eating. Therefore, it is easier to eat healthier, reach a healthy weight, and ultimately sustain that weight.
Who qualifies for these weight loss surgeries?
As with all procedures, not everyone can get every type of surgery. There are certain qualifications that patients have to meet to participate. Generally, for people who want weight loss surgery they should:
- Be more than 100 pounds (about 45 kilograms) above the ideal weight for your specific height
- Have a Body Mass Index (BMI) of over 40
- Have a BMI of 35 – 39.9 and you cannot reach normal fasting blood sugar (less than 125 mg/dl or HbA1c less than 7 percent)
In some cases, patients with a BMI of less than 35 (30 – 34.9) can get bariatric surgery. However, this is only if their diabetes is severe enough or is not being controlled with medication.
There are also certain things that can prevent you from qualifying for bariatric surgery. These include:
- an inflammatory condition of the gastrointestinal tract (like Crohn’s disease)
- hypertension (high blood pressure)
- previous bowl surgery or trauma
- a recent heart attack or stroke
- serious heart disease
- serious lung disease
- illnesses like cancer or liver disease
- drug or alcohol use
Types of surgeries for type 2 diabetes
There are different types of weight-loss surgeries that can help people with type 2 diabetes, all with their respective risks and benefits. Some of these have requirements to qualify, like falling under a specific BMI range, while others do not. Each procedure is briefly discussed below. However, you should talk with your doctor to definitively decide which surgery is best for you.
Some surgeries are labeled as “laparoscopic”. This means that the surgical instruments that are used in the procedures are inserted via small incisions as opposed to large ones. This type of procedure has a number of benefits for the patient. The first is that the time needed to recover is lessened and the scarring is minimal. In addition, smaller incisions lower the risk of developing an infection. They also protect the patient’s immune system, as opposed to open surgery which can weaken a person’s immune system.
Biliopancreatic diversion with duodenal switch (BPD-DS)
Procedure: BPD-DS is done in two stages: the initial stage being the sleeve gastrectomy, which is followed by the second stage – the intestinal bypass.
The sleeve gastrectomy makes the stomach smaller by removing about 70% of it. This gives the stomach the shape of a tube. This tube is then attached to the small intestine.
Then, the second stage begins: the intestinal bypass. Here, the lower intestine is divided so that about two-thirds of it is bypassed. This includes the duodenum (first part of the small intestine), jejunum (second part of the small intestine), and part of the proximal ileum. These are then connected near the ileocecal valve. Only a few feet of the intestine are left where food and digestive enzymes meet.
In patients who are very overweight, however, this process is split and performed in two surgeries spaced out over a few months. First, the sleeve gastrectomy is done. Then, about nine months to a year later, the intestinal bypass is performed.
Recovery time: You should stay in the hospital for about 2 – 4 days after the procedure, with a full recovery expected in about 4 to 6 weeks after surgery.
Expected results: This procedure usually results in the loss of about 60% – 80% of a person’s excess body weight in about two years’ time. About 85% of patients experience remission.
Specific qualifications: This procedure is usually only done for patients with a BMI of 50 or higher.
Specific risks: Patients may experience dumping syndrome (more frequent bowel movements), vitamin deficiency, trouble digesting food, and trouble absorbing calories.
Laparoscopic Roux-en-Y Gastric Bypass
Procedure: In Roux-en-Y, the first step is to staple off a portion of the stomach. This then creates a small pouch, which is then attached to the lower part of the small intestine. A bypass is then created, going around the lower stomach, duodenum, and jejunum. Through this, the absorption of calories is inhibition. However, this is also the reason that a risk of this procedure is nutrient deficiency. This bypass makes it harder for the body to absorb nutrients, as well.
The main result of this surgery is that the amount of food that a person can eat is decreased. The pouch, which is smaller than what the stomach initially was, can only hold a small amount of food, which gives the satisfying feeling of feeling full faster. There is also a change in the interaction between the stomach and the pancreas.
Recovery time: Patients usually recover in about three to four weeks after surgery.
Expected results: Patients lose about half to two-thirds of their weight in the first one to two years after surgery. About 80% of people have no signs of diabetes after the surgery, while 15% see an improvement in their diabetes.
Specific qualifications: None – any patient who qualified for bariatric surgery can qualify for this surgery.
Specific risks: The risks of this procedure include vitamin deficiency, a decrease in the absorption of nutrients, dumping syndrome, and diarrhea. The surgery is irreversible. There is a chance for weight regain if the proper dietary recommendations are not implemented.
Laparoscopic Sleeve Gastrectomy (LSG)
Procedure: This procedure is done by removing a large part of the stomach, about two-thirds of it. The resulting shape is a tube or sleeve. This narrowing of the stomach then reduces the space that is allowed for food in the stomach, decreasing food intake. The removal also reduces the levels of the hormone ghrelin. This hormone is what gives people the feeling of being hungry, so a reduction of this will make you feel less hungry. Ghrelin also increases blood glucose levels, so reducing it will, in turn, lower blood sugar levels.
One major benefit of this procedure is that it is less invasive compared to the other surgeries listed here. Unlike gastric banding, nothing is implanted in your body. There is also no rearrangement of your intestines, as there is in the gastric bypass.
However, one important factor is that this procedure is irreversible. Once the part of the stomach is removed, there is no way to reverse the surgery.
Recovery time: Patients stay at the hospital for one day and then should experience a full recovery in about three to four weeks after surgery.
Expected results: After three years, patients lose about half of their excess weight. About 60% of patients will experience remission after surgery.
Specific qualifications: This procedure is usually only done for patients with a BMI of 40 or higher.
Specific risks: Patients are at risk for nutrient deficiency and vitamin deficiency. The procedure is irreversible.
Laparoscopic Gastric Banding
Procedure: This surgery uses a band to separate the stomach into two parts. A soft silicone ring with a flexible balloon in the middle is placed around the stomach, close to the top. So, the stomach then has two parts: the smaller pouch at the top, and a larger pouch under the band. When you eat, the top pouch is filled up first. Then, food slowly passes through the space between the two pouches, like an hourglass. This makes it to where you only eat enough to fill up the smaller pouch, not the larger one.
The band can be adjusted, which can be done at the doctor’s office and does not require extra surgery. The tightness of the silicone band can be changed by inflating or deflating the balloon that is in the middle of the band. The sizes of the two pouches can change based on the amount of saline added to the band. More saline makes the two pouches smaller, slowing down the passage of food to the larger part of the stomach. Removing saline does the opposite.
The band can also be taken out after its insertion.
Recovery time: A full recovery is expected after about six to eight weeks.
Expected results: Patients usually lose about 40% or 60% of their excess weight (which is less than the other procedures listed here). About 45% to 60% of patients experience remission.
Specific qualifications: None – any patient who qualified for bariatric surgery can qualify for this surgery.
Specific risks: The most important risk of this procedure is the band slipping or wearing out. This would result in the need for another operation to reposition the band.
Risks of weight loss surgery for Type 2 Diabetes
As with all types of surgery, bariatric surgery has a number of risks that come with it. Some of these risks include:
- dumping syndrome – stomach pain, nausea, and vomiting following meals
- gallstones and kidney stones
- intestinal blockage or leakage
- poor response to anesthesia
- damage to other organs during surgery
In addition, the mortality rate for bariatric surgery is fairly low. Within the first month, there is about a 0.5% chance of death. The number then increases as time goes by, but does not go up significantly. The rate after about a year after surgery increases to approximately 1%. After about five years, that number increases to about 6%.
Benefits of weight loss surgery for Type 2 Diabetes
The main benefit of bariatric surgery is obvious: it results in weight loss. In the first year to two years, many patients lose about 50% to 80% of their excess weight. The decrease in weight also has other positive effects, like the reduction of the chance of heart attacks, strokes, heart failure, and kidney failure. Patients with sleep apnea have experienced an improvement in their condition, as well.
However, for the person with type 2 diabetes, there are other benefits in addition to the ones mentioned above. Most notably, the effects on a patient’s blood glucose levels are almost immediate. Over time, some patients (about 30%) can even reduce or altogether eliminate their use of medication. After about two years, approximately 85% of patients experience remission.
Ultimately, there are many options for diabetics who want to treat their condition with bariatric surgery. They all have their own risks and benefits, as well as their own procedures and requirements. Therefore, you have to talk to your doctor to choose which one will fit you and your situation best. However, with all of these differences, there is one similarity: after the surgery, there need to be lifestyle changes to sustain that weight and keep it off. So, though surgeries will help, the main change needs to be made in you, through the incorporation of diet and exercise into your daily life.
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