Efficacy and Safety of Sleeve Gastrectomy with Jejunoileal Bypass Compared with Roux-en-Y Gastric Bypass: Results from a Cohort Study

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.

Clinical application of a novel stent-assisted in situ intestinal bypass in preventing postoperative anastomotic leakage for low-mid rectal cancer: A retrospective study

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.

Enhanced glucose homeostasis via Clostridium symbiosum-mediated glucagon-like peptide 1 inhibition of hepatic gluconeogenesis in mid-intestinal bypass surgery

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.

Acute Liver Failure following Sleeve Gastrectomy with Jejuno-Ileal Bypass

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.

[Three Cases of Unresectable, Advanced, and Recurrent Colorectal Cancer Associated with Gastrointestinal Obstruction That Were Treated with Small Intestine-Transverse Colon Bypass Surgery]

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.

Effects of sleeve gastrectomy with jejuno-jejunal or jejuno-ileal loop on glycolipid metabolism in diabetic rats

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 (AUC_OGTT), 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 AUC_OGTT, HOMA-IR, fasting serum triglyceride and cholesterol (AUC_OGTT: 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.

[Recent advances of anastomosis techniques of esophagojejunostomy after laparoscopic totally gastrectomy in gastric tumor]

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.

[The results of treatment of gastric cancer in the Provincial Hospital in Zielona Góra]

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%).

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

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.

Surgical control of obesity and diabetes: the role of intestinal vs. gastric mechanisms in the regulation of body weight and glucose homeostasis

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.

Reasons and operative outcomes after reversal of gastric bypass and jejunoileal bypass

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.

Bariatric surgery in obesity: changes of glucose and lipid metabolism correlate with changes of fat mass

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.

Plasma visfatin concentrations in severely obese subjects are increased after intestinal bypass

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.

Idiopathic sclerosing encapsulating peritonitis (or abdominal cocoon): A report of 5 cases

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.

Effect of Weight Loss following Bariatric Surgery on Myocardial Dispersion of Repolarization in Morbidly Obese Patients

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.

Vertical gastric resection (sleeve gastrectomy) in a morbidly obese patient with past jejunoileal bypass

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.

Hepatic outcomes after jejunoileal bypass: is there a publication bias?

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.

Peptide YY(1-36) and peptide YY(3-36): Part II. Changes after gastrointestinal surgery and bariatric surgery

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.

Bariatric surgery for morbid obesity: risks and benefits in chronic kidney disease patients

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.

A case of congenital jejunal atresia associated with bilateral athelia and choanal atresia: new syndrome spectrum

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.

Bariatric Surgery: Past and Present

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.

Change in Oral Absorption of Tacrolimus in a Liver Transplant Recipient After Reversal of Jejunoileal Bypass: Case Report

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.

Fatigue, weakness, and sexual dysfunction after bariatic surgery - not an unusual case but an unusual cause

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.