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Postoperative Management of Diabetes Mellitus

Challenges in Post-operative Diabetic Care

The principles of post-operative diabetic management has not been clearly defined. As the time taken for the remission to occur is variable, along with a subgroup of patients who will fail to achieve complete remission, defining a specific management protocol is important. But as outlined by Fenske et al. this has a lot of challenges [6].

  • 1. Varied management strategies among various centers
  • 2. The exact definition of remission/cure is still controversial
  • 3. No validated treatment protocol currently exists for post bariatric patients

The recent ADA (American Diabetology Association) definition for complete remission of T2DM states return to normal glucose values (HbA1C <5.7 %, fasting capillary glucose (FCG) <5.6 mmol/L) for at least 1 year after bariatric surgery without glucose lowering medication [7].

Predicting the time scale for glycemic control to occur in the post-operative period is difficult and variable [8, 9]. Many centers tend to stop all hypoglycemic agents and insulin abruptly in anticipation of remission and to prevent the occurrence of hypoglycemia [8, 10-12]. However a healthy glucose environment is needed in the immediate post-operative period when the alteration of the incretin milieu could allow the pancreas to undergo regeneration. Hence glucotoxiticity should be avoided, which could hamper the beta cell glycemic memory [6]. For this a well-defined protocol of immediate T2DM management is needed to avoid both hypoglycemia and glucotoxicity.

The other factor to be considered is long-term management of T2DM after bariatric surgery. Many long term studies have pointed out the direct relationship between T2DM relapse and the time interval after surgery. The Swedish Obese subjects (SOS) study published a follow up report where the T2DM remission rates decreased from 72.3 % at 2 years to 30.4 % at 15 years [13]. No much literature exists for the clinical management of these post bariatric surgery patients with recurrence of diabetes.

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