Surgical Treatment of Type 2 Diabetes

Definition and Overview

Surgical treatment of type 2 diabetes, aka metabolic surgery or popularly known as “sugar surgery” refers to treatment methods aimed at controlling blood sugar through certain surgical procedures aimed at controlling blood sugar through certain surgical procedures for the stomach and intestines. This approach was born mainly from obesity surgery; following the observation that diabetes was largely improved in patients with Type 2 diabetes undergoing obesity surgery, special surgical techniques were developed to control diabetes. As part of the surgical treatment of diabetes, operations are performed that change the hormonal balance of the gastrointestinal tract. Thus, the secretion of insulin by the pancreas increases, the body's sensitivity to insulin increases, and blood sugar levels can be permanently withdrawn to values close to normal. With these surgical methods, in a significant proportion of patients with Type 2 diabetes, the need for oral antidiabetic drugs or insulin is largely eliminated, even the disease remission It can enter a period of (full recovery).

Metabolic surgery is not a single type of surgery, but a group of surgeries. Among the most commonly applied methods Roux-en-Y gastric bypass, mini gastric bypass, duodenal switch and gaining popularity in recent years ileal interposition with bipartitional transit It can be counted surgeries. What these surgeries have in common is that they positively influence intestinal hormones (such as incretins) that regulate appetite and blood sugar through changes in the stomach and small intestine. For example, creating a new connection that will allow food to reach the final part of the small intestine faster (transit bipartition) or taking a piece from the final part of the small intestine and placing it in the initial part (ileal interposition) are among these methods. As a result of these operations GLP-1 Hormones that increase insulin secretion, such as insulin, are released more and blood sugar control improves.

In summary, surgical treatment of type 2 diabetes stands out as a powerful treatment option that alters metabolism in eligible patients who cannot control blood sugar with classical methods (diet, exercise, medication).

How Is It Done?

Metabolic surgical operations are usually performed by the laparoscopic (closed) method and can last from 2 to 4 hours, depending on the technique applied. The choice of surgical method to be used is determined by a joint assessment of the surgeon and endocrinologist, taking into account the patient's state of health, weight, level of diabetes and other concomitant diseases. If we briefly talk about the main applied methods:

• Gastric Bypass (Roux-en-Y): A small pouch is formed in the upper part of the stomach, and a section of the small intestine is directly connected to this pouch. Thus, both the amount of food taken is reduced, and the food passes faster to the advanced segments of the small intestine, triggering the release of hormones. It is a classic and effective method of controlling type 2 diabetes.
  
  
• Duodenal Switch: At the first stage, tube stomach surgery is performed, after which a large part of the small intestine is deactivated, shortening the flow of food. It is very effective in patients with high weight diabetes, as the absorption of ingested foods is also reduced. But due to the risk of vitamin-mineral deficiencies, its follow-up requires rigor.
  
  
• Ileal Interposition: A segment is cut from the last part of the small intestine, placing it in the initial part after the duodenum. In this way, nutrients come into contact with the last part of the intestine earlier than usual, and the secretion of the hormone GLP-1 increases. Usually the tube is performed in combination with gastric surgery. This method is used in some centers in our country, especially in patients with BMI <35 and uncontrolled diabetes.
  
  
• Bipartitional Transit: In addition to tubal gastric surgery, a connection (anastomosis) is established from the middle part of the small intestine to its final part. Thus, food goes both on the usual path and on the partially shortened new path. The goal is to connect the last part of the small intestine with food early and increase hormone release. This method is also a relatively new and promising technique.
  
  

All these operations are performed under general anesthesia. The healing process is faster compared to open surgery, as access to the stomach, intestines and other organs is provided with laparoscopic instruments during surgery. The surgeon carefully performs such steps as cutting and suturing the stomach in accordance with the chosen procedure, creating new connections in the intestines. Since these surgeries are technically similar to obesity surgery, the surgical process and hospital stay times are similar.

After the operation is completed, the patient is awakened and when his vital signs have stabilized, he is taken to the ward. Patients who typically undergo metabolic surgery 3-5 days followed up at the hospital. During this time, blood sugar levels are closely monitored; most patients experience or no need for very low doses of insulin or pills immediately after surgery. In the postoperative period, nutrition is started primarily with liquid foods, and the diet is gradually advanced, as in other bariatric surgeries (liquid, puree, soft and solid nutrition phases). When the patient is discharged, diabetes medications are regulated according to the new situation (often reducing or discontinuing doses) and detailed training is given on the nutrition plan.

Who is it suitable for?

Metabolic surgery is not a method that can be applied to every patient with Type 2 diabetes. Suitable candidates usually have the following characteristics:

• People with Type 2 Diabetes with High Body Mass Index: Patients with a body mass index (BMI) above 35 and with Type 2 diabetes are the strongest candidates for surgical treatment. It is aimed at both giving off excess weight in such people and improving diabetes. In diabetic patients with a BMI over 40, metabolic surgery has much higher success rates than classical treatments.
  
  
• Moderately Obese (BMI 30-35) and Uncontrolled Diabetes: The BMI is in the range of 30-35, and patients who, despite taking medication, cannot regulate blood sugar, have very high insulin resistance and have started complications due to diabetes can also be evaluated. In particular, metabolic surgery may be an option in patients with high HbA1c levels despite using insulin. In this group, the decision is made more rigorous; not every center may perform surgery within this BMI range.
  
  
• What the Pancreas Can Still Produce Insulin: In order for patients with type 2 diabetes to benefit from surgical treatment, the pancreas must still have sufficient insulin reserves. In patients who have had diabetes for more than 10 years and whose C-peptide level is very low (i.e. the body can hardly produce insulin at all), the chances of success of surgery decrease. Therefore, the patient's pancreatic capacity is measured by performing a C-peptide test in the candidate evaluation.
  
  
• Those who are not very advanced in age and whose general health is amenable to surgery: Usually, patients with diabetes aged 18-65 years are considered suitable. In patients over 65 years of age, the decision is made based on their individual condition. In addition, there should be no conditions that can increase the risk of surgery, such as severe heart failure, uncontrolled psychiatric illness.
  
  
• People who do not have Type 1 Diabetes: Metabolic surgery is not performed on patients with Type 1 diabetes (that is, the pancreas cannot produce insulin at all). It can only be considered in Type 2 diabetes and rarely in some special types of non-Type 1 diabetes (for example, rare types of diabetes associated with obesity).
  
  

Each patient should be evaluated individually by a multidisciplinary team and a risk-benefit analysis of surgical treatment should be performed. Surgical treatment of diabetes is a strong option to consider, especially in patients with high body mass index, but patient selection is one of the most critical keys to success.

Possible Risks and Complications

Metabolic surgery carries similar risks as they are part of bariatric surgery. Although these risks may vary depending on the type of surgery and the patient's overall health condition, rates of serious complications are low when performed by experienced surgeons. Nevertheless, the main risks that patients should be informed about are:

• Surgical Risks (Leakage, Bleeding, etc.): As with tubal gastric surgery, there is a risk of leakage (leakage of stomach contents into the abdomen) if the stomach is cut and reattached as part of the operation. There is a similar risk of leakage at the sites of anastomosis (new connection) to the intestine. These risks are usually less than 2%, but if they occur, intensive care and re-surgery may be required. There is also a risk of bleeding during or after the operation. To minimize the risk of bleeding and leakage, all connections are tested during surgery and necessary precautions are taken.
  
  
• Infection and Abscesses in the Abdomen: Due to both the leakage of stomach/intestinal contents and the surgical area, there is a risk of intra-abdominal infection. This, in turn, can sometimes lead to the formation of abscesses in the abdomen. To reduce the risk of infection, prophylactic (preventive) antibiotics are administered, and during surgery, maximum attention is paid to sterility.
  
  
• Clot Throwing (Embolism): Obesity and diabetes increase the risk of clots. In addition to postoperative immobility, the risk of a clot developing in the leg vessels and ejecting it into the lung (pulmonary embolism) is also a major concern after metabolic surgery. With blood-thinning measures (needle, varicose stockings) and early mobilization, this risk is pulled to fairly low levels.
  
  
• Nutrition and Absorption Problems: Especially with bypass (bypass) techniques in the intestines, vitamin and mineral deficiencies can be observed in the long term, as the absorption path of food is shortened. Absorption of substances such as vitamin B12, iron, calcium, vitamin D may decrease. Patients may need to take vitamin supplements for life and be followed up with regular blood tests. Also in some patients dumping syndrome The so-called, sudden decrease in sugar after eating and a feeling of discomfort can be experienced (especially after gastric bypass). Dumping syndrome can be managed with dietary adjustments.
  
  
• Change in Bowel Habits: Patients after metabolic surgery may initially have complaints such as diarrhea or, conversely, constipation. For example, consumption of fatty foods can lead to severe diarrhea because fat absorption is reduced after surgeries involving more intestinal bypass, such as duodenal switch. These problems are usually controlled when proper nutrition is maintained with dietary counseling.
  
  
• Hernias (Hernias): Although the incisions made in the abdominal wall are small, with rapid weight loss, some patients may develop a hernia at the incision site. In addition, the type of hernia that can occur as a result of displacement of the intestines, called internal hernia, can be seen in the long term, although rarely in the long term, especially after operations such as gastric bypass. This risk is minimized with the surgical technique.
  
  
• Inadequate Diabetes Control or Relapse: Although metabolic surgery can largely correct Type 2 diabetes, in some cases the expected response may not be achieved. Especially in patients with a very reduced pancreatic reserve or in those with a very long period of diabetes, there may be a partial improvement in blood sugar, but complete remission may not be achieved. In addition, even if remission is achieved in the first years, very rarely symptoms of diabetes can return years later. This condition is usually associated with the patient regaining weight; maintaining a healthy lifestyle minimizes this risk.
  
  

All these risks are explained to the patient in detail before the operation. It should be remembered that Type 2 diabetes itself is a disease that leads to serious organ damage and can shorten life expectancy. The low-rate risks that metabolic surgery brings are often lower than the long-term risks of diabetes (heart attack, stroke, kidney failure, etc.). Indeed, international publications show that these surgeries are quite safe in experienced centers; the rates of serious complications are below 1%, while the risk of death is less than one in a thousand.

Healing Process

The recovery process after surgical procedures for type 2 diabetes is generally similar to other gastrointestinal surgeries. The patient's blood glucose fluctuations, who are closely monitored in the hospital for the first few days after surgery, are monitored with regular measurements. Usually, even in the first days of surgery, the patient's blood sugar approaches normal values; if he is using insulin, the doses can be greatly reduced or completely discontinued. This rapid effect is one of the most striking aspects of metabolic surgery.

During the hospital stay, the patient is fed liquid food. Just as after a tube stomach or gastric bypass, patients undergoing diabetes surgery are admitted to a gradual nutrition program:

1. Fluid Period: The first 1 week begins feeding with clear liquids, water, sugar-free compotes, grain-free soups.
   
   
2. Puree Period: In the second and third week, we switch to blenderized foods, yoghurts, puree soups and foods with a soft consistency.
   
   
3. Soft Period: Between the 3-6th week, soft solid foods, well-cooked crushable foods are consumed.
   
   
4. Solid Period: After about 6-8 weeks, the transition to normal healthy solid foods is made.
   
   

This transition process is adjusted under dietitian control for each week. The goal is both to adapt to the new stomach/intestinal system and to ensure that the body receives the nutrients it needs. Intense physical activity is avoided in the first weeks after the patient is discharged, with the exception of light brisk walks. After 4-6 weeks, more active exercises can be gradually started with the approval of the surgeon.

The weight loss of patients undergoing metabolic surgery also begins simultaneously, since in most methods the stomach volume is reduced. In the first 3-6 months, most of the extra pounds are given off, while the progression of organ damage due to diabetes stops and even begins to regress. As blood sugar is brought under control, patients' energy levels increase, their daily life improves markedly. In the case of problems such as vision disorders due to diabetes, nerve damage, stopping of progress or partial reversal may also be possible.

In the postoperative period, patients are regularly monitored. During the first year, check-ups are usually scheduled in the 1st, 3rd, 6th and 12th months. In these checks, blood tests monitor the patient's hunger/satiety blood sugar, HbA1c (quarterly sugar average), vitamin levels, kidney function. The use of the drug is reorganized. For example, if you are taking blood pressure or cholesterol medications, these medications may no longer be needed along with weight loss.

Psychologically, a new era is entering for patients who have used insulin needles for many years or have lived with the restrictions of diabetes. These patients are also provided with psychological support in necessary cases and the continuation of a healthy lifestyle is encouraged. Dietitian follow-up is critical, especially in terms of adjusting food portions and establishing a balanced eating habit. Surgery is a start; the main success comes when the patient adopts this new metabolic pattern as a way of life.

Diabetes Surgery at Central Hospital Istanbul

Central Hospital Istanbul offers hope to its patients with its expert staff and advanced technological infrastructure in the field of surgical treatment of type 2 diabetes. The decision on metabolic surgery in our hospital is made by a multidisciplinary board that includes endocrinologists, general surgeons experienced in obesity surgery, nutrition and dietitians, as well as cardiologists and psychologists. Each patient is evaluated individually; it is decided whether surgery is appropriate, taking into account the duration of diabetes, existing complications, body mass index and general state of health.

When the decision to operate is made, the operation process is explained to our patients in detail. The most up-to-date and effective surgical techniques are used in Type 2 diabetes surgeries performed at Central Hospital Istanbul. Our surgeons have experience in both standard methods such as gastric bypass and advanced techniques such as ileal interposition and transit bipartition. Surgeries are performed in our fully equipped operating rooms, using laparoscopic method and with the help of modern imaging systems. During surgery, advanced anesthesia and monitoring devices are used for the safety of our patients, each stage is carefully controlled.

After surgery, our intensive care and service teams closely monitor our patients undergoing diabetes surgery. Blood sugar changes and fluid intake are carefully monitored, especially in the first 48 hours. Our diabetes training nurses educate our patients on whether they should have a blood sugar measurement after surgery, the new dose of their medication, and nutrition. During the discharge process, our patients are provided with a comprehensive guide on what to look out for in their new lifestyle.

Postoperative follow-up at Central Hospital Istanbul is an integral part of success. Therefore, we invite our patients to regular check-ups to monitor their weight status, blood sugar values and overall health trends. Our Nutrition and Diet department helps them develop proper eating habits by staying in touch with our patients during every postoperative period. We also support our patients with exercise programs and lifestyle recommendations when needed.

The greatest happiness for us is that our patients who have regained their health with Type 2 diabetes surgery can step into a new life free from the constraints of diabetes, saying goodbye to insulin needles. At Central Hospital Istanbul, we continue to stand by our patients with all our knowledge and compassion to achieve this goal.