Metabolic surgery could help achieve remission of type-2 diabetes in a selected few patients, and better blood sugar control in many when the disease remains uncontrolled despite appropriate medical treatment, a senior AIIMS doctor said.

Dr Manjunath Maruti, professor in the Department of Surgery said the procedure should not be viewed as a treatment for every person with diabetes, but as one of the evidence-based options for patients whose blood sugar remains uncontrolled despite medicines and lifestyle changes.

"For some patients medication and lifestyle modification will be sufficient. For others, despite appropriate medical therapy, diabetes would remain uncontrolled. In these patients, metabolic surgery may provide an opportunity to achieve remission, and in some, much better glycaemic control" Dr Manjunath said.

According to the protocol followed by his unit, metabolic surgery may be considered when a patient's HbA1c, a measure of average blood sugar, remains above 7.5 per cent despite treatment with more than three oral anti-diabetic medicines, with or without a GLP-1 receptor agonist or insulin.

The patient should also have been living with type-2 diabetes for at least two years.

Surgery may also be considered when a patient has been advised or started on insulin because medicines are no longer sufficient to control blood sugar, he said.

Another important indication is the presence of early diabetes-related organ damage, irrespective of the HbA1c level, Dr Manjunath said.

This could include protein or albumin in the urine, suggesting early kidney damage; pain in the legs while walking due to reduced blood flow; heart related chest pain or a history of angioplasty or stent placement indicating heart disease; a transient ischemic attack or stroke; or reduced vision caused by diabetic eye disease.

"In simple terms, uncontrolled diabetes means diabetes that remains inadequately controlled despite more than three medicines, or when insulin was started, or when diabetes has already started causing damage to important organs," he said.

Dr Manjunath said the upfront cost of metabolic surgery need to be weighed against the substantial long-term health and economic burden of uncontrolled diabetes.

Over time, diabetes can cause complications such as kidney failure requiring dialysis or transplantation, heart disease requiring procedures or bypass surgery, diabetic retinopathy requiring laser treatment, peripheral vascular disease that may require surgery or, in severe cases, amputation, and stroke requiring prolonged hospitalisation.

"No treatment can guarantee that these complications will never occur. But sustained improvement in metabolic health following metabolic surgery has the potential to reduce the long-term burden of diabetes and its complications," he said.

The decision, he said, should therefore take into account not only the immediate cost and risks of surgery but also the possible long-term consequences of living with uncontrolled diabetes.

Dr Manjunath stressed that prevention should remain the starting point in tackling diabetes, with healthier food choices, regular physical activity, adequate sleep and early identification of metabolic disease.

Patients who develop diabetes should have timely access to effective medical treatment, while those whose disease remains uncontrolled despite appropriate therapy should be assessed by a multidisciplinary diabetes and metabolic surgery team, he said.

For appropriately selected patients, metabolic surgery can form part of the modern treatment approach, provided it is carried out by an experienced team at a dedicated centre with structured follow-up, he added.

Dr Manjunath said his unit's experience of treating 67 patients with uncontrolled type-2 diabetes, including 18 patients with a body mass index (BMI) of 23-35 kg/m2 and 15-25 years of diabetes, highlights the potential role of metabolic surgery in such patients.

However, long-term prospective follow-up would be important to determine how durable diabetes remission and metabolic improvements are after surgery, he said.

"Do not wait for diabetes to damage the organs before you intensify treatment," Dr Manjunath said.

"Metabolic surgery is not for everyone but for the right patient, at the right time, it can be transformative."

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