March 2018

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Type 2 diabetes has reached epidemic proportions in Trinidad and Tobago. The International Diabetes Federation puts the number of adult cases at 117,400. Region-wide the number of cases is estimated to be between 10 to 15 percent of the adult population. The disease takes lives and limbs, an estimated 500 limbs per year in Trinidad alone, says Health Minister Terrence Deyalsingh. The Minister put its annual cost to T&T at $3.5 billion.

Yet type 2 diabetes is a lifestyle disease, so the standard treatment has been, along with diet, exercise and medication, to make better lifestyle choices. Doctors have possibly found a better way: surgery.

“The data is so strong to use surgery to treat diabetes that in the future hopefully when someone gets the disease it will be treated just like appendicitis,” says Professor Dilip Dan, head of the Department of Clinical and Surgical Sciences at UWI’s Faculty of Medical Sciences. “You consider surgery for it.”

In an interview at his office at the Eric Williams Medical Sciences Complex, Professor Dan spoke about his vision for metabolic (diabetes or other metabolism-related) surgery in T&T and the Caribbean. The interview followed his February 1 professorial lecture held at the Daaga Auditorium at the St. Augustine Campus. The packed lecture, titled “Crossing Boundaries: From Scarless Surgery to Surgery for Diabetes,” was very much a snapshot of his career as a pioneering surgeon and educator.

Professor Dan placed special emphasis on metabolic surgery:

“It’s hard to conceptualise taking a lifestyle disorder and having surgery for it. You have no diseased organs. But the surgery changes some things so that your intestinal hormones work in a different way improving glucose control. And the results have been phenomenal.”

Numerous studies have shown incredible results for Diabetes mellitus type 2 patients through metabolic surgery. Studies have shown that patients who had the surgery within five years of their diagnosis have a greater than 70 to 75 percent chance of complete remission. Between 83 and 85 percent of patients experienced early (within days) and sustained improvement over five years.

“Sustained” is the key word, because like most lifestyle-based treatments, traditional medical treatment for diabetes depends on the patient changing how they live. This is notoriously difficult to maintain.

“When you look at the medical treatments (medication, diet and exercise), the patient’s blood sugar comes down but this is not sustained over time,” Professor Dan says.

Interestingly enough, the results of metabolic surgery were initially the unintended outcome of another type of surgery. Bariatric surgery (gastric bypass) is a procedure that reduces the size of the stomach and bypasses the small intestine to spur weight loss. The surgery is extremely effective. However, surgeons noticed that within days of carrying out the procedure, patients with diabetes were experiencing major positive effects within a few days. Many were off diabetes medications in less than a week.

The surgery reactivates hormones in the small intestine that stimulate insulin production and receptivity. The prevailing theory is that by bypassing the proximal small intestine where hormone-producing cells are defective, the food gets access to the normal ones further down thereby improving gut hormone production.

“If we had to re-invent diabetes today it wouldn’t be a disease of the pancreas it would be a disease of the small intestine,” Professor Dan says, quoting Professor Paul Teelucksingh, who has done considerable work in the area of diabetes.

With its effectiveness, metabolic surgery has become an increasingly compelling treatment for type 2 Diabetes. In September 2015, at the 2nd Diabetes Surgery Summit in London, the leading diabetes agencies from around the world agreed that the surgery should be included to the algorithm for the treatment of the disease. In T&T, metabolic surgery is practised by private doctors and was also on a lesser scale in the public health system due to budgetary constraints.

“In the future we should consider metabolic surgery as a first line treatment for newly diagnosed young diabetics. When you are young, newly diagnosed, you have your whole life ahead of you. That is the best time to fix it. If you wait ten years when complications set in then reversibility is affected.”

Professor Dan concedes that there will always be risk in a surgical procedure. But the risk of the disease far outweighs the surgery, especially since the development of minimally invasive (laparoscopic) surgical procedures. In fact, the professor is the pioneer of laparoscopic surgery in the region and has trained a cadre of surgeons throughout the Caribbean in the method.

“Surgery is the love of my life,” he says. “As a young doctor, if you are a person who wants to see results and you want to see them quick then surgery can offer you that.” He adds, laughing, “now with it comes risk and stress.”

As does the position he has held as the Head of Clinical and Surgical Studies at The UWI. And unlike surgery, progress can be slow in administration. Nevertheless he is pleased with the progress he has made at the Faculty of Medical Sciences and looks forward to doing more to enhance medical education in T&T and the region. In particular, he is focusing on postgraduate education to improve the quality of new doctors.

Asked about the professorial lecture, he says: “I was quite happy to see that the hall was filled. That makes you feel appreciated. It makes you feel that the contribution you have made has helped to change the lives of a lot of people. I don’t mean just patients, but all the medical students and the doctors in training at the post-grad level.”

And with his work and advocacy for metabolic surgery, perhaps the next milestone for which Dilip Dan will be remembered is contributing to the defeat of the scourge of type 2 diabetes.