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कहते हैं कि लाइफ में कुछ चीजें सदाबहार होती हैं

कहते हैं कि लाइफ में कुछ चीजें सदाबहार होती हैं

” कहते हैं कि लाइफ में कुछ चीजें सदाबहार होती हैं “, ©️ Aparna Govil Bhasker बचपन वाली शैतानियों कि मस्ती कि चमक आखों में जब दिखे तो सदाबहार होती है, दोस्तों के बेकार सा जोक सुनाने पर भी जब एक मीठी सी हंसी आ […]

HAPPY NURSE’S WEEK

HAPPY NURSE’S WEEK

As a young and inexperienced intern, my first surgical knot was taught to me by an OR nurse. After I joined surgery, my first breathless day in minor OT was supervised by a senior nurse who could do the excisions and sutures seamlessly and took […]

Metabolic surgery for treatment of Diabesity- A reality

Metabolic surgery for treatment of Diabesity- A reality

 

Dr. Aparna Govil Bhasker

Bariatric Surgeon, Mumbai

 

“A picture speaks a thousand words”.

diabetes care book

In February 2016, the cover page of Diabetes Care, one of the best international journals in the field of diabetes, carried a picture of a surgery being performed in the military hospital in the first world war. This was not only the first time, surgeons featured on the cover of a medical journal, but this entire issue was a special article collection dedicated to “metabolic surgery and the changing landscape of diabetes care”.

Quintessentially, diabetes has been a medical disease, traditionally treated with pills and injections. Metabolic surgery in mumbai for the treatment of type 2 diabetes is a novel concept that has come to fore in the recent years. In 1978, Dr. Henry Buchwald from Minnesota, USA defined metabolic surgery as the operative manipulation of a normal organ or organ system to achieve a biological result for potential health gain [1]. Today, the term metabolic surgery is typically used to describe surgical procedures to treat type 2 diabetes and other components of metabolic syndrome.

Though the concept is not very new and has been around for about 30 years now, medical community has been very slow to warm up to the idea of metabolic surgery. Way back in 1995, Sir Walter Porries from USA, published a provocative paper – “Who would have thought it? An operation proves to be the most effective therapy for adult onset diabetes” [2]. In the same year-“metformin”, the wonder drug of diabetes treatment was discovered. While metformin went on to be the most commonly used drug in the diabetes spectrum, metabolic surgery still remains one of the most underutilized treatment option. 

Lack of proper evidence has been cited as one of the reasons for the slow uptake of metabolic surgery. In addition to all the other evidence, in the recent years we have level 1 evidence in the form of eleven randomized controlled trials that have compared metabolic surgery with best medical management in overweight and obese patients. One hundred percent of these studies have shown that when it comes to over weight and obese patients, metabolic surgery is far superior in achieving glycaemic control [3]. In 2015, an Italian researcher compiled results of metabolic surgery in more than ninety thousand diabetic patients. In this study more than 71% diabetic patients achieved remission after metabolic surgery [4]. By remission, I mean that these patients had normal fasting blood glucose and HbA1c levels despite no medications for at least one year. Metabolic surgery has also been shown to lead to a significant improvement in high blood pressure and patients are six times more likely to reduce ≥ 30% of their blood pressure medications after surgery [5]. It is needless to say that metabolic surgery leads to an improvement in metabolic and inflammatory profile and decreases the long-term cardio-vascular risk in this patient population. With data and results available for almost one hundred thousand obese diabetic patients, I think it is time that we put the argument about lack of evidence to rest.

In 2015, a landmark meeting was held in London where 48 international scholars came together and formulated guidelines for metabolic surgery. It is important to note that out of 48, 75% of the voting delegates were non-surgeons. The voting panel mainly consisted of diabetologists, endocrinologists and physicians along with a few academic surgeons. These guidelines have been endorsed by 54 international societies across the world, many of which are diabetes societies. Diabetes India is one of them [6]. In 2017, the American Diabetes Association (ADA) accepted these guidelines as an integral part of management of type 2 diabetes [7].

The ADA guidelines for metabolic surgery are as under:

  • Metabolic surgery should be recommended to treat type 2 diabetes in appropriate surgical candidates with BMI ≥ 40 kg/m2 (BMI ≥ 37.5 kg/m2 in Asian Americans), regardless of the level of glycemic control or complexity of glucose-lowering regimens, and in adults with BMI 35.0– 39.9 kg/m2 (32.5–37.4 kg/m2 in Asian Americans) when hyperglycemia is inadequately controlled despite lifestyle and optimal medical therapy.
  • Metabolic surgery should be considered for adults with type 2 diabetes and BMI ≥ 30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian Americans) if hyperglycemia is inadequately controlled despite optimal medical control by either oral or injectable medications (including insulin).

The ADA also acknowledged that obesity management delays the progression of pre-diabetes to diabetes and is also beneficial in treatment of type 2 diabetes. They also said that modest weight loss reduces the need for glucose lowering agents.

Despite great results, presence of evidence and guidelines from the ADA, metabolic surgery is not even being performed for 1% of the eligible patient population who stand to benefit from this. I believe that the biggest reason for this is lack of awareness. People are still not aware about the potential benefits of this therapy. I agree that surgery comes with a risk of anaemia, calcium and vitamin deficiencies but these are preventable with a good follow up and team approach. The advent of laparoscopy has reduced the mortality rate by ten folds as compared to open surgery and the overall complication rate after a Roux-en y gastric bypass is about 3.4% which is about the same as that of a gall bladder or a knee surgery. It is up to us to choose the trade off between preventable nutritional deficiencies and a low complication rate after surgery with potential complications of remaining obese and diabetic in the long term. Given a choice I would rather have my patients on multi-vitamin, iron and calcium supplementation rather than being on insulin or in worse cases kidney transplants, angioplasties, amputations etc.

There is also a contention that even after metabolic surgery, the weight along with diabetes comes back after a few years. Approximately one-third of the patients do experience a relapse or recurrence after a median 8.3 years. I would say that this is not bad at all. 8.3 years of disease-free interval has the potential to yield significant long-term cardiovascular benefits. Metabolic surgery is not an absolute “cure” but it does buy the patient almost a decade of good quality of life and has the potential to push back the expected complications of diabetes.

In conclusion, metabolic bariatric surgery in mumbai is a powerful tool for the treatment of obese diabetics. There is a substantial body of evidence that is showing that surgery on the GI tract yields better glycemic control in this patient population as compared to medical management alone. The role of gut in diabetes is being studied and is a hot topic across the world. Hopefully we shall have some tangible answers in the near future to explain the mechanisms behind diabetes remission after surgery. In the meanwhile, the medical community needs to break down walls and start building bridges so that the best possible therapy is advised to the patients. It is important to be cognizant of the burden that this burgeoning epidemic of diabesity is adding to our healthcare system. Diabetes and obesity are a deadly combination and although we cannot guarantee a cure, we can atleast endeavour towards getting a better glycemic control and quality of life. Metabolic surgeons and diabetologists/endocrinologists need to work in conjunction to provide the best treatment options to their patients.

Although it is true that ultimately it is He who heals, we as doctors must give our best to our patients.

 

References:

  1. Buchwald H. Metabolic surgery: a brief history and perspective. Surg Obes Relat Dis.2010 Mar 4;6(2):221-2.
  2. W J PoriesM S SwansonK G MacDonaldS B LongP G MorrisB M BrownH A BarakatR A deRamonG IsraelJ M Dolezal. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995 Sep; 222(3): 339–352.
  1. Viktoria L Gloy et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ 2013;347:f5934
  2. Panunzi S, De Gaetano A, Carnicelli A, Mingrone G (2015). Predictors of remission of diabetes mellitus in severely obese individuals undergoing bariatric surgery: do BMI or procedure choice matter? A meta-analysis. Ann Surg 261:459–467
  1. Schiavon CABersch-Ferreira ACSantucci EV et al. Effects of Bariatric Surgery in Obese Patients With Hypertension: The GATEWAY Randomized Trial (Gastric Bypass to Treat Obese Patients With Steady Hypertension). 2018 Mar 13;137(11):1132-1142.
  2. Rubino FNathan DMEckel RH et al. Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations. Diabetes Care.2016 Jun;39(6):861-77.
  3. American Diabetes Association (2017) Obesity management for the treatment of type 2 diabetes. Diabetes Care 40:S57–S63

 

DR. APARNA GOVIL BHASKER- BEST BARIATRIC SURGEON IN MUMBAI, INDIAAbout Dr. Aparna Govil Bhasker

Dr. Aparna Govil Bhasker is an accomplished and renowned Bariatric Surgeon in Mumbai and Laparoscopic Surgeon.

Read more about Dr. Aparna Govil Bhasker- https://www.bestbariatricsurgeon.org/dr-aparna-govil-bhasker/  

Please write in to info@bestbariatricsurgeon.org or draparnagovil@gmail.com & Call/Text/WhatsApp: +919819566618 or +919930922761

Dr. Aparna’s website is- https://www.bestbariatricsurgeon.org

You can read her lovely blogs on- http://www.aparnagovilbhasker.com

Dr. Aparna Govil Bhasker is a visiting consultant at the following hospitals:

  • Gleneagles Global Hospital, Parel, Mumbai
  • Surya Hospital, Santacruz West, Mumbai
  • Hinduja Healthcare Surgical, Khar West, Mumbai
  • Apollo Hospital, CBD Belapur, Navi Mumbai
  • Suchak Hospital, Malad, Mumbai
  • Namaha Hospital Kandivali, Mumbai
  • Currae Specialty Hospital, Thane
  • MGM Hospital, Vashi, Navi Mumbai
  • Apollo Spectra Hospital, Tardeo and Chembur, Mumbai
  • Saifee Hospital, Mumbai

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Using bariatric surgery to fight obesity

Using bariatric surgery to fight obesity

Dr. Aparna Govil Bhasker Bariatric and Laparoscopic Surgeon In the last week amongst the other patients I saw, there was one with a history of a stroke a few days back, one with a history of stroke, 2 years ago and a young lady with […]

HEALERS OF A BROKEN SYSTEM

HEALERS OF A BROKEN SYSTEM

© Dr. Aparna Govil Bhasker

When Chandrayan 2 fell short of just one more mile, from making history, no “failure” could be proclaimed to be more “heroic” than that. A true leader, the honourable Prime Minister, went out of his way to support our scientists and said that there is “no failure in science, it is a journey and one or two difficulties must not hold us back”. The entire nation stood behind ISRO like never before, and rightly so. It was a perfect example of embracing failure, expressing our solidarity with our scientists and a beautiful lesson in forgiveness. It was humane and graceful and makes me feel proud of my countrymen and women. On a lighter note, it was the hug of the century.

However, in the current times, when it comes to “failure in medicine”, it is neither heroic nor graceful. As a profession medicine is one of the most, “failure averse”. From our early days in medical school, we doctors are indoctrinated with the mantra that, “failure is not an option”. The paradox however is that, in life, failure is inevitable and the medical profession is no exception to this. As doctors we fight the toughest battles with the two of the biggest enemies of mankind- disease and death. To say the least, nothing can be more humbling and as we grow in experience we learn the lessons in humility the hard way.

So, first and foremost, why are we doctors, so hard on ourselves? Most of us have immense difficulty in accepting that despite best efforts, sometimes things may not go our way. Though we are taught lessons in detachment, are we really able to practice them? No one has ever escaped death, but when it happens on our watch, we feel the burden of the lost life on our fragile shoulders. Unfortunately, no amount of money can snatch away a loved one from the clutches of disease and death. As doctors, sometimes even we are guilty of suffering from the God complex. At times we ourselves tend to forget that we are only human at the end of the day.

Doctors and patients are two sides of the same coin. Let’s flip the coin and see it from the patient’s perspective. From time immemorial patients have reverred doctors next only to God. There is an extremely strong emotional element that is associated with the practice of medicine. Unlike other service industries, healthcare can never be proportionate to the amount of money paid. An x amount of money may guarantee you a business class seat in an airline or the best suite in a seven star hotel, but no amount of money can guarantee getting good health back. Money is just a way to define value for a service, but in case of healthcare it falls severely short. Money is never enough to make up for the loss of a loved one, and neither is it enough to compensate a doctor for saving a loved one. But until we have another way of valuing the services of doctors and healthcare, money will be the third prong in the wheel. I am not an economist, but I dont need to be one, to know that most people in this country are barely able to make ends meet. We may be close to eradicating polio, but we are nowhere near eradicating poverty in this country. India is a country with a burgeoning population and, in the absence of solid universal health coverage and public health institutes falling severely short, the burden of dealing with a disease and its treatment falls on individuals. A burden they probably cannot carry. I dont feel proud when I say that India has one of the lowest healthcare budgets in the world. Indian citizens are deeply dissatisfied and disappointed when it comes to the basic human right of being provided with good healthcare. Private healthcare is expensive and like all businesses the goal is to make profits. In an emergency, when public healthcare is not an option people turn to private healthcare, which unfortunately is unaffordable for most. And when expectations are not met, it leads to friction and sometimes escalates to violence.

For ages, Indian doctors have held a broken healthcare system together and have done a great job of it. Success stories of everyday never make head line news but what we have achieved in the realm of healthcare with our “meagre resources” is nothing short of a miracle. However, it certainly is not enough for a country with 1.37 billion people. Doctors are the face of medicine and while they are the foot soldiers who are fighting this battle with minimal support, they are repeatedly facing the ire of dissatisfied masses. Every other day, we hear of doctors being abused and hospitals being vandalized. Impatience has become the hallmark of today’s society. While the world becomes smaller and digital, we need to understand that we are still eons away from curing diseases of the complex human body with a click of a button or by using artificial intelligence.

Today, there is increasing dejection and demotivation amongst healthcare practitioners and doctors. Doctors are also citizens of this great country and it might help our morale if we received some grace too. For us, every patient is precious and we succeed more often than we fail. Death is invincible, but doctors are the only ones in this world who dare to fight it. If not a hug, atleast we don’t deserve to be chided by our dear Prime Minister time and again and be beaten up for failures that may sometimes be out of our control. It is our sincere appeal to the government to increase the healthcare spends in the upcoming budget and show some positive inclination towards supporting the Indian citizens for this basic human right that is “health”.

Dr. Aparna Govil Bhasker is a Bariatric and Laparoscopic surgeon practicing in Mumbai. Alongwith Dr. Debraj Shome they have published the iconic book “Dear People, With Love and Care, Your Doctors”, which is an anthology of short stories set in the healthcare environment. The book has consistently been in the top 10 best sellers list and is in its 4th reprint already, within four months of being released. To know more about the book, click on http://www.dearpeople.in

DIL SE EK DUA HAI NIKLI

DIL SE EK DUA HAI NIKLI

© Dr. Aparna Govil Bhasker Dil se ek dua hai nikli, Ki har khwaish teri ho puri, Chand aur sitare ho sarey tere, Har khushi aye hisse hamesha tere, Chu le tu har unchai ko, Na roke koi raste mein tujhko, Dil se ek dua […]

AAJKAL AKHBAR KHOLNE KO JI NAHI KARTA

AAJKAL AKHBAR KHOLNE KO JI NAHI KARTA

AAJKAL AKHBAR KHOLNE KO JI NAHI KARTA © Dr. Aparna Govil Bhasker Aajkal akhbar kholne ka ji nahi karta, Umar chahe paanch ki ho ya pachaas ki, Rang chahe gora ho ya kaala, Anpadh ho ya padhi likhi, Shadishuda ho ya nahi, Kisi se koi […]

YOU ONLY LIVE ONCE “YOLO” 💃🏻

YOU ONLY LIVE ONCE “YOLO” 💃🏻

-Dr. Aparna Govil Bhasker

I wake up every morning and without fail, spend atleast ten painstaking minutes standing in front of my wardrobe thinking what to wear. And every single day, for as many years as I can remember, I have been plagued by this one thought-

“I dont have enough clothes (translates to shoes, accessories, jewellary etc etc)!”

My husband ofcourse has a starkingly different opinion on this but I guess like all other husbands in successful marriages he has mastered the art of ignoring certain things. Works better that way 😃!!

A shopaholic by my own confession, my dedication to shopping sometimes extends into 4.00 am shopping sprees at airports. For me it forms for a fabulous start to a great day ahead. I have this innate ability to be able to shop anywhere, anytime… Much to my husband’s chagrin, I still have no qualms about picking
up stuff from the local stores of Hill Road, junk jewellary from the Colaba causeway or footwear from the Linking road. I have the same zeal and dedication when I buy stuff from a village in Rajasthan or from a branded store in Mumbai. I love to bargain with local shop-keepers and to be honest I still haven’t gotten over the embarassing habit of looking discreetly at the price tags in the high end stores!

Just passing by a crowded market area is enough to elevate my mood. My mother often tells me that what I buy will not last me very long… and I am like, “Mom, that’s exactly why I bought it! I don’t want it to last too long!” Afterall, variety is the spice of life. I dont want to wear the same pair of shoes for 2 years.. I would rather have a new set every few months!

Since I started earning myself, I allocate a monthly budget exclusively for myself. Its not much but its enough to make me happy. I disagree with the common perception that happiness is difficult to find. Nothing elevates my mood more than finding something that I like. Shopping works like a drug for me! The world is cruel at times but the mall always has a healing effect! Lol!

As I grow older, I realize that pampering myself is an important aspect of life. An extra shade of lipstick, a new pair of earrings, an extra pair of shoes, one more book on my shelf or new cup for my coffee does wonders for me!

As women, pampering others comes more naturally to us than the other way round. Most of us have to work hard at learning to love ourselves. All I have to say is that there is only one life we all get… We all struggle for the big things in life, in the process don’t give up on the small pleasures (even if they are a little materialistic by worldly standards… lol). Ultimately happiness is not a goal that we will achieve one fine day in the future, it is a continuous phenomenon. It is a drug that we need on a daily basis, to go on.

All of us have that one thing that makes us happy, and the trick is to identify it. We all need our drug. Make an effort towards finding your drug and learn to pamper yourself a little sometimes, for life is short and you only live once (YOLO 💃🏻).

Dr. Aparna Govil Bhasker

Cadaver- A Surgeons First Teacher

Cadaver- A Surgeons First Teacher

Dr Aparna Govil Bhasker MS, Bariatric and Laparoscopic Surgeon, Mumbai, India   The business of saving lives begins in the company of death. For most of us something changed the moment we walked into the anatomy dissection hall on the first day of our medical […]