Ileal transposition is a surgical procedure which was developed by a Brazilian surgeon, Dr Aureo-de Paula and is expected work towards controlling level of blood sugar in select patients suffering from type 2 diabetes mellitus. The surgery helps control the level of blood sugar within six months. The basic philosophy of the procedure is that it increases the secretion of the gastro intestinal hormone, GLP-1 which results in increase secretion of insulin and stimulates of the Beta cells of the pancreas (i.e. the cells that produce insulin).
The increased secretion of the gastrointestinal hormone is attributed to the early contact of undigested food with the transposed ileal segment of the intestine. This simple procedure of transposition has been proven effective as type 2 diabetes treatment strategy. Several American patients are reviewing the options of metabolic surgery abroad, considering the low cost of bariatric surgery and ileal transposition surgery for diabetes type 2 treatment.
Why ileal transposition for management of Diabetes II?
Type II Diabetes accounts to 80% to 90% of all cases of diabetes mellitus and is a rapidly growing epidemic across the world. Diabetes type II occurs when the pancreas fails to produce adequate quantity of insulin to regulate the level of sugar in the blood or the metabolic cells of the body fail to identify insulin and utilize it appropriately.
Though, considerable amount of research is underway to identify the most effective treatment and cure for diabetes, most of the efforts have failed to yield results. Most patients are treated with conventional therapeutic modalities, which are just palliative in controlling diabetes but fail to achieve a complete cure.
However, recent advances in surgical science and treatment have proven that surgery is the best and the most effective for management of diabetes type II, especially among non-obese patients. Evidence suggests that ileal transposition surgery changes the patterns of gastro intestinal hormones secretions and clinical evidence has been suggestive of glycemic control in type 2 diabetes patients within a few days after the surgery.
In recent years increasing number of physicians and surgeons are considering metabolic surgery as appropriate option for normal weight diabetic individuals. Many surgeons are considering the option of metabolic surgery as the key to manage the twin epidemic of diabetes and obesity.
Patient selection for ileal transposition surgery for diabetes type II
One of the most essential and crucial part of surgical for management of diabetes, is the appropriate selection of the patient. The patient has to undergo a battery of tests and various investigations to ensure that he/she is fit for the surgery.
- The surgery is the preferably conducted on thin or normal weight diabetic patients who have been suffering from diabetes type II for over three years and which has not responded well to medications and life style changes and the condition is progressively worsening. The patient should be ideally less than 65 years of age.
- Surgery is best suited for patients with uncontrolled sugar levels despite all treatment plans, progressive disease with steady deterioration over time, high genetic predisposition, with other members of the family affected. Patients with impending danger of complications to other organs (kidney, eyes or heart) as the best candidates for the surgery.
- As a part of the preliminary assessment the patient has to undertake basic investigations like blood sugar (fasting and post prandial), HbA1c and serum insulin.
- This is followed by a complete physical examination of the patient to assess the fitness of the patient for anesthesia during the surgery. A series of required investigations are requested for which include complete blood count, lipid profile, liver function tests, Kidney function tests, Lung function and X ray of the chest, electrocardiogram, ultrasound of the whole abdomen, etc. In addition a ophthalmic examination and dental examination are essential prior to the surgery, to assess the extent of complications associated with diabetes and reduce possibility of post operative infections.
- The patient is admitted two to three days prior to the scheduled surgery. During hospitalization the patient is kept on a strictly liquid diet.
The procedure of ileal transposition
- It is a major surgical intervention, which is conducted under general anesthesia. The procedure on an average takes about four to six hours.
- The procedure is conducted laproscopically, with small surgical incisions ranging between 5 mm to 12 mm, made on the abdomen
- In the procedure the last part of the small intestine (i.e. ileum) is brought up close to the stomach. A segment of last part of small intestine (ileum) is, dissected and interposed into the 2nd part of small intestine (i.e. jejunum) beyond the stomach. Hence after the interposition, the terminal part of the ileum is midway between the jejunum and the proximal part of the ileum is connected to the large intestine. No part of the intestine is removed and the length of the intestine is maintained. This allows normal access for any future endoscopic vision, if required.
- It is worthwhile to note that the intestinal length is maintained and the food is not diverted (i.e. no bypass is created). This doesn’t affect the overall nutritional status of the patient and has practically no long term side effects.
Post operative care and diet after ileal transposition for diabetes type 2
- The post-operative hospitalization stay may last for four to five days.
- The patient is allowed to ingest water about six hours after the procedure, while other liquids are allowed about two days after the surgery. Semi solid food is allowed about eight days after the procedure
- On an average, the patient can return to routine work about ten to fourteen days after the surgery.
- For the first couple of days after the procedure the patient would require to be on liquid diet, which is followed by a soft diet for the next couple of days. Subsequently a strong diabetic diet is recommended
- Ideal dietary measures include taking small quantities of food. The food has to be consumed at an interval of three to four hours.
- For ensuring greater effectiveness of the results, the patient is suggested to limit the consumption of carbohydrates and consume slow digesting carbohydrates like fruits, vegetables and whole grains. In addition the patient should increase the intake of lead proteins and should consume modest amount of unsaturated fat form natural sources like pecans, walnuts, olive oil, almonds, etc.
- Physical exercise is essential part of ensuring that the body metabolism and level of blood sugar is controlled. It is recommended that the patient start with long walks after abouat two weeks of the surgery, which is followed by aerobic activities and weight training a month after the surgery. Abdominal exercises are recommended a after three to four months.
Additional information about Ileal transposition surgery for diabetes type II
- The complications would be very similar to any major surgical procedure and would include surgical site infections, hematomas, gastro intestinal problems like nausea, vomiting, etc. In addition bleeding or leakage from the internal organs is a rare possibility. Another complication, which is reported less frequently, includes internal intestinal herniation.
- The surgery is only for effective management of patients’ suffering from Type -2 diabetes. In type-2 diabetes, the pancreas has a few B-cells which produce some amount of insulin, which is essential for the success of the operation. On the other hand, in Type-1 diabetes, all the B cells on the pancreas are completely destroyed (due to some autoimmune response or trauma), and no insulin is produced. The procedure attempts to manipulate the gastro intestinal structure to promote physiological stimulation of the pancreas B cells, and increase the secretion of insulin on eating food.
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