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Help us to help you

Help us to help you

At the last count, 573 doctors in India have lost their lives during #Covid19 pandemic. Doctors groups on social media carry new #obituaries everyday. And yet, the medical community continues to fight the battle not only against Covid 19 but also against the hundreds of […]

Obesity and Metabolic Surgery Society of India (OSSI) Recommendations for Bariatric and Metabolic Surgery Practice During the COVID-19 Pandemic

Obesity and Metabolic Surgery Society of India (OSSI) Recommendations for Bariatric and Metabolic Surgery Practice During the COVID-19 Pandemic

Very proud to be a part of this committee of experienced bariatric surgeons in India to help in formulating these important guidelines for resumption of #bariatricsurgery during the ongoing COVID 19 pandemic. #Obesity has emerged as one of the most serious risk factors affecting the […]

TWO INCIDENTS- ONE PERSPECTIVE

TWO INCIDENTS- ONE PERSPECTIVE

Just as the lockdown opened up, my husband and I resumed our daily morning walks. On one Sunday morning, we were just about a hundred meters from our complex and two bikers came in and snatched the chain from my neck. Before we could react they fled. Later we were told that rising unemployment and misery during the lockdown has led to an increase in the crime rates. Everyone said, it’s not safe anywhere, anymore. We need to be cautious and we must not trust anyone.

After a few days, while I was on the way to the hospital, my car broke down on the highway. Though the lockdown had lifted, there were hardly any people on the road. Those days and even now, it’s a night mare to get hold of a taxi. Patients were waiting for me at the hospital and there were continuos calls to ask when would I reach. There was no way a mechanic could reach us before an hour. As the driver tried to fix the car, I stood out hoping and praying that somehow we could get a mechanic soon. After a few minutes an uber taxi driver stopped of his own accord. He came over to help us and pushed the car as we tried to jump start it. It was deserted with just the three of us on the highway and I was already getting uncomfortable. Eventually, much to my chagrin, i had no choice, but to request the cab driver to drop me to the hospital. In my mind, I thought that considering my desperation he would definitely try to fleece me and charge a lot more. I was totally convinced that it was for this reason he had stopped to help us in the first place. Also, cabbies were hardly getting any rides those days and this would be an easy way to make an extra buck. These are desperate times. Well, as long as I could get to the hospital at the earliest and start seeing patients, I didn’t mind paying more. Throughout the journey I was very cautious as those days there were hardly any people on the road and I didnt want to have another horrible experience. I kept my phone close to me, just in case…..

Finally we reached the hospital and asked him how much did I need to pay. I was totally taken aback when he refused to take any money. He said that he just wanted to help me and also especially because I was a doctor. I felt exposed as though he had read my suspicious thoughts during the ride, but I was also pleasantly surprised. It rekindled a faith that I seemed to be losing.

These are difficult times. Desperation is in the air. Crime rate is rising and I experienced it first hand, however it is heartening to see that there are many people who are going beyond themselves to help others. It is easier to help when God blesses us with plenty, but much harder to help and be considerate when there is nothing in your own house. That taxi driver taught me to keep the faith in humanity.

……Because to stay alive we need to believe and we need to have faith. Life is a mix of good and bad. We cannot avoid either, but it’s for us to choose whether we want to see a glass that is half full or half empty.

©️Dr. Aparna Govil Bhasker

CHANGE IS THE ONLY CONSTANT

CHANGE IS THE ONLY CONSTANT

©️Dr. Aparna Govil Bhasker I grew up in a small town and one of my favourite childhood memories is about heading out to this small nearby village on my bike. I had a favourite spot there. A beautiful tree by a lake. I would usually […]

A Dose of Realistic Optimism for Surgeons

A Dose of Realistic Optimism for Surgeons

“Action, heroism, certainty and optimism”, are some of the key tenets of surgical culture all across the world. However, in today’s times surgeons have been compelled to cope up with, “inaction, fearfulness, uncertainty and some degree of pessimism”. To say that COVID-19 pandemic has disrupted […]

THE NOWHERE PEOPLE

THE NOWHERE PEOPLE

They were everywhere and yet they were nowhere,
They were invisible and yet their presence was felt most profoundly,
They created the skyscrapers and yet had no roof on their heads,
They took care of our kids while theirs cried of hunger,
They walked for thousands of miles, while we took months to arrange for a few trains,

They were the nowhere people… and all they ever wanted was, to go home to be loved and feel safe just like all of us.

©️Dr. Aparna Govil Bhasker

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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