A new biliodigestive anastomosis technique to prevent reflux and stasis

Side-to-Side Jejunoileal Bypass Induces Better Glucose-Lowering Effect than End-to-Side Jejunoileal Bypass on Nonobese Diabetic Rats

BACKGROUND

Jejunoileal bypass (JIB) can markedly ameliorate diabetes in obese patients and rodents. The aim of this study is to systematically evaluate the role of the operational manner and the retained distal small bowel length in mediating changes in glucose homeostasis after intestinal bypass surgeries in nonobese diabetic rats.

METHODS

Streptozotocin-induced diabetic rats underwent side-to-side jejunoileal bypass plus proximal loop ligation (SSJIBL), end-to-side jejunoileal bypass (ESJIB), proximal small bowel resection (PBR), and sham operation. Each operational manner included two subgroups, in which 30 cm (L-30) or 40 cm (L-40) distal small bowel was retained. Main outcome measures were fasting blood glucose levels (FBG), insulin sensitivity, serum insulin, glucagon-like peptide-1 (GLP-1), bilirubin (BIL), and total bile acids (TBA) levels.

RESULTS

Global food intake in the sham group was higher than in the operation groups, and global body weight and food intake in the SSJIBL group were higher than in the ESJIB and PBR groups. Global body weight and food intake in L-40 group were higher than in L-30 group. The SSJIBL procedure induced better improvement in glucose homeostasis and insulin sensitivity than the ESJIB and PBR procedures, and L-30 group showed better antidiabetic effects than L-40 group. Serum GLP-1, BIL, and TBA levels in SSJIBL group were higher than in ESJIB and PBR groups.

CONCLUSIONS

This study shows that side-to-side jejunoileal bypass induced better glucose-lowering effects than end-to-side jejunoileal bypass and proximal small bowel resection, and intestinal bypass surgery that retained shorter distal small bowel yielded better antidiabetic effects.

Breath Hydrogen as a Biomarker for Glucose Malabsorption after Roux-en-Y Gastric Bypass Surgery

Objective. Abdominal symptoms are common after bariatric surgery, and these individuals commonly have upper gut bacterial overgrowth, a known cause of malabsorption. Breath hydrogen determination after oral glucose is a safe and inexpensive test for malabsorption. This study is designed to investigate breath hydrogen levels after oral glucose in symptomatic individuals who had undergone Roux-en-Y gastric bypass surgery. Methods. This is a retrospective study of individuals (n = 63; 60 females; 3 males; mean age 49 years) who had gastric bypass surgery and then glucose breath testing to evaluate abdominal symptoms. Results. Among 63 postoperative individuals, 51 (81%) had a late rise (≥45 minutes) in breath hydrogen or methane, supporting glucose malabsorption; 46 (90%) of these 51 subjects also had an early rise (≤30 minutes) in breath hydrogen or methane supporting upper gut bacterial overgrowth. Glucose malabsorption was more frequent in subjects with upper gut bacterial overgrowth compared to subjects with no evidence for bacterial overgrowth (P < 0.001). Conclusion. These data support the presence of intestinal glucose malabsorption associated with upper gut bacterial overgrowth in individuals with abdominal symptoms after gastric bypass surgery. Breath hydrogen testing after oral glucose should be considered to evaluate potential malabsorption in symptomatic, postoperative individuals.

Asymptomatic gastric bacterial overgrowth after bariatric surgery: are long-term metabolic consequences possible?

BACKGROUND

Patients with postbariatric bacterial overgrowth were reinvestigated after a follow-up of 15 years. It was hypothesized that systemic associations analogous to those reported for whole gut microbiome would be revealed.

METHODS

Patients (n = 37, 70.3 % females, 42.4 ± 9.9 years old, preoperative BMI 53.5 ± 10.6 kg/m(2), current BMI 32.8 ± 10.8 kg/m(2)), all submitted to RYGB on account of morbid obesity, were followed during 176.8 ± 25.7 months. Blood tests included fasting blood glucose, HbA1c, liver and pancreatic enzymes, and lipid fractions. Bacterial overgrowth was diagnosed by quantitative culture of gastric fluid in both the excluded remnant and the gastric pouch, with the help of double-balloon enteroscopy. Absolute counts of aerobes and anaerobes in both gastric reservoirs were correlated with nutritional and biochemical measurements, aiming to identify clinically meaningful associations.

RESULTS

Patients denied diarrhea, abdominal pain, weight loss, or other symptoms related to bacterial overgrowth. Biochemical profile including enzymes was also acceptable, indicating a stable condition. Positive correlation of bacterial count in either segment of the stomach was demonstrated for BMI and gamma-glutamyl transferase, whereas negative correlation occurred regarding fasting blood glucose.

CONCLUSIONS

An antidiabetic role along with deleterious consequences for weight loss and liver function are possible in such circumstances. Such phenotype is broadly consistent with reported effects for the whole gut microbiome. Prospective controlled studies including molecular analysis of gastrointestinal fluid, and simultaneous profiling of the entire microbiome, are necessary to shed more light on these findings.

Treatment of hilar cholangiocarcinoma of Bismuth-Corlette type III with hepaticojejunostomy

Aim of the study

The present study aims to explore the value of application of hepaticojejunostomy in surgical treatment of Bismuth-Corlette type III hepatic hilar cholangiocarcinoma.

Material and methods

The clinical data of hepaticojejunostomy in 6 patients with Bismuth-Corlette type III hepatic hilar cholangiocarcinoma from January 2008 to October 2011 were retrospectively analyzed. There were 5 males and 1 female, aged 45–69 years, on average 58 years old. There were 3 cases of Bismuth-Corlette type IIIa and 3 cases of Bismuth-Corlette type IIIb.

Results

The 6 patients all successfully underwent hepaticojejunostomy, with operation time of 160–310 min, on average 210 ±28 min. One patient suffered a small amount of bile leakage (3–20 ml) and his drainage tube was taken out after being cured with conservative treatment for 18 days. Three patients showed postoperative mild increases of aspartate aminotransaminase (AST), alanine transaminase (ALT) and AKP, which were improved after drug treatments. There was no biliary stricture in the 6 patients after follow-up for 3–18 months.

Conclusions

Hepaticojejunostomy was simple and flexible, with a good effect on biliary reconstruction of Bismuth-Corlette type III hepatic hilar cholangiocarcinoma. It solved the difficulties in multiple choledochojejunostomy, and with less complications; therefore, it is worth being popularized.

Influence of biliary anastomosis on recovery from secondary biliary cirrhosis

OBJECTIVE

The influence of choledochoduodenostomy and choledochojejunostomy on the repair of hepatic lesions secondary to biliary obstruction is not well known. The aim of the present study was to compare the effects of choledochoduodenostomy and choledochojejunostomy on the recovery of these lesions in rats with biliary obstruction.

METHODS

Rats subjected to 4 weeks of biliary obstruction underwent choledochoduodenostomy (n=10) or choledochojejunostomy (n=10). The following variables were measured: total bilirubin, alkaline phosphatase, aminotransferases, and albumin. Hepatic mitochondrial energy metabolism was evaluated by calculating the respiratory control ratio and the oxidative phosphorylation index. Hepatic morphometry was used to estimate the mass of the hepatocytes, bile ducts, and fibrosis, as well as the hepatic stellate cell count.

RESULTS

After choledochoduodenostomy and choledochojejunostomy, there was a regression in cholestasis and a reduction in the oxidative phosphorylation index. However, the total bilirubin, alkaline phosphatase, albumin, and respiratory control ratio values improved only after choledochojejunostomy. The mass of the liver, spleen, and fibrosis was reduced after both choledochoduodenostomy and choledochojejunostomy, but the number of hepatic stellate cells increased. After choledochojejunostomy, the hepatic mass recovered completely, and the spleen mass was significantly reduced compared with that after choledochoduodenostomy. After both choledochoduodenostomy and choledochojejunostomy, enterobiliary reflux, biliary contamination, and an exacerbation in hepatic inflammation developed.

CONCLUSION

Choledochojejunostomy was more effective than choledochoduodenostomy, but both techniques induced enterobiliary reflux and biliary contamination, which may explain the maintenance of hepatic alterations, especially after choledochoduodenostomy.

Clinical and nutritional status in the late postoperative of pancreaticoduodenectomy: influence of pylorus preservation procedure

PURPOSE: To evaluate the nutritional status of patients in the late postoperative period of pancreaticoduodenectomy (PD) and compare the long-term outcome according to pylorus-preserving (PPPD) or the standard technique (SPD) in which the pylorus is resected. METHODS: This prospective study was conducted twelve months prior or more in patients who had underwent PD (PD Group, n=15) and health volunteers (Control Group, n=15). At a post hoc analysis, the PD Group was divided in PPPD Subgroup (n=9) and SPD Subgroup (n=6), according to the PD techniques. Gastrointestinal complaints and nutritional status were evaluated, apart from a biochemical assessment; Student t-test or Mann-Whitney test were used. RESULTS: The patients recovered their body weight and the gastrointestinal complaints were uncommon. The PD Group showed higher energy and protein intake even though BMI was lower than in Control Group. There were no differences in laboratorial data, except for higher glycemia, serum alkaline phosfatase and C-reactive protein in PD Group. There was no difference in the various parameters evaluated when the Subgroups (PPPD and SPD) were compared. CONCLUSION: For long-term pancreaticoduodenectomy, the gastrointestinal symptoms are minimal and the patients had the clinical and nutritional status preserved, regardless of pylorus preservation.

Evaluation of hepatobiliary excretion and enterobiliary reflux in rats with biliary obstruction submitted to bilioduodenal or biliojejunal anastomosis

Bilioduodenal and biliojejunal anastomoses are effective for the treatment of biliary obstruction. The objective of this study was to compare the effects of these anastomoses on hepatobiliary excretion and enterobiliary reflux. Enterobiliary reflux and biliary excretion were evaluated respectively after oral administration of technetium ((99m)Tc) in combination with sodium phytate and intravenous infusion of (99m)Tc with diisopropyl-iminodiacetic acid. Enterobiliary reflux occurred to an equal degree in the bilioduodenal and biliojejunal groups. Maximum hepatic activity time (T(max)) and radiotracer clearance half-time (T(1/2)) were similar in both groups. However, when compared with that found for the sham-operated group, T(max), and T(1/2) were higher in the biliojejunal group (P = 0.02 and P = 0.01, respectively). Histopathological analysis showed marked reduction in ductal proliferation in both groups. These data undermine the theoretical advantages attributed to biliojejunal anastomosis and further the understanding of the pathophysiology of cholangitis that occurs even with patent anastomosis.

"Hepar divisum"--as a rare donor complication after intraoperative mortality of the recipient of an intended living donor liver transplantation

In this study, we present our experience with 4 healthy donors having the rare condition of "hepar divisum" after the intraoperative death of the recipient of an intended right adult living donor liver transplantation (LDLT). The study included 4 donors and 4 intended right LDLT recipients affected by neuroendocrine tumor (n = 2), hepatocellular carcinoma (n = 1), and cryptogenic cirrhosis (n = 1). All 4 recipients died intraoperatively. At the time of recipient death, the dissection of the donor liver parenchyma was complete, the vessels intact, and the hepatic duct(s) already divided. In each case, reconstruction of the donor biliary tract was performed: hepaticojejunostomy (HJ) in 2 cases, each with 3 ducts, and duct-to-duct anastomosis in 2. Of the donors receiving the HJ, 1 had a cut surface bile leak and the other experienced an anastomotic leak, treated by percutaneous drainage and reoperation, respectively. The latter patient experienced recurrent HJ stenosis at 44 months and 50 months after the operation and was treated by percutaneous balloon dilatation. One duct-to-duct reconstruction was complicated by early stenosis (postoperative day 6) and treated with endoscopic stenting. In conclusion, in the case of intraoperative death of the recipient of an intended LDLT, when the parenchyma and the hepatic duct of the donor have already been divided, the options are completion of the donor hepatectomy or the status of "fegatum divisum" with reconstruction of biliary tract. The high incidence of biliary complication, however, is of concern. When more than 1 hepatic duct is present, the donor hepatectomy should be completed and the graft reallocated according to the policy of the transplant institution.

Small bowel transit and gastric emptying after biliodigestive anastomosis using the uncut jejunal loop

BACKGROUND

The Roux-en-Y loop is an effective procedure for biliodigestive drainage. However, up to 15% of patients suffer from postoperative cholangitis or blind loop syndrome. A new technique to prevent motility abnormalities has been developed.

METHODS

Male Lewis rats were used to compare gastric emptying and transit in the small bowel after either a standard Roux-en-Y anastomosis or a new biliodigestive anastomosis technique which involves creating an "uncut" jejunal loop with luminal occlusion. Unoperated rats served as controls. (99)Technetium HIDA and (111)Indium-tagged amberlite were respectively used to investigate small bowel transit and gastric emptying.

RESULTS

Histopathology showed distinctive abnormalities only in the liver of conventional Roux-en-Y animals. No recanalization of the obliterated gut lumen occurred in uncut Roux animals. Distribution of (99)Tc-HIDA and (111)In showed were similar in both groups. Gastric emptying is slowed in both groups.

CONCLUSIONS

The uncut proximal jejunum loop is a good alternative to the conventional Roux-en-Y loop and showed preserved small bowel motility and adequate jejunal transit. Gastric emptying is slowed in both groups.