Ileal Interposition with BMI-adjusted Sleeve Gastrectomy
Ileum is the 3rd & last part of the small intestine. Ileal interposition therefore, is a transplant of a segment of the ileum, to the beginning of the small intestine ( after the stomach), or to the beginning of the 2nd part of small intestine, in jejunal portion. The upper (duodenum & jejunum) & lower parts of small intestine (ileum), secrete different hormones. The initial part secretes those hormones that are insulin resistant. These include ghrelin, GIP and glucagon. The final part of the ileum, on the other hand excretes those hormones that are sensitive to insulin. An example for this kind of hormone is GLP-1. The main objective of this surgery is to increase the amount of insulin sensitive hormones and to reduce the amount of insulin resistant hormones.
In Ileal interposition, a part of the ileum is displaced surgically. In addition to this, the upper portion of the stomach is also removed. This is done so that the effect of the interposition is very well pronounced. By the removal of upper stomach portion, the amount of ghrelin is decreased. This hormone has 2 primary functions:
- The hormone sends impulses to the brain so as to create the sensation of hunger.
- The hormone is also associated with intra-cellular insulin resistance.
There is also yet another reason having the stomach portion removed. If it is not done, gastric dilatation shall happen. Accompanying this, other conditions like vomiting, nausea etc shall also result.
By this surgery, the amount of ghrelin that is secreted is significantly reduced. Thus, the excessive secretion of this hormone during type 2 diabetes is compensated. Also, the patient shall feel only less sensation of hunger even after very little consumption.
It can be concluded that the purpose of this surgery is not entirely to minimize the stomach area.
Bariatric surgeries have become advantageous in not only controlling obesity, but also in controlling other conditions like hypertension, diabetes etc. Ileal interposition combining sleeve gastrectomy is a metabolic surgery that can also lead to weight loss.
This is a very prominent surgical method for the management of diabetes mellitus type 2. In this laparoscopic procedure, the area that produces ghrelin is excised. Since ghrelin acts against insulin, any decrease in the amount of ghrelin can lead to increase in the amount of insulin. By this procedure, a portion of ileum is surgically cut and placed very close to the stomach. GLP-1, the substance secreted by the ileum, increases the insulin secretion. Therefore, the dependency of insulin injections can be significantly reduced through this surgery and in most patients can be completely stopped.
In addition, the food can reach the ileum in a very short span of time. Therefore, the undigested food enters the ileum fast and this action accelerates the production of GLP-1. GLP-1 further stimulates the insulin producing beta cells of the pancreas.
Procedure: General anesthesia is administered for the operation. At first an ileal segment of 170cm is created beginning at a distance of 30cm from the ileo-cecal junction. Interposition of this segment with duodenum or jejunum is then performed. For performing this, the duodenum or jejunum is divided. The 3 anastomoses (connection between the intestinal segments ) are also performed using staplers. In order to prevent internal herniation, the mesenteric gaps are closed using polypropylene sutures.
Jejunal Ileal Interposition
In this surgery, the jejunum is sectioned almost 50 cm distal to the duodenojejunal junction by employing a linear stapler. The jejunal ends are interposed with the proximal and distal ends of the ileal segment. This is performed at the site of jejuna division. Closure of the mesenteric gaps is then performed. As the fundus of the stomach is also removed, the secretion of ghrelin is significantly reduced. Although the entire surgical procedure is complex and time consuming, the result obtained is long lasting.
Duodenal Ileal Interposition
The surgical procedure is similar to the jejunoileal interposition. Analogous to the former surgery, here the duodenum is divided and then this portion is then interpositioned with the distal and proximal ends of the ileal segment. This is performed in the duodenojejunal junction.
Advantage of Ileal interposition surgery.
There are a number of advantages for this procedure. Some of the advantages are as follows:
- The surgery does not cause any malabsorption.
- The surgery can reduce the intake of calories.
- Loss of ghrelin can be brought out by this surgery.
- The surgery also leads to lower fluctuations of plasma glucose.
In addition, this surgery also includes the advantages of bariatric surgeries. These include:
- Reduction in the level of cholesterol & triglycerides, high blood pressure, sleep apnea, liver problems etc.
- Reduction / reversal of protein leakage and damage of kidneys, or the risk of cardiovascular problems, of early damage of nerves or retina of eyes.
Even with good medical treatment, diabetes goes on progressing.
* Complications of Diabetes are major- kidneys, eyes, nerves , heart, brain.
** Surgery can control diabetes and stop destruction of pancreas and other vital organs; its physiological; no chances of low sugars.
** Controls High blood pressure, improves kidneys, cholesterol, nerves, reduces excess weight.
Am I a type-1 or type-2 diabetic ?
If you had to take insulin from the beginning of treatment for control of sugar & if it started in childhood, then you are most probably Type -1 diabetic.
Why surgery Only for Type-2 diabetes, why not for type-1?
In Type-2 diabetes body usually has some insulin with at least a minimal amount of functioning B-cells, which is important for success of this operation. In Type -1 diabetes body does not produce insulin, as nearly all B-cells are destroyed, hence surgery will not help.
This operation is a physiological procedure where your body is helped to produce more insulin on eating food, by increasing stimulation of pancreas B-cells, which has got disturbed in you.
When am I a candidate for surgery?
If you have diabetes for 3 years & control is not good in spite of all medication & lifestyle change, &/or you have hereditary factors, &/or you have a progressive worsening of the diabetes
Age should be between 18 to 65 years. If you are above age 65 years then only if you are fit & active.
Who should seek treatment soon?
Uncontrolled sugar levels inspite of all treatment
Progressive disease with on-going deterioration over time
High genetic load-- other members of family also affected
Do not wait for complications to affect the kidneys, eyes or heart
The diabetes is mild, stable over many years, easily controlled & not progressive and not morbidly obese.
Is there any selection criteria?
These blood tests are required for Selection for surgery
Se. Insulin fasting
Oral Glucose Tolerance Test with measurements of Blood Glucose & C-peptide at Fasting(0 min)-- 60 mins-- 120 mins.
Sufficient level of C- Peptide is required in your body (checked with a blood test).
If C-peptide blood test shows that some pancreatic B-cell function still exists, and fitness is good , then it will work.
Is it a surgery of Pancreas?
Is it a operation for obese only?
No , it is for diabetics of any weight.
What is the operation called?
It is called Ileal Interposition with sleeve gastrectomy.
How did the operation originate
New research has shown that there are some intestinal hormones which have a great effect on the pancreas and insulin secretion, especially in response to food intake. On basis of this, a Brazilian surgeon, Dr. Aureo dePaula, devised this operation and has done >700 cases in last 7 years. After training in Brazil we started this operation from Feb.2008 and have successfully operated on 46 patients. The majority have already stopped their medicines for diabetes and high blood pressure.
What is done in operation?
A long segment of last part of small intestine called ileum is brought up close to stomach. The stomach size is also reduced, by narrowing it, using stapling device.
It maintains normal access to stomach & bile duct for future endoscopic vision if necessary.Since there is no loss of intestinal length and no diversion of food, there are no long-term side effects & no nutritional deficiency.
A hormone called GLP-1 secretion is triggered from the interposed ileum when the undigested food you eat comes in contact with this portion of ileum. GLP-1 in turn stimulates pancreas to increase Insulin & thus controls your blood sugar levels.
How safe is this surgery?
It is safe because we use disposable staplers for all cutting & joining of intestine. State of art operation equipment is used. A team of surgeons & anesthetist who have been doing advanced laparoscopy work since 15 years will be attending to you.
What are the complications?
Same as in any major surgery & anesthesia. Additionally leakage or bleeding from the stapled sections or internal intestinal herniation have been reported elsewhere as being very rare.
How much time it takes for operation?
Operating time will vary from patient to patient --between 4 to 6 Hrs.
How fast can I recover from surgery?
This operation is done by laparoscopy. 6 small incisions are made on your abdomen , three each of 12mm & 5mm. Thus post operative pain is minimal & you will be up & about in 2-3 days
When will food be allowed?
Water can be taken 6hrs after operation. Other liquids are started after 2 days of surgery. Semi-solid diet from 8th day of surgery.
When can I go back to work?
Normally by 8 - 10 days after surgery
How many days of hospital stay?
Total 7-8 days; usually 1-2 days before operation and 4-5 days after.
Any problems after surgery?
You will be able to take only small amount of food at a time as your stomach size is reduced ( if stomach stapling was done due to excess body-weight). For everyone, its best to have small quantities of food at 3-4 hourly interval.
Will I have to visit hospital often after discharge?
No. Visits will be due at 1 , 3 , 6 month after operation with some blood tests, for us to monitor your progress. Then 1st & 2nd year of surgery. In between monthly we will arrange "Support Group Meetings" of all those who have under gone this operation along with doctors & dietician to sort out any problems & exchange views.
What are the other advantages of this surgery?
In obese patients, weight will be reduced to normal, high blood pressure is normalized thus no need for anti-hypertensive drugs, micro- albuminuria is reversed & increased lipid levels are reduced to normal.
How much time it will take after surgery for control?
Any where from 2 weeks to 6 months depending on duration of your diabetes & C- peptide levels.
Is the control permanent?
It has been reported in studies, that the patients who showed increased insulin levels after weight reduction surgery , had same level of improvement even 20 years after the surgery. This indicates that this cure will be permanent.
Can this operation produce hypoglycemia?
No, because like in normal person , insulin is increased only when food is eaten.
Will there be weakness or loss of energy after surgery?
After few days of surgery you will regain your energy & vitality by following dietician's advice combined with exercise.
I am also obese, can it be treated at the same time?
Yes, you will loose weight and reach normal weight.
I have renal problems/ eye problems. Can this be reversed?
If in the early stages, it might. You can have surgery but if the disease is in advanced state it may continue to deteriorate in spite of diabetic cure after surgery.
I am well controlled on minimal tablets
If your HbA1c levels are below 7 you do not require surgery.
heck your HbA1c levels every 3 months
Please take your diabetes control seriously before it produces serious damage to you. Decrease your stress levels at work, eat healthy & exercise regularly for a long healthy life. Control your central obesity, which is initiator of diabetes & maintain a healthy weight. Yoga, pranayama, Art of Living & Vipasana Meditation will surely help.