If I were a diabetic, often I ask myself- would I take a surgery that promises to halt the disease, even for a few years, that lasts an hour with a hospital stay of one day, would leave me 4 tiny scars on my belly, make me satisfied after eating a grilled fish and leave me popping vitamins for life?

Well I don’t know. I am not a diabetic and I am not an expert in mind reading either.  But I have always judged a procedure by asking myself one question- would I recommend it for my own kin or precious me. If the answer were yes then I wouldn’t hesitate to offer it to my patients.

Now let’s scientifically evaluate this fascinating and awesomest claim that a surgery can reverse a disease so far thought to be irreversible. But first lets talk about the disease in question.

Basically, diabetes per se is a disease of absolute or relative insulin deficiency. That means that either insulin is not available in the body or not working. The Lazy Insulin! So what does insulin do? Insulin pushes in glucose from the blood to all the cells in the body and fuels them up to work. In type 1 diabetes insulin itself is deficient and in type 2 it is there but unable to work. The net result is same- the body cells are starved and undergo progressive degeneration. Ultimately a diabetic therefore has multiple organ damage including the eyes, heart, kidneys, liver, nerves, blood vessels, etc. It is no surprise therefore that diabetic patients need treatment for the same. Often they need to undergo eye surgery, heart stenting, kidney dialysis, nerve vitamin supplementation and leg and feet amputations.

In the last 3 decades there has been evidence that the reason why insulin doesn’t work in type 2 diabetics is because they have chemicals in the blood that inhibits it’s action. They are called anti-incretins. It is further known that a certain part of the gut is responsible for liberating it. So if we were to bypass the food from entering this part of the gut it would lead to amelioration of diabetes. This has been adequately exemplified in rat models (Rubino et al) and it is this knowledge that is fundamental to the concept of diabetes surgery. But there is a lot more than this. The fat cells in the body earlier thought to be an inactive body tissue is now known to liberate chemicals (adipokines)  that have been shown to be pro diabetic. This comes as no surprise since it was common knowledge that diabetes affected the obese more than leaner individuals and the weight loss is instrumental for diabetes control.

More research to excavate the cause of diabetes has revealed the role of liver and bile salts.

The liver when laden with fat (NAFLD) produces insulin resistance and is thought to be contributory to the development of metabolic syndrome of which diabetes is an important component.

Bile salts- secreted by the liver and absorbed in the gut via receptors – have been shown to be instrumental in keeping the blood glucose at optimal levels. It has been demonstrated that these bile salt receptors in the gut go haywire in diabetes.

Metabolic or Diabetes surgery – the Mini Gastric Bypass in particular – have profound effects on all these aspects of diabetes. Lets enumerate the ways metabolic surgery works in resolving diabetes:

1. Calorie restriction- obviously by reducing the food intake and hopefully, the carb intake in a sensible compliant patient, the glucose load is decreased thereby allowing insulin to breathe easy. So with reduced glucose burden, the lazy insulin works!

1. Duodenal bypass- this arguably reduces the anti incretins and allows insulin to perform. It is therefore no surprise that gastric bypass- conventional or mini gastric bypass- works better in diabetes than procedures like sleeve (Stampede trial)

1. Adipolysis- fat melting is the biggest boon after the metabolic surgery – in the eyes of most patients- and helps in reducing the adipokines – chemicals liberated by fat cells.  Yes they are not as innocent as you might think. This leads to improved insulin function and normalisation of blood glucose as mentioned earlier.

1. Resolution of fatty liver (NASH) – the liver, post surgery, becomes less fatty. This translates into better liver function, decreased insulin resistance and diabetes resolution.

1. Alteration of bile salt pool- this has become an area of active research in recent times. It is known that the gastric bypass especially the MGB has pronounced action on them and are potentially one of the methods of ameliorating diabetes.

Phew! That’s a lot to digest. So what am I suggesting to my readers – the diabetics more so? Am I recommending diabetes surgery? Well I have put the evidence as it is – plain and simple- without resorting to gobbledygook. The patient should always have the last word.

However in my humble opinion – totally based on personal belief on reading literature and with modest experience with my patients- if I was a diabetic and obese with high blood fat, I WOULD consider a surgery. To carry the statement further, I would definitely go for surgery if medicines were failing to control diabetes.  I wouldn’t accept the risks of damage to eye, heart, kidney, nerves and vulnerability to infections lying down. Accepting to eat moderately and sensibly and taking vitamins daily sounds like a good trade off for diabetes in that situation. So to answer the question I asked at the beginning of the article, my answer is “yes I would take surgery for diabetes if need be”.

Watch this video on YouTube on Diabetes Surgery.