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BARIATRIC THE CURE FOR DIABETES
METABOLIC AND ITS COMPLICATIONS
INSTITUTE

“Be The Change, Feel The Change”

DIABETES OTHER COMPLICATIONS
HOW BIG IS THE PROBLEM ?
Heart Disease
AS OF 2011 6th
Blindness
25.8 Million Leading Killer in
the India Amputation
Diabetics in the India ALL OF THIS COULD BE PREVENTED
231,404
BY 2050 84 % OF DIABETES PATIENT ARE
Deaths Linked to AT RISK OF COMPLICATIONS
165 % Diabetes in 2017
WHAT IF THERE WAS A WAY TO
Projected Growth Rate CURE DIABETES ?
in Diagnosed Diabetics

IN 1 YEAR

1.9 Million
New Case Diagnosed

EVERY MINUTE

4 People

Are Diagnosed Diabetic

“METABOLIC SURGERY IS THE ONLY OPTION AS CURE FOR INSULIN RESISTANCE ”

Copyright @ drtapanshah Reg. No. L - 29988/2016, Diary No. 275/2016-CO/L

Whats is Metabolic Whats is Metabolic
Syndrome ? Suygery ?

Metabolic Syndrone is clustering of at Metabolic surgery is approved as a
Least three of five of the following treatment method in individuals who
are obese (i.e. Body mass index/BMI >
medical condi ons : Abdominal ( Central) 27 kg/m2) Associated with a metabolic
obesity. elevated blood pressure disorder. especially if the condi on is
not well controled on medical treatment
elevated fas ng plasma glucose, high or impending to health complica on like
serum triglycerides, and low high- cardio-metabolic or bio-mechanical
dens ty lipoprotein (HDL) levels.
disorders.

11 10
Parient
Assistance Recommendation

03 09
Insulin
Sensitivity Inferences

at Risk 08

04 FourCardinal
Questions
Hypothesis
for Metabolic

Surgery

INSIUNSLUINLINSSEENNSSITIIVTIITVYITY
AATT RRIISSKK

Diabetes 2 is an
imbalance between

insulin sensitivity &
insulin resistance.

Two incontrovertible conclusions can be derived, and several areas can be
identied as requiring clarication. First, Surgically induced direct delivery of
nutrients to the small intestine will increase the GLP-1 response to a meal and
enhance the insulin response. Second induction of sudden negative calorie
balance by any means in type 2 diabetes normalises plasma glucose levels within
day, and this is the predominant mechanism underlying the early metabolic
changes after bariatric surgery.
The reversal is induced by modication in brain glucose metabolism, neuro-
endocrine factors, changes in ora of small bowel, early exposure of meals and
delayed bile acid activation. This induces what is called UNIQUE SURGICAL
STARVATION, that initially induce stimulation of gluconeogenessis from protien but
immediately leads to lipolysis and gylcerol production from adipose deposition.

HYPOTHESIS FOR
METABOLIC SURGERY

Physio-Surgical Starvation Neuro endocrine Changes

Physiological starvation brings long Intestinal Gluconeogenesis may be
standing starvation without any regarded as a key signal to the brain
nutritional decit. It brings early responsible for the control of glucose

Gluconeogenesis and after 24 hours leads and energy homeostasis.
to massive mobilization of stored fat
Bile Flow Alteration
in visceral organs. Hence reversing the
insulin resistance.

Biooral Changes

Prediabetic and Metabolic syndrome Patients BA may inhibit gluconeogenesis
have altered biooral in form of fermitides. On facilitate insulin-dependent control of
glucose metabolism in Liver, and through
diversion, there is re-establishment of increase in FGF19 levels improve insulin
enterobacteriae.
resistance.

In normal patients, after meals Endogenous Insulin releases for glucose entry in the cell. But
the excess glucose is stored in glycogen and later in adipose tissue with the help of Insulin.
This Fat deposition on Insulin receptors leads to Insulin resistance, ultimately to that body
responds with producing higher amount of Insulin. This insulin (anabolic hormone) would
keep storing excess glucose to fat. Hence the insulin resistance would perpetuate, nally
leading to insulin exhaustion leading to diabetes mellitus type 2. This is a vicious self-
compounding circle that needs intervention.

Therefore, in order to control the amount of insulin released, one needs to control the glucose entering the
system, which stimulates insulin release. A long fast should stop most glucose concentration increases in
the blood, as well as most insulin release from the pancreas.

Surgical Physiological Starvation

Mobilization of adipose deposition
and reduction of fatty acid hence
increase in insulin sensitivity.

Early Phase

Gluconeogenesis of protein within
rst 24 hours later leads to persistent
lipolysis hence improvement of
insulin sensitivity

HINDGUT HYPOTHESIS The hindgut hypothesis
suggests that the
FOREGUT HYPOTHESIS expedited delivery of
nutrients to the distal
In Contrast, the foregut ileum (as a result of the
hypothesis suggests that shortened length of the
the exclusion of the small bowel) improves
proximal bowel (as a glycemia through the
consequence of GI enhanced secretion of
rearrangement) prevents gut peptides such as
the secretion of an GLP-1, which augments
unidentied “putative glucose- dependent
signal” that promotes insulin secretion
insulin resistance and
type 2 diabetes

BIOFLORAL FACTOR

Bacteria ora induces insulin 58 obese ob1
resistance 88 ob2

The average human body, consisting of about ten trillion 80 ob3
cells, has about ten times that number of microorganisms
in the gut.[32][33][34][35] The metabolic activity performed 74 gb3
by these bacteria is equal to that of a virtual organ, leading 100
to gut bacteria being termed a ‘forgotten” organ.[36] gb1
Gastric bypass surgery (GBP) strongly altered gut microbiota 73 gastric-bypass
and resulted in a large increase in Gammaproteobacteria 100
(a member of family enterobacteriaceae), a proportional gb2
decrease in rmicutes and a loss of metha nogens. 0.1
nw1
BILE ACID FACTOR normal weight

Ileal interposition nw2

- produced in intestinal L cells nw3
- secr. in resp. to calorie intake
- inhib. GI motility & secr. pancr/int. - Plasma GLP-1
- produces satiety & dism. intake - Plasma PYY
- low PPY production in obese indiv. - Plasma bile acids
- Plasma glucose
Ahima & Carr, Gastroenterology 2010 - Glucose tolerance
Cummings et al, Gastroenterology 2010 - Glucose-stimulated insulin secretion
- Pancreatic B-cell mass
- Plasma triglycerides
- Adipocyte size
- Ectopic fat in muscle and liver

“FOUR CARDINAL
QUESTIONS”

??

BLOOD
GLUCOSE

ENDO EXO THE
INSULIN INSULIN
ROOTCAUSE
Does Exogenous Insulin
perpetuate more Insulin INSULIN
RESISTANCE
resistance?
Does our treatment
? ignore Insulin
Resistance?

?

Eyes

IR Kidney
DM2
NORMAL

Heart

Legs

Will medica on ever bring Will risk of diabetes
remission or reduc on in complica on reduce in
euglycemic DM pa ent?
dose ?

INFERENCE

Metabolic surgery provides only option for remission of insulin
resistance and ultimately provides better health and quality life.

LANCET 2015 / STAMPADE 2015

REMISSION METABOLIC IMPROVEMENT

INTERNATIONAL

RECOMENDATIONS

International Metabolic surgery is an appropriate treatment for people with type 2
Diabetes diabetes and obesity not achieving recommended treatment targets with
Federation medical therapies, especially when there are other major co-morbidi es.
Surgery should be an accepted op on in people who have type 2 diabetes
and a BMI between 30 and 35 when diabetes cannot be adequately
controlled by op mal medical regimen. Especially in the presence of other
major cardiovascular disease risk factor. In Asian and some other ethnici es
of increased risk, BMI ac on points may be reduced by 2.5kg/m2. Available
evidence indicates that Metabolic surgery for obese pa ents with type 2
diabetes is cost-effec ve.

According to many RCT, there is 80% remission in diabetes type 2 achieved
presistently for 10 years post metabolic surgery. Even if you do not have
complete remission, Metabolic surgery can offer major improved in glucose
control, in addi on to weight loss. The long-term benefit of improve glucose
control may be the reduc on of diabetes complica ons. Few people who do
not experience remission of diabetes following bariatric surgery s ll may be
able to reduce blood glucose medica ons. Medical and suppor ve care a er
surgery is very important to reduce the risk of nutri onal deficiencies and
weight regain.

Grade A, BEL 1 for BMI>35kg/m2 and therapeu c target of weight control
and improved biochemical markers of cardiovascular disease(CVD)risk.
Grade B, BEL 2 for BMI>30kg/m2 and therapeu c target of weight control
and improved biochemical markers of CVD risk. Grade C, BEL 3 for
BMI<30kg/m2 and therapeu c target of glycemic control in T2D and
improved biochemical markers if CVD risk.

Considera ons should be given to extending the benefits of Metabolic
surgery to pa ents with class I obesity(BMI 30kg/m^2^), who have a
condi on that can be cured or markedly improved by substan al and
sustained weight loss; this extension requires more data and long term risk-
to-benefits analysis. Because Metabolic surgery can be cost-effec ve in less
than 4 years, in comparison with non opera ve management, cri cal
examina on of the cost-to-benefit ra o of Metabolic surgery is indicated.

RX We have an assistant team of Nutritionist, Metabolic Counsellor, Patient
Educator, Assistant Doctor, Team of Surgeons, Team of Anesthesiologist &
PATIENT Intensivist, Critical care Nurses and Physiotherapist. These individual
ASSISTANCE experts are trained and having long experience in their respective eld. All
the members are very proactive, polite and warm, they are always ready to
help with a single moto of making your health recovery smooth.

Our Dedication and honesty is a distinct feature that stands out
from many of our competitors. We provide you a true family experience
with truthful advices, transparency in communication and patience to hear
your troubles and queries.

We also stand by you as a family member till you are completely
recovered and not just during your hospital stay. We try to give you an
experience where in you can sense our core values of quality, dedication
and humanity for our patient.

MEDICAL / SURGICAL ASSESSMENT &
CONSULTATION DIAGNOSIS

BEHAVIOR &
NUTRITION

COUNSELLOR HOLISTIC BIOMECHANIC &
APPROACH EXERCISES
DIAGNOSTIC
EVALUATION CARDIO PULMONARY
EVALUATION

GASTROENTEROLOGY
EVALUATION

AHMEDABAD I VADODARA I ANAND I SURAT

Dr. Tapan Shah

G.I & Metabolic Surgeon
Ph : 9925033348
Email : [email protected]
www.drtapan.com
www.facebook.com/liversurgeon