The Insulin Resistance at type 2 diabetes patients has both pre-cell and in-cell components. In this situation digestive system sourced resistance hormones play a key role by wrapping the cells just like a shield, thus preventing the entrance of insulin into the cells. Digestive system sourced resistance hormones are eliminated sas a result of Metabolic Surgery applications. The shield around the cell is opened and insulin easily penetrates into the cell. Similarily, 2-3 months after the operation the fat, protein metabolism and liver lipoidosis and damage recover, and the cell internal signal mechanisms reverse. As a result of this, along with the normalisation of blood sugar, cholesterol and triglyceride levels in patients after Metabolic Surgery applications, also problems like hyper-tension, liver lipidosis, eye and kidney damage, and foot ulceration are eliminated with a single operation.
Who are Metabolic Surgery Candidates?
- Patients incapable of getting blood sugar under control though appropriate treatment
- Patients experiencing organ damage symptoms and with problems with eye, heart, kidney, liver, or feet
- Patients with serious weight problems.
The most important difference of Metabolic Surgery from obesity operations is the operation mechanism that is based on the principle that the small intestines are not disabled by bypass operation and that they benefit from hormonal changes through a transposition / interposition procedure. Another difference is the positive effects of Metabolic Surgery applications on this type of diabetic patients who do not have serious weight problems, regardless of weight loss, on the ability to change this hormonal order and thus on blood sugar control. For this purpose, there are 2 basic metabolic surgery applications in clinical practice. The first is Ileal Interposition and the second is Transit Bipartition (TB).
The term Ileal Interposition, in brief, is a kind of exchange of the initial and final parts of the small intestine. The insulin resistance hormones, Ghrelin (stomach), GIP (duodenum) and glucagon (pancreas), are excreted from the initial parts of the digestive system and the insulin sensitivity hormone, called GLP-1, is released from the L cells in the last part of the intestine. GLP-1 is a hormone that increases the effects of insulin and stimulates insulin production by the pancreas. Basically, the goal of this procedure is to leave the resistance hormones aside and increase the sensitivity hormones.
The final part of the intestine is called the Ileum. Displacing the last part of the small bowel (ileum) surgically is called ‘Ileal Interposition’.
Not only is an area of the last part of the intestine displaced by this surgery, but also a part of the stomach is removed, in order to create other hormonal changes in a manner that strengthens the effect of the Ileal Interposition surgery. The levels of a hormone, called Ghrelin, excreted from the upper left part of the stomach, are diminished by removal of this part of the stomach.
There are two important functions of ghrelin:
- To send impulses to the brain centre called the Hypothalamus, at the base of the brain, in order to create and/or increase feelings of hunger.
- Intra-cellular insulin resistance.
There is another important reason to remove this part of the stomach in Ileal Interposition surgery: in the event that the ileal displacement is only made on the intestines but without any procedure on the stomach, then gastrectasia that is called Gastric Dilatation occurs, plus persistent nausea and vomiting seizures are present. For the reason of these 3 effects, the left upper outer part of the stomach, known as the fundus, is removed.
The ghrelin hormone that has been excreted excessively, especially in Type 2 Diabetics, goes down to very low levels by the removal of the fundus of the stomach. Additionally, having the proximal and distal parts of the small bowel exchanged during the Ileal Interposition surgery aids in patients not feeling very much hunger, even if they do not eat for a long time in the post-operative period.
Therefore, the objective in removing a part of the stomach in the Ileal Interposition surgical operation is not, as a matter of fact, to reduce the volume of the stomach. The objective, in this respect, is to bring down the excretion levels of the ghrelin hormone triggering the feelings of hunger and to prevent the state of gastric dilatation that may emerge subject to a displacement at the intestine and occurring together with resistant nausea-vomiting. The stomach is left wider than the ‘tube stomach’ surgical operation (sleeve gastrectomy) that is done for morbid obesity. The reason for less food consumption by the patients post-operatively is the new internal arrangement, constituting hormonal changes. As a consequence of this, not withstanding that the Ileal Interposition surgical operation is an advanced digestive system surgery from the anatomical point of view, it completely turns out to be a ‘Metabolic Surgical Operation’ process when it is looked at in respect of the mechanisms that are affected. Each step that is applied in the Ileal Interposition surgical operation has a hormonal target. These objectives are assessed in consideration of various numbers of factors for each individual patient, and relevant changes may be made to the process according to the specific situation of the patient. Within this framework Ileal Interposition may be said to be a dynamic decision-making process.
Gained to the medicine literature by the Brazilian surgeon Sergio Santoro, this surgical technique is similar to the other techniques as it is a combined operation with sleeve gastrectomy procedure. However, unlike similar procedures, the entire distal part of small bowel is brought to the lower stomach and a second exit is provided, therefore all the food can pass through the entire small bowel segments.
In this procedure, 100 or 120 cm starting from the connection point between the small bowel and the large bowel is measured and marked. The choice between 100 or 120 cm is determined according to patient characteristics.
Afterwards, another 150 cm is measured, and small bowel is dissected at 250 cm distance to the connection between the small bowel and the large bowel.
Dissected lower end is connected to the stomach. Higher end is connected to the 100th cm marked beforehand. As a result, direct food passage is granted to the last 250 cm part of the small bowel.
2nd Option: Transit Bipartition
Only important point is that approximately 1/3 of the food passes through the duodenum, which is the natural path, while 2/3 of the food passes through the last segment of the small bowel, thanks to the new connection.
These rates have been determined by the screening tests which are done either with oral contrast material or marked isotopes.
Iron and vitamin deficiencies in diabetic patients
- Vitamin D and Vitamin B1 (thiamine) deficiencies in diabetic and especially obese diabetic patients who never had any surgery before is quite common (%32-60 and %18-45, respectively).
- In the same patient groups, iron deficiency is also reported between %8-19.
Transit Bipartition Results:
- 5 year follow up results of the patients who underwent Transit Bipartition operation show that the need for these vitamins is below %10.
- Main advantage of this operation is that less than %7 of the patients have a blood hemoglobin value of 12 gr/dl (between 10-12 gr/dl).
- Long term iron supplement requirement has not been observed in any of the patients except thalassemia carriers.
- About %95 of the patients can continue their lives without any supplement.
Transit Bipartition Other Advantages
- Low intragastric pressure and accordingly prevention of sleeve leaks.
- Preservation of the sleeve size and prevention of sleeve dilatation in the long term, both thanks to low intragastric pressure.
- Entirety of the small bowel can be reached by endoscopic means. This prevents gall bladder, pancreas and bile channels being unreachable, which is commonly seen in techniques that disable the duodenum.
- Food passage and absorption through the entire digestive system
- Any part of the digestive system can be reached by endoscopic means
- Duodenum and the bile channels can be reached with ERCP
- Preservation of the antrum, the pylorus and the duodenum remove the need for vitamin, mineral, iron and calcium supplement
Bariatric and Metabolic Outcomes
- 5 year results of Transit Bipartition operation have been published in 2012, which show that in this 5 year period, patients lost %74 of their excess weight and %86 of the patients achieved blood sugar control without medication.
- Preliminary reports of 8 year results state that these rates have been preserved at the same level.
Pre and Post Surgical Period
Before the operation
1-2 days prior to your operation your hospitalization will be performed and blood diluting medicine and purgative medicine for the cleaning of the intestines will be supplied. Your blood sugar and hyper tension will be taken under control. 1 day prior to the operation you will need to start a liquid diet (water, fruit juices, soup, tea, ayran, stewed fruits and the like) and not to eat and drink anything after 10 pm. (This will provide that your intestines remain clean, so an enema will not be necessary, the operation will be clean and the risk of an infection will decrease).
During the operation
An oxygen measurement pin will be attached to your finger during the operation in order to control the oxygen saturation in your blood, and a blood pressure device is used to automatically measure your blood pressure levels, in order to control tension. A venous path will be established in order to provide the flow of the anaesthesia and other medicine. While you are under anaesthesia catheters allowing sufficient and safe liquid flow. Access to a vein in your hand or arm will be maintained after metabolic surgery applications. (These will be removed after 3-4 days upon the start of intake of sufficient liquid after the operation.) In extremley overweight patients, or with additional problems, a vein path is opened in the hand or wrist in order to measure blood pressure and oxygen quantity in the vein (this is removed 1 day after the operation). You will wear tight leg socks in theatre, and afterwards, which will ensure sufficient blood flow in your legs until you start to walk. In addition to these, massage will be applied on your legs with pressurized devices in order to prevent blood accumulations in your legs during the operation. You will have a urine catheter inserted prior to the operation. This catheter will be removed when you start to meet your toilet needs by yourself.
After the operation
- Commonly you will need to stay in the intensive care unit on the first day after the operation in order to keep you under close observation. The effects of the anaesthesia will continue while your are being transferred to the intensive care unit.
- You may move your hands and legs and take a comfortable position after having been transferred to the Intensive Care Unit.
- You will have a blood pressure device attached to your arm in order to measure your blood pressure every 15 or 30 minutes. A measurement clip will be on your finger in order to provide control of the oxygen quantity after the operation.
- Besides this, an oxygen mask will be applied to you for a term of 2-4 hours. (You will be able to breath normally.)
- You can drink only water during the first day after the operation. Other liquids and proteins will be supplied to you intravenously, until your oral nutrition achieves a sufficient level.
- You should start breathing excersizes 1 day after the operation in order to strengthen your lungs.
- 1 day after the operation, you may need assistance when you sit and stand up, as you may experience dizziness for a couple of seconds when you stand. It is ofteh the case that you will start taking liquid food within 2-3 days. It will be ideal to take small meals every 3 hours.
- Patients are normally discharged 4-5 days after the operation.
- You should, depending on the operation, continue with the liquid or semi-solid food diet and take your meals in 2-3 hours intervals.
- You need to drink at least 1.5 litres water per day. Your daily urine amount needs to be above 1.5 litres.
- You will need to take stomach protector (Pantoprazole pill 40 mg, daily 1 pc.) for 1 month and gallbladder protector (ursodeoxycholic acid 250 mg, daily 2 pc.) for 2 months.
- You will need to take vitamin syrop and calcium supplements until your oral nutrition becomes sufficient.
- Depending on your blood sugar level, it may be necessary that you take diabetes medication after the operation until your blood sugar reaches normal levels.
- You will need to measure and record your weight and blood sugar daily.
- Your tension medication needs will decrease, too, but it is recommended you measure and record your blood pressure for 15 days.
You will need to perform blood and urine tests, respectively in the 1st 3rd 6th 12th 18th and 24th month after the operation. It may be necessary to perform an endoscopy in order to review the status of the stomach.