Diabetes Mellitus, marked by elevated blood sugar levels, arises either from insulin deficiency or its impaired function. Without treatment, it can damage multiple organs and is a leading cause of kidney failure, vision loss, and non-traumatic lower extremity amputations.

Diabetes is categorized into Type 1 and Type 2:

Type 1 Diabetes typically manifests at an early age, often before 30. It results from the immune system attacking pancreatic cells, leading to a complete halt in insulin production. Patients are generally underweight or of normal weight and require lifelong insulin therapy.

Type 2 Diabetes involves inconsistent insulin production and secretion, with the primary issue being ineffective blood sugar regulation. It has a strong genetic link. Treatment often starts with oral medications and may progress to insulin in advanced stages.

Diabetes is diagnosed with laboratory blood tests. The tests are fasting blood glucose, postprandial blood glucose, HbA1c, and Oral Glucose Tolerance Test (OGTT).

Fasting Blood Sugar: Normal levels are below 100 mg/dl. Prediabetes is indicated by 100-125 mg/dl, and diabetes is diagnosed if levels exceed 126 mg/dl.

HbA1c Test: This ‘3-month sugar average’ shows blood sugar levels over 2-3 months. Below 5.7% is normal, 5.7%-6.4% suggests prediabetes, and above 6.5% indicates diabetes.

OGTT: Less common in general diagnosis but frequent in pregnancy. Normal levels are below 140 mg/dl, 140-199 mg/dl suggests prediabetes, and above 200 mg/dl indicates diabetes.

Post-diagnosis, additional tests help differentiate between Type 1 and Type 2 diabetes.

Managing diabetes involves tailored approaches based on the diabetes type and individual health. Type 1 diabetes typically requires insulin management, whereas Type 2 diabetes treatment often begins with oral medications and may include insulin in advanced stages. Therapeutic strategies focus on reducing liver sugar production, increasing tissue sensitivity to insulin, and lowering blood sugar levels. Insulin therapy, administered by injection, helps lower blood sugar by facilitating sugar’s entry into cells. It includes both short-acting and long-acting insulin forms, and its administration and dosage should always be supervised by a healthcare professional.

For Type 2 diabetes, metabolic surgery (sugar surgery) is an additional treatment option for those with sufficient insulin reserves. This surgical intervention is not beneficial for Type 1 diabetes patients.

Eligibility for metabolic surgery requires Type 2 diabetes and a sufficient pancreatic insulin reserve. A critical aspect is the body’s adequate insulin response to satiety. For patients with effective insulin production and secretion, using oral antidiabetic pills or insulin is not a barrier to surgery. Comorbid conditions like obesity, hypertension, asthma, or sleep-apnea syndrome don’t preclude surgery and may even see symptom improvement postoperatively. While previous abdominal surgeries may complicate the procedure, they don’t prevent it. Post-surgery, patients typically stop taking sugar pills and insulin early on, with phased discontinuation of antihypertensive, anticholesterol medications, and gradual cessation of CPAP for sleep apnea. Eligible patients should also have consultations in internal medicine, cardiology, and anesthesiology.

Type 1 diabetes patients, due to insufficient insulin, are not suitable candidates for this surgery and should continue with insulin therapy.

The routine approach is to evaluate the patients in the preoperative period and to take possible precautions by determining the risks. All patients should be examined in detail during the process of planning the surgery. The main purpose is to detect and treat possible deficiencies and diseases before the operation, and, if necessary, postpone the surgery.

The assessments that have to be done for this purpose, are; evaluation of the lung (such as chest X-ray, pulmonary function tests, consultation from a pulmonologist), assessment of the heart (ECG, ECHO, cardiology consultation, and further examinations like stress ECG, Holter, or angiography if necessary), psychiatric evaluations (questioning the history of drug use, substance abuse, presence of psychiatric disease, and psychiatric consultation), surgical tests (abdominopelvic ultrasonography, doppler ultrasonography, history of previous abdominal surgeries), internal medicine (non-surgical) evaluations (existence of other diseases and treatments being used, internal medicine consultation, etc.), endoscopic exploration (visual assessment of the esophagus, stomach, and small intestine with endoscopy), laboratory tests (blood work, assessment of liver functions, kidney functions, and establishing the bleeding time).

The medications used by the patients should also be taken into account (such as blood thinners, antihypertensive and antidiabetic drugs, and psychiatric drugs). During the operation, some drugs should be discontinued or replaced with other medications, and re-continued after the surgery, as soon as possible.

In the presence of additional comorbidities (like previous operations, heart attack, lung infections, neurological and psychiatric diseases, hypertension, diabetes, and obstructive sleep apnea syndrome), the patient should be checked in the relevant department, and the evaluations and suggestions of the specialist there should be taken into account.

The medications used by the patient must be evaluated, and their use, dosage, or discontinuation in pre-and post-operative time should be planned.

High-risk patients must be hospitalized and treated before the operation.

Oral water intake begins in a controlled manner 6 hours after the operation. The next day, nutrition is provided with controlled fluid consumption and intravenous fluid support. In oral nutrition, clear liquid support is given (such as water, tea, sugar-free drinks, grain-free soups). Following the gas discharge of the patient, the transition to watery soups, yogurt, ayran, lactose-free milk, kefir is provided. This process continues until the end of the 2nd week.

Between weeks two and four, a transition to a puree diet is made (eggs, omelettes, cream cheeses, fruit-vegetable purees, pureed vegetable dishes, meat-fish and chicken, minced meat). In addition, soft fruits can be consumed during this process.

From the 1st month, a controlled diet with solid food is started.

Dietitian support and recommendations should be followed throughout the nutrition process. We provide follow-up of our patients with a dietitian after the surgery.

In the first month after the operation, gastric protection and vitamin support drugs are given. After the first month, these drugs are released in a controlled manner. The use of supplements such as protein powder in the first month is left to the patient’s choice.

Oral antidiabetic drugs and insulins used in patients who are suitable for surgery are not used after metabolic surgery.

The period with the highest weight loss after surgery is the first month. The reasons for this are a low-calorie diet with liquid foods and the loss of excess fluid in the body, along with normal fat loss. After the balance is achieved, weight loss is parallel to the lost fat. The average weight loss seen in the first month is 5-10 kilograms.

If the person is overweight after sugar surgeries, the main goal is to lose their excess weight. Therefore, it is aimed for the patient to reach the target weight. In thin patients, weight loss is not expected after the 1st month.

Some patients may experience skin sagging after weight loss surgeries. What determines this is related to how overweight the person is, the presence of sagging before the surgery, and the rate of weight loss.

It is recommended that surgeries related to sagging be postponed until after weight loss is complete.

Type 1 diabetes patients are not operated because they will not benefit from the surgery. In type 2 diabetes patients, patients with inadequate pancreatic reserve are not operated on.

Surgery is contraindicated to patients with severe heart failure, uncontrolled cardiovascular disease, end-stage lung disease, cancer or treated for cancer, cirrhosis in the presence of portal hypertension, uncontrolled substance or alcohol abuse, and people with severely impaired intellectual capacity.

Although every surgical intervention has some complications and risks, there are complications and risks specific to each surgery. What scientifically important is the occurrence and treatability of these complications.

Complications that can be seen in laparoscopic metabolic surgery are; bleeding through surgical incisions, wound problems (such as surgical site infections, and poor wound healing), specific complications (like surgical site bleeding, and leaks after the disruption of the site’s integrity), positional complications of the structural integrity of the stomach (strictures throughout the passage, twisting of the stomach around itself (torsion), etc.), post-surgical complications unrelated to the surgical site (such as lung infections, urinary tract infections, heart problems), long-term complications (weight loss faster or slower than expected, ineffective/inactive weight loss or weight gain, vitamin and mineral deficiencies).

The incidence of these complications ranges from one percent to 1 in 10 thousand to even 1 in 100 thousand. At this point, what’s important is the early diagnosis of preventable complications and the application of appropriate treatment when they occur. Likewise, identification of the causes that increase the risk of complications even before the surgery (such as the presence of other diseases, smoking, alcohol, other factors affecting wound healing, or other diseases that may increase the adverse side effects of anesthesia) and if necessary removing these risk factors first, reduces the prevalence of the complications considerably. Similarly, precautions for postoperative complications can be taken (such as early mobilization, respiratory muscle training, strict aftercare and follow-up, and early initiation of appropriate medical treatment) to ensure the process is completed without any problems.

Another important point in the postoperative period is the early detection and appropriate treatment of undesirable complications. The fact that “Early diagnosis saves lives”, which is always said in diseases such as cancer, is valid for every aspect of medicine, especially in surgical complications. Unfortunately, failure to diagnose a complication at an early stage that can be brought under control with appropriate treatment can cause the situation to worsen and may become uncontrollable and untreatable. Therefore, it is important to inform and check in with the patients at every step and to follow up with the patient closely after the surgery. It should never be forgotten that the experience and knowledge of the surgical team is the most important component in the management of surgical complications.