No more shots? Surgery keeps diabetes in check

[rajman]

Times Of India, Nov. 14, 2012

MUMBAI: When 43-year-old Shankar Nair landed in Mumbai, he was tired of diabetes. The sugar-imbalance disease had cost him his vision and, by extension, his well-paying job in Saudi Arabia. He had a stent in his heart and his kidneys were failing. The Thiruvananthapuram native was in Mumbai for a drastic step: Enroll for a clinical trial in which doctors would cut his stomach and rearrange his small intestine in such a manner that his diabetes would come under control.

Today, four years later, Nair still cannot see and his kidneys still pose a problem. "But I don't need insulin anymore," says Nair whose sugar used to hover between 200 and 300 units before surgery.

Surgery is still far from being hailed as a cure for diabetes, but Indian doctors are reporting remission of more than five years in patients who struggled with severe diabetes. No more irritating insulin shots or multiple pills to swallow. "Basically, surgeons are able to achieve remission in a disease that seemed unstoppable earlier even with oral medicines," says surgeon Ramen Goel, who operated on Nair.

In Pune, 21-year-old Rujuta Durape smilingly talks about being the youngest Asian to have undergone a surgery to control her diabetes. "I was 17 years old and 75kg when I underwent a gastric bypass surgery," she says. Her father, a chronic diabetic patient, would often cry for "gifting diabetes" to his daughter. "The minute he heard that a surgery could control diabetes, he enrolled me for it," says Rujuta, who now weighs 48kg and has started working for a call centre.

Last week, results of city surgeon Muffazal Lakdwala's five-year-long study were published in medical journal, Surgery for Obesity and Related Diseases. "This is among the longest-running studies in the world. It proves beyond doubt that diabetes can be controlled for five years and more with a gastric bypass surgery (see 'What is Type 2 diabetes') in patients who have a body mass index (BMI) of 30-35," said Dr Lakdawala. However, doctors agree that the surgery cannot be an option for all patients.

Considering that India is home to more than 60 million diabetic patients, the disease generates a lot of interest—both from the masses and the pharmaceutical industry. The surgical option, which presents an opportunity for medical devices companies, is also being intensely studied. It is now believed that surgery leads to production of certain enzymes in the digestive system that help balance blood sugar.

Not surprising then that doctors in India believe 2012 is a game-changing year for diabetes when surgery stopped being an experimental option. In March 2012, the New England Journal of Medicine published a study showing that surgery in a certain group of diabetic patients helped them better than medicines. "Previously, people would talk about undergoing weight-loss surgery to control diabetes. But now most people come in seeking diabetes control," says Dr Lakdawala.

In fact, a new term 'diabetes remission' entered the medical lexicon only recently. "A couple of years back, the American Diabetes Association defined diabetes remission for the first time after seeing the results of surgery. It is a phase of more than five years without medication," says Dr Shashank Shah, who operated on Rujuta and 900 other diabetic patients over the last eight years. He has started on a 100-patient clinical trial in which he will operate on diabetic patients with a BMI of less than 30. "In 2014 when our trial ends, we will be able to talk more authoritatively about this treatment."

His first patient, Salma Sheikh (name changed) weighed 80kg and was 30 years old when he operated on her. "I now weigh 64kg and have had two deliveries thereafter. Best of all, I have no medication," she says.

Doctors agree that it's too early to embrace surgery as the best option for diabetes. "We cannot say how the patient's body will react a decade or two decades after surgery," admits Mumbai-based surgeon Ramen Goel. But, he says, it earns patients a break from the harmful effects of diabetes. "It means that their eyes, kidneys, hearts and nervous system have more time without suffering the side-effects of the disease," he says, adding that patients may have better options in the near future.

Medical experts who were wary of the surgical option are now not so sceptical. Delhi-based endocrinologist Anoop Misra says, "There are good points and bad points of surgery. At present, we say people with a BMI of up to 30 can undergo the surgery. Five years back, it was only offered to people with a BMI of over 35. It is still not the norm, but it is certainly helping some patients."