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Gastrointestinal Metabolic Surgery

Type 2 Diabetes

For appointments and information, please call (646) 962-8462

Diabetes is a chronic metabolic disorder that occurs when the body does not produce enough insulin and/or cannot effectively use the insulin it produces (a condition referred to as "insulin resistance"). Inadequate insulin production and action lead to raised blood glucose levels (hyperglycemia), which can adversely affect various organs and tissues including the heart, kidneys and eyes. Type 2 diabetes is associated with various cardio-metabolic disorders including obesity, high blood pressure (hypertension) and increased blood cholesterol and triglycerides (dyslipidemia).Type 2 diabetes is a progressive disease, characterized by continuing deterioration of insulin secretion over time. This leads increasing need for medication, while persistent or worsening glycemic control may increase risk of diabetes complications (i.e. hearth attacks and strokes, kidney failure, eye disease and blindness etc).Although the exact underlying causes of type 2 diabetes are not yet fully understood, a number of risk factors have been identified. These include: obesity, diet, lack of physical activity, increasing age, insulin resistance, family history of diabetes and ethnicity.

Severely obese women have an estimated 93-fold higher risk of developing type 2 diabetes, while severely obese men have an estimated 42-fold higher risk compared to people of healthy weight. Obesity also contributes to the metabolic syndrome – the dangerous cluster of heart attack risk factors that includes central (abdominal) obesity, hypertension and dyslipidemia.

Treatment of Type 2 Diabetes

The key factor in treating type 2 diabetes is keeping blood glucose levels as close to normal as possible. In addition, treatment of diabetes must include control of other cardiovascular risk factors such as hypertension, high cholesterol and smoking.

Management options include lifestyle modification (diet and exercise), oral medications (oral hypoglycemic agents) injectables including insulin and exenatide and,where appropriate, surgery.

Bariatric surgery was originally developed to achieve substantial and sustained weight loss as a treatment for severe obesity. It involves various surgical procedures on the gastrointestinal tract to decrease food intake and modify the physiological changes that drive weight regain. Given the increasing evidence that some bariatric procedures provide metabolic changes that cannot be completely explained by their effects on body weight alone, the name 'metabolic surgery' is emerging as a more appropriate term. When used with the specific intent to improve diabetes this surgery is also now being referred to as "diabetes surgery".

In severely obese individuals, surgery can cause "remission" of diabetes in the majority (normal blood sugars without medications) and significant "improvement" in blood glucose in others (improved blood sugars with lesser medication).

Approximately, 40-50% of morbid obese and diabetic patients who have laparoscopic gastric banding achieve remission of type-two diabetes. With gastric bypass or biliopancreatic diversion, the rate of remission is reported to be superior ~ 70-80%.

In addition to providing excellent control of diabetes and weight loss, gastrointestinal metabolic surgery has several additional benefits, including improvement of hyperlipidemia, hypertension and sleep apnea. Moreover, the incidence of cancer is reduced in obese patients who have had bariatric surgery. Most importantly, several reports have consistently shown that in patients with diabetes and severe obesity, surgery increases long-term survival.

Why is it difficult to treat diabetes by medical therapy?

Significant weight loss through lifestyle modification and medical methods is modest at best and is rarely sustained in obese, and particularly severely obese people. Medical options for controlling blood glucose levels are also unfortunately less effective in severely obese people. In addition, a number of medications used for treating type 2 diabetes, including insulin, can result in weight gain. When diabetes is difficult to control, especially in patients with severe obesity, surgery should be considered as a valuable option to achieve control of blood sugar and reduction of cardiovascular risk factors.

Why is it difficult to treat diabetes by medical therapy?

A recent position statement of the International Diabetes Federation recommends that surgery be considered early in the management of disease in obese patients, and not only as a last resort.

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Gastrointestinal Metabolic Surgery
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