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Tosta GA, de Almeida Leite RM, de Marchi DD, Ricciardi R, Zilberstein B. Efficacy and Safety of Sleeve Gastrectomy with Jejunoileal Bypass Compared with Roux-en-Y Gastric Bypass: Results from a Cohort Study. J Laparoendosc Adv Surg Tech A 2024; 34:1-6. [PMID: 37831926 DOI: 10.1089/lap.2023.0322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023] Open
Abstract
Background: We previously described sleeve gastrectomy with jejunoileal bypass (SGJIB) as promising novel technique for the surgical treatment of obesity Methods: A retrospective analysis of a prospective database in a Private Practice of Alimentary Tract Surgery in São Paulo, Brazil. We analyzed 176 patients with 60 months of follow-up, 74 of whom underwent Vertical Sleeve Gastrectomy with Jejunoileal Bypass (VSG-JIB) (50 women and 24 men) with a mean age of 38 years and a mean body mass index (BMI) of 40 kg/m2, and 102 patients underwent Roux-en-Y gastric bypass (RYGB) (90 women and 12 men) with a mean age of 36.5 years and a mean BMI of 39.73 kg/m2. Results: There was no statistically significant difference in long-term weight loss between the two groups. The rate of postoperative complications immediately after surgery was similar, but there was a tendency toward less severe complications in the SGJIB cohort. Conclusion: Sleeve gastrectomy with jejunoileal bypass is a novel surgical procedure for weight loss with comparable efficacy and safety compared with laparoscopic RYGB.
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Affiliation(s)
- Gil Abdallah Tosta
- Sao Leopoldo Mandic School of Medicine, Campinas, Brazil
- Gastromed Zilberstein Institute, São Paulo, Brazil
- Beneficencia Portuguesa Hospital, São Paulo, Brazil
| | - Rodrigo Moises de Almeida Leite
- Gastromed Zilberstein Institute, São Paulo, Brazil
- Beneficencia Portuguesa Hospital, São Paulo, Brazil
- Gastrointestinal Surgery Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Danilo Dallago de Marchi
- Sao Leopoldo Mandic School of Medicine, Campinas, Brazil
- Gastromed Zilberstein Institute, São Paulo, Brazil
- Beneficencia Portuguesa Hospital, São Paulo, Brazil
| | - Rocco Ricciardi
- Gastrointestinal Surgery Division, Massachusetts General Hospital, Boston, Massachusetts, USA
- Colon and Rectal Surgery Department, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Bruno Zilberstein
- Sao Leopoldo Mandic School of Medicine, Campinas, Brazil
- Gastromed Zilberstein Institute, São Paulo, Brazil
- Beneficencia Portuguesa Hospital, São Paulo, Brazil
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Zhou X, Bai L, Li QG, Xie J, Liu CA, Wen ZL. Clinical application of a novel stent-assisted in situ intestinal bypass in preventing postoperative anastomotic leakage for low-mid rectal cancer: A retrospective study. Medicine (Baltimore) 2023; 102:e35756. [PMID: 37933042 PMCID: PMC10627669 DOI: 10.1097/md.0000000000035756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/02/2023] [Indexed: 11/08/2023] Open
Abstract
This study aimed to investigate the safety and feasibility of a novel stent-assisted in situ intestinal bypass for low-mid rectal cancer patients. Patients who were diagnosed with rectal cancer and received laparoscopic low anterior rectal resection plus a novel stent-assisted in situ intestinal bypass were respectively included from March 2022 to June 2022. Biofragmentable intestinal stent with a protective sleeve was placed in the proximal colon before anastomosis, and feces could be discharged through the protective sleeve without touching the anastomosis, which achieved an in situ bypass of feces. Perioperative characteristics and short-term outcomes were collected. Rectal imaging was performed each week after surgery for the first 3 weeks to surveil the stent and feces delivery. Follow-ups were conducted for more than 3 months. Thirty patients who successfully received surgery were included in this study. There were 18 (60.0%) males and 12 (40.0%) females. As for perioperative characteristics, operation time was 213.8 ± 43.0 minutes, blood loss was 53.3 ± 24.6 mL, time to first flatus via protective sleeve after surgery was 3.2 ± 1.1 days, postoperative hospital stay was 11.8 ± 1.6 days, and time to discharge stent was 22.4 ± 3.2 days. As for short-term outcomes, 6 patients suffered from pneumonia, urinary tract infection or incision infection. During the follow-up, there was no anastomotic leakage or mortality. This novel stent-assisted in situ intestinal bypass is safe and feasible, it might be an applicable way to prevent postoperative anastomotic leakage for patients with low-mid rectal cancer.
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Affiliation(s)
- Xiong Zhou
- Department of Gastrointestinal Surgery, Yongchuan Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lian Bai
- Department of Gastrointestinal Surgery, Yongchuan Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qi-Gang Li
- Department of Gastrointestinal Surgery, Yongchuan Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jian Xie
- Department of Gastrointestinal Surgery, Yongchuan Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chang-An Liu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ze-Lin Wen
- Department of Gastrointestinal Surgery, Yongchuan Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Luo X, Tao F, Tan C, Xu CY, Zheng ZH, Pang Q, He XA, Cao JQ, Duan JY. Enhanced glucose homeostasis via Clostridium symbiosum-mediated glucagon-like peptide 1 inhibition of hepatic gluconeogenesis in mid-intestinal bypass surgery. World J Gastroenterol 2023; 29:5471-5482. [PMID: 37900993 PMCID: PMC10600812 DOI: 10.3748/wjg.v29.i39.5471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/11/2023] [Accepted: 10/11/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND The small intestine is known to play a crucial role in the development and remission of diabetes mellitus (DM). However, the exact mechanism by which mid-small intestinal bypass improves glucose metabolism in diabetic rats is not fully understood. AIM To elucidate the mechanisms by which mid-small intestinal bypass improves glucose metabolism. METHODS Streptozotocin (STZ) was used to induce DM in Sprague-Dawley (SD) rats at a dose of 60 mg/kg. The rats were then randomly divided into two groups: The mid-small intestine bypass (MSIB) group and the sham group (underwent switch laparotomy). Following a 6-wk recovery period post-surgery, the rats underwent various assessments, including metabolic parameter testing, analysis of liver glycogen levels, measurement of key gluconeogenic enzyme activity, characterization of the gut microbiota composition, evaluation of hormone levels, determination of bile acid concentrations, and assessment of the expression of the intestinal receptors Takeda G protein-coupled receptor 5 and farnesoid X receptor. RESULTS The MSIB group of rats demonstrated improved glucose metabolism and lipid metabolism, along with increased hepatic glycogen content. Furthermore, there was a decrease in the expression of the key gluconeogenic enzymes phosphoenolpyruvate carboxykinase 1 and glucose-6-phosphatase. Importantly, the MSIB group exhibited a substantial increase in the abundances of intestinal Lactobacillus, Clostridium symbiosum, Ruminococcus gnavus, and Bilophila. Moreover, higher levels of secondary bile acids, such as intestinal lithocholic acid, were observed in this group. Remarkably, the changes in the gut microbiota showed a significant correlation with the expression of key gluconeogenic enzymes and glucagon-like peptide 1 (GLP-1) at 6 wk postoperatively, highlighting their potential role in glucose regulation. These findings highlight the beneficial effects of mid-small intestine bypass on glucose metabolism and the associated modulation of the gut microbiota. CONCLUSION The findings of this study demonstrate that the introduction of postoperative intestinal Clostridium symbiosum in the mid-small intestine contributes to the enhancement of glucose metabolism in nonobese diabetic rats. This improvement is attributed to the increased inhibition of hepatic gluconeogenesis mediated by GLP-1, resulting in a favorable modulation of glucose homeostasis.
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Affiliation(s)
- Xin Luo
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi Province, China
| | - Fang Tao
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi Province, China
| | - Cai Tan
- Department of Women’s Health, Jiangxi Maternal and Child Health Hospital, Nanchang 330000, Jiangxi Province, China
| | - Chi-Ying Xu
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi Province, China
| | - Zhi-Hua Zheng
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi Province, China
| | - Qiang Pang
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi Province, China
| | - Xiang-An He
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi Province, China
| | - Jia-Qing Cao
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi Province, China
| | - Jin-Yuan Duan
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi Province, China
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Aktas A, Gokler C, Sansal M, Karadag N, Kayaalp C. Acute Liver Failure following Sleeve Gastrectomy with Jejuno-Ileal Bypass. Obes Res Clin Pract 2021; 15:297-299. [PMID: 33766490 DOI: 10.1016/j.orcp.2021.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 03/10/2021] [Accepted: 03/13/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric surgery in recent years, and some modifications have emerged to improve its efficacy. Melissas has described SG plus jejuno-ileal bypass (JIB), which has reported good results in a few studies. We performed this procedure in 21 cases and in one case, we observed acute liver failure (ALF) that has not been reported before. CASE PRESENTATION A 38-year-old female (BMI: 56.1 kg/m2) underwent laparoscopic SG plus JIB. There was no sign of diarrhea, malnutrition or liver failure for eight months and her BMI was 43.0 kg/m2. At the 9th month, she was hospitalized for abdominal pain, jaundice and ALF. The patient was treated by plasmapheresis and molecular absorptive recirculation system. She was planned to undergo liver transplantation but died of multiorgan failure on the 40th day of hospitalization. CONCLUSION ALF can be observed following SG plus JIB. JIB reversal before compromising liver functions should be taken into consideration.
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Affiliation(s)
- Aydin Aktas
- Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey.
| | - Cihan Gokler
- Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey.
| | - Mufit Sansal
- Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey.
| | - Nese Karadag
- Department of Pathology, Inonu University, Malatya, Turkey.
| | - Cuneyt Kayaalp
- Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey.
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Ida A, Miyaki A, Miyauchi T, Yamaguchi K, Naritaka Y. [Three Cases of Unresectable, Advanced, and Recurrent Colorectal Cancer Associated with Gastrointestinal Obstruction That Were Treated with Small Intestine-Transverse Colon Bypass Surgery]. Gan To Kagaku Ryoho 2016; 43:1632-1634. [PMID: 28133081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Herein, we report 3cases of unresectable, advanced, and recurrent colorectal cancer associated with gastrointestinal obstruction. The patients were treated with small intestine-transverse colon bypass surgery, which improved the quality of life (QOL)in all cases. Case 1 was an 80-year-old woman who presented with subileus due to ascending colon cancer. After surgery, her oral intake was reestablished, and she was discharged home. Case 2 was an 89-year-old woman whose ileus was caused by cecal cancer with multiple hepatic metastases. After surgery, the patient was discharged to a care facility. Case 3 was an 83-year-old man whose ileus was caused by a local recurrence and small intestine infiltration after surgery for rectosigmoid cancer. He underwent surgery after a colonic stent was inserted. His oral intake was re-established and he was discharged home. Small bowel-transverse colon bypass surgery can be used to manage various conditions rostral to the transverse colon. It is still possible to perform investigations in patients whose general condition is poorer than that of patients who undergo resection of the primary lesion. This avoids creating an artificial anus and allows continuation of oral intake, which are useful for improving QOL in terminal cases.
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Affiliation(s)
- Arika Ida
- Dept. of Surgery, Tokyo Women's Medical University Medical Center East
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Zhong MW, Liu SZ, Zhang GY, Zhang X, Hu SY. Effects of sleeve gastrectomy with jejuno-jejunal or jejuno-ileal loop on glycolipid metabolism in diabetic rats. World J Gastroenterol 2016; 22:7332-7341. [PMID: 27621579 PMCID: PMC4997644 DOI: 10.3748/wjg.v22.i32.7332] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 07/26/2016] [Accepted: 08/08/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To explore the effect of sleeve gastrectomy (SG) with jejuno-jejunal or jejuno-ileal loop on glycolipid metabolism in diabetic rats.
METHODS Diabetic rats, which were induced by high-fat diet (HFD), nicotinamide and low-dose streptozotocin, underwent sham operations, SG, SG with jejuno-ileal loop (SG-JI) and SG with jejuno-jejunal loop (SG-JJ) followed by postoperative HFD. Then, at the time points of baseline and 2, 12 and 24 wk postoperatively, we determined and compared several variables, including the area under the curve for the results of oral glucose tolerance test (AUCOGTT), serum levels of triglyceride, cholesterol and ghrelin in fasting state, homeostasis model assessment of insulin resistance (HOMA-IR), body weight, calorie intake, glucagon-like peptide (GLP)-1 and insulin secretions after glucose gavage at dose of 1 g/kg.
RESULTS At 2 wk postoperatively, rats that underwent SG, SG-JJ and SG-JI, compared with sham-operated (SHAM) rats, demonstrated lower body weight, calorie intake and ghrelin (P < 0.05 vs SHAM), enhanced secretion of insulin and GLP-1 after glucose gavage (P < 0.05 vs SHAM), improved AUCOGTT, HOMA-IR, fasting serum triglyceride and cholesterol (AUCOGTT: 1616.9 ± 83.2, 837.4 ± 83.7, 874.9 ± 97.2 and 812.6 ± 81.9, P < 0.05 vs SHAM; HOMA-IR: 4.31 ± 0.54, 2.94 ± 0.22, 3.17 ± 0.37 and 3.41 ± 0.22, P < 0.05 vs SHAM; Triglyceride: 2.35 ± 0.17, 1.87 ± 0.23, 1.98 ± 0.30 and 2.04 ± 0.21 mmol/L, P < 0.05 vs SHAM; Cholesterol: 1.84 ± 0.21, 1.53 ± 0.20, 1.52 ± 0.20 and 1.46 ± 0.23 mmol/L). At 12 wk postoperatively, rats receiving SG-JJ and SG-JI had lower body weight, reduced levels of triglyceride and cholesterol and elevated level of GLP-1 compared to those receiving SG (P < 0.05 vs SG). At 24 wk after surgery, compared with SG, the advantage of SG-JJ and SG-JI for glucolipid metabolism was still evident (P < 0.05 vs SG). SG-JI had a better performance in lipid metabolism and GLP-1 secretion of rats than did SG-JJ.
CONCLUSION SG combined with intestinal loop induces better glycolipid metabolism than simple SG, with the lipid metabolism being more improved with SG-JI compared to SG-JJ.
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Li X, Ke C. [Recent advances of anastomosis techniques of esophagojejunostomy after laparoscopic totally gastrectomy in gastric tumor]. Zhonghua Wei Chang Wai Ke Za Zhi 2015; 18:512-515. [PMID: 26013872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The esophageal jejunum anastomosis of the digestive tract reconstruction techniques in laparoscopic total gastrectomy includes two categories: circular stapler anastomosis techniques and linear stapler anastomosis techniques. Circular stapler anastomosis techniques include manual anastomosis method, purse string instrument method, Hiki improved special anvil anastomosis technique, the transorally inserted anvil(OrVil(TM)) and reverse puncture device technique. Linear stapler anastomosis techniques include side to side anastomosis technique and Overlap side to side anastomosis technique. Esophageal jejunum anastomosis technique has a wide selection of different technologies with different strengths and the corresponding limitations. This article will introduce research progress of laparoscopic total gastrectomy esophagus jejunum anastomosis from both sides of the development of anastomosis technology and the selection of anastomosis technology.
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Affiliation(s)
- Xi Li
- Department of Gastrointestinal Surgery, Changhai Hospital, The Second Military Medical University, Shanghai 200433, China.
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Siemion L, Bandurski J, Malinger S. [The results of treatment of gastric cancer in the Provincial Hospital in Zielona Góra]. Przegl Lek 2015; 72:120-125. [PMID: 26731867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Gastric cancer is the third leading cause of death from cancer worldwide in both sexes, following lung and breast cancer. The incidence of gastric cancer in Poland is approximately 5% in men and approximately 2.5% in women, among the complete incidence of cancers. Deaths from gastric cancer in men in Poland in 2009 amounted to 6.6%, while in women--4.6%. The highest mortality rate in men is observed in the Lubuskie, Podkarpackie, Slaskie and Opolskie provinces. European average 5-year survival in the EUROCARE-4 study is 24.5%. AIM The aim of this paper was to assess the treatment of gastric cancer in the Department of General and Oncological Surgery of the Provincial Hospital in Zielona Góra. MATERIALS AND METHODS The retrospective analysis of 109 patients with gastric cancer, operated in the years 2003-2007, was performed. The analysis included patients scheduled for admission with the histopathological confirmation of adenocarcinoma, prepared to and subjected to laparotomy. The post-operative intrahospital deaths were estimated up to 30 days after surgery. The analysis of the survival rates was performed up to 1, 6, 12, 36 and 60 months since lapatoromy. All the continuous variables with the standard distribution were expressed as the mean ± standard deviation, while the total survival rates were assessed by means of the Kaplan-Meier method. RESULTS 55 patients (50.5%) underwent the radical surgical procedure intended to cure them. The remaining 54 patients (49.5%) could not be qualified for the radical surgical procedures. In 35 cases (32%) underwent laparotomy with biopsy, in 19 cases (17%) palliative surgery (intestinal bypass, gastrostomy, palliative resection). Out of 55 patients underwent the radical surgical procedure 9 patients died after the procedure (16.4%). The survival rates calculated for all the patients revealed that 21.1% patients survived 5 years after the surgery. CONCLUSIONS Almost a half of the patients (49.5%) who were admitted for treatment had an advanced stage of the disease that could not be qualified for the radical surgical procedures. The distant results of surgical treatment are non-satisfactory due to the fact that the disease was so advanced. 5-year-long survival rates (21.1% in our data) are higher that the ones listed in the EUROCARE-4 test for Poland (14.4%), but lower than the European average (24.5%).
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Sun X, Zheng M, Song M, Bai R, Cheng S, Xing Y, Yuan H, Wang P. Ileal interposition reduces blood glucose levels and decreases insulin resistance in a type 2 diabetes mellitus animal model by up-regulating glucagon-like peptide-1 and its receptor. Int J Clin Exp Pathol 2014; 7:4136-4142. [PMID: 25120793 PMCID: PMC4129028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Accepted: 06/23/2014] [Indexed: 06/03/2023]
Abstract
This study is to explore the possible mechanism of ileal interposition (IT) treatment of glycemic control of the type 2 diabetes mellitus (T2DM) by establishing an IT animal model. Twelve T2DM rats (GK rats) of 8-week old were divided into GK IT surgery group (GK-IT) and GK sham group (GK-Sham). Six Wistar rats were used as the non-T2DM sham group (WS-Sham). Enzyme-linked immunosorbent assay was used to detect plasma insulin concentration and fasting pancreas glucagon-like peptide-1 (GLP-1) concentration changes. Homeostasis model assessment of insulin resistance was used to quantitatively measure insulin resistance. Glucagon-like peptide-1 receptor (GLP-1R) expression was detected by Western blotting. IT significantly decreased fasting blood glucose level and the oral glucose tolerance, and reduced insulin resistance of GK rats by increasing GLP-1 concentration and GLP-1R levels. The postoperative pancreatic β-cell apoptosis rate of GK-Sham group was significantly higher than those in the GK-IT group and the WS-Sham group. IT significantly reduces blood glucose and decreases insulin resistance by up-regulating GLP-1 concentrations and GLP-1R levels, which may contribute to insulin secretion of pancreatic β-cells and decreases apoptosis of pancreatic β-cell.
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Affiliation(s)
- Xu Sun
- Department of Gastrointestinal Tumor Surgery, Shandong Cancer Hospital440 Jiyan Road, Jinan 250117, Shandong, China
| | - Meizhu Zheng
- Breast Cancer Center, Shandong Cancer Hospital440 Jiyan Road, Jinan 250117, Shandong, China
| | - Maomin Song
- Department of General Surgery, Beijing Tiantan Hospital, Capital Medical UniversityBeijing 100050, China
| | - Rixing Bai
- Department of General Surgery, Beijing Tiantan Hospital, Capital Medical UniversityBeijing 100050, China
| | - Shi Cheng
- Department of General Surgery, Beijing Tiantan Hospital, Capital Medical UniversityBeijing 100050, China
| | - Ying Xing
- Department of General Surgery, Beijing Tiantan Hospital, Capital Medical UniversityBeijing 100050, China
| | - Huisheng Yuan
- Department of General Surgery, Beijing Tiantan Hospital, Capital Medical UniversityBeijing 100050, China
| | - Pilin Wang
- Department of General Surgery, Beijing Tiantan Hospital, Capital Medical UniversityBeijing 100050, China
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Patel RT, Shukla AP, Ahn SM, Moreira M, Rubino F. Surgical control of obesity and diabetes: the role of intestinal vs. gastric mechanisms in the regulation of body weight and glucose homeostasis. Obesity (Silver Spring) 2014; 22:159-69. [PMID: 23512969 DOI: 10.1002/oby.20441] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 02/18/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To elucidate the specific role of gastric vs. intestinal manipulations in the regulation of body weight and glucose homeostasis. DESIGN AND METHODS The effects of intestinal bypass alone (duodenal-jejunal bypass -DJB) and gastric resection alone (SG) in Zucker Diabetic Fatty (ZDF) rats were compared. Additional animals underwent a combination procedure (SG + DJB). Outcome measures included changes in weight, food intake (FI), oral glucose tolerance (GT) and gut hormones. RESULTS DJB did not substantially affect weight and FI, whereas SG significantly reduced weight gain and food consumption. DJB rats showed weight-independent improvement in GT, which improved less after SG. Furthermore, SG significantly suppressed plasma ghrelin and increased insulin, glucagon like peptide-1 (GLP-1), glucose-dependent insulinotropic peptide and peptide YY response to oral glucose whereas DJB had no effects on postprandial levels of these hormones. DJB restored postprandial glucagon suppression in diabetic rats whereas SG did not affect glucagon response. The combination procedure (SG + DJB) induced greater weight loss and better GT than SG alone without reducing food intake further. CONCLUSIONS These findings reveal a dominant role of the stomach in the regulation of body weight and incretin response to oral glucose whereas intestinal bypass primarily affects glucose homeostasis by a weight-, insulin- and incretin-independent mechanism.
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Affiliation(s)
- Rajesh T Patel
- Section of GI Metabolic Surgery, Diabetes Surgery Center, Department of Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY 10065, USA
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Abstract
Limited information is available regarding reversal of gastric bypass. While reversal will lead to weight regain and return of comorbid conditions, procedure reversal is sometimes necessary due to complications. The decision to reverse versus revise is difficult; currently, there are no established guidelines. The objective was to review one center's experience with reversals of gastric bypass and jejunoileal bypass procedures and identify potential indications as well as technical feasibility and short-term outcomes. A retrospective review of a prospectively collected database from 1999 to 2010 was conducted; 12 patients who underwent reversal of non-banding bariatric procedures were included. There was no major perioperative morbidity in elective patients; one patient whose reversal was part of a second-look operation had massive intestinal necrosis. There was one (8.3 %) non-procedure-related postoperative death. No leaks were identified in any of the reversals. Leak rates were compared with other revisional procedures such as reversals, revisions, and conversions, with no statistical significance regarding leak rates between all three groups; however, revisions and conversions were performed via open or laparoscopic approach, while reversals were performed exclusively via open approach. Reversals of bariatric (non-banding) procedures, either combined or purely malabsorptive, are technically challenging. Indications remain poorly defined. In our experience, short gut syndrome, renal failure, marginal ulceration, and malnutrition were the most common indications for reversal, differing from previously published data. Indications can depend on patient and surgeon preferences, but primarily on surgeon experience and type of complications. Based on this initial experience, these operations can be performed using the open approach with good outcomes.
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Frige' F, Laneri M, Veronelli A, Folli F, Paganelli M, Vedani P, Marchi M, Noe' D, Ventura P, Opocher E, Pontiroli AE. Bariatric surgery in obesity: changes of glucose and lipid metabolism correlate with changes of fat mass. Nutr Metab Cardiovasc Dis 2009; 19:198-204. [PMID: 18684601 DOI: 10.1016/j.numecd.2008.04.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Revised: 04/08/2008] [Accepted: 04/17/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Bariatric surgery induces significant weight loss and improves glucose metabolism in obese patients (BMI>35 kg/m(2)). Our aim was to compare restrictive (LAGB, laparoscopic gastric banding) and malabsorptive approaches (BIBP, biliary-intestinal bypass) on the loss of fat-free mass (FFM), fat mass (FM), and on changes of glucose and lipid metabolism. METHODS AND RESULTS Body composition (bio-impedance analysis, BIA), blood glucose (BG), insulin, triglycerides, total- and HDL-cholesterol, liver enzymes (AST and ALT) were measured at baseline and 1 year after surgery in patients undergoing LAGB, BIBP, and in diet-treated control patients. In the main study, with patients matched for initial BMI (43-55 kg/m(2), LAGB=24, BIBP=12, controls=6), decreases of BMI, FM, BG and cholesterol were greater in patients with BIBP than with LAGB (p<0.01), while decreases of FFM, insulin, HOMA-IR and triglycerides were similar. No effects on BMI, FM, FFM, BG, insulin, HOMA-IR or cholesterol were observed in the control patients. Decreases of BG, insulin, HOMA-IR, cholesterol and triglycerides correlated with FM but not with FFM decrease. Similar results were obtained in an additional study in patients with a different initial BMI (LAGB=25, BIBP=6, controls=24) and when considering all subjects together. A decrease of liver enzymes (ALT) was greater with LAGB than with BIBP, and HDL-cholesterol increased with LAGB and decreased with BIBP. CONCLUSION BMI, FM, BG and cholesterol decrease more with malabsorptive than with restrictive surgery, while FFM, insulin, HOMA-IR and triglycerides decrease in a similar way. FFM loss is of low entity. Changes of glucose and lipid metabolism are proportional to a decrease of fat mass but not of fat-free mass.
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Affiliation(s)
- F Frige'
- Università degli Studi di Milano, Milano, Italy
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García-Fuentes E, García-Almeida JM, García-Arnés J, García-Serrano S, Rivas-Marín J, Gallego-Perales JL, Rojo-Martínez G, Garrido-Sánchez L, Bermudez-Silva FJ, Rodríguez de Fonseca F, Soriguer F. Plasma visfatin concentrations in severely obese subjects are increased after intestinal bypass. Obesity (Silver Spring) 2007; 15:2391-5. [PMID: 17925464 DOI: 10.1038/oby.2007.284] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Visfatin has shown to be increased in obesity and in type 2 diabetes. The aim of this study was to determine the change in plasma visfatin in severely obese (SO) persons after weight loss following bariatric surgery in relation to glucose concentration. RESEARCH METHODS AND PROCEDURES Visfatin and leptin were studied in 53 SO persons (BMI, 54.4 +/- 6.8 kg/m(2)) before and 7 months after bariatric surgery and in 28 healthy persons (BMI, 26.8 +/- 3.8 kg/m(2)). All of the patients underwent bariatric surgery with biliopancreatic diversion or gastric bypass. RESULTS The pre-surgery levels of visfatin in the SO group were greater than in the control group (55.9 +/- 39.9 vs. 42.9 +/- 16.6 ng/mL, p = 0.024). This increase was significant in the SO group with impaired fasting glucose (63.4 +/- 36.6 ng/mL) and diabetes (60.0 +/- 46.0 ng/mL). SO patients with normal fasting glucose had similar levels of visfatin to the controls. Seven months after surgery, visfatin levels were significantly increased (84.8 +/- 32.8 ng/mL, p < 0.001). This increase was independent of the pre-surgical glucose levels. The type of bariatric surgery had no influence on visfatin levels. Post-surgical visfatin was significantly correlated with the post-surgery plasma concentrations of leptin (r = 0.39, p = 0.014). DISCUSSION Plasma levels of visfatin in the SO group were increased but only when accompanied by high glucose levels, even in the range of impaired fasting glucose. Bariatric surgery causes an increase in visfatin, which is correlated mainly with the changes produced in the leptin concentration.
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Affiliation(s)
- Eduardo García-Fuentes
- Fundación Instituto Mediterraneo para el Avance de la Biomedicina y la Investigación Biosanitaria (IMABIS), Málaga, Spain.
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14
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Abstract
Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction that is characterized by a thick grayish-white fibrotic membrane encasing the small bowel. SEP can be classified as idiopathic, also known as abdominal cocoon, or secondary. It is difficult to make a definite pre-operative diagnosis. We experienced five cases of abdominal cocoon, and the case files were reviewed retrospectively for the clinical presentation, operative findings and outcome. All the patients presented with acute, subacute and chronic intestinal obstruction. Computed tomography (CT) showed characteristic findings of small bowel loops congregated to the center of the abdomen encased by a soft-tissue density mantle in four cases. Four cases had an uneventful post-operative period, one case received second adhesiolysis due to persistent ileus. The imaging techniques may facilitate pre-operative diagnosis. Surgery is important in the management of SEP.
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Affiliation(s)
- Ping Xu
- Department of Gastroenterology, First Affiliated Hospital, Zhejiang University School of Medicine, Qingchun Road 79, Hangzhou 310003, Zhejiang Province, China
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15
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Russo V, Ammendola E, De Crescenzo I, Ricciardi D, Capuano P, Topatino A, Docimo L, Santangelo L, Calabrò R. Effect of Weight Loss following Bariatric Surgery on Myocardial Dispersion of Repolarization in Morbidly Obese Patients. Obes Surg 2007; 17:857-65. [PMID: 17894142 DOI: 10.1007/s11695-007-9160-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Weight-stable obese subjects have an increased risk of arrhythmias and sudden death, even in the absence of cardiac dysfunction, and the risk of sudden cardiac death (SCD) with increasing weight is seen in both genders. The mechanism of unexplained deaths in obese patients is still unclear and may be related to ventricular repolarization abnormalities. The aim of this study is to determine the effect of severe obesity on spatial and transmural ventricular repolarization and to clarify the influence of bariatric surgery with a consequent substantial weight loss on arrhythmogenic substrate in the morbidly obese population. METHODS For the study, we enrolled 100 severely obese patients; 50 age-matched non-obese healthy subjects were also recruited as controls. All subjects underwent conventional 12-lead electrocardiography for analysis of spatial and transmural ventricular repolarization assessed by corrected QT dispersion (QTc-d), corrected JT dispersion (JTc-d) and transmural dispersion of repolarization, (TDR). All subjects underwent bariatric surgery and were resubmitted to electrocardiographic, biochemical and anthropometric examination 12 months postoperatively. RESULTS Severely obese patients had greater values in QTc-d, JTc-d and TDR than the normal-weight controls. Bariatric surgery reduced significantly the QTc-d value, JTc-d value and TDR value. There was a significant correlation between decrease of heterogeneity of repolarization indexes (QTd, JTd and TDR) and bariatric surgery-induced weight loss. CONCLUSIONS In severely obese patients, surgically-induced weight loss is associated with significant decrease in the heterogeneity of ventricular repolarization. The reduction of spatial (QTc-d, JTc-d) and transmural dispersion of repolarization (TDR) may be of clinical significance, by reducing the risk of potentially fatal arrhythmias in morbidly obese subjects.
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16
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Abstract
Jejunoileal bypass (JIB) is a purely malabsorptive operation, which has been abandoned in the USA and Western Europe due to occasional serious complications. We are still seeing past JIB patients who have become obese again over the years, but are not suffering side-effects of the previous JIB, and are complaining of typical co-morbidities of the obesity. We present a prior JIB patient who underwent a sleeve gastrectomy in 2003 for recurrence of morbid obesity. The patient has been followed for another 4 years with regular laboratory tests, monitoring of weight loss, bone densitometry and possible complications. Selected morbidly obese patients who have undergone past JIB, can be safely treated by a restrictive procedure, sleeve gastrectomy, to accomplish successful weight loss without increasing the risk of possible serious complications.
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17
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Abstract
BACKGROUND One of the reasons why jejunoileal bypass (JIB) was abandoned were reports of liver failure. The aim of this study was to describe histological findings in the intraoperative and follow-up liver biopsies of a cohort of super-obese patients who had undergone JIB. METHODS 50 consecutive patients underwent JIB. Samples of liver biopsies performed intraoperatively (41 patients) and in the follow-up (31 patients) were evaluated. Brunt's scale was used. RESULTS Mean age at operation was 37.9 +/- 7.6 years, and 15 patients (30.6%) had diabetes type 2, 20 (40.8%) had dyslipidemia, 29 (59.2%) had high blood pressure, and one (0.5%) had hepatitis C. Mean BMI preoperatively was 52.8 +/- 7.5 kg/m(2). Mean follow-up time was 67.0 +/- 42.8 months. At the time of the latest liver biopsy, the mean BMI was 35.7 +/- 7.5 kg/m(2). The % excess weight loss (%EWL) was 62.4 +/- 20.0%. 8 deaths (16%) have occurred, none from liver-related complications. At liver biopsy during the JIB operation, NAFLD was confirmed in 36 patients (86.7%) and NASH in 13 (31.7%). In 25 patients with mean follow-up of 4.8 +/- 4.0 years, there was no statistically significant change in the liver histology regarding the extent of steatosis (P=0.20), steatohepatitis (P=0.74) and fibrosis (P=0.71). CONCLUSIONS There was a significant metabolic improvement, maintenance of the %EWL, and no worsening of liver histology. There has possibly been a publication bias concerning liver outcomes, where the type of JIB and the concomitance of hepatitis C were not taken into account.
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19
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Abstract
Peptide YY (PYY) is secreted as a 36 amino acid, straight chain polypeptide, and is found in greatest concentrations in the terminal ileum, colon and rectum. After secretion, dipeptidyl peptidase IV (DPP-IV) cleaves the N-terminal Tyrosine-Proline residues from PYY(1-36), producing PYY(3-36). PYY(1-36) acts at all four human Y receptors, Y1, Y2, Y4 and Y5, while PYY(336) is a specific Y2 receptor agonist. PYY participates in the regulation of appetite and weight balance through hypothalamic-based mechanisms. PYY(1-36) stimulates appetite and weight gain through Y1 and Y5 receptors. PYY(3-36) suppresses appetite and stimulates weight loss through Y2 receptors. GI diseases that cause malabsorption increase both basal and meal-stimulated PYY levels. In contrast, obesity decreases both basal and meal-stimulated PYY levels. Mutations in the human PYY and Y2 receptor genes may contribute to the development of obesity. Small bowel resection elevates PYY levels in humans. Colon resections increase PYY levels in animal models but not in man. PYY changes following bariatric operations are incompletely studied. Vertical banded gastroplasty, open Roux-en-Y gastric bypass and jejunoileal bypass significantly elevate basal and meal-stimulated PYY levels. In dogs with Pavlov pouches, Roux-en-Y duodenojejunostomy (duodenal switch) increases PYY levels compared to Roux-en-Y gastrojejunostomy. DPP-IV activity is increased in obese individuals and remains increased after biliopancreatic diversion. Thus, diseases or operations which cause malabsorption, elevate basal and meal-stimulated PYY levels. Bariatric operations also increase basal and meal-stimulated PYY levels. This suggests that the combination of increased PYY levels and elevated levels of DPP-IV observed after bariatric operations may generate increased circulating levels of PYY(3-36), leading to hypothalamic-mediated suppression of appetite and promotion of weight loss through Y2 receptor mediated mechanisms.
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Affiliation(s)
- Garth H Ballantyne
- Director of Minimally Invasive and Telerobotic Surgery, Hackensack University Medical Center, Hackensack, NJ 07601, USA.
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20
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Abstract
Obesity is one of the most preventable causes of morbidity and mortality of the 21st century. Chronic kidney disease (CKD) has been a largely overlooked consequence of obesity; however, accumulating evidence elucidates the association. Obesity is at the core, promoting a cascade of secondary pathologies including diabetes, dyslipidemia, inflammation, hypertension, and the metabolic syndrome; these comorbidities constitute great risk for CKD. With the diagnosis of CKD, there is an increased threat of cardiovascular disease and the attendant increase in morbidity and mortality rates. Substantial weight loss in the obese population can be effectively achieved and maintained through bariatric surgery, which confers major health benefits by producing resolution or improvement of obesity-related comorbidities. This surgical procedure presents an early hazard of acute on chronic kidney failure, which is offset by a potential improvement in the risk of CKD progression with anticipated improvement in hypertension, diabetes, and CKD risk factors. Future research is needed to describe the clinical course and risks and benefits of bariatric surgery in the CKD population.
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Affiliation(s)
- Kerstyn C Zalesin
- Department of Medicine, Divisions of Cardiology, Nutrition and Preventive Medicine, William Beaumont Hospital, Royal Oak, MI 48073, USA.
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Uchida K, Konishi N, Inoue M, Otake K, Kusunoki M. A case of congenital jejunal atresia associated with bilateral athelia and choanal atresia: new syndrome spectrum. Clin Dysmorphol 2006; 15:37-38. [PMID: 16317306 DOI: 10.1097/01.mcd.0000184967.53855.a6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We present a case of bilateral choanal atresia, cleft of the posterior palate. Cardiac, respiratory and central nervous system examinations were normal. An examination of the chest revealed aplasia of the bilateral absence of the bilateral nipple-areola complex. Skin, soft tissue and bilateral pectoral muscles of the chest wall were normal. The patient did not have scalp nodules or abnormal ears. Four hours after birth, an X-ray examination showed the distended intestinal loops, suggesting small bowel obstruction. Exploration was performed and congenital jejunal atresia was surgically identified. A primary anastomosis was performed. At 3 years of age, the patient had mild mental and growth retardation. Chromosome analysis was normal (46,XX). Magnetic resonance imaging showed no abnormal finding in the spinal cord; however, mild atrophy of the left cerebrum was pointed out. An abdominal echo examination showed no abnormal findings in the kidney. These associations may represent a previously undescribed syndrome spectrum.
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Affiliation(s)
- Keiichi Uchida
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Mie, Tsu, Japan
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22
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Abstract
Bariatric operations are either restrictive, limiting the amount of food ingested; malabsorptive, limiting the amount of nutrient absorbed; or a combination of both. Bariatric surgery dates back to the 1950s when jejunoileal bypass was introduced. Since then, numerous improvements have been made in procedures and techniques. Currently, the two most common bariatric procedures performed are laparoscopic adjustable gastric banding and laparoscopic Roux-en-Y gastric bypass. Both of these operations provide excellent results, with the majority of patients losing more than 50% of their excess weight and with most obesity-related comorbidities such as diabetes and hypertension reversed or prevented. Morbidly obese patients considering such operations have to meet strict criteria and must be evaluated by a multidisciplinary team. They need to commit to long-term dietary changes, behavioral modifications, and medical supervision. The choice of procedure is guided by multiple factors, including the patient's and the surgeon's preference.
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Affiliation(s)
- J R Salameh
- Department of Surgery, University of Mississippi, Jackson, Mississippi 39216, USA.
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23
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Dallal RM, Akhondzadeh M. Minimally invasive management of complications from jejunoileal bypass. Surg Obes Relat Dis 2006; 2:226-7. [PMID: 16925349 DOI: 10.1016/j.soard.2006.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2005] [Revised: 12/31/2005] [Accepted: 01/09/2006] [Indexed: 11/23/2022]
Affiliation(s)
- Ramsey M Dallal
- Department of Surgery, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA.
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Kelley M, Jain A, Kashyap R, Orloff M, Abt P, Wrobble K, Venkataramanan R, Bozorgzadeh A. Change in Oral Absorption of Tacrolimus in a Liver Transplant Recipient After Reversal of Jejunoileal Bypass: Case Report. Transplant Proc 2005; 37:3165-7. [PMID: 16213338 DOI: 10.1016/j.transproceed.2005.07.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Jejunoileal bypass (JIB) was, at one time, a popular surgical technique for the treatment of morbid obesity. However, this operation was also associated with major complications. Consequently, many such procedures were eventually reversed. One of the most serious of these complications was liver failure. For those patients who developed cirrhosis, liver transplantation was one therapeutic alternative. Tacrolimus is one of the primary immunosuppressive agents used in liver transplantation. It is effective to prevent acute rejection episodes, but shows a narrow therapeutic index and can cause nephrotoxicity and neurotoxicity. This report describes the change in tacrolimus absorption that was observed after JIB reversal in a 57-year-old female liver transplant recipient. RESULTS Prior to JIB reversal, the mean tacrolimus dose was 7 mg twice daily with a whole-blood tacrolimus concentration ranging from 5.2 to 6.4 ng/mL. There was no appreciable peak in tacrolimus concentration, and the area under the concentration-time curve (AUC) was 10.9 ng/mL/h. After reversal, the daily tacrolimus dose was decreased to 5 mg twice daily, with a now-discernable peak concentration at 3 hours postdose. Furthermore, the AUC increased 90% to 20.7 ng/mL/h. CONCLUSION After JIB reversal, the patient showed higher systemic levels of tacrolimus and required lower steady-state doses. It is therefore imperative that such patients be monitored closely to avoid tacrolimus-related toxicity.
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Affiliation(s)
- M Kelley
- Department of Pharmacy, Division of Transplantation, University of Rochester Medical Center-Strong Memorial Hospital, Rochester, New York 14642, USA
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Schuetz P, Peterli R, Ludwig C, Peters T. Fatigue, weakness, and sexual dysfunction after bariatic surgery - not an unusual case but an unusual cause. Obes Surg 2004; 14:1025-8. [PMID: 15329198 DOI: 10.1381/0960892041719653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Malabsorptive bariatic surgery for morbid obesity has been very effective in producing weight loss. However, patients may experience some degree of malnutrition, which may lead to various clinical symptoms, such as fatigue and weakness. Morbid obesity is often associated with impaired reproductive function, and weight loss generally improves sexual function in both sexes. However, women with extreme weight loss may experience secondary amenorrhea. In men, zinc deficiency may lead to impaired testosterone synthesis resulting in hypogonadism and impotency. CASE REPORT A 43-year-old male 5 years after jejunoileal bypass for morbid obesity performed in a foreign institution presented with a recent history of progressive fatigue, general weakness, and declining libido and potency. Unexpectedly, his symptoms were not related to the operation or to his weight loss but rather to a structural cause. Endocrine and radiologic evaluations revealed a cystic tumor in the sella turcica causing partial hypopituitarism and secondary hypogonadism. CONCLUSION Long-term follow-up is mandatory in patients after bariatic surgery. Non-specific symptoms and findings should be further investigated. A loss of sexual activity and performance may have causes other than the previous bariatic operation.
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Affiliation(s)
- Philipp Schuetz
- Department of Internal Medicine, St. Claraspital, Basel, Switzerland.
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Lubrano C, Cornoldi A, Pili M, Falcone S, Brandetti F, Fabbrini E, Ginanni-Corradini S, Eramo A, Marini M, Migliaccio S, Giancotti V, Badiali M, Falsetto N, Prossomariti G, Spera G. Reduction of risk factors for cardiovascular diseases in morbid-obese patients following biliary-intestinal bypass: 3 years' follow-up. Int J Obes (Lond) 2004; 28:1600-6. [PMID: 15543161 DOI: 10.1038/sj.ijo.0802782] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Obese patients are often affected by hypertension, dyslipidaemia, impaired glucose metabolism, and suffer from cardiovascular disease (CVD), related to the characteristic metabolic alterations. AIM OF THE STUDY To evaluate reduction of risk factors for CVDs in morbid-obese patients (body mass index (BMI)>40 kg/m2) after weight loss upon bariatric surgery intervention of biliary-intestinal bypass. SUBJECTS 45 (17 men, 28 women) morbid-obese patients (age: 19-49 y, BMI>40 kg/m2). All patients were selected on the basis of medical history, physical and biochemical evaluation and of psychiatric tests, which were performed on all individuals admitted to our Day Hospital to verify the safety of surgical intervention. MEASUREMENTS Body weight, body composition (by dual X-ray absorptiometry, DXA), blood pressure, lipid profile, fibrinogen and glucose metabolism were monitored at baseline and 1, 3, 6, 9, 12, 24 and 36 months after surgery. RESULTS A significant and persistent weight loss was present in all patients at the end of the 3 y follow-up period (P<0.001), with a progressive reduction of total and trunk fat mass as evaluated by means of DXA. Additionally, a parallel significant reduction in systolic (P<0.001) and diastolic (P<0.001) blood pressure was observed. Total and LDL cholesterol were significantly reduced (P<0.001), while HDL showed no modifications; triglycerides declined progressively during the 3 y follow-up (P<0.001). Fibrinogen decreased from 364.5+/-82.4 to 266.4+/-45.7 mg/dl at the end of the period (P<0.001). Fasting glucose levels and glucose levels 120 min after an oral glucose tolerance test were reduced from 95.1+/-20.3 to 78.6+/-9.1 mg/dl (P<0.001) and from 116.9+/-34.7 to 77.6+/-15.5 mg/dl (P<0.001), respectively, at baseline and at the end of the study. Moreover, fasting insulin decreased from 30.0+/-20.4 to 8.6+/-2.9 microUI/ml (P<0.001) after 3 y, while insulin levels after (120 min) oral glucose load decreased from 105.5+/-61.5 to 12.0+/-6.0 microUI/ml (P<0.001). CONCLUSION Our results show that biliary-intestinal bypass may represent a valid and alternative therapeutic approach in patients with morbid obesity since it induces a significant and stable reduction of body weight and obesity-related risk factors for CVD.
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Affiliation(s)
- C Lubrano
- Dipartimenti di Fisiopatologia Medica, Università degli Studi di Roma La Sapienza, Policlinico Umberto I, Roma, Italia
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Picard M, Frédéric Simon H, Stéfane L, Simon M, Simon B. Complications of combined gastric restrictive and malabsorptive procedures: part 2. ACTA ACUST UNITED AC 2004; 60:274-9; discussion 279-81. [PMID: 14972252 DOI: 10.1016/s0149-7944(02)00791-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Marceau Picard
- Department of Surgery, Laval Hospital, Laval University, Quebec City, Canada
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28
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Souto KEP, Meinhardt NG, Stein AT. Evaluation of Quality of Life and Metabolic Improvement after Jejunoileal Bypass in a Community of Low Socioeconomic Status. Obes Surg 2004; 14:823-8. [PMID: 15318989 DOI: 10.1381/0960892041590872] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Bariatric operations are currently the only effective treatment for morbid obesity The first operation, jejunoileal bypass (JIB), has been superceded. However, JIB has left a heritage which must be followed. We report the long-term follow-up of a series of patients who had undergone JIB in south Brazil. METHODS 49 super-obese patients (85% female) from a poor community were submitted to JIB from 1987 to 2001. 5 deaths occurred and 4 patients were lost during follow-up. Quality of life was evaluated by means of the Bariatric Analysis and Reporting Outcome System (BAROS) applied to 40 patients. RESULTS Preoperatively, 11 patients (22.4%) were diabetic,13 (26.5%) were dyslipidemic, and 23 (46.9%) had high blood pressure. After a mean postoperative period of 64.3 +/- 40.0 months, there was complete resolution of co-morbidites in all patients. Mean preoperative BMI was 52.8 +/- 10.3 kg/m(2), and the postoperative mean excess weight loss was 58.9% +/- 18.9%. CONCLUSION JIB was adequate in reduction of weight, resolution of co-morbidites, and improvement in the quality of life as measured by BAROS. Since February 2001, we perform biliopancreatic diversion with duodenal switch, but we continue to follow our patients with JIB.
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Affiliation(s)
- Katia Elisabete Pires Souto
- Division of Endocrinology, Fundação Faculdade Federal de Ciênçias Médicas, Hospital Nossa Senhora da Conceição, Class III Obesity Care Center, Rua Francesco Trein, 596 Porto Alegre, Rio Grande do Sul, CEP:91350-200 Brazil
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Abstract
BACKGROUND Peripheral arterial occlusive disease (PAOD) is common in older age. PAOD is associated with an increased risk of vascular events (e. g. myocardial infarction or stroke). Therefore, the prevention and treatment of PAOD is important, especially at a time when the elderly population is increasing. There is an association between lipid abnormalities and the risk of developing PAOD. However, it is not yet definitively established if early intervention with lipid lowering drugs prevents the development of PAOD and improves outcome. RESULTS OF STUDIES In a 5-year follow-up study, in which hypercholesterolemia was treated by partial ileal bypass (POSCH study), the incidence of claudication was reduced to 19% (n = 126) in the surgical treatment group vs. 33.6% (n = 119) in the control group (p < 0.01). Direct imaging of peripheral atherosclerosis was not performed and a partial ileal bypass operation is followed by considerable changes in nutrition. A 2-year follow-up study of 153 patients with femoral atherosclerosis treated with colestipol-niacin demonstrated a decreased progression of angiographically assessed femoral atherosclerosis (p < 0.02). A subgroup analysis of the Scandinavian Simvastatin Survival Study (n = 4,444) reported worsening symptoms in 3.6% in the placebo group as compared to 2.3% in the simvastatin group (p = 0.008). In an open trial lipid-lowering therapy with statins did not improve functional outcomes including 6 minutes walking distance and 4 minutes walking velocity in 392 men and women with an ankle-brachial-index (ABI) < 0.90. A summary performance score combined performance in walking speed, standing balance, and time for five repeated chair rises into an ordinal score ranging from 0 to 12 (12 = best) was improved (p < 0.001). A randomized placebo controlled prospective study with simvastatin including 43 patients in each group demonstrated an improved painfree and total walking distance as well as an increased ABI after 6 months. A second placebo controlled study investigated the effect of 10 mg and 80 mg atorvastatin in 354 patients after 12 months. Painfree walking time was only improved by 80 mg atorvastatin, maximum walking time and ABI remained unchanged. A questionnaire regarding physical activity showed improved results already for 10 mg atorvastatin, whereas quality of life did not change. Pathomechanistic explanations, such as regression of peripheral atherosclerosis, were not described. CONCLUSION All in all the association between the progression of PAOD and lipid abnormalities is surprisingly inconclusive and the effects of lipid-lowering are not defined. Well designed long-term studies assessing primary and secondary prevention of PAOD with defined endpoints, such as amputation rate or number of vascular interventions are missing. The mechanisms improving physical activity whithout affecting PAOD outcome have to be investigated.
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Affiliation(s)
- Thomas Wittlinger
- Klinik und Polklinik für Angiologie, Universitätsklinik Essen, Essen, Germany
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30
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Sedletskiĭ II. [Metabolic syndrome and grounds for its surgical treatment]. Vestn Khir Im I I Grek 2003; 162:111-4. [PMID: 12942626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
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31
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Chenhsu RY, Wu Y, Katz D, Rayhill S. Dose-Adjusted Cyclosporine C2 in a Patient with Jejunoileal Bypass as Compared to Seven Other Liver Transplant Recipients. Ther Drug Monit 2003; 25:665-70. [PMID: 14639052 DOI: 10.1097/00007691-200312000-00004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Jejunoileal bypass (JIB) is a weight loss procedure in which malabsorption is produced by connecting a short length of proximal jejunum to the distal ileum. Because 90% of the small intestine is bypassed, it may have impact on the dose-concentration response of oral cyclosporine (CsA). The authors characterized the dose-adjusted blood concentrations of CsA obtained 2 hours (C2) after oral microemulsion CsA (ME-CsA) in a liver transplant (LTx) subject with an intact JIB, as compared with those from seven LTx controls without JIB. The biliary reconstruction involved choledochocholedochostomy without external drainage in all patients. ME-CsA was administered via a nasogastric tube within 24 hours after graft reperfusion. Oral fluconazole was given prophylactically to the study subject only for 6 days after LTx. During the first week after LTx, the dose-adjusted C2 (mean +/- SD) for the study subject and for controls was 53 +/- 10 and 106 +/- 47 ng/mL, respectively (P < 0.001). The corresponding value during the period from day 7 to day 107 was 105 +/- 40 and 257 +/- 86 ng/mL, respectively (P < 0.001). Multiple linear regression revealed that dosage, days after LTx, and the presence of a JIB were all independent predictors of C2 (R2 = 0.798, P = 0.037). Lack of bile resulting in malabsorption of ME-CsA was not thought to be significant contributor to her low dose-adjusted C2 because there was no external bile drainage and a portion of terminal ileum, where most bile acid reabsorption occurred, was still available after JIB. The fact that fluconazole failed to increase the dose-adjusted C2 in the study subject supports that enteric clearance of CsA may become clinically unimportant after JIB. Therefore, the low dose-adjusted C2 is most likely explained by the reduced bowel length and associated absorptive surface area after JIB. In conclusion, patients with JIB may require higher doses of ME-CsA.
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Affiliation(s)
- Rou-Yee Chenhsu
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Arteaga JR, Huerta S, Basa NR, Livingston EH. Interval jejunoileal bypass reduces the morbidity and mortality of Roux-en-Y gastric bypass in the super-obese. Am Surg 2003; 69:873-8. [PMID: 14570366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
Among Roux-en-Y gastric bypass (RYGB) patients, large male patients carry the greatest risk for severe, life-threatening complications. The higher complication rate is partly related to large amounts of intra-abdominal fat that increases the technical difficulty of the RYGB. In order to minimize the risk for complications, we established a staged approach for weight loss surgery for high-risk, super-obese patients. Patients with intra-abdominal fat at exploration which precluded the performance of RYGB underwent jejunoileal bypass (JIB). Following an initial period of weight loss (6-24 months), they were converted to a RYGB during a second operation. Twenty-four patients underwent initial JIB that was associated with a major complication rate of 8.3 per cent (2/24) and no mortality. Eight patients lost 53.4 +/- 6.3 kg prior to their conversion to RYGB (mean, 14.1 months). There was one major complication (12%) and no deaths (0%). Following RYGB, an additional period of weight loss resulted in overall excess weight loss (EWL) totaling 62 per cent. A two-step procedure is a safe and effective approach for minimizing complications for high-risk patients undergoing RYGB. The initial JIB was associated with low morbidity and no mortality, and the follow-up RYGB procedure was a technically simple operation that could be performed with few complications.
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Affiliation(s)
- James R Arteaga
- VA Greater LA Healthcare System, Los Angeles, California, USA
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Dubei L, Georgescu S, Lăzescu D, Cîrdei C. [ Jejunoileal bypass]. Rev Med Chir Soc Med Nat Iasi 2003; 107:641-5. [PMID: 14756078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
Obesity is a condition which can be found very frequently today, both in developed and 3rd world countries. The incidence of obesity in adult population of Romania is about 35%, and most of these patients are females. We'll present the case of a 54 years old woman with BMI = 57 kg/m2, who was hospitalized for the treatment of a postoperative eventration after an umbilical hernia. Her nocturnal breathing troubles, knee pains and walking difficulties made us consider the idea of a digestive by-pass. The surgical intervention consisted of jejunoileal by-pass, abdominoplasty and dermolipectomy with bipolar drainage. Many complications occurred in the postoperative period (renal failure due to severe diarrhea). The weight loss after 18 months was 37%, which means 66% of the weight surplus (similar results can be found in professional statistics--around 70%). After 18 mounts her weight is 95 kg and she allowed to consume any food. 18 mounts after the operation, the number of stools decreased to normal (1-2 per day). In conclusion the morbid obesity can and must be treated surgically. Jejunoileal by-pass is a highly effective procedure, but surgeons must be aware of the pact that severe complications which may occur anytime and must be treated immediately. After this kind of operation, weight stabilization can be achieved within 2 years, no diet being necessary as an additional treatment.
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Affiliation(s)
- L Dubei
- Universitatea de Medicină şi Farmacie Gr.T. Popa Iaşi, Facultatea de Medicină, Clinica I Chirurgie, Spitalul Clinic de Urgenţă Sf. Spiridon Iaşi
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Affiliation(s)
- James R Burton
- Oregon Health Sciences University, Division of Gastroenterology/Hepatology, Portland 97239, USA
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Affiliation(s)
- Kenneth G MacDonald
- Department of Surgery, Division of Gastrointestinal Surgery and Surgical Endoscopy, The Brody School of Medicine at East Carolina University, TA 245, 600 Moye Boulevard, Greenville, NC 27834-4354, USA.
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Norton KS, Brown WA, Johnson LW. Roux-en-Y limb intussusception: two case reports and a review of the literature. J La State Med Soc 2003; 155:57-8. [PMID: 12656278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Affiliation(s)
- Kathryn S Norton
- Louisiana State University Health Sciences Center, Shreveport, USA
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Abstract
Obesity is associated with a chronic inflammatory state that predisposes to atherogenesis, thrombogenesis, and carcinogenesis and may increase susceptibility to infections. Critically ill, obese patients have higher mortality. MOF is the best predictor of ICU mortality for obese patients. Pulmonary hypertension and higher BMI are associated with higher surgical risk. Progress in surgical technique and anesthesia has substantially improved the safety of performing operations in severely obese patients.
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Affiliation(s)
- Daniela Levi
- Albert Einstein College of Medicine, Critical Care Services, Montefiore Medical Center, 111 East 210 Street, Bronx, NY 10467, USA.
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Abstract
Morbid obesity is defined as obesity with a body mass index >/=40, or >/=35 with secondary serious diseases. Conservative medical therapies in these individuals generally fail to sustain weight loss. Thus, surgical operations have evolved which are based on gastric restriction and/or malabsorption. Historically, the intestinal bypass operation was followed by the gastric bypass operation (in some instances combined with intestinal bypass) or by the gastric restriction operations (gastroplasty or gastric banding). Laparoscopic techniques are now being used for these operations, but require surgical expertise in both the bariatric operations and advanced laparoscopic skills. All operations may have complications, but these occur in a very small percent. Postoperative follow-up and nutritional surveillance are mandatory. The operations result in significant weight loss, and the current operations have a mean lasting weight loss of about 50 percent of excess body weight, with improvement or resolution of most obesity-associated conditions. There is evidence that even modest to moderate weight loss in these individuals has significant medical benefit.
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Affiliation(s)
- Mervyn Deitel
- International Federation for the Surgery of Obesity, Toronto, Canada.
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Abstract
BACKGROUND The Program on the Surgical Control of the Hyperlipidemias (POSCH), a secondary intervention trial, was the only lipid/atherosclerosis randomized clinical trial that used a surgical modality--partial ileal bypass. POSCH provided solid evidence for the clinical and arteriographic benefits of lipid profile normalization. Few longterm followup reports have been published in this field. This report concerns overall mortality, the primary endpoint of POSCH, with a mean followup of 18 years (range 15.5 to 23.0 years). STUDY DESIGN Overall mortality data were compiled from reports to the POSCH clinics, followup telephone calls, death certificates, and the US National Death Index. RESULTS There were 144 deaths in the control group (n = 417) and 120 deaths in the intervention group (n = 421), using intent-to-treat analysis. The risk reduction in the intervention group was 0.201 (20%); the risk ratio was 0.799, or 0.8 (95% confidence intervals, 0.628 to 1.018, p = 0.07). The proportion of patients alive was 65.7% in the control group and 72.0% in the intervention group, for a difference of 6.3% in the intervention group (p = 0.05). Kaplan-Meier survival analysis (p = 0.046) and disease-free intervals analysis at 70% survival (p < 0.001) were confirmatory. The gain in life expectancy in the intervention group was 2.7 years. CONCLUSIONS Longterm followup POSCH data demonstrate that lipid profile normalization will decrease overall mortality and will maintain a persistent and constant increase in life expectancy.
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Affiliation(s)
- Henry Buchwald
- Department of Surgery, School of Public Health, University of Minnesota, Minneapolis 55455, USA
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Shrivasatava UK, Minocha VR, Shukla R, Kumar D, Tandon OP. Effect of partial ileal bypass on the lipid profile in the hyperlipedemic rabbits. Indian J Physiol Pharmacol 2002; 46:338-42. [PMID: 12613398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
The hypocholesterolemic effect of partial ideal bypass was studied in two groups of healthy albino rabbits. Both groups of rabbits were made hypercholesterolemic by feeding them cholesterol suspended in groundnut oil (1 ml/kg bw) at a dose of 100 ml/kg bw/day for one week. Group I rabbits were subjected to partial ileal bypass and group II rabbits were sham operated. Weekly estimation of serum lipid profiles were done for four more weeks while continuing cholesterol feed. After end of 5th week, it was found that partial ileal bypass not only prevented but also brought down its level from 132.8 mg% to 44.8 + 2.24 mg%, as compared to sham operates group where cholesterol level was 279 + 5.84 mg%. There was improvement in other parameters of lipid profiles namely HDL-C & LDL-C + VLDL-C and TAG.
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Affiliation(s)
- U K Shrivasatava
- Department of Surgery, University College of Medical Sciences, Guru Tegh Bahadur Hospital, Delhi, 110 095
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Ueno T, Shibata C, Naito H, Jin XL, Funayama Y, Fukushima K, Matsuno S, Sasaki I. Ileojejunal transposition delays gastric emptying and decreases fecal water content in dogs with total colectomy. Dis Colon Rectum 2002; 45:109-16; discussion 116-8. [PMID: 11786773 DOI: 10.1007/s10350-004-6122-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of the study was to investigate the effect of ileojejunal transposition, in which the distal ileum is interposed isoperistaltically into the proximal jejunum, on gastric emptying, gastrointestinal motility, and fecal water content in dogs with total colectomy. METHODS Dogs were divided into three groups: dogs with intact colons (control), total colectomy alone (sham operated group), or total colectomy and ileojejunal transposition group. The alimentary tract was reconstructed by ileal J-pouch-rectal anastomosis. Gastric emptying was measured by a validated freeze-drying method, and gastrointestinal motility was measured by strain gauge force transducers. Plasma peptide YY was measured by specific radioimmunoassay. Fecal water content was measured in dogs with total colectomy. RESULTS Gastric emptying of solids in the ileojejunal transposition group was delayed longer than 120 minutes after meal ingestion compared with that in the sham operated group. The duration of the digestive state was prolonged in the ileojejunal transposition group, only when compared with the control group. Plasma peptide YY was increased in the ileojejunal transposition group compared with the sham operated group. Fecal water content was decreased in the ileojejunal transposition group compared with the sham operated group. CONCLUSIONS Ileojejunal transposition delays gastric emptying of solids and decreases fecal water content in dogs with total colectomy, indicating that ileojejunal transposition might be able to improve intractable watery diarrhea after total colectomy.
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Affiliation(s)
- Tatsuya Ueno
- Division of Biological Regulation and Oncology, Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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Badiali M, D'Agostini A, Filippis AM, Corradini SG, Grossi A, Eramo A, Spera G, Lubrano C, Massa R, Scopinaro F. Patency of anastomoses after bilio-intestinal bypass: radioisotope demonstration. Obes Surg 2001; 11:615-8. [PMID: 11594105 DOI: 10.1381/09608920160557110] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Bilio-intestinal bypass (BIB) is effective for the treatment of refractory obesity. BIB permits bile flow into the non-functional jejunum, whereas food transit occurs via the remaining intestine. We used the radioisotope method of 99mTc-Hida cholescintigraphy (HC) in the follow-up of patients. METHODS 21 patients were studied 3 months to 3 years after BIB with HC. After 3 hours acquisition, images were reviewed by two independent observers. Regions of interest (ROIs) were drawn on images: liver parenchyma, cholecysto-jejunal anastomosis (CC), choledochus (COL). Radioactivity taken up by liver was compared with radioactivity of CC and COL. % radioactivity passing through CC (%CC) and through COL (%COL) were determined. The final parameter, -COL, indicates the radioactive bile which does not pass through the choledochus. RESULTS Anastomoses were found patent a few months to 3 years after operation. -COL showed linear correlation with the decrease in cholesterolemia and in body weight in the 1st year after BIB. CONCLUSIONS HC shows passage of radioactive bile through anastomoses and provides semiquantitative evaluation of bile flux diversion. Bile flux towards the gallbladder and non-functional jejunal limb far exceeds flux directed towards the duodenum via the choledochus.
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Affiliation(s)
- M Badiali
- Istituto di III Clinica Chirurgica, Università La Sapienza Roma, Italy
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Ljungmann K, Hartmann B, Kissmeyer-Nielsen P, Flyvbjerg A, Holst JJ, Laurberg S. Time-dependent intestinal adaptation and GLP-2 alterations after small bowel resection in rats. Am J Physiol Gastrointest Liver Physiol 2001; 281:G779-85. [PMID: 11518690 DOI: 10.1152/ajpgi.2001.281.3.g779] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Existing data on morphological adaptation after small bowel resection are obtained by potentially biased methods. Using stereological techniques, we examined segments of bowel on days 0, 4, 7, 14, and 28 after 80% jejunoileal resection or sham operation in rats and correlated intestinal growth with plasma levels of glucagon-like peptide-2 (GLP-2). In the jejunum and ileum of the resected rats, the mucosal weight increased by 120 and 115% during the first week, and the weight of muscular layer increased by 134 and 83%, compared with sham-operated controls. The luminal surface area increased by 190% in the jejunum and by 155% in the ileum after 28 days. The GLP-2 level was increased by 130% during the entire study period in the resected rats. Small bowel resection caused a pronounced and persistent transmural growth response in the remaining small bowel, with the most prominent growth occurring in the jejunal part. The significantly elevated GLP-2 level is consistent with an important role of GLP-2 in the adaptive response.
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Affiliation(s)
- K Ljungmann
- Surgical Research Unit, Department of Surgery L, Aarhus University Hospital, DK-8000 Aarhus C, Denmark.
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44
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Abstract
Coronary artery disease (CAD) is still a major cause of mortality in developed countries, and dyslipidemia is one of its major causes. In an attempt to reduce both mortality and morbidity from CAD, several dietary, pharmacological, and surgical approaches have been used to reduce plasma cholesterol levels. In this brief review, we summarize the evidence for cholesterol-lowering effects and safety of partial ileal bypass (PIB) procedure in both human and animal studies. The results of the Program on the Surgical Control of the Hyperlipidemias (POSCH), which involved a total of 838 subjects with myocardial infarction, are promising. A 5-year follow-up of this study revealed significant reductions of up to 27% in total cholesterol (TC) and up to 42% in low-density lipoprotein (LDL) cholesterol levels along with an increase of up to 8% in high-density lipoprotein (HDL) cholesterol levels as compared to controls. These changes were associated with other benefits such as increased HDL/TC and HDL/LDL ratios, and a significant decrease in apolipoprotein (apo) B100 and increase in apo AI levels. Similar results were also demonstrated by other studies. PIB surgery is one of the most effective methods for reduction of plasma cholesterol levels, particularly in patients with heterozygous familial hypercholesterolemia. This procedure is also applicable to treatment of sitosterolemia, a rare genetic disorder in which the absorption of plant sterols is abnormally high. Although no major complications of this method have been reported, more extensive studies are required to evaluate its long-term effects on renal and hepatic function. Similarly, long-term impact of this procedure on progression/regression of atherosclerotic lesions must be documented. Finally, indications for this procedure should be carefully considered, particularly in view of availability of other treatments of dyslipidemia.
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Affiliation(s)
- M H Moghadasian
- Department of Pathology, University of British Columbia, Vancouver, Canada.
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45
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Abstract
The incidence of obesity (especially childhood obesity) and its associated health-related problems have reached epidemic proportions in the United States. Recent investigations suggest that the causes of obesity involve a complex interplay of genetic, environmental, psychobehavioral, endocrine, metabolic, cultural, and socioeconomic factors. Several genes and their protein products, such as leptin, may be particularly important in appetite and metabolic control, although the genetics of human obesity appear to involve multiple genes and metabolic pathways that require further elucidation. Severe obesity is frequently associated with significant comorbid medical conditions, including coronary artery disease, hypertension, type II diabetes mellitus, gallstones, nonalcoholic steatohepatitis, pulmonary hypertension, and sleep apnea. Long-term reduction of significant excess weight in these patients may improve or resolve many of these obesity-related health problems, although convincing evidence of long-term benefit is lacking. Available treatments of obesity range from diet, exercise, behavioral modification, and pharmacotherapy to surgery, with varying risks and efficacy. Nonsurgical modalities, although less invasive, achieve only relatively short-term and limited weight loss in most patients. Currently, surgical therapy is the most effective modality in terms of extent and duration of weight reduction in selected patients with acceptable operative risks. The most widely performed surgical procedure, Roux-en-Y gastric bypass, achieves permanent (followed up for more than 14 years) and significant weight loss (more than 50% of excess body weight) in more than 90% of patients.
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Affiliation(s)
- E C Mun
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA.
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Muldoon MF, Manuck SB, Mendelsohn AB, Kaplan JR, Belle SH. Cholesterol reduction and non-illness mortality: meta-analysis of randomised clinical trials. BMJ 2001; 322:11-5. [PMID: 11141142 PMCID: PMC26598 DOI: 10.1136/bmj.322.7277.11] [Citation(s) in RCA: 137] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/11/2000] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the association between cholesterol lowering interventions and risk of death from suicide, accident, or trauma (non-illness mortality). DESIGN Meta-analysis of the non-illness mortality outcomes of large, randomised clinical trials of cholesterol lowering treatments. STUDIES REVIEWED 19 out of 21 eligible trials that had data available on non-illness mortality. INTERVENTIONS REVIEWED: Dietary modification, drug treatment, or partial ileal bypass surgery for 1-10 years. MAIN OUTCOME MEASURE Deaths from suicides, accidents, and violence in treatment groups compared with control groups. RESULTS Across all trials, the odds ratio of non-illness mortality in the treated groups, relative to control groups, was 1.18 (95% confidence interval 0.91 to 1.52; P=0.20). The odds ratios were 1.28 (0.94 to 1.74; P=0.12) for primary prevention trials and 1.00 (0.65 to 1.55; P=0.98) for secondary prevention trials. Randomised clinical trials using statins did not show a treatment related rise in non-illness mortality (0.84, 0.50 to 1.41; P=0.50), whereas a trend toward increased deaths from suicide and violence was observed in trials of dietary interventions and non-statin drugs (1.32, 0.98 to 1.77; P=0.06). No relation was found between the magnitude of cholesterol reduction and non-illness mortality (P=0.23). CONCLUSION Currently available evidence does not indicate that non-illness mortality is increased significantly by cholesterol lowering treatments. A modest increase may occur with dietary interventions and non-statin drugs.
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Affiliation(s)
- M F Muldoon
- Center for Clinical Pharmacology, University of Pittsburgh School of Medicine, PA 15260, Pittsburgh, USA.
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Abstract
BACKGROUND The safety and effectiveness of conversion to the Lap-Band system, of patients who had failure of adequate weight loss and/or severe symptoms from prior bariatric procedures has been measured by prospective evaluation of a consecutive group of 50 patients. METHODS The patients were drawn as a subgroup of 713 patients who had placement of the Lap-Band system between July 1994 and May 2000. The preceding procedures were gastroplasty (35 patients), non-adjustable gastric banding (11), gastric bypass (2) and jejuno-ileal bypass (2). All operations were by open laparotomy. Initial reversal of the initial procedure was performed in 28 patients. M:F ratio was 6%/94%. Inadequate weight was the primary problem in 69%, and symptoms of obstruction were present in 31%. RESULTS Significant perioperative complications occurred more frequently than after primary placement (17% vs 1.1%). However, late complications were less frequent (2% vs 18%). In particular, there have been no occurrences of prolapse (slippage) of the stomach through the band or erosion of the band into the stomach in this group to date. Weight loss of 47% of excess weight had occurred at 3-year follow-up. This is not significantly different from the 53% EWL in the primary Lap-Band group. All symptoms of obstruction were relieved by the revision, and a number of comorbidities are seen to be markedly improved. CONCLUSIONS We observe that, when compared to primary Lap-Band placement, revision of failed bariatric procedures to Lap-Band is associated with more perioperative adverse events but fewer late complications. Weight loss is equivalent and is associated with marked improvement in comorbidities and quality of life. The outcomes are better than have been achieved by revision to another form of gastric stapling and should be considered in those patients who have had an unsatisfactory outcome from other bariatric procedures.
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Affiliation(s)
- P O'Brien
- Monash University Department of Surgery, Alfred Hospital, Melbourne, Australia.
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Rodriguez JA, Sandoval M, Udall JN, O'Leary JP, Hempe JM. Zinc, copper, and metallothionein metabolism after jejunoileal bypass surgery or small bowel resection in rats. Am Surg 2000; 66:1004-10. [PMID: 11090006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Liver dysfunction is a frequent complication of jejunoileal bypass (JIB) surgery, a procedure commonly used until recently to treat morbid obesity. It has been suggested that liver failure in JIB patients is due to bacterial overgrowth and translocation from the bypassed intestine. Because invading microorganisms cause hepatic inflammation these experiments evaluated zinc, copper, and metallothionein (MT) in two experimental rat models of intestinal surgery to determine whether their distribution in plasma and tissues was similar to the highly characteristic pattern observed during an inflammatory response. In the JIB rat model 90 per cent of the small intestine was isolated from the flow of digesta but remained viable in the abdominal cavity. In the small bowel resection (SBR) model 90 per cent of the small intestine was removed and the remaining intestine was resected. Data collected 21 days after surgery showed decreased growth rate and plasma zinc in the SBR and JIB rats that was significantly improved by supplemental zinc. All other measures of zinc, copper, and MT metabolism in the SBR rats were similar to those of controls. In JIB rats, however, liver copper, MT protein, and MT mRNA were significantly elevated, and a high proportion of the intracellular zinc and copper was associated with MT. The pattern of zinc, copper, and MT distribution in systemic circulation and liver of JIB rats suggests hepatic inflammation superimposed on low zinc and copper status. Lack of a similar response in the SBR rats confirms the involvement of the bypassed intestinal segment and supports the hypothesis that bacterial overgrowth and translocation are responsible for liver inflammation and dysfunction in JIB patients.
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Affiliation(s)
- J A Rodriguez
- Department of Surgery, Louisiana State University School of Medicine, New Orleans, USA
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49
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Burkolter D, Schär B. [Fulminant liver failure in anamnestic morbid obesity]. Schweiz Med Wochenschr 2000; 130:924-7. [PMID: 10909718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Jejunoileal bypass was an effective method of treatment for weight reduction in severe cases of obesity. However, long-term follow-up revealed serious and even lethal side-effects, e.g. acute liver failure, as shown in a case report of a patient who died 28 years post-operatively of acute liver failure as a direct result of liver cirrhosis. We therefore conclude that jejunoileal bypass should no longer be performed, especially as better methods, such as gastric banding, exist. Patient care and monitoring is highly important and, if feasible, the bypass procedure should be reversed.
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50
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López-Santamaria M, Migliazza L, Gamez M, Murcia J, Diaz-Gonzalez M, Camarena C, Hierro L, De la Vega A, Frauca E, Diaz M, Jara P, Tovar J. Liver transplantation in patients with homozygotic familial hypercholesterolemia previously treated by end-to-side portocaval shunt and ileal bypass. J Pediatr Surg 2000; 35:630-3. [PMID: 10770402 DOI: 10.1053/jpsu.2000.0350630] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Familial hypercholesterolemia is the result of mutations in the gene that encodes the synthesis of the cellular receptor for low density lipoprotein (LDL). In the homozygous form of the disease (HFHC), cellular LDL receptors either do not form, or, when present, cannot bond LDL and mediate its cellular uptake LDL, and the cholesterol that it transports accumulate in plasma, producing severe premature atherosclerosis and death from coronary artery disease usually before the age of 20. Currently, the only effective treatment is liver transplantation, which, alone or in association with medications, normalizes plasma cholesterol levels. The authors report the cases of 2 siblings with HFHC who underwent portocaval shunt at the ages of 2.5 and 1.5 years, respectively. Portocaval shunt produced an immediate, but insufficient decrease in cholesterol (by 40% and 35%, respectively), leaving them with cholesterol concentrations of about 500 mg/dL. One year later they each underwent ileal bypass without obtaining any significant response. Liver transplantation at the ages of 18 and 16 years, respectively, reduced plasma cholesterol concentrations to 129 and 225 mg/dL, respectively. The earlier operations seriously increased the technical difficulty of liver transplantation and did not produce a favorable effect on the natural course of the disease, so portocaval shunt and ileal bypass are not indicated in HFHC, not even for the purpose of delaying liver transplantation.
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Affiliation(s)
- M López-Santamaria
- Department of Pediatric Surgery, Pediatric Hospital La Paz, Madrid, Spain
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