1. Javed Iqbal, FCPS, FRCS Professor of SurgeryQuaid-e-Azam Medical College, Bahawalpur, Pakistan
2. Whats new in surgery for the Diabetics
3.  “240 million people worldwide are living with diabetes; 380 million by 2025” “It kills one person every 10 seconds”
4. The usual domain of the surgeons in Diabetes  Diabetic foot  Infections.  Neuropathies.  Vascular narrowing
5. The Surgical Cure of Diabetes
6. The Key Questions. Is there a surgical cure? Can we cut out Diabetes?
7. Background. The Historical Perspectives of gastrointestinal anastomosis. The Rebirth of Bariatric surgery
8. Metabolic SurgeryTreatment of metabolic derangements withalterations of the gut anatomy remission of diabetes
9. The Evidence There is overwhelming evidence indicating that several types of bariatric operations promote profound weight loss and cause complete remission of type 2 diabetes. Pories and Swanson, Ann surg 222:339-350 Sjostrom and Larsonet al NEJM 357: 741-752
10. Association of Diabetes and ObesityDIABETES + OBESITY = DIABESITY DIABETES OBESITY 90% WEIGHT LOSS T2D WEIGHT GAIN T2D
11. How can we correct it ?  Dietary control  Lifestyle changes.  Medical management
12. Why Surgery ? Non Surgical methods of weight loss are associated with higher failure rates. NIH consensus Panel 1991 recommendation:“Surgery is the only long term sustainable weight loss method” *American Diabetic association has also recommended weight loss surgery in Diabetics with BMI 35 or above. *ADA clinical practice recommendations 2008
13. Benefits of surgical weight loss (morbidity and mortality improvement) Weight loss is associated with resolution of co morbidities. ◦ DM=>80% ◦ Hypertension=>60% ◦ Hyperlipidemia=>60-95% ◦ Obstructive Sleep Apnoea => 80-80% ◦ Pories and Swanson, Ann surg 222:339-350 Swedish obese subjects study shows clear benefit of survival for surgery patients from cardiovascular events.(24%) Sjostrom and Larsonet al NEJM 357: 741-752
14. BARIATRIC SURGERY AND DIABETES Bariatric patients would have a sustained weight loss and thus would have a complete resolution of diabetes T2D even if are not obese still would achieve resolution after SG or GBP Schauer&Burguera AnnalsSurgery 2003;238:467-84 Gann ss& Horgensen ANZ J Surgery 2007;77:958-62
17. Mechanisms of Diabetes Resolution after Gastrointestinal Bypass Surgery Enhanced secretion of something good for glucose homeostasis ?Reduced production of something bad for glucose homeostasis ?
18. What is The Mechanism?  Sudden reduction in caloric intake  Reduced Ghrelin Levels  Increased production of bile acidsBA + TGR 5 c AMP dependant THAE Increased Energy Expenditure
19. The QueryWeight loss surgery patients experience areduction in or resolution of diabeticsymptoms immediately following surgery,before weight loss has had a chance to takeplace.
20. THE ANSWER The Immediate control The Entero insular Axis The Francesco Rubino Experiment. The Foregut Hypothesis The Hindgut Hypothesis The role of GLP-I& GIP
21. The exclusion of theduodenal nutrientpassage may offset anabnormality ofgastrointestinalphysiology responsiblefor insulin resistanceand type 2 diabetes
22. Nutrients reach the distalileum within 5 min of theingestion of food and thisstimulates the secretion ofGLP1 by L cellslocated in this area
23. The Entero Insular Axis Anti-Incretins DPP-4 INCREASED INSULIN AVAILABILTY GLP-1 Insulin Production Incretins GIP b-cell Neogenesis PYY Statiety.
24. THE ANSWER Long Term Resolution Decreased adipose tissue leads to modulation of the Adipo Insular Axis Adipocytokines. Leptin.Adiponectin. Decreased Insulin Resistance Resistin.
25. The Net Effect Decreased insulin destruction  Increased Insulin Production Decreased Insulin Resistance
26. WHO WOULD HAVE THOUGHT IT? An Operation Can be The mosteffective Therapy For Adult Onset Diabetes Mellitus
27. Where do we stand?
28.  Workshop in Rome Workshop with Mufazzal Lakhdawala Spent some time with Prof. Mumtaz Maher Extensive hands of course with Prof Karl Miller Acquired all necessary equipments Extensive training hand-swen gut surgery Developed a team Regularly performing sleeve gastrectomy
29. How much it costs?Nothing is more costly than a healthy life