At first glance, it may seem strange, but there is a recognized and powerful method for effectively treating type 2 diabetes, which is surgery. Gastric bypass surgery, designed for individuals with obesity and diabetes, offers a dual benefit by not only promoting weight loss but also regulating blood sugar levels. While it’s important to note that diabetes mellitus, a serious chronic disease, cannot be entirely cured, many patients experience long-term remission following bariatric surgery. Within just a few days of the procedure, most patients no longer require daily medication or frequent glucose level monitoring. This remarkable outcome offers an improved quality of life and, simultaneously, a safeguard against the potential complications of diabetes. We had the opportunity to discuss this transformative approach with the renowned bariatric surgeon, Prof. Dr Antanas Mickevičius.

In which cases is bariatric surgery recommended for patients with diabetes?

First and foremost, it’s important to recognize that obesity is strongly linked to an elevated risk of developing type 2 diabetes. Over time, obesity can contribute to the onset of chronic conditions such as type 2 diabetes, hypertension, high cholesterol, sleep apnoea, joint problems, and polycystic ovary syndrome in women. This cluster of conditions, including obesity itself, is collectively referred to as metabolic syndrome. Left unaddressed, this diagnosis can potentially reduce one’s lifespan by 10-20 years. In recent years, the number of individuals affected by obesity has risen, leading to a higher incidence of metabolic syndrome. Bariatric surgery not only facilitates weight loss but also provides a significant improvement in the aforementioned conditions. In such case, bariatric surgery is often called metabolic surgery. When discussing the management of diabetes through bariatric surgery, it is typically referring to type 2 diabetes. However, there are instances where bariatric procedures have shown substantial positive effects even in patients with type 1 diabetes. For individuals with type 2 diabetes of up to five years’ duration, undergoing bariatric surgery and achieving weight loss often results in remission. This means that the symptoms of the disease diminish, and the need for medication is no longer necessary. The likelihood of achieving remission after certain surgical interventions can be as high as 80-85%.

What criteria are employed to recommend gastric bypass surgery for individuals in such cases?

For a long time, the criteria for advising bariatric surgery included a body mass index (BMI) of 35 or higher, particularly when accompanied by comorbidities such as diabetes mellitus, arterial hypertension, and other chronic diseases mentioned before. However, observing the good results of bariatric surgery in patients with diabetes, the World Association of Bariatric Surgeons and the North American Association of Bariatric Surgeons adopted new guidelines in 2022. They now recommend considering bariatric surgery when the patient has a BMI of 30 or more and is also dealing with diabetes. This shift is based on the premise that gastric bypass surgery can not only facilitate weight loss but also help prevent diabetes-related complications. Living with diabetes for an extended period can lead to a variety of health problems and disorders, including micro and macrovascular angiopathy, which damages small blood vessels, affecting the eyes and intestinal motility. The nervous system and kidneys can also be adversely impacted.

What physiological processes in the human body lead to a reduction in diabetes symptoms and an improvement in the condition following bariatric surgery?

Type 2 diabetes is primarily a result of insulin resistance. Following most bariatric surgeries, several key physiological changes occur. Insulin resistance diminishes, there is an alteration in intestinal hormone balance, driven by factors like calorie restriction, negative energy balance, and weight loss. Bariatric surgery leads to a reduction in the production of ghrelin, a hormone responsible for stimulating appetite. Concurrently, the production of other intestinal hormones, such as GLP-1, increases, which in turn stimulates insulin production. This increased insulin production enhances the rapid transportation of glucose from the bloodstream to the body’s cells, where it’s utilised to meet energy demands rather than lingering in the circulation. This process contributes to the reduction in blood glucose levels.

Is this effect long lasting?

Diabetes is a chronic condition, but after weight loss surgery, individuals often find themselves no longer requiring medications to lower their blood glucose levels. At this point, it is recognised as achieving remission. However, it’s crucial to understand that remission doesn’t equate to a cure; it is typically a long-term outcome, closely tied to weight loss. For a small number of patients who undergo bariatric surgery, there’s a potential for weight to return within 5-10 years if they don’t adhere to the principles of a healthy diet and maintain low physical activity. A similar tendency can be observed with diabetes. Among the 80-85% of patients with diabetes who experience improvements after gastric bypass surgery, around 20-25% may experience a recurrence of diabetes within a decade or more. They may once again require medications to maintain normal blood glucose levels. Nonetheless, achieving a 10-year remission is a significant accomplishment, even for those individuals with a long history of type 2 diabetes. While complete remission isn’t always attainable after surgery, the overall quality of life improves considerably. For instance, individuals who previously had severe type 2 diabetes controlled solely with prescription insulin analogues may find that post-surgery weight loss enables them to effectively manage their condition with oral medications. In my practice, this is a substantial positive step in terms of enhancing the quality of life for patients. They often express both happiness and surprise when they observe their blood glucose levels decreasing as early as the third day after surgery.

Which type of bariatric surgery is most commonly recommended for individuals with diabetes?

The most effective and long-term treatment for type 2 diabetes is often achieved through laparoscopic gastric bypass surgery. This procedure involves creating a new, smaller stomach while disconnecting it from the larger stomach. Additionally, a bypass is constructed to allow food to move past most of the stomach and a portion of the small intestine. As a result, food enters the small intestine directly, stimulating hormone secretion and increasing insulin release. The reduced capacity of the new smaller stomach means that feelings of fullness occur more rapidly, leading to reduced food intake. Moreover, the shortened intestine absorbs fewer nutrients. Compared to other surgical options, gastric bypass surgery has been shown to result in faster weight loss. Scientific studies have proven its status as the most effective procedure for achieving long-term weight loss and, concurrently, diabetes remission. To attain the best results, adopting new eating habits post-surgery is of great importance.

Are there any additional risks associated with gastric bypass surgery for patients with diabetes?

In the case of diabetes, there is a slight increase in the risk of wound suppuration due to weakened immunity. However, these risks are more likely to occur when diabetes is poorly controlled and medications fail to adequately lower blood sugar levels. Hence, thorough preparation for metabolic surgery is crucial. Prior to the surgery, we routinely refer patients with diabetes to an endocrinologist for guidance. The endocrinologist can assist in optimizing blood glucose levels both before the operation and during the post-operative period. This approach minimises the associated risks and leads to a swifter recovery following surgery. When patients have additional concurrent chronic diseases, we collaborate with specialists in the relevant medical fields to ensure these conditions are well managed. If needed, treatment can be adjusted to achieve better results, and only after reaching satisfactory outcomes do we proceed with gastric bypass surgery.

Is it true that bariatric surgery can also serve as a preventive measure to lower the risk of developing type 2 diabetes?

Yes, bariatric surgery can indeed function as a preventive measure to mitigate the risk of developing type 2 diabetes. Consequently, when an individual is diagnosed with metabolic syndrome but has not yet developed diabetes, it’s recommended to consider gastric bypass surgery. This is particularly relevant when a prediabetic condition is identified, marked by impaired glucose tolerance or the necessity to adhere to a strict diet to maintain appropriate glucose levels. These indicators signal that without intervention, the likelihood of progressing to diabetes is significant. In such cases, the choices are relatively limited: either opt for non-intervention and commit to long-term medication-based treatment or choose a more proactive approach through surgery. Surgery offers the prospect of effectively managing this condition and averting its potential complications in the future. We invite individuals with diabetes who are also dealing with obesity, as well as those diagnosed with metabolic syndrome or prediabetic conditions, to visit the Newman Bariatric Clinic and consult with Prof. Dr Antanas Mickevičius. With over 15 years of experience in the field of bariatric surgery and more than 6,000 procedures performed in Lithuanian and British hospitals, Professor Dr Mickevičius is highly proficient in various globally recognized gastric bypass surgeries, including laparoscopic gastric bypass, laparoscopic sleeve gastrectomy, gastric bikini line sleeve surgery, laparoscopic gastric plication, and revisional bariatric surgery. Additionally, he offers a less invasive obesity treatment method involving the insertion of an intragastric balloon.

At the Newman Bariatric Clinic, the clinic’s team of doctors conducts a comprehensive evaluation of the patient’s health before any gastric bypass surgery. This integrated approach brings together highly qualified specialists from different fields work in one place to better understand and detect all possible health problems: bariatric surgeon Prof. Dr Antanas Mickevičius, nutritionist, endocrinologist, psychologist-psychotherapist, plastic surgeon, massage and sports medicine specialists. Together, they assist patients in preparing for surgery and adapting to the changes that follow.