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Evaluation of Bariatric Surgery in remission

of Diabetes

Statement of Funds:

At our public tertiary teaching hospital and regional referral centre, the project will continue without any financial aid for affording class of patients.

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2 Summary

Type 2 diabetes mellitus is a chronic disease with severe long-term health

consequences. Its importance in the Indian setup is immeasurable. The medical management of Diabetes mellitus has long been the only means of its treatment.

Currently, bariatric surgery is the most effective treatment for obesity and is indicated for patients with a BMI >40 kg/m2, or for individuals with a BMI >35 kg/m2 and significant obesity-related co-morbidities. In view of its favourable metabolic effects , bariatric surgery is also referred to as ‘‘metabolic surgery’’ and is advocated for the treatment of type 2 diabetes even in overweight individuals who do not meet the current BMI criteria . In the recent Diabetes Surgery Summit consensus conference, clinical trials to investigate the exact role of surgery in patients with less severe obesity and diabetes were considered a priority.

In patients with type 2 diabetes mellitus(T2DM) who are also morbidly obese, an abundance of clinical evidence exists showing that significant clinical improvement in their diabetes occurs following certain types of bariatric, or weight loss, surgical procedures. There is additional data showing that bariatric surgical procedures that bypass the beginning of the small intestine, such as the Roux-en Y gastric bypass, can markedly improve type 2 diabetes even before significant weight loss has occurred.

Most often, improvement of the diabetes is seen within days of surgery. Various theories to explain this rapid change include calorie restriction and hormonal changes from exclusion of the upper gastro-intestinal tract. Weight loss accounts for the sustained improvements in glucose control. The patients who benefit the most are those who are early in their disease course. Having a single treatment for both obesity and T2DM is ideal. As bariatric surgery has become a safe operation when performed by experienced surgeons, it should be considered a treatment for these diseases. The impact it can have on the lives of individual patients and society as a whole is tremendous.

India being the global capital for diabetes, We take this opportunity to evaluate the impact of bariatric surgery in remission of diabetes.

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3 Background:

Diabetes mellitus type 2 affects more than 150 million people worldwide. Although the incidence of complications of type 2 diabetes can be reduced with tight control of hyperglycemia, current therapies do not achieve a cure. Some operations for morbid obesity not only induce significant and lasting weight loss but also lead to improvements in or resolution of co morbid disease states, especially type 2 diabetes.

The prevalence of type 2 diabetes has markedly increased in the last decade worldwide, but in particular in Asian countries such as India and China, in strong correlation with a comparably steep increase in the prevalence of obesity. The primary risk factor for type 2 diabetes is obesity, and 90% of all patients with type 2 diabetes are overweight or obese.

In our study, we aim to evaluate with BMI ranging widely from 30-35 kg/m2 having Type 2 Diabetes Mellitus in order to understand and evaluate the effect of Metabolic surgery in comparison with Routine Medical Management with Oral Hypoglycemic agents or Insulin.

The below mentioned Table shows results of Bariatric surgery and its effects on remission of diabetes

Table 1. Randomized Trials Evaluating Sleeve Gastrectomy and Roux En Y Gastric

Bypass

Author Procedures (N) Mean Preoperative BMI (kg/m2) Follow-up Weight Loss Conclusions Woelnerhanssen et al.1 LSG (11) LRYGB (12) LSG 45 LRYGB 47 12 months LSG 28% TBW LRYGB 35% TBW No differences in weight loss, insulin sensitivity, or effects on adipokines (adiponectin, leptin), Kehagias et al.2 LSG (30) LRYGB (30) LSG 46 LRYGB 45 36 months LSG 68% EWL LRYGB 62% EWL No differences in weight loss.

LSG and LRYGB are equally safe and effective in the amelioration of comorbidities. LSG is associated with fewer postoperative metabolicdeficiencies Lee et al3 LSG (30) Mini-GB (30) LSG 30 LRYGB 30 12 months LSG 76 % EWL Mini-GB 94% EWL*

GB patients more likely to achieve remission of T2DM (HbA1c < 6.5%, 93% vs. 47%, p=0.02) Karamanakos et al.4 LSG (16) LRYGB (16) LSG 45 LRYGB 46 12 months LSG 69% EWL LRYGB

Greater weight loss with SG at one year.

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4

60% EWL**

similarly after either procedure.

Greater ghrelin reduction and appetite suppression after SG compared with LRYGB Himpens et al.5 LSG (40) LAGB (40) LSG 39 LAGB 37 36 months LSG 66% EWL LAGB 48% EWL**

Weight loss and loss of feeling of hunger after 1 year and 3 years are better after SG than LAGB.

GERD is more frequent at 1 year after SG and at 3 years after GB Peterli et al.6 LSG (14) LRYGB (13) LSG 46 LRYGB 47 3 months LSG 39% EBMIL LRYGB 43% EBMIL* Both procedures markedly improved glucose homeostasis: insulin,

GLP-1, and PYY levels increased similarly after either procedure

Recently many centers are performing Single Anastomosis Gastric Bypass(Mini)(SAGB) with comparable results to Roux-en-Y Gastric Bypass.

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5 Hypothesis:

AIMS:

To study the results of surgery in treating Type 2 Diabetes mellitus in

obese ,severely obese and morbid obesity, pertaining to following parameters

1 Effect of different bariatric surgical modalities on remission of diabetes with respect to requirement of insulin or OHA

2 To evaluate for remission after surgery with respect to duration of DM

OBJECTIVES:

To conduct a prospective study design to evaluate the role of metabolic surgery in management of Type 2 Diabetes mellitus

Primary objective – Patients having complete remission of Diabetes mellitus

Secondary objective – Patients with partial remission reflected by decreased insulin or OHA requirements

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6 Methods:

OBJECTIVES:

To conduct a prospective study design to evaluate the role of metabolic surgery in management of Type 2 Diabetes mellitus at tertiary teaching Hospital and regional referral centre.

Prospective Study of such patients over a period of one year will be based on clinical and laboratory parameters. Patients will be divided into two groups- one on medical treatment and one who have undergone surgery. A comparative study between these two groups to achieve the aims and objectives of the study would be done with 2 monthly follow up schedule as shown below. Later statistical analysis would be done.

FOLLOW UP

FBS PPBS HBA1C(3monthly)

to be done after 4 months

Requirement Of Insulin Requirement Of OHA(Oral Hypoglycemic Agents) 1mnth NA 2mnth NA 4mnth 6mnth 8mnth a) CASE SELECTION INCLUSION CRITERIA

1. All patients between age group 20 and 65 years with Type 2 Diabetes mellitus on medical treatment.

2. Patients with Type 2 DM and obesity, severe obesity or morbid obesity on medical management; and

3. Normal and overweight patients with uncontrolled Type 2 Diabetes on medical treatment. 4. Patient willing for study.

EXCLUSION CRITERIA 1. Patient below 20 years and above 65years of age. 2. Patient not willing for study.

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7 3. Pregnant patients

4. Patient unfit for surgery

5. Patients with contraindications for bariatric surgery like Past gastric Surgery, Inflammatory bowel disease, patient on steroids,

immunosuppressive state

LIMITATION

Although Hormone levels of Serum Ghrelin, GLP -1, PEPTIDE YY, CCK-PZ, Leptin and Adiponectin are required to be studied for a

Wholesome approach, due to cost factors and unavailability of the Investigations, these parameters are excluded from the study.

SAMPLE SIZE MINIMUM 30 PATIENTS

PERIOD OF STUDY 1 Year

Note: This prospective study requires long term follow up of 10 years duration approximately for deducing the exact period of remission but in view of the duration of study being 1 year it is out of scope of this study

STUDY DESIGN

Patients will be admitted and thoroughly investigated

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Group A Group B

Patients on medical treatment Patients who have opted surgical management

Pre-op investigations

Follow up Observation and collection of data ( Insulin and OHA Requirement )

Randomization according to patients choice (Surgery)

Lap. Sleeve Lap.RYGB Lap. SAGB(Mini) Gastrectomy

(LSG)

Post op Follow up

Analysis,Results and Conclusion

TYPES OF BARIATRIC AND METABOLIC SURGERIES TO BE OFFERED IN THE STUDY 1) Standard LAPAROSCOPIC SLEEVE GASTRECTOMY

2) Standard LAPAROSCOPIC GASTRIC BYPASS SURGERY

3) Standard LAPAROSCOPIC GASTRIC MINI BYPASS SURGERY(SAGB)(Mini)

Laparoscopic Single Anastomosis Gastric Bypass-(SAGB)(Mini)

The Mini gastric bypass procedure was first developed by Dr Robert Rutledge from the USA in 1997, as a modification of the standard Billroth II procedure. Mini gastric bypass involves making of a long narrow tube of the stomach along its right border, the lesser curvature. A loop of the

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small gut is brought up and hooked to this tube at about 180 cms from the start of the intestine (ligament of Treitz).

Numerous studies show that the loop reconstruction (Billroth II gastrojejunostomy) works more safely when placed low on the stomach, but can be a disaster when placed adjacent to the esophagus. Today thousands of "loops" are used for surgical procedures to treat gastric problems such as ulcers, stomach cancer, and injury to the stomach. The Mini gastric bypass uses the low set loop reconstruction and thus has rare chances of bile reflux.

The MGB has been suggested as an alternative to the Roux en-Y procedure due to the

simplicity of its construction, which reduces the challenges of Bariatric surgery. The surgery is becoming more and more popular because of low risk of complications and good sustained weight loss. It has been estimated that 15.4% of weight loss surgery in Asia is now performed via the MGB technique7

Diagnosis Criteria of diabetes:

The diagnosis of diabetes was based on the following American Diabetes Association criteria: FPG >126 mg/dL (7.0 mmol/L), or symptoms of diabetes plus random plasma glucose >200 mg/dL (11.1 mmol/L), or 2-h postload glucose >200 mg/dL during a 75-gm oral glucose tolerance test.

They were admitted, investigated and managed accordingly. Preoperative and postoperative complications were noted.

Diabetes outcomes classification:

Diabetes remission was defined as HbA1c <6% and FBS level of < 110mg/dl without use of any diabetes medications.

Criteria for reduction or withdrawal of diabetes medications:

Diabetes medications were titrated, with dosage decreased if fasting and postprandial glucose levels were <120 and <160mg/dL, respectively. Diabetes medications were discontinued if HbA1c levels remained 6%.

Selection of Surgical Modality:

The Type of Surgery adopted for each individual patient was decided

according to patient’s consent for their desired operation after duly explaining to them in detail about the procedure, its outcomes and complications.

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10 References:

1. Woelnerhanssen B,Peterli,Steinert RE,Peters T,Borbeley Y, Beglinger C. :Effects of postbariatric surgery weight loss on adipokines and metabolic

parameters:Comparison of Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve gastrectomy—a prospective randomized trial:Surg Obes Rela Dis.2011 Sept-Oct;7(5):561-8,doi: 10.1016/j.soard.2011.01.044

2. I. Kehagius, M. Tsoli,F. Kalfarenztos, Horomone changes and diabetes resolution

after biliopancreatic diversion and laparoscopic sleeve gastrectomy: a comparison

prospective study, Surgery for Obesity and related diseases, vol 9, no. 5 ,

pp.667-677,2013

3. Medical Author:Melissa Conrad Stöppler, MD , William C. Shiel Jr., MD, FACP,

FACR http://www.medicinenet.com/diabetes_mellitus/page5.htm

4. AmericanDiabetesAssociation. Diagnosis and classification of diabetes mellitus

(Position Statement). Diabetes Care 2010; 33(Suppl. 1):S62–S69

5. Henry Buchwald; Yoav Avidor; Eugene Braunwald; et al.

Bariatric Surgery: A Systematic Review and Meta-analysis

JAMA. 2004;292(14):1724-1737 (doi:10.1001/jama.292.14.1724)

6. Pories WJ, Swanson MS, MacDonald KG et al.Who would have thought it? An

operation proves to be the most effective therapy for adult-onset diabetes

mellitus.Ann Surg 1995; 222: 339-52.

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Active participation in SAGES meet 2015, NAshville.

We Have submitted two videos for SAGES 2015 meet at Nashville.

1)Retrograde Jejunal Melanoma with Inguinal Lymphadenopathy

2)Single Anastomosis Gastric Bypass(SAGB) with Intraoperative suprise

Available Resources:

Well Equipped Operation Theatres, Laparoscopy Sets & Instruments, Energy

Sources, Adequate Man-Power

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SAGES RESEARCH GRANT APPLICATION

BUDGET SHEET

Detailed budget for 12 month period from 01/05/2014 through

31/04/2015

Dollar amount requested (Omit cents)

30000$

NAME POSITION

TITLE

TIME/EFFORT SALARY FRINGE BENEFITS SUB-TOTALS % Hrs/ Week 1. Dr. Ajay H Bhandarwar Principal Investigator* 12.5 5hours/w eek 2. Dr. Chintan Babubhai Patel Co-investigator 12.5 5hours/w eek 3. Dr. Praveen N Tungenwar Co-investigator 12.5 5hours/w eek 4. Dr. Amol N Wagh Co-investigator 12.5 5hours/w eek 5. Dr. Ajay Pai Co-investigator 12.5 5hours/w eek CONSULTANT COSTS 0 0 EQUIPMENT (List all Items&Total

Equipment Cost)

Items-

0

SUPPLIES (List all Items&Total

Supplies Cost) Items-Endostitch, EndoStaplers/Cartridges 21925$ TRAVEL** SAGES meeting 1000$ PATIENT CARE

COSTS Special Blood Investigations 7075$

CONSORTIUM/CONT

RACTUAL COSTS NA 0

OTHER EXPENSES (List all Items & Total

Cost) NA 0 TOTAL DIRECT COSTS Total 30000$

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CV of Principal Investigator

BIOGRAPHICAL SKETCH

Provide the following information for the Senior/key personnel and other significant contributors in the order listed on Form Page 2.

Follow this format for each person. DO NOT EXCEED FOUR PAGES.

NAME Dr. Ajay H Bhandarwar POSITION TITLE

Professor and Unit head, Division of Minimal Access Surgery/Bariatric/Metabolic Surgery

EDUCATION/TRAINING MS Surgery, FMAS,FICS, FAIS, FLCS, FBMS

INSTITUTION AND LOCATION DEGREE

(if applicable) MM/YY FIELD OF STUDY

Grant Government Medical College and Sir J.J. Group of Hospitals, Mumbai

MS Surgery, FMAS, FICS, FAIS, FLCS, FBMS 11/1990 07/2008 10/2009 12/2008 03/2012 10/2012 General Surgery

Minimal Access Surgery Colorectal Surgery General Surgery

Lap. Colorectal Surgery Bariatric Surgery

A. Personal Statement

India is a global capital for Diabetes.

Type 2 diabetes mellitus is a chronic disease with severe long-term health consequences. Its importance in the Indian setup is immeasurable. The medical management of Diabetes mellitus has long been the only means of its treatment.

In patients with type 2 diabetes mellitus who are also morbidly obese, an abundance of clinical evidence exists showing that significant clinical improvement in their diabetes occurs following certain types of bariatric, or weight loss, surgical procedures. There is additional data showing that bariatric surgical procedures that bypass the beginning of the small intestine, such as the Roux-en Y gastric bypass, can markedly improve type 2 diabetes even before significant weight loss has occurred.

The relationship between obesity and type 2 diabetes mellitus is well known. Morbidly obese patients with T2DM who undergo bariatric surgery have improvement or remission of their diabetes.

At Grant Government Medical College and Sir J.J. Group Of Hospitals ( Tertiary Teaching Hospital And Regional Referral Center) I take this opportunity to provide quality healthcare to non-affording people and evaluate remission of diabetes.

Our center being the only government organization in state of Maharashtra , India where we routinely perform bariatric surgeries, we request you to give us this honour of research project and be a part in alleviating human suffering from diabetes.

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B. Positions and Honors

1993-1999 Assistant Professor, General Surgery, IGMC and Mayo General Hospital, Nagpur, India 1999-2011 Associate Professor, General Surgery, Division of Minimal Access, Bariatric & Metabolic Surgery, Grant Government Medical College & Sir J.J. Group of Hospitals, Mumbai , India

2011-till date Professor, General Surgery, Division of Minimal Access, Bariatric & Metabolic Surgery, Grant Government Medical College & Sir J.J. Group of Hospitals, Mumbai , India

Other Experience and Professional Memberships

2006 AMASI(Association of Minimal Access Surgeons of India) 2007 IAGES(Indian Association of Gastro-Endoscopic Surgeons) 2008 ASI (The Association of Surgeons Of India)

2014 SAGES member

2014 OSSI Affiliated to IFSO(Obesity and Metabloic surgery society of India)

Honors

1) Government of Maharashtra Awarded the certificate of appreciation for the role played in the management of victims During the Mumbai Terror attacks on 26th

November 2008.

2) Best Associate Professor in Surgery Award – 2010, at Grant Medical College & Sir JJ Group of Hospitals, Mumbai .

3) Awarded the 1st prize for the best poster (Rapunzel Syndrome), at MASICON

2009, Aurangabad.

4) Awarded the 1st prize for the best poster (Central Ameloblastoma of Mandible), at MASICON 2010, Solapur.

5) Best Professor in Surgery Award – 2012, at Grant Medical College & Sir JJ Group of Hospitals, Mumbai

6) Most Prominent Clinical And Research Professional in Western India by BIG RESEARCH

FOUNDATION-2012

C. Selected Peer-reviewed Publications

(A) International Publications: (Index Journals)

1) Anterior mandibular ameloblastoma, Feb 14, 2012 – Clinics and Practice, DOI: 10.4081/cp.2012.e30 (Author Status -I)

2) Giant recurrent retroperitoneal liposarcoma presenting as a recurrent inguinal hernia Clinics and Practice, Vol 1, No 4 (2011), doi:10.4081/cp.2011.e130 (Author Status -I)

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3) Surgical Response to 2008 Mumbai Terror Attack. PMID: 22139597; [PubMed - indexed for MEDLINE]

British Journal Of Surgery,, March 2012, 368-372, DOI: 10.1002/bjs.7738 (Author Status -I) 4) First Case Reported from India & Second Such Case Report in the World

“Acute retention of urine due to a loose peritoneal body”. PMID:9014730; [PubMed - indexed for MEDLINE] British Journal Of Urology, 78(6):951,952, December 1996, DOI: 10.1046/j.1464-410X.1996.131430.x

(Author Status -I)

5) First Adult Case Reported in the World literature.

‘’Rapunzel Syndrome with gastric perforation in an adult – A rare case report.’’ Digestive Endoscopy Volume 20, Issue 1, pages 37–40, January 2008 Tokyo, Japan, DOI:

10.1111/j.1443-1661.2007.00761.x

6) Primary Extra Ampullary Duodenal Neuroendocrine Carcinoma In An Adult Male – Rare Case Report. Dig Endosc. 2009 Jul; 21(3):185-7, Tokyo, Japan. (First Case Reported from India).

Article Images appeared on Cover page of Journal. PMID: 19691767[PubMed - indexed for MEDLINE]

(Author Status -I)

7) Right posterior branch draining into intra-pancreatic common duct: the triple duct sign, Updates Surg. 2010 Dec;62(3-4):199-202, DOI 10.1007/s13304-010-0032-9,December 2010 PMID:2112804[PubMed - indexed for MEDLINE] (Author Status -I)

8) Caeco-colic intussusception in an adult: a rare case report, DOI 10.1007/s13304-011-0104-5, August 2011. PMID: 21850552 [PubMed - as supplied by publisher] (Author Status -I) 9) Impact of Laparoscopic Nissens Fundoplication on response of Disease specific Symptoms and quality of life, Updates in Surgery, March 2013, Volume 65, Issue 1,pp 35-41 10) Review Article(Research Paper):

Splenic Hydatidosis-A Review of Literature, Bombay Hospital Journal. 2002 Apr; 44(2): 282-4. (Author Status -I)

11) “26/11 Mumbai Terror Attacks: Mortality Pattern. Journal of Trauma and Acute Care Surgery,72(5):1329(2012) PMID 22673262 USA.

Original Article. (Author Status -I)

11) Acute appendicitis in left scrotum.Indian J Gastroenterology , 195,2004. (Author Status -II)

12) Colorectal foreign body.Bombay Hospital Journal ,January 05. (Author Status -I)

13) Lymphangioma:A tongue in cheek situation.Bombay Hospital Journal , April , 05. (Author Status -I)

14) Recurrent ileoileal intussusception cause by pedunculated cystic Polyp

containing hetertropic Panceatic tissue.Bombay Hospital Journal , Jan 07 (Author Status -I) 15) An unusual presentation of gastric volvulus in a Non traumatic diaphragmatic

Hernia in old man. Bombay Hospital Journal, July 2008. (Author Status -I)

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Completed Research Support

As a Guide for ICMR (Indian Council of Medical Research) for Under Graduate Research activities:

Comparitive study of Laparoscopic Versus Open Appendicectomy - 2008 Comparitive Trial between Harmonic Scalpel versus Conventional

Haemmorrhoidectomy - 2009.

Comparitive study of Laparoscopic Versus Open Hernia repair - 2010

As a Guide for Research Papers ( MS Gen. Surgery):

Outstanding Original Research Work:

55 HIV patients were operated (rejected mostly from private), studied & managed surgically prospectively. The various lesions were analyzed.

Other Research Work :

1) Comparative study of Laparoscopic Transabdominal Preperitoneal Inguinal hernia repair versus open inguinal mesh repair.

Maharashtra University of Health Sciences, Nashik 2009

2) Difficult Laparoscopic Gallbladder. Mumbai university submission:

May 2008.

3) Amoebic Liver Abscess in HIV Positive Patients. Mumbai university

submission: Nov 2007.

4) Surgery in the management of HIV patients. Mumbai university submission:

May 2007.

5) Surgical management of splenic hydatidosis. Mumbai university submission:

January 2006

6) Randomized clinical trial of laproscopic versus open appendicectomy.

Mumbai university submission: January 2005.

7) Prospective Randomized study of leproscopic versus opun high ligation of the testicular veins for the treatment of varicocele. Mumbai university submission:

January 2004.

8) Randomized clinical trial of the laproscopic VS open appendicectomy in over weight patients. Mumbai university submission: January 2004.

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CV of Co-investigator

NAME Dr. Pravin. Narsingrao.Tungenwar POSITION TITLE

Associate Professor, Division of Minimal Access Surgery/Bariatric/Metabolic Surgery

EDUCATION/TRAINING MS Surgery, FMAS, FICS, FAIS, FLCS, FBMS

INSTITUTION AND LOCATION

DEGREE (if

applicable)

MM/YY FIELD OF STUDY

Grant Government Medical College and Sir J.J. Group of Hospitals, Mumbai

MS Surgery, FMAS, FIAGES FBMS 01/2003 2008 02/2014 General Surgery

Minimal Access Surgery Gastrointestinal And Endoscopy Surgery Bariatric Surgery

A. Personal Statement

India is a global capital for Diabetes.

Type 2 diabetes mellitus is a chronic disease with severe long-term health consequences. Its importance in the Indian setup is immeasurable. The medical management of Diabetes mellitus has long been the only means of its treatment.

In patients with type 2 diabetes mellitus who are also morbidly obese, an abundance of clinical evidence exists showing that significant clinical improvement in their diabetes occurs following certain types of bariatric, or weight loss, surgical procedures. There is additional data showing that bariatric surgical procedures that bypass the beginning of the small intestine, such as the Roux-en Y gastric bypass, can markedly improve type 2 diabetes even before significant weight loss has occurred.

The relationship between obesity and type 2 diabetes mellitus is well known. Morbidly obese patients with T2DM who undergo bariatric surgery have improvement or remission of their diabetes.

At Grant Government Medical College and Sir J.J. Group Of Hospitals ( Tertiary Teaching Hospital And Regional Referral Center) I take this opportunity to provide quality healthcare to non-affording people and evaluate remission of diabetes.

Our center being the only government organization in state of Maharashtra , India where we routinely perform bariatric surgeries, we request you to give us this honour of research project and be a part in alleviating human suffering from diabetes.

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2003-2010 Assistant Professor, General Surgery, IGMC and Mayo General Hospital, Nagpur, India 2010-till date Associate Professor, General Surgery, Division of Minimal Access, Bariatric & Metabolic Surgery,

Grant Government Medical College & Sir J.J. Group of Hospitals, Mumbai , India Other Experience and Professional Memberships

2006 AMASI(Association of Minimal Access Surgeons of India) 2007 IAGES(Indian Association of Gastro-Endoscopic Surgeons) 2008 ASI (The Association of Surgeons Of India)

2014 OSSI Affiliated to IFSO(Obesity and Metabloic surgery society of India)

Honors

1) Government of Maharashtra Awarded the certificate of appreciation for the role played in the management of victims During the Mumbai Terror attacks on 26th November 2008.

2) Best Associate Professor in Surgery Award – 2011, at Grant Medical College & Sir JJ Group of Hospitals, Mumbai .

Trainings:

C. Selected Peer-reviewed Publications

1) Giant Solitary Fibrous Tumor of Pleura, Bombay Hospital Journal ,Vol. 50,N0. 3,493-5,2008 2) An Unusual Case of Intussusception in A Case of Abdominal Tuberculosis with HIV Disease, Bombay Hospital Journal ,333;3745,2006

3) Seminoma of Ectopic Testis in Polyorchidism Mimicking Bladder Tumor , Bombay Hospital Journal ,Vol. 51,N0. 3,378-9,2009

4) Small intestinal Gangrene and Perforation in Retroperitoneum ,Bombay Hospital Journal , Vol. 51,N0. 3,388-90,2009

5) Vulval Lipoma-A Rare Case Report, Bombay Hospital Journal ,Vol. 52,N0. 1,105-7,2010 6) Cholecysto Gastric Fistula With Mirizzi type I A Case report,Bombay Hospital Journal ,

7) Ricter's Type of small Bowel Herniation in an Epigastric Hernia, Bombay Hospital Journal ,Vol. 54,N0. 4,617-19,2012

8) As a Guide for ICMR (Indian Council of Medical Research) for Under Graduate Research activities: Role of Hydroheal as newer modality in wound Healing

References

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