Diabetes, more commonly known among the public as diabetes mellitus, has been on the rise worldwide over the past few decades. What treatments have you used to treat your diabetes?
Which diabetic patients benefit from this treatment and who are the appropriate candidates?
We treat patients with type-2 diabetes through a surgical method. It is called metabolic surgery. The classic paradigm for treating type-2 diabetes is education on the issue, diet, exercise and the use of medications. Yet, the disease can progress despite all these treatments. Sometimes, despite intensive insulin use, effective results are not achieved. In these cases, metabolic surgery should be considered as an effective treatment alternative.
Is the treatment method different for type-1 and type-2 diabetes?
Of course. Type-1 and type-2 diabetes are completely different diseases. In type 1, there is no insulin production. On the other hand, in type 2, the body produces insulin but cannot use this insulin. We can only help patients with type-2 diabetes. Which means that we enable the body to use the insulin that the body already produces.
Is surgical treatment needed for type-2 diabetes because conventional treatments are not enough?
Type-2 diabetes is a spectrum of heterogeneous and dynamic diseases with multiple factors. It is a process in which not only hormonal but also neurological, psychogenic and environmental factors are also involved. The main solution in classical treatment is diet and exercise. But few people can maintain a lifelong exercise regimen. The percentage of patients who manage to follow an appropriate diet and exercise at the required level does not exceed 5% in any study. And medical treatments fail and are not designed to change the overall progress of the disease, but to regulate blood glucose day-to-day. If we want to combat type-2 diabetes, with its associated organ damage and decline in performance, we must implement more radical but no less rational treatments.
In this context, is metabolic surgery the most radical and rational treatment?
Actually, the most radical and rational treatment would be to regulate the food industry, urban planning and the automobile industry. The problem comes from the food we eat and from modern lifestyles. But at this stage, I don't think anyone, any institution, or even a government, could plan such a drastic change.
We, modern people have failed to get used to our new food industry and to industrial life in the big city. The ingredients of the foods we eat have changed within the last 25 years. People who live in developed cities are used to eating refined, i.e., processed foods. By the time these foods reach the mid-section of the small intestine, they have already become digested in a biochemical sense.
What is left is coarse food, with very little beneficial content. The insulin-resistant hormones are released in the first part of the small intestine, and the insulin-sensitive hormones come from the far part of the intestine.
As the nutrients arriving from the hindgut continue to become poorer in nutritional value, the activity of sensitive hormones decreases. We help the insulin-sensitive hormones to activate more efficiently by modifying the initial and final parts of the small intestine with surgical intervention.
How do prolonged high blood sugar levels impact our body's organs?
Both types of diabetes cause organ damage by damaging the walls of blood vessels. Organ damage differs according to the type of vessels and the site affected. In overweight patients, the medium and large blood vessels are particularly affected, leading to problems such as heart attack or paralysis respectively. In patients with fewer problems associated with excess weight, eye, kidney and leg problems usually occur as a result of the effect on the small and medium-sized blood vessels. But there are always exceptions.
At what stage do you suggest surgery?
In type-2 diabetes, the damage to the medium and large blood vessels starts long before the disease is diagnosed. It is estimated that most patients have a 2–3-year clinical history prior to the diagnosis of diabetes. You only find out about the pre-activation of blood vessel damage at the time of diagnosis. Fortunately, type-2 diabetes generally has little progression. Which means that most complications appear and progress slowly and quietly over years. That's why it's called an "insidious" disease. After researching type-2 diabetic patients for all these years, it is generally accepted that a patient consumes his or her supply of insulin within 10-12 years, and after that period, symptoms of organ damage begin to appear. This is the time when patients usually apply for treatment with us. Many patients are reluctant to have surgery, especially if everything seems fine. So, in brief, in order to help a patient through surgery, they either need to be unable to control their blood sugar levels with medication, or the symptoms of organ damage may have already appeared. Of course, there are many positive benefits of administering treatment before organ loss occurs and before the insulin supply runs out.
You said "if everything looks okay". What do you mean?
Many organisations, such as the World Health Organisation, the American Diabetes Association, the International Diabetes Federation, are working to develop standards for the management of type-2 diabetes. These organisations have set specific targets for the treatment of type-2 diabetes. However, even with the best combinations of treatments, fewer than 50% of patients can reach the required goals.
What are the results of metabolic surgery in this regard?
It is possible to establish disease control in over 90% of patients for at least 10 years.
How is the decision to perform surgery made?
The most important thing is to know for sure that the patient has type-2 diabetes. But this alone is not enough.
The patient must have adequate insulin stores and sufficient organ function and activity. Also, resistant hormones produced by adipose tissue must be positive, and materials that cause damage to insulin-producing cells must be within normal limits.
Certainly, the most important thing to consider when deciding on surgery is that the patient must be unable to take control of blood sugar or other symptoms of metabolic disorders by other means.
What are the other components of metabolic syndrome?
High blood pressure, overweight, high cholesterol and other fats in the blood.
What is this method of treatment called and what is this surgical intervention?
The method is called "ileal interposition." This operation is a procedure that involves the stomach, duodenum and small intestine. The left upper outer part of the stomach is removed, the connection between the stomach and duodenum is closed, which slightly changes the orientation of the stomach, and the terminal part of the small intestine is replaced with part of the initial part.
How many patients have you cured so far with this method?
In our clinic I have cured about 1400 patients using the ileal interposition method. The results show that over 90% of patients can regain control of their blood sugar without the help of additional medication or insulin.
Do the problems of diabetic patients disappear in the postoperative period? Does the use of medication and insulin permanently end? If so, is this period temporary?
It is insulin reserves and organ functionality that determine how much benefit a patient with type-2 diabetes will have. The greater the insulin reserves and the higher the organ activity, the greater the success that can be expected. But the most important thing that should not be forgotten is that diabetes has hormonal, neurological and psychogenic structures. This surgery only treats the hormonal part of diabetes. To explain more briefly: when the patient whom we have provided hormonal control feels distress for any reason, or happiness, or anger, then there will be a fluctuation in the blood sugar level. Actually, this kind of fluctuation can also be seen in patients without diabetes, of course. However, the duration and severity of this fluctuation that is seen in patients without diabetes is less. This fluctuation persists in a mild form after surgery, but normalizes more quickly than before. Type-2 diabetes is a dynamic disease with different progression over time. Important criteria are mean blood sugar levels and the state of organ damage 3 months after surgery.
Is the production of insulin by the pancreas sufficient to feed without a special diet without postoperative treatment or should the treated patient continue the diet for life?
The effectiveness of the surgery decreases 10 years after it was performed. This is because two natural processes are involved. The first is: we age. When we age our muscle mass and muscle activity decrease.
The second process is that our metabolism slows down. This operation reduces the rate of insulin consumption in the body. However, the function of our insulin stores will decrease year after year. What needs to be emphasized here is the reduction in the rate of insulin consumption in the body after the operation. In this way, the body uses the insulin stores more economically. There is no specific diet to follow after these surgeries.
In fact, if the patient is going to make the effort to follow a specialized diet, why would he or she undergo surgery (remember that only 5% of people manage to maintain such a long-term diet)? But there are several important dietary changes after surgery. We can express them as follows:
Patients who have undergone surgery don't feel as hungry. Their food choices and their approach to food changes.
They eat more modest portions, and these portions make the patient feel full for longer.
Patients physically cannot eat as much as they used to, even if they want to. But the truth is they don't want to eat so much food.
How is this surgery performed? What is the immediate postoperative period like?
This surgery is done laparoscopically (not open surgery). In other words, it is not a long abdominal incision procedure: it is done through small access incisions.
The biggest disadvantage of the operation is that it is very difficult to perform from a technical point of view and requires very serious training and technical skills.
A few hours after the operation, patients start drinking water. After the patient has spent 3 or 4 days on a liquid diet it is possible to slowly start eating soft vegetable foods.
After about 6 months, patients can eat whatever they want.
Are there any side effects to this healing method? If yes, what are they?
We must divide the question into two parts – complications that occur in the early postoperative period and complications that occur in the later years. There are specific rates for complications for each type of surgery and this rate is about 10% for upper digestive tract surgeries. This percentage also applies to our surgery. Some of these complications are bleeding, infection, leakage and problems related to anaesthesia. The complication rate among my patients is 6%. It is lower than the published rates.
There are two potential problems that may loom in the long term. One is herniation. A hernia can develop at the incision lines or an internal hernia. The rate of this complication is 1%. The other potential problem is the risk of developing stones or sludge in the gallbladder. The rate of this complication is 12%. It can be reduced to 5% with prophylactic medication. But if I notice any oedema or adhesions with my current administration, I remove the gallbladder and thus eliminate the risk.
What are the differences and advantages/disadvantages compared to the treatment modalities that are administered to obese patients?
In general, the primary goal of surgery for obesity is to achieve weight control. Sugar control is an incidental outcome of these surgeries. In fact, you can take significant control of blood sugar levels with weight loss in a patient who suffers from obesity-related problems. On the other hand, the situation is very different and more difficult in patients who are not on the verge of obesity. While the main problem in obese patients is insulin resistance associated with excess fat tissue, resistance hormones originating in tissues from the pancreas, small intestine and liver are the main cause of the problem in patients who do not have serious obesity problems. In such cases, blood sugar control cannot be achieved with weight loss alone. For these patients, a more complex operation with more than one hormonal target must be performed. The only surgery that can provide all this is ileal interposition. In addition, the patient must take vitamin and mineral supplements for the rest of their life after the anti-obesity surgery. However, after ileal interposition surgery, patients do not need to take vitamin and mineral supplements after one year. They live a completely free life.
How long does it take for your patients to return to their normal routine after this surgery?
The first 3 to 4 weeks after surgery are a period of adaptation to the changes. During this period, the body tries to get used to its new metabolism. Fluctuations in blood sugar and blood pressure levels happen. During this period the patient may feel tired and irritable. What needs to be stressed most here is that the recovery period after surgery develops very individually in diabetics. There are two factors that determine recovery after surgery. Male patients compared to female patients, young patients compared to elderly, demonstrate rapid improvements. Certainly, the length of time the patient has had diabetes, how the disease developed, the presence of organ damage and its severity are very important factors in the recovery period.
Basically, the body gets used to its new metabolism after 3 to 4 weeks and the patient starts to feel better. About 2 to 2 and a half months after the surgery, the patient will have started a new life. Energy levels and daily activities gradually increase and sleep becomes regular.
The patient wakes up rested and fresh in the morning. Life after this period seems like a miracle. We recommend that during this period the patient should not allow himself to get hungry or thirsty, he should take extra medication and vitamins and daily walks of 15-20 minutes would be beneficial. The need for medications and vitamins gradually decreases and the majority of our patients stop taking these supplements within 6 months of surgery. In addition, we implement a daily, weekly and monthly follow-up program.
Are there any lasting problems for patients when they return to their daily routine? If there are, what are they?
Patients must get used to new eating habits after surgery. They have to live with more modest portions and eat more often. This is the recommendation that every diabetic has heard from every doctor, however this condition develops spontaneously after surgery. But patients take time to get used to this new eating behaviour. During the first 3 to 4 months of the adaptation period, patients may have symptoms similar to diarrhoea. These symptoms are temporary and will not be a problem for long as the patient's condition is monitored and appropriate treatment is administered.
Where did this operation begin and how long has it been practiced?
Brazil is where this operation originated. The Brazilian surgeon Aureo De Paula introduced this application to the world medical literature. It has been performed since 1999.
In which other countries is this method of treatment applied? What are the results in these countries?
This application is practiced by 8 surgeons in 6 countries worldwide. The overall results show that control is achieved in over 90% of the components of metabolic syndrome.
Do you share information with your colleagues who apply this treatment method?
There is an organization called GASRD (Global Association for Surgical Treatment and Research on Diabetes). We share data within this organisation. In addition, we attend and make presentations at the international meetings of many medical organizations that are held once and twice a year.
In recent years, the prevalence of diabetes has increased in our country and in the European Union. Research shows that the percentage of patients with diabetes has risen by 15%. As far as we understand, the method you are applying is a long-term and effective treatment for type-2 diabetes.
Are there any meetings or conferences where this treatment method is discussed with your European colleagues and explained to a wider audience? If they are to be held, where and when will they be?
I attend meetings and organisations at home and abroad almost every month and explain this treatment method. In the last two years I have attended meetings in Japan, India (Hyderabad and New Delhi), Singapore, Germany (Hamburg and Frankfurt), Spain (Malaga and Barcelona) and 6 meetings in Turkey. I have given presentations and delivered speeches. I have started to write a book on the subject, train new surgeons and organize about 15 websites. I am dedicated to this and will continue to explain this process and its benefits as long as I live.