Diabetes Surgery

Q: "I heard about a type of bariatric surgery being done in Brazil called ileal transposition surgery that may cure Type 2 diabetes. As I understand it, it involves moving the part of the small intestine called the ileum from the far end of the intestine to the near end, right next to the stomach. Can you comment on the success rate of this surgery and whether it might become available in the United States?"

A: Actually, this surgery is already being done in the United States. About two years ago, surgeons at the University of Texas in Houston began developing a trial to pilot this operation, and the first patient had the surgery done in March 2012. Since that time, three other patients have undergone the sleeve gastrectomy with ileal transposition (SGIT) surgery, as it is known.

All the patients who underwent this surgery lived with diabetes for five or more years, and all had a glycosylated hemoglobin (HgA1c), a measure of how much sugar is in the blood, greater than 7.5% (normal is < 6%) despite being on insulin and at least two oral medications to treat their diabetes.

Dr. Snyder and his team offered these patients the opportunity to have this operation under strict inclusion and exclusion criteria and under the scrutiny of an internal review board and data safety monitoring board. That is, he did it "by the book" to make sure the science was right and safe. All four patients had the operation successfully and without any major complications. All the surgeries were done laparoscopically, and the average hospital stay was about 3 days.

The patients were followed up at one month intervals for three consecutive months, and then every three months after that. The results were wonderful. The average HgA1c dropped 1.8%. This was a big deal because even with aggressive medication management, a drop of only 1% is extremely hard to accomplish. Seeing a drop this big in such a small amount of time was exciting for the patients and the physicians involved.

What was also very interesting was the way the patients now responded to meals. Most patients with type II diabetes have high sugar without eating anything. We call this the fasting glucose level. After eating, their blood sugars may go really high in response to the sugar they ate. For people without type II diabetes, out gut responds to food by producing a hormone called glucagon-like peptide-1 (GLP-1) and this causes us control the glucose level in their blood. Type II diabetics are missing this response completely. We call this enteroinsular impairment. After the surgery, the patient’s fasting glucoses fell from an average of 123 mg/dl to 114 mg/dl and postprandial glucose from 189 mg/dl to 113 mg/dl, suggesting a new founded and appropriate response to oral glucose load. In addition, the GLP-1 response to oral glucose increased from 0.02 to 0.06 pmol/ml. This suggested that the enteroinsular axis was being restored to normal.

By three months, three out of the four patients were off all their diabetic medications.

Our experience suggests that the SGIT has a tremendous potential to assist in controlling long standing, refractory diabetes, and so far we have seen a trend toward substantial improvement in glycemic control.