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Role of Bariatric Surgery in Diabetes mellitus
Bariatric surgery is not just a procedure for weight loss; It is a metabolic surgery as well. This means that it leads to certain metabolic alterations which have a positive impact in terms of insulin secretion and remission of diabetes. Large number of studies and meta analyses have proved That diabetes is improved in the majority (> 80%)of patients with some (40-50%) being completely cured of the disease in the long term.
There are 4 basic mechanisms by which there is improvement in diabetes after bariatric surgery
1. Restriction – this is the first and foremost mechanism By which there is early improvement in blood sugar levels following any kind of bariatric surgery.
2. Weight loss- this plays a major role in decreasing the peripheral resistance to insulin And increasing the overall effectiveness of the hormone in glucose homeostasis in an individual
3. Incretins – these are hormones produced by the small intestine in response to caloric load And have found to be increased after bariatric surgical procedures. These hormones stimulate the release of insulin from the pancreas and help in blood sugar control.
4. Insulin sensitivity- this appears to be increased after certain bariatric surgical Procedures like BPD independent of weight loss and caloric restriction. The exact mechanism of this remains unclear.
Currently, bariatric surgery has been accepted as a treatment for diabetes And associated metabolic diseases for persons having BMI> 35 kg/m2. However, recent randomised trials by prominent surgeons in USA have shown Bariatric surgery to be significantly More effective than intensive medical treatment for mildly obese people (BMI 30-35 kg/m2) with diabetes mellitus which opens a new door of opportunity in the management of such patients.
The people who are most likely to benefit from bariatric surgery In their diabetes are those who are young, females, with a short duration of disease and who are controlled on oral tablets and donot have requirement for insulin. On the other hand, older male people with longer duration of diabetes and poor control with requirement of insulin are Less likely to get cured of the disease by bariatric surgery. However, there is a significant improvement even in these patients and Bariatric surgery has proved to be More effective than lifestyle modification and drugs in long term blood sugar control.
Although all bariatric surgical procedures Have some impact on diabetes, certain operations like gastric bypass and BPD-DS are more effective and have shown greater long term remission than other procedures. New procedures are also being developed which are postulated to have better results In terms of diabetes remission but the long term results are still awaited.