Metabolic surgery can reverse Type 2 diabetes
Posted on 23 November 2017
Because of the noticeable medical benefits bariatric surgery offers to patients with Type 2 diabetes, surgeons are starting to refer to the procedure as metabolic surgery (surgery to help resolve metabolic disorders) rather than bariatric surgery (surgery to help resolve obesity).
Dr Etienne Swanepoel, a surgeon at Mediclinic Durbanville, has performed over 350 bariatric surgical procedures over the last ten years and says the statistics in support of metabolic surgery as curative treatment for Type 2 diabetes is overwhelming.
For instance, the five-year STAMPEDE (Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently) trial published this year in the New England Journal of Medicine demonstrates that bariatric surgery with intensive medical therapy is a better long-term treatment option than intensive medical therapy alone for obese patients with uncontrolled Type 2 diabetes, even those with a body mass index (BMI) as low as 27 kg/m2.
Amongst other research, a landmark 2004 study published in the Journal of the American Medical Association (JAMA) of more than 22,000 people who underwent bariatric surgery showed that:
- Type 2 diabetes was completely resolved or improved in 86% of patients;
- High blood lipids improved in 70% or more of patients;
- High blood pressure was resolved or improved in 78% of patients.
Additionally in a joint statement by international diabetes organisations published in 2016, it was stated that although additional studies are needed to further demonstrate long-term benefits, there is sufficient clinical and mechanistic evidence to support inclusion of metabolic surgery among antidiabetes interventions for people with type 2 diabetes and obesity. To date, the DSS-II guidelines have been formally endorsed by 45 worldwide medical and scientific societies.
‘Following the release of the STAMPEDE study there has been a huge paradigm shift in diabetic societies the world over, recommending metabolic surgery for obese patients with a body mass index (BMI) over 40 (and in some cases BMI 35 – 40 ) as preferable to medical therapy,’ says Dr Swanepoel. ‘The BMI groups of 32 to 35 would also benefit from the surgery if they’re not well-controlled on medication.
‘When a patient has a BMI of 40 or over, many co-morbid conditions such as Type 2 diabetes, high cholesterol, sleep apnea, high blood pressure and fatty liver disease may be associated with their obesity, as well as a higher incidence of stroke and certain cancers in women,’ Dr Swanepoel explains. ‘We can’t cure all these illnesses with metabolic surgery but we can cure some of them and improve or prevent many of the other illnesses’.
He adds that from his patient data, Type 2 diabetes patients with a BMI over 40, have a greater than 70% chance of being cured of their condition after the surgery.
Controlling the risks
The risks of the surgery include anastomotic leaks, bleeding, ulcers and infections. Dr Swanepoel has operated on 350 patients over the past ten years and all those complications showed an incidence of under 1%. A post-operative care plan that also includes early aggressive mobilisation reduces the risk of deep vein thrombosis as a result of the surgery.
In South Africa, the South African Society of Surgery Obesity and Metabolism and the Centres of Excellence for Metabolic Medicine and Surgery (CEMMS) allow both surgeons and patients to benefit from a centrally-managed peer review and quality control system. All patient information is submitted to the central database pre-operatively which is accessed by the governing body.
In addition, the patient needs to be seen by a multi-disciplinary team of CEMMS-accredited medical professionals before surgery.
An endocrinologist ensures the patient doesn’t have a medical illness, such as hypothyroidism, that can be cured or treated with medication.
A psychiatrist evaluates each patient for certain traits or personality disorders that lead to binge eating and might make them an unsuitable candidate for surgery.
A gastroscopy identifies problems that may require a different form of the surgery. This includes testing for the bacteria H. pylori which puts patients at high risk for developing ulcers. This would need to be eradicated before proceeding with the surgery.
If the patient suffers from sleep apnea, a correct diagnosis needs to be made pre-operatively and pre-operative CPAP therapy is used to reduce the anaesthetic risk
After surgery, a dietician tailor-makes a long-term eating plan to ensure they don’t develop any mineral or micronutrient deficiencies after the surgery, while a biokineticist and physician formulate a rehabilitation plan.
‘Patients can lose up to 75% of their excess weight, most of it within 18 months after the surgery,’ says Dr Swanepoel. ‘Some patients have even lost up to 90% of their excess weight. They may regain some, but are unlikely to ever be as overweight as they were before the surgery – unless they really set out to fail.’
Mediclinic currently offers three Centres of Excellence for metabolic surgery at Mediclinic Durbanville through Dr Swanepoel’s practice and additionally at Mediclinic Bloemfontein (Dr Geofré Heyns and associate doctors) and Mediclinic George (Dr. Danie Folscher and associate doctors).
Types of bariatric surgery:
In normal digestion, food passes through the stomach and enters the small intestine where most of the nutrients and calories are absorbed. ‘In this laparoscopic procedure, a small part of the stomach is stapled to create a new, egg-sized stomach pouch,’ says Dr Geofré Heyns at the Mediclinic Bloemfontein Bariatric Centre of Excellence. ‘The outlet from this newly-formed pouch empties directly into the lower portion of the jejunum (the middle segment of the small intestine). This means food bypasses the duodenum (the upper portion of the small intestine) and is delayed in mixing with bile and pancreatice juices that aid nutrient absorption.’ The result is an early sense of satiety which reduces the desire to eat.
Vertical Sleeve Gastrectomy
During this procedure, approximately 60 – 85% of the right side of the stomach is removed, creating a ‘sleeve’ or tubular stomach. Afterwards, the stomach functions as before but the quantity of food it can manage is considerably restricted. ‘Because the greater curvature of the stomach is removed, fewer hormones are produced, including ghrelin that makes you feel hungry,’ Dr Heyns explains. Vertical Sleeve Gastrectomy can also be used as the first stage operation of a two-stage procedure.