Treatment of Type 2 Diabetes

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The condition that includes obesity, diabetes, high cholesterol and hypertension is called Metabolic Syndrome. The treatment of Metabolic Syndrome by surgical methods is called Metabolic Surgery. In the last years, metabolic syndrome and especially type 2 diabetes has become a global health problem threatening the entire world. Our foundation aims to create public awareness about metabolic syndrome and its surgical treatment under the guidance of scientific knowledge.

Our foundation does not have any intention of praising or criticizing any treatment option. But there are 2 important points that must be known. First, it is not possible to fight the diabetes pandemic with the current treatment options. Presented as the golden standard and first step treatment, life style changes which are based on exercise and diet can only be achieved by %3 of patients in a 3 year long period. At this point, 2 yearfollow-up studies titled DPP (Diabetes Prevention Program) and DPS (diabetes Prevention Study) guide us.

Despite all these factors, long term weight control cannot be established
And the ‘protection’ you acquire will not have any permanent effect on long term results!
%80 of obese patients (BMI>30kg/m2) lose %10 of their excess weight with diet intervention, but %95 of these patients will regain lost weight (even more than the lost weight) in 2 to 5 years.* *Kaplan LM, Seeley RJ, Harris JL. Myths associated with obesity and bariatric surgery. Review. Bariatric Times 2012; 9 (9): c5-7.
Secondly, it should be known that the most effective treatment of metabolic syndrome and especially type 2 diabetes is surgery. There is no other treatment option that can provide %90 long term control over all metabolic syndrome components. Perhaps the most important point here is that metabolic surgery operations are different procedures than obesity surgery operations.
One of the most important goals of our foundation is to end the confusion between metabolic surgery and obesity surgery. Sadly, we observe that some of our colleagues contribute to this confusion. Like most of the other countries, our country has misperceptions of its own. When diabetes operation is mentioned everyone thinks of gastric band, sleeve and gastric bypass. Our foundation also aims to emphasize the difference between metabolic surgery and obesity surgery.

Majority of obesity surgery procedures are based on restriction. These are mechanical restrictions. Gastric band, sleeve gastrectomy are examples to mechanical restriction. Mechanical restriction is a static obstacle and cause discomfort with the first bite, which means before satiety occurs. Restriction can be combined with mal absorptive procedures to a certain degree. Gastric bypass is the best example of this. Even though other mal absorptive operations such as BPD and DS don’t cause such severe restriction, a significant portion of the small intestines are removed from the absorption process, which means bypassed. This procedure causes severe malabsorption and nutritional problems in the following years.

Malabsorption is a disease defined by World Health Organization. All surgeons working in this field must reconsider their responsibility concerning this matter. From a different point of view, this is the same as ending a disease while at the same time inviting another.

There is only one surgical procedure that aims for the surgical treatment of type 2 diabetes on patients without serious weight problems. In all studies about this operation known as ‘Ileal Interposition’ or ‘Ileal Transposition’ in medicine literature, reports of treatment of individuals without weight problems, but can be defined as ‘Metabolic Patient’, can be found. It is possible to reach those publications through foundation library.

What is the difference between Ileal Transposition and obesity surgery? Why Ileal Transposition?

The important thing here is to distinguish mechanic restriction from functional restriction. First of all, restriction is against human nature. For the treatment of obesity, any restriction can work out for some time but will eventually fail later on. There can be such powerful returns that patients might miss their pre-restriction state. At this point, what is important for the scientific community is the absorption and nutrition physiology. Absorption system and especially small intestines are the largest endocrine limbs in our body. Almost all of the hormones that provide satiety and increase insulin sensitivity are secreted from the distal part of the small intestines, ileum. And almost all of the hormones that cause insulin resistance and hunger are released from the duodenum and stomach. Which means negative hormones in terms of diabetes are released from the beginning part of the small intestines and stomach while positive hormones are released from the distal part of the small intestines. As a result, what needs to be done is to disable resistance and hunger hormones, activate sensitivity and satiety hormones and most importantly, is to achieve this without causing severe malabsorption. The only operation that has been proven of capable of achieving this effect for both obese and non-obese type 2 diabetic patients is ileal transposition procedure.

To turn ileal transposition into a widespread procedure, our foundation performs seminars and symposia on a regular basis. During these activities, educational meetings and live surgeries are performed. Bariatric and Metabolic Surgery procedures are still an evolving concept. Evolution is an indispensable part of science and it will take some time for this technique to be known and learnt. What makes this difficult is that the operation is technically quite hard and demand significant training and skill. More importantly, this operation cannot be performed by a single surgeon and require excellent team work.

Our foundation has recently completed Technical Feasibility and Safety Profile study regarding this operation. The results show us that the complication rates of ileal transposition operation are the same as the other frequently performed bariatric operations and even lower rates than malabsorptive procedures. These results will be shared with the scientific community in the near future. However, we would like to point out that these operations cannot be done by any general surgeon. Also, we want to emphasize that the operation itself is the least important part of this treatment method, but the most important part is the decision and pre-operative preparation period.

Recently some doctors who present themselves as ‘Metabolic Surgery Specialist’ on media are drawing attention. As of this moment, there is no expertise as ‘Metabolic Surgery Specialist’. Some of these individuals focus on obesity surgery while others claim they perform ileal transposition even though they lack the necessary training, knowledge, skill and experience. For that purpose, they do not hesitate to claim they received their training in our institution. Our foundation receives numerous complaints from patients and their relatives because of complications caused by these individuals. Warning the public and creating awareness regarding this issue is another duty of Turkish Metabolic Surgery Foundation.

An article titled ‘From the Triumvirate to the Ominous Octet’ by Ralph de Fronzo was published in the medicine magazine ‘Diabetes’ in 2009.* In the aforementioned article, 8 mechanisms responsible of the progression of type 2 diabetes were discussed. These 8 mechanisms became the inspiration of our symbol and the 8 armed monster in our statue symbolizes type 2 diabetes. As a warrior stabs the monster with his spear through its abdomen, the monster holds the leg of the warrior with one of its arms while struggles to get up with another. This is done to indicate that despite its effective results, even this surgical procedure cannot change two components of diabetes, which are insulin resistance present in the central nerve system and renal glucose transport. The remaining 6 arms, on the other hand, have given up the struggle with the spear (the spear symbolizes the scalpel), stabbed by the warrior. Those 6 arms symbolize the 6 mechanisms we can treat with surgery. What makes the story of the statue even more interesting is that its sculptor, Ahmet Özer, underwent Metabolic Surgery operation in 2011.
*Ralph de Fronzo. From the Triumvirate to the Ominous Octet. A new paradigm for the treatment of type 2 diabetes mellitus. Diabetes2009; 58: 773-795.