1
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Alsayed Hasan M, Schwartz S, McKenna V, Ing R. An Imbalance of Pathophysiologic Factors in Late Postprandial Hypoglycemia Post Bariatric Surgery: A Narrative Review. Obes Surg 2023; 33:2927-2937. [PMID: 37530920 DOI: 10.1007/s11695-023-06758-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 07/18/2023] [Accepted: 07/25/2023] [Indexed: 08/03/2023]
Abstract
With a rise in obesity and more patients opting for bariatric surgery, it becomes crucial to understand associated complications like postprandial hypoglycemia (PPH). After bariatric surgery, significant changes are seen in insulin sensitivity, beta cell function, glucagon-like peptide 1 (GLP-1) levels, the gut microbiome, and bile acid metabolism. And in a small subset of patients, exaggerated imbalances in these functional and metabolic processes lead to insulin-glucose mismatch and hypoglycemia. The main treatment for PPH involves dietary modifications. For those that do not respond, medications or surgical interventions are considered to reverse some of the imbalances. We present a few case reports of patients that safely tolerated GLP-1 agonists. However, larger randomized control trials are needed to further characterize PPH and understand its treatment.
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Affiliation(s)
- Marah Alsayed Hasan
- Department of Internal Medicine, Main Line Health System/Lankenau Medical Center, 100 E Lancaster Ave, Wynnewood, PA, 19096, USA.
| | - Stanley Schwartz
- Affiliate, Main Line Health System, Emeritus, University of Pennsylvania, 100 E Lancaster Ave, Wynnewood, PA, 19096, USA
| | - Victoria McKenna
- Main Line Health Bariatric Surgery - Bryn Mawr, 830 Old Lancaster Road Suite 300, Bryn Mawr, PA, 19010, USA
| | - Richard Ing
- Bariatric Center of Bryn Mawr Hospital, Main Line Health System, Bryn Mawr Medical Building North, 830 Old Lancaster Road, Bryn Mawr, PA, 19010, USA
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2
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KOMAEI I, CURRÒ G, SARRA F, GUCCIONE F, DAMIANO C, IDONE A, ROSI F, GIOFFRE A, DE PASQUALE G, AMMENDOLA M, NAVARRA G. Liquid tolerance following laparoscopic sleeve gastrectomy: Long-term results of a single bariatric center. Chirurgia (Bucur) 2022. [DOI: 10.23736/s0394-9508.21.05334-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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3
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Camastra S, Palumbo M, Santini F. Nutrients handling after bariatric surgery, the role of gastrointestinal adaptation. Eat Weight Disord 2022; 27:449-461. [PMID: 33895917 PMCID: PMC8933374 DOI: 10.1007/s40519-021-01194-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 04/10/2021] [Indexed: 01/19/2023] Open
Abstract
Bariatric surgery determines a rearrangement of the gastrointestinal tract that influences nutrient handling and plays a role in the metabolic changes observed after surgery. Most of the changes depend on the accelerated gastric emptying observed in Roux-en-Y gastric bypass (RYGB) and, to a lesser extent, in sleeve gastrectomy (SG). The rapid delivery of meal into the jejunum, particularly after RYGB, contributes to the prompt appearance of glucose in peripheral circulation. Glucose increase is the principal determinant of GLP-1 increase with the consequent stimulation of insulin secretion, the latter balanced by a paradoxical glucagon increase that stimulates EGP to prevent hypoglycaemia. Protein digestion and amino acid absorption appear accelerated after RYGB but not after SG. After RYGB, the adaptation of the gut to the new condition participates to the metabolic change. The intestinal transit is delayed, the gut microbioma is changed, the epithelium becomes hypertrophic and increases the expression of glucose transporter and of the number of cell secreting hormones. These changes are not observed after SG. After RYGB-less after SG-bile acids (BA) increase, influencing glucose metabolism probably modulating FXR and TGR5 with an effect on insulin sensitivity. Muscle, hepatic and adipose tissue insulin sensitivity improve, and the gut reinforces the recovery of IS by enhancing glucose uptake and through the effect of the BA. The intestinal changes observed after RYGB result in a light malabsorption of lipid but not of carbohydrate and protein. In conclusion, functional and morphological adaptations of the gut after RYGB and SG activate inter-organs cross-talk that modulates the metabolic changes observed after surgery.Level of evidence Level V, narrative literature review.
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Affiliation(s)
- Stefania Camastra
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy. .,Interdepartmental Research Center "Nutraceuticals and Food for Health", University of Pisa, Pisa, Italy.
| | - Maria Palumbo
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Ferruccio Santini
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy.,Interdepartmental Research Center "Nutraceuticals and Food for Health", University of Pisa, Pisa, Italy
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4
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Kingma JS, Burgers DMT, Monpellier VM, Wiezer MJ, Blussé van Oud-Alblas HJ, Vaughns JD, Sherwin CMT, Knibbe CAJ. Oral drug dosing following bariatric surgery: General concepts and specific dosing advice. Br J Clin Pharmacol 2021; 87:4560-4576. [PMID: 33990981 PMCID: PMC9291886 DOI: 10.1111/bcp.14913] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 04/06/2021] [Accepted: 05/01/2021] [Indexed: 11/30/2022] Open
Abstract
Bariatric or weight‐loss surgery is a popular option for weight reduction. Depending on the surgical procedure, gastric changes like decreased transit time and volume and increased pH, decreased absorption surface in the small intestine, decreased exposure to bile acids and enterohepatic circulation, and decreased gastrointestinal transit time may be expected. In the years after bariatric surgery, patients will also substantially lose weight. As a result of these changes, the absorption, distribution, metabolism and/or elimination of drugs may be altered. The purpose of this article is to report the general influence of bariatric surgery on oral drug absorption, and to provide guidance for dosing of commonly used drugs in this special population. Upon oral drug administration, the time to maximum concentration is often earlier and this concentration may be higher with less consistent effects on trough concentrations and exposure. Additionally, prescription of liquid formulations to bariatric patients is supported by some reports, even though the high sugar load of these suspensions may be of concern. Studies on extended‐release medications result in an unaltered exposure for a substantial number of drugs. Also, studies evaluating the influence of timing after surgery show dynamic absorption profiles. Although for this group specific advice can be proposed for many drugs, we conclude that there is insufficient evidence for general advice for oral drug therapy after bariatric surgery, implying that a risk assessment on a case‐by‐case basis is required for each drug.
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Affiliation(s)
- Jurjen S Kingma
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Desirée M T Burgers
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Valerie M Monpellier
- Nederlandse Obesitas Kliniek (Dutch Obesity Clinic), Huis ter Heide, The Netherlands
| | - Marinus J Wiezer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Janelle D Vaughns
- Department of Anesthesia and Pain Medicine, Children's National Health System, Washington, DC, USA.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Catherine M T Sherwin
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.,Division of Systems Biomedicine & Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands
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5
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Ladebo L, Pedersen PV, Pacyk GJ, Kroustrup JP, Drewes AM, Brock C, Olesen AE. Gastrointestinal pH, Motility Patterns, and Transit Times After Roux-en-Y Gastric Bypass. Obes Surg 2021; 31:2632-2640. [PMID: 33709293 DOI: 10.1007/s11695-021-05308-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/17/2021] [Accepted: 02/23/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Studies investigating the underlying pathophysiology are needed to help explain and understand the postoperative complications following Roux-en-Y gastric bypass (RYGB) surgery. This study aimed to characterize segmental gastrointestinal pH profiles, motility measures, and transit times in patients with RYGB. MATERIALS AND METHODS Nineteen patients with RYGB underwent a standardized wireless motility capsule assessment. The oro-cecal segment was defined from capsule ingestion until the passage of the ileocecal junction. Segmental median pH, motility index, and transit time were determined for the oro-cecal and colonic segment as well as for the first and last hour of both these segments. For comparison to reference values, data from 17 healthy age- and gender-matched controls was used. A mixed effect model was used to describe differences between groups. RESULTS Median pH was high in patients with RYGB during the first hour of the oro-cecal segment (6.45 ± 0.4 vs 3.65 ± 1.55 pH units for healthy controls; P < 0.001), as well as during the entire oro-cecal segment (6.97 ± 0.4 vs 5.51 ± 1.1 pH units; P < 0.001). The same was evident for the median motility index (152 ± 64 vs 35.8 ± 31.1 mmHg*sec/min; P < 0.001 and 130 ± 65.9 vs 89.1 ± 20 mmHg*sec/min; P < 0.012, respectively). Median motility index was low the first hour of the colon (55.2 ± 45.7 vs 122 ± 77.9 mmHg*sec/min; P < 0.002). Additionally, patients had short oro-cecal transit time (5.8 ± 1.6 vs 7.6 ± 1.4 h; P < 0.001) and long colonic transit time (29.4 ± 17.5 vs 19.6 ± 12.2 h; P = 0.048). CONCLUSIONS In patients with RYGB, the oro-cecal segment was characterized by an alkaline intraluminal environment, high motility activity, and short transit time. In contrast, colonic transit time was long.
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Affiliation(s)
- Louise Ladebo
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Medicinerhuset 4th floor, Mølleparkvej 4, DK-9000, Aalborg, Denmark. .,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | | | - Grzegorz J Pacyk
- Department of Clinical Medicine and Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Jens Peter Kroustrup
- Department of Clinical Medicine and Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn M Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Medicinerhuset 4th floor, Mølleparkvej 4, DK-9000, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Medicinerhuset 4th floor, Mølleparkvej 4, DK-9000, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne E Olesen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Clinical Pharmacology, Aalborg University Hospital, Aalborg, Denmark
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Steenackers N, Vanuytsel T, Augustijns P, Tack J, Mertens A, Lannoo M, Van der Schueren B, Matthys C. Adaptations in gastrointestinal physiology after sleeve gastrectomy and Roux-en-Y gastric bypass. Lancet Gastroenterol Hepatol 2021; 6:225-237. [PMID: 33581761 DOI: 10.1016/s2468-1253(20)30302-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 01/19/2023]
Abstract
Linked to the growing obesity epidemic, demand for bariatric and metabolic surgery has increased, the most common procedures being sleeve gastrectomy and Roux-en-Y gastric bypass. Originally, bariatric procedures were described as purely restrictive, malabsorptive, or combined restrictive-malabsorptive procedures limiting food intake, nutrient absorption, or both. Nowadays, anatomical alterations are known to affect gastrointestinal physiology, which in turn affects the digestion and absorption of nutrients and drugs. Therefore, understanding gastrointestinal physiology is crucial to prevent postoperative nutritional deficiencies and to optimise postoperative drug therapy. Preclinical and clinical research indicates that sleeve gastrectomy accelerates liquid and solid gastric emptying and small intestinal transit, and increases bile acid serum levels, whereas its effects on gastrointestinal acidity, gastric and pancreatic secretions, surface area, and colonic transit remain largely unknown. Roux-en-Y gastric bypass diminishes gastric acid secretion, accelerates liquid gastric emptying, and increases bile acid serum levels, but its effects on intestinal pH, solid gastric emptying, intestinal transit time, gastric enzyme secretions, and surface area remain largely unknown. In this Review, we summarise current knowledge of the effects of these two procedures on gastrointestinal physiology and assess the knowledge gaps.
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Affiliation(s)
- Nele Steenackers
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Patrick Augustijns
- Department of Chronic Diseases and Metabolism, and Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Ann Mertens
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
| | - Matthias Lannoo
- Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
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7
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Porat D, Vaynshtein J, Gibori R, Avramoff O, Shaked G, Dukhno O, Czeiger D, Sebbag G, Dahan A. Stomach pH before vs. after different bariatric surgery procedures: Clinical implications for drug delivery. Eur J Pharm Biopharm 2021; 160:152-157. [DOI: 10.1016/j.ejpb.2021.01.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 01/18/2021] [Accepted: 01/24/2021] [Indexed: 01/19/2023]
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8
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Albaugh VL, Williams DB, Aher CV, Spann MD, English WJ. Prevalence of thiamine deficiency is significant in patients undergoing primary bariatric surgery. Surg Obes Relat Dis 2020; 17:653-658. [PMID: 33478908 DOI: 10.1016/j.soard.2020.11.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 09/20/2020] [Accepted: 11/26/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients undergoing metabolic and bariatric surgery are prone to developing micronutrient deficiencies, necessitating life-long nutritional supplementation and monitoring. Historically, these deficiencies were thought to be driven by postsurgical changes in absorption. Recent data, though, have demonstrated that obesity alone is also associated with micronutrient deficiencies. Thiamine deficiency, in particular, can lead to permanent neurologic deficits. OBJECTIVE Identify thiamine deficiency prevalence within the preoperative metabolic and bariatric surgery patient population. SETTING Single institution academic medical center. METHODS A retrospective review of deidentified data was examined that included whole blood thiamine measured from consecutive patients from April 2018 to June 2019 (n = 346). Cohort characteristics were assessed including age, operation, preoperative weight, and race/ethnicity. The majority of the cohort were women (83%) with an average age of 44.9 years. Racial representation included White/Caucasian (73%) and Black (21%), while operations included Roux-en-Y gastric bypass (58%), sleeve gastrectomy (31%), and revisions (10%). RESULTS Thiamine concentration was normally distributed with a mean of 144 nM. Overall, 3.5% of patients had thiamine concentrations below the lower limit of normal of <70 nM, while 35 additional patients (14%) were at risk for thiamine deficiency with concentrations <100 nM. On the average, these patients were of similar age and were all undergoing primary procedures (50% gastric bypass, 50% sleeve gastrectomy). Regression methods demonstrated that patients with thiamine deficiency tended to be females with higher body mass index, even after controlling for sex, height, and preoperative weight. After covariate adjustment, male sex and increasing height were both associated with higher thiamine concentration. CONCLUSION Previously quoted rates of thiamine deficiency in the preoperative patient are variable, but we describe a significant number of patients with, or at risk of, thiamine deficiency. Male sex and increasing height are likely associated with increased skeletal muscle mass, which is enriched with thiamine. Routine thiamine measurement, either preoperatively or at the time of surgery, is warranted given its limited stores within the body and potential catastrophic complications associated with acute or chronic deficiency.
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Affiliation(s)
- Vance L Albaugh
- Vanderbilt Center for Surgical Weight Loss, Vanderbilt University Medical Center, Nashville, Tennessee
| | - D Brandon Williams
- Vanderbilt Center for Surgical Weight Loss, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chetan V Aher
- Vanderbilt Center for Surgical Weight Loss, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew D Spann
- Vanderbilt Center for Surgical Weight Loss, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wayne J English
- Vanderbilt Center for Surgical Weight Loss, Vanderbilt University Medical Center, Nashville, Tennessee.
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9
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Stillhart C, Vučićević K, Augustijns P, Basit AW, Batchelor H, Flanagan TR, Gesquiere I, Greupink R, Keszthelyi D, Koskinen M, Madla CM, Matthys C, Miljuš G, Mooij MG, Parrott N, Ungell AL, de Wildt SN, Orlu M, Klein S, Müllertz A. Impact of gastrointestinal physiology on drug absorption in special populations––An UNGAP review. Eur J Pharm Sci 2020; 147:105280. [DOI: 10.1016/j.ejps.2020.105280] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 02/10/2020] [Accepted: 02/24/2020] [Indexed: 02/07/2023]
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10
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Jirapinyo P, Makuvire TT, Dong WY, Chan WW, Thompson CC. Impact of Oral-Cecal Transit Time on the Interpretation of Lactulose Breath Tests After RYGB: a Personalized Approach to the Diagnosis of SIBO. Obes Surg 2020; 29:771-775. [PMID: 30627990 DOI: 10.1007/s11695-018-3575-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Traditionally, small intestinal bacterial overgrowth (SIBO) is diagnosed when there is an early peak in breath hydrogen or methane. Given unclear intestinal transit time in Roux-en-Y gastric bypass (RYGB) patients, it is unknown if the traditional approach at diagnosing SIBO is adequate in this patient population. AIM To assess oral-cecal transit time (OCTT) and its impact on the interpretation of breath tests in the diagnosis of SIBO in patients with RYGB. METHODS This study was a retrospective review of prospectively collected data on RYGB patients who underwent testing for SIBO using lactulose breath test (LBT) with or without small bowel follow-through (SBFT) to assess OCTT. Outcomes of SIBO test based on LBT alone versus LBT with OCTT were compared using a chi-squared test. RESULTS Sixty-two of the 151 RYGB patients who underwent LBT underwent an additional SBFT to assess OCTT. Median OCTT was 60 min. Of these, 59.7% had OCTT shorter than 90 min. Based on LBT alone, 36/62 patients (58.1%) were classified as positive SIBO. When LBT results were combined with OCTT, 26/36 patients (72.2%) had hydrogen or methane rise within OCTT, suggesting 27.8% false positive rate. Patients with true positive SIBO based on LBT and OCTT had a higher response rate to antibiotics compared to those with false positive SIBO (78.3% vs. 33.3%, p = 0.03). CONCLUSION A personalized approach of combining LBT with SBFT to assess OCTT may improve the accuracy of SIBO testing and enhance clinical outcomes in patients with RYGB.
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Affiliation(s)
- Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | - Tracy T Makuvire
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Harvard Medical School, Boston, MA, USA.
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11
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Jegatheesan P, Seyssel K, Stefanoni N, Rey V, Schneiter P, Giusti V, Lecoultre V, Tappy L. Effects of gastric bypass surgery on postprandial gut and systemic lipid handling. Clin Nutr ESPEN 2020; 35:95-102. [PMID: 31987128 DOI: 10.1016/j.clnesp.2019.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/06/2019] [Accepted: 11/11/2019] [Indexed: 12/20/2022]
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12
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Figueiredo Reis GM, Malheiros CA, Savassi-Rocha PR, Cançado Júnior OL, Thuler FR, Faria ML, Guerra Filho V. Gastric Emptying and Food Tolerance Following Banded and Non-banded Roux-en-Y Gastric Bypass. Obes Surg 2020; 29:560-568. [PMID: 30402805 DOI: 10.1007/s11695-018-3561-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Gastric emptying (GE) and food tolerance (FT) can be altered after Roux-en-Y gastric bypass (RYGB) has been performed, especially when it involved the use of a restrictive mechanism (such as a silastic ring). AIM To assess GE and FT in patients who underwent banded (BRYGB) or non-banded Roux-en-Y gastric bypass (RYGB). METHODS Forty-seven BRYGB patients and 47 RYGB patients underwent gastric emptying scintigraphy (GES) and FT assessment (by means of a questionnaire) between 6 months and 2 years postoperatively. RESULTS GES was performed on average 11.7 ± 5.0 months (6 to 24) postoperatively. T½ medians (time taken for the gastric radioactivity to decrease to half of the original value in the gastric pouch) in the RYGB and BRYGB groups were 48.7 min (40.6-183.0 min) and 56.3 min (41.1-390.9 min), respectively (p = 0.031). The median of total questionnaire scores was 24 points (18-27) in the RYGB group and 20 points (13-27) in the BRYBG group (p < 0.001). CONCLUSIONS The band (silastic ring) delays GE time and does not affect patient satisfaction or food tolerance to vegetables, bread, or rice, but does affect tolerance to the intake of meat, salad, and pasta. The best tolerated foods are vegetables, salad, and fish. Banded patients are more likely to regurgitate and vomit. Gastric emptying does not affect FT.
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Affiliation(s)
- Galzuinda Maria Figueiredo Reis
- Department of Surgery, Santa Casa of São Paulo Medical School, Rua Cesário Mota Jr, 61, São Paulo, SP, CEP 02112-020, Brazil. .,Department of Surgery, Santa Casa of Belo Horizonte, Av. Francisco Sales, 1111 - Santa Efigênia, Belo Horizonte, MG, CEP 30150-221, Brazil.
| | - Carlos Alberto Malheiros
- Department of Surgery, Santa Casa of São Paulo Medical School, Rua Cesário Mota Jr, 61, São Paulo, SP, CEP 02112-020, Brazil
| | - Paulo Roberto Savassi-Rocha
- Department of Surgery School of Medicine, Federal University of Minas Gerais (UFMG), Av. Prof. Alfredo Balena, 190 - Santa Efigênia, Belo Horizonte, MG, CEP 30130-100, Brazil
| | - Omar Lopes Cançado Júnior
- Department of Surgery, Santa Casa of Belo Horizonte, Av. Francisco Sales, 1111 - Santa Efigênia, Belo Horizonte, MG, CEP 30150-221, Brazil
| | - Fábio Rodrigues Thuler
- Department of Surgery, Santa Casa of São Paulo Medical School, Rua Cesário Mota Jr, 61, São Paulo, SP, CEP 02112-020, Brazil
| | - Mauro Lima Faria
- Department of Surgery, Santa Casa of Belo Horizonte, Av. Francisco Sales, 1111 - Santa Efigênia, Belo Horizonte, MG, CEP 30150-221, Brazil
| | - Vicente Guerra Filho
- Department of Surgery School of Medicine, Federal University of Minas Gerais (UFMG), Av. Prof. Alfredo Balena, 190 - Santa Efigênia, Belo Horizonte, MG, CEP 30130-100, Brazil
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13
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Douros JD, Tong J, D’Alessio DA. The Effects of Bariatric Surgery on Islet Function, Insulin Secretion, and Glucose Control. Endocr Rev 2019; 40:1394-1423. [PMID: 31241742 PMCID: PMC6749890 DOI: 10.1210/er.2018-00183] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 04/23/2019] [Indexed: 01/19/2023]
Abstract
Although bariatric surgery was developed primarily to treat morbid obesity, evidence from the earliest clinical observations to the most recent clinical trials consistently demonstrates that these procedures have substantial effects on glucose metabolism. A large base of research indicates that bariatric surgeries such as Roux-en-Y gastric bypass (RYGB), vertical sleeve gastrectomy (VSG), and biliopancreatic diversion (BPD) improve diabetes in most patients, with effects frequently evident prior to substantial weight reduction. There is now unequivocal evidence from randomized controlled trials that the efficacy of surgery is superior to intensive life-style/medical management. Despite advances in the clinical understanding and application of bariatric surgery, there remains only limited knowledge of the mechanisms by which these procedures confer such large changes to metabolic physiology. The improvement of insulin sensitivity that occurs with weight loss (e.g., the result of diet, illness, physical training) also accompanies bariatric surgery. However, there is evidence to support specific effects of surgery on insulin clearance, hepatic glucose production, and islet function. Understanding the mechanisms by which surgery affects these parameters of glucose regulation has the potential to identify new targets for therapeutic discovery. Studies to distinguish among bariatric surgeries on key parameters of glucose metabolism are limited but would be of considerable value to assist clinicians in selecting specific procedures and investigators in delineating the resulting physiology. This review is based on literature related to factors governing glucose metabolism and insulin secretion after the commonly used RYGB and VSG, and the less frequently used BPD and adjustable gastric banding.
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Affiliation(s)
- Jonathan D Douros
- Division of Endocrinology, Duke Molecular Physiology Institute, Duke University, Durham, North Carolina
| | - Jenny Tong
- Division of Endocrinology, Duke Molecular Physiology Institute, Duke University, Durham, North Carolina
| | - David A D’Alessio
- Division of Endocrinology, Duke Molecular Physiology Institute, Duke University, Durham, North Carolina
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14
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Debédat J, Amouyal C, Aron-Wisnewsky J, Clément K. Impact of bariatric surgery on type 2 diabetes: contribution of inflammation and gut microbiome? Semin Immunopathol 2019; 41:461-475. [DOI: 10.1007/s00281-019-00738-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 03/15/2019] [Indexed: 02/06/2023]
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Laferrère B, Pattou F. Weight-Independent Mechanisms of Glucose Control After Roux-en-Y Gastric Bypass. Front Endocrinol (Lausanne) 2018; 9:530. [PMID: 30250454 PMCID: PMC6140402 DOI: 10.3389/fendo.2018.00530] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/22/2018] [Indexed: 12/14/2022] Open
Abstract
Roux-en-Y gastric bypass results in large and sustained weight loss and resolution of type 2 diabetes in 60% of cases at 1-2 years. In addition to calorie restriction and weight loss, various gastro-intestinal mediated mechanisms, independent of weight loss, also contribute to glucose control. The anatomical re-arrangement of the small intestine after gastric bypass results in accelerated nutrient transit, enhances the release of post-prandial gut hormones incretins and of insulin, alters the metabolism and the entero-hepatic cycle of bile acids, modifies intestinal glucose uptake and metabolism, and alters the composition and function of the microbiome. The amelioration of beta cell function after gastric bypass in individuals with type 2 diabetes requires enteric stimulation. However, beta cell function in response to intravenous glucose stimulus remains severely impaired, even in individuals in full clinical diabetes remission. The permanent impairment of the beta cell may explain diabetes relapse years after surgery.
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Affiliation(s)
- Blandine Laferrère
- Division of Endocrinology, New York Obesity Nutrition Research Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, United States
| | - François Pattou
- Translational Research on Diabetes, UMR 1190, Inserm, Université Lille, Lille, France
- Endocrine and Metabolic Surgery, CHU Lille, Lille, France
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DEL GRANDE LM, HERBELLA FAM, KATAYAMA RC, SCHLOTTMANN F, PATTI MG. THE ROLE OF THE TRANSDIAPHRAGMATIC PRESSURE GRADIENT IN THE PATHOPHYSIOLOGY OF GASTROESOPHAGEAL REFLUX DISEASE. ARQUIVOS DE GASTROENTEROLOGIA 2018; 55Suppl 1:13-17. [DOI: 10.1590/s0004-2803.201800000-39] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 01/29/2018] [Indexed: 12/15/2022]
Abstract
ABSTRACT Gastroesophageal reflux disease (GERD) is the most common disease of the upper gastrointestinal tract in the Western world. GERD pathophysiology is multifactorial. Different mechanisms may contribute to GERD including an increase in the transdiaphragmatic pressure gradient (TPG). The pathophysiology of GERD linked to TPG is not entirely understood. This review shows that TPG is an important contributor to GERD even when an intact esophagogastric barrier is present in the setting of obesity and pulmonary diseases.
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Purnell JQ, Johnson GS, Wahed AS, Dalla Man C, Piccinini F, Cobelli C, Prigeon RL, Goodpaster BH, Kelley DE, Staten MA, Foster-Schubert KE, Cummings DE, Flum DR, Courcoulas AP, Havel PJ, Wolfe BM. Prospective evaluation of insulin and incretin dynamics in obese adults with and without diabetes for 2 years after Roux-en-Y gastric bypass. Diabetologia 2018; 61:1142-1154. [PMID: 29428999 PMCID: PMC6634312 DOI: 10.1007/s00125-018-4553-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 11/22/2017] [Indexed: 01/20/2023]
Abstract
AIMS/HYPOTHESIS In this prospective case-control study we tested the hypothesis that, while long-term improvements in insulin sensitivity (SI) accompanying weight loss after Roux-en-Y gastric bypass (RYGB) would be similar in obese individuals with and without type 2 diabetes mellitus, stimulated-islet-cell insulin responses would differ, increasing (recovering) in those with diabetes but decreasing in those without. We investigated whether these changes would occur in conjunction with favourable alterations in meal-related gut hormone secretion and insulin processing. METHODS Forty participants with type 2 diabetes and 22 participants without diabetes from the Longitudinal Assessment of Bariatric Surgery (LABS-2) study were enrolled in a separate, longitudinal cohort (LABS-3 Diabetes) to examine the mechanisms of postsurgical diabetes improvement. Study procedures included measures of SI, islet secretory response and gastrointestinal hormone secretion after both intravenous glucose (frequently-sampled IVGTT [FSIVGTT]) and a mixed meal (MM) prior to and up to 24 months after RYGB. RESULTS Postoperatively, weight loss and SI-FSIVGTT improvement was similar in both groups, whereas the acute insulin response to glucose (AIRglu) decreased in the non-diabetic participants and increased in the participants with type 2 diabetes. The resulting disposition indices (DIFSIVGTT) increased by three- to ninefold in both groups. In contrast, during the MM, total insulin responsiveness did not significantly change in either group despite durable increases of up to eightfold in postprandial glucagon-like peptide 1 levels, and SI-MM and DIMM increased only in the diabetes group. Peak postprandial glucagon levels increased in both groups. CONCLUSIONS/INTERPRETATION For up to 2 years following RYGB, obese participants without diabetes showed improvements in DI that approach population norms. Those with type 2 diabetes recovered islet-cell insulin secretion response yet continued to manifest abnormal insulin processing, with DI values that remained well below population norms. These data suggest that, rather than waiting for lifestyle or medical failure, RYGB is ideally considered before, or as soon as possible after, onset of type 2 diabetes. TRIAL REGISTRATION ClinicalTrials.gov NCT00433810.
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Affiliation(s)
- Jonathan Q Purnell
- Department of Medicine, The Knight Cardiovascular Institute, Mailcode MDYMI, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.
| | - Geoffrey S Johnson
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Abdus S Wahed
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Chiara Dalla Man
- Department of Information Engineering, University of Padova, Padova, Italy
| | | | - Claudio Cobelli
- Department of Information Engineering, University of Padova, Padova, Italy
| | | | - Bret H Goodpaster
- Translational Research Institute for Metabolism and Diabetes, Sanford-Burnham Institute, Orlando, FL, USA
| | | | - Myrlene A Staten
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD, USA
| | | | - David E Cummings
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - David R Flum
- Department of Surgery, University of Washington, Seattle, WA, USA
| | | | - Peter J Havel
- Departments of Molecular Biosciences and Nutrition, University of California, Davis, Davis, CA, USA
| | - Bruce M Wolfe
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
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Cano-Valderrama O, Sánchez-Pernaute A, Rubio-Herrera MA, Domínguez-Serrano I, Torres-García AJ. Long-Term Food Tolerance After Bariatric Surgery: Comparison of Three Different Surgical Techniques. Obes Surg 2018; 27:2868-2872. [PMID: 28451933 DOI: 10.1007/s11695-017-2703-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Food tolerance has been related to quality of life after bariatric surgery. However, long-term results about this issue are quite limited. The aim of this study was to evaluate the long-term food tolerance in obese patients submitted to surgery, comparing the results between gastric bypass (GBP), long alimentary modified biliopancreatic diversion (MBPD), and long alimentary modified duodenal switch (MDS). METHODS A cross-sectional analytic study was performed. Food tolerance was studied with a questionnaire based on subjective alimentary satisfaction, tolerance to different foods, and frequency of vomiting and regurgitation. A food tolerance score was obtained (1 point being the worst possible tolerance and 27 points being a perfect one). Information was obtained with a telephone interview. RESULTS One hundred ninety-six patients submitted to bariatric surgery were included. Ninety-nine patients were submitted to GBP, 54 to MBPD, and 43 to MDS. One hundred and sixty-one patients (82.1%) were not lost during a mean follow-up time of 87.9 months. Mean food tolerance score was 24.2. Tolerance satisfaction was good or excellent in 73.3% of the patients. Red meat was the worst tolerated food, but nearly 80% of the patients could tolerate it without any problem. Mean food tolerance score was 24.6, 24.0, and 23.7 for GBP, MBPD, and MDS, respectively. There were no significant differences between these procedures in food tolerance score, alimentary satisfaction, or frequency of vomiting. CONCLUSIONS Long-term food tolerance after bariatric surgery is good. No differences between GBP, MBPD, and MDS were found.
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Affiliation(s)
- Oscar Cano-Valderrama
- Department of Surgery, Hospital Rey Juan Carlos, Calle Gladiolo SN, Móstoles, 28933, Madrid, Spain.
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Yska JP, Punter RJ, Woerdenbag HJ, Emous M, Frijlink HW, Wilffert B, van Roon EN. A gastrointestinal simulation system for dissolution of oral solid dosage forms before and after Roux-en-Y gastric bypass. Eur J Hosp Pharm 2018; 26:152-156. [PMID: 31428323 DOI: 10.1136/ejhpharm-2017-001360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 01/13/2018] [Accepted: 01/22/2018] [Indexed: 12/31/2022] Open
Abstract
Background The Roux-en-Y gastric bypass (RYGB) is a bariatric procedure, greatly reducing the stomach size and bypassing the duodenum and proximal jejunum. Hence, RYGB may reduce the absorption and bioavailability of oral medication. For clinical decisions on the use of medication, knowledge of altered modifications in drug disposition is a prerequisite. An in vitro dissolution method for solid oral medications, simulating conditions before and after RYGB, might be a valuable tool to predict the pharmaceutical availability of medicines frequently used by patients after RYGB. Objectives To develop a gastrointestinal simulation system (GISS), mimicking conditions before and after RYGB for investigating dissolution characteristics of solid oral medications, and to assess the pharmaceutical availability of metoprolol from immediate-release (IR) and controlled-release (CR) tablets under these conditions. Methods With an adjusted, pharmacopoeial paddle dissolution apparatus, the GISS enables variation in parameters which are relevant to drug release in vivo: pH, volume, residence time, osmolality and agitation. Metoprolol tartrate 100 mg IR tablets and metoprolol CR tablets were tested. Release profiles were determined by measuring the concentrations of metoprolol spectrophotometrically. Results From IR tablets, under all conditions applied, >85% of metoprolol was released within 25 min. From all tested CR tablets >90% of metoprolol was released after 22 hours. Conclusions This GISS is a suitable dissolution system to assess pharmaceutical availability before and after RYGB. In patients who have undergone RYGB, no problems in pharmaceutical availability of metoprolol IR and CR tablets are to be expected. Any changes in response to metoprolol in patients after RYGB should therefore be ascribed to changes in bioavailability.
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Affiliation(s)
- Jan Peter Yska
- Department of Clinical Pharmacy and Clinical Pharmacology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Ronald J Punter
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, Groningen Research Institute of Pharmacy, Groningen, The Netherlands
| | - Herman J Woerdenbag
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Marloes Emous
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Henderik W Frijlink
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, Groningen Research Institute of Pharmacy, Groningen, The Netherlands
| | - Bob Wilffert
- University of Groningen, Groningen Research Institute of Pharmacy, PharmacoTherapy, Epidemiology and Economics, Groningen, The Netherlands.,Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Eric N van Roon
- Department of Clinical Pharmacy and Clinical Pharmacology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands.,University of Groningen, Groningen Research Institute of Pharmacy, PharmacoTherapy, Epidemiology and Economics, Groningen, The Netherlands
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20
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Effect of meal size and texture on gastric pouch emptying and glucagon-like peptide 1 after gastric bypass surgery. Surg Obes Relat Dis 2017; 13:1975-1983. [PMID: 29055668 DOI: 10.1016/j.soard.2017.09.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 09/05/2017] [Accepted: 09/05/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) accelerates gastric pouch emptying, enhances postprandial glucagon-like peptide 1 (GLP-1) and insulin, and lowers glucose concentrations. To prevent discomfort and reactive hypoglycemia, it is recommended that post-RYGB patients eat small, frequent meals and avoid caloric drinks. However, the effect of meal size and texture on GLP-1 and metabolic response has not been studied. OBJECTIVES To demonstrate that frequent minimeals and solid meals (S) elicit less GLP-1 and insulin release and less reactive hypoglycemia and are better tolerated compared with a single isocaloric liquid meal (L). SETTING A university hospital. METHODS In this prospective study, 32 RYGB candidates were enrolled and randomized to L or S groups before gastric bypass. Each subject received an L or S 600-kcal single meal (SM) administered at hour 0 or three 200-kcal minimeals administered at hours 0, 2, and 4 on 2 separate days. Twenty-one patients were retested 1 year after RYGB. Blood and visual analogue scale measurements were collected up to 6 hours postprandially. Outcome measures included gastric pouch emptying, glucose, insulin, and GLP-1; hunger, fullness, and stomach discomfort were measured by visual analogue scale. RESULTS Twenty-one were patients retested after RYGB (L: n = 12; S: n = 9). Meal texture had a significant effect on peak GLP-1 (L-SM: 106.1 ± 67.2 versus S-SM: 45.3 ± 25.2 pM, P = .004), peak insulin, and postprandial glucose. Hypoglycemia was more frequent after the L-SM meal compared with the S-SM. Gastric pouch emptying was 2.4 times faster after RYGB but was not affected by texture. CONCLUSIONS Meal texture and size have significant impact on tolerance and metabolic response after RYGB.
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Deden LN, Cooiman MI, Aarts EO, Janssen IMC, Gotthardt M, Hendrickx BW, Berends FJ. Gastric pouch emptying of solid food in patients with successful and unsuccessful weight loss after Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 2017; 13:1840-1846. [PMID: 28935201 DOI: 10.1016/j.soard.2017.07.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 07/25/2017] [Accepted: 07/25/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND After Roux-en-Y gastric bypass (RYGB), approximately 10% of patients have insufficient weight loss (excess body mass index loss<50%). Gastric pouch emptying may have a role in weight loss. OBJECTIVES To compare pouch emptying of patients with poor weight loss and patients with successful weight loss after RYGB. SETTING A research-intensive nonacademic hospital and center of expertise in bariatric surgery in the Netherlands METHODS: Female patients were included from among patients with the least (poor weight loss group [P-WL]) and the most weight loss (successful weight loss group [S-WL]) in our center 2 years after RYGB. Pouch emptying scintigraphy was performed after ingestion of a radiolabeled solid meal. Emptying curves, intestinal content (IC) at meal completion and after 15, 30, 45, and 60 minutes, half emptying time, and maximal pouch emptying rate were compared. RESULTS Five individuals were included in P-WL and 5 in S-WL, on average 2.5 ± .3 years after RYGB. Total weight loss was 18 ± 4.1% in P-WL and 44 ± 5.7% in S-WL (P<.001). In P-WL, a fast initial pouch emptying and exponential emptying curve was observed, compared with a slower initial emptying and more linear curve in S-WL. Faster emptying in P-WL was also shown by a larger ICmeal (42 ± 18% versus 4.0 ± 3.3%,), IC15 (76 ± 15% versus 35 ± 22%), and IC30 (85 ± 12% versus 54 ± 25%), and a greater maximal pouch emptying rate (17 ± 4.7 versus 5.6 ± 3.4%/min) compared with S-WL (P<.05). A linear correlation was found between total weight loss and maximal pouch emptying rate (Pearson R = .82, P = .004). CONCLUSIONS Pouch emptying for solid food was faster in patients with the least weight loss compared with patients with the most weight loss after RYGB. If pouch emptying is an important mechanism in weight loss, altering the pouch outlet may improve poor weight loss management.
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Affiliation(s)
- Laura N Deden
- Vitalys Clinic, Velp, the Netherlands; Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands.
| | - Mellody I Cooiman
- Vitalys Clinic, Velp, the Netherlands; Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - Edo O Aarts
- Vitalys Clinic, Velp, the Netherlands; Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - Ignace M C Janssen
- Vitalys Clinic, Velp, the Netherlands; Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - Martin Gotthardt
- Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, the Netherlands
| | - Baudewijn W Hendrickx
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frits J Berends
- Vitalys Clinic, Velp, the Netherlands; Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands
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Albaugh VL, Banan B, Ajouz H, Abumrad NN, Flynn CR. Bile acids and bariatric surgery. Mol Aspects Med 2017; 56:75-89. [PMID: 28390813 PMCID: PMC5603298 DOI: 10.1016/j.mam.2017.04.001] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 02/27/2017] [Accepted: 04/04/2017] [Indexed: 12/12/2022]
Abstract
Bariatric surgery, specifically Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG), are the most effective and durable treatments for morbid obesity and potentially a viable treatment for type 2 diabetes (T2D). The resolution rate of T2D following these procedures is between 40 and 80% and far surpasses that achieved by medical management alone. The molecular basis for this improvement is not entirely understood, but has been attributed in part to the altered enterohepatic circulation of bile acids. In this review we highlight how bile acids potentially contribute to improved lipid and glucose homeostasis, insulin sensitivity and energy expenditure after these procedures. The impact of altered bile acid levels in enterohepatic circulation is also associated with changes in gut microflora, which may further contribute to some of these beneficial effects. We highlight the beneficial effects of experimental surgical procedures in rodents that alter bile secretory flow without gastric restriction or altering nutrient flow. This information suggests a role for bile acids beyond dietary fat emulsification in altering whole body glucose and lipid metabolism strongly, and also suggests emerging roles for the activation of the bile acid receptors farnesoid x receptor (FXR) and G-protein coupled bile acid receptor (TGR5) in these improvements. The limitations of rodent studies and the current state of our understanding is reviewed and the potential effects of bile acids mediating the short- and long-term metabolic improvements after bariatric surgery is critically examined.
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MESH Headings
- Animals
- Bile Acids and Salts/metabolism
- Diabetes Mellitus, Type 2/metabolism
- Diabetes Mellitus, Type 2/microbiology
- Diabetes Mellitus, Type 2/pathology
- Diabetes Mellitus, Type 2/surgery
- Enterohepatic Circulation
- Gastrectomy
- Gastric Bypass
- Gastrointestinal Microbiome/physiology
- Gene Expression Regulation
- Glucose/metabolism
- Homeostasis/physiology
- Humans
- Insulin Resistance
- Obesity, Morbid/metabolism
- Obesity, Morbid/microbiology
- Obesity, Morbid/pathology
- Obesity, Morbid/surgery
- Receptors, Cytoplasmic and Nuclear/genetics
- Receptors, Cytoplasmic and Nuclear/metabolism
- Receptors, G-Protein-Coupled/genetics
- Receptors, G-Protein-Coupled/metabolism
- Rodentia
- Signal Transduction
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Affiliation(s)
- Vance L Albaugh
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Babak Banan
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Hana Ajouz
- American University of Beirut, Beirut, Lebanon
| | - Naji N Abumrad
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Charles R Flynn
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
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Contribution of Malabsorption to Weight Loss After Roux-en-Y Gastric Bypass: a Systematic Review. Obes Surg 2017; 27:2194-2206. [DOI: 10.1007/s11695-017-2762-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Increased Esophageal Exposure to Weakly Acidic Reflux 5 Years After Laparoscopic Roux-en-Y Gastric Bypass. Ann Surg 2017; 264:871-877. [PMID: 27429035 DOI: 10.1097/sla.0000000000001775] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To evaluate the long-term effects of laparoscopic Roux-en-Y Gastric Bypass (LRYGB) on gastroesophageal function. BACKGROUND LRYGB is considered the weight loss procedure of choice for obese patients with gastroesophageal reflux disease (GERD). However, long-term instrumental evaluations of GERD after LRYGB are not available. METHODS Morbidly obese patients selected for LRYGB were included in a prospective study. We performed clinical evaluation with GERD-HRQoL questionnaire, upper endoscopy, esophageal manometry, and 24-hour impedance pH (24-hour MII-pH) monitoring preoperatively and at 12 and 60 months after surgery. This trial is registered with ClinicalTrials.gov (no. NCT02618044). RESULTS From May 2006 to May 2009, 86 patients entered the study and 72 (84%) completed the 5-year protocol. At preoperative 24-hour MII-pH monitoring, 54 patients (group A) had normal values, whereas 32 (group B) had diagnosis of GERD: 23 had acidic reflux, whereas 9 had combined reflux [acidic + weakly acidic reflux (WAR)]. The groups were similar in preoperative age, body mass index, and comorbidities. At 12 and 60 months, significant improvement in questionnaire scores was observed in group B patients. No manometric changes occurred in both groups; 24-hour MII-pH monitoring showed a significant reduction in acid exposure, but an increase of WAR in both group A (from 0% to 52% to 74%) and group B (from 35% to 42% to 77%). At long-term follow-up, esophagitis was found in 14 group A (30%) and in 18 group B patients (69%) (P < 0.001). CONCLUSIONS LRYGB allows to obtain an effective GERD symptom amelioration and a reduction in acid exposure. However, 3 out 4 patients present with distal esophagus exposure to WAR.
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Shani-Levi C, Alvito P, Andrés A, Assunção R, Barberá R, Blanquet-Diot S, Bourlieu C, Brodkorb A, Cilla A, Deglaire A, Denis S, Dupont D, Heredia A, Karakaya S, Giosafatto CVL, Mariniello L, Martins C, Ménard O, El SN, Vegarud GE, Ulleberg E, Lesmes U. Extending in vitro digestion models to specific human populations: Perspectives, practical tools and bio-relevant information. Trends Food Sci Technol 2017. [DOI: 10.1016/j.tifs.2016.10.017] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Steinert RE, Feinle-Bisset C, Asarian L, Horowitz M, Beglinger C, Geary N. Ghrelin, CCK, GLP-1, and PYY(3-36): Secretory Controls and Physiological Roles in Eating and Glycemia in Health, Obesity, and After RYGB. Physiol Rev 2017; 97:411-463. [PMID: 28003328 PMCID: PMC6151490 DOI: 10.1152/physrev.00031.2014] [Citation(s) in RCA: 358] [Impact Index Per Article: 51.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The efficacy of Roux-en-Y gastric-bypass (RYGB) and other bariatric surgeries in the management of obesity and type 2 diabetes mellitus and novel developments in gastrointestinal (GI) endocrinology have renewed interest in the roles of GI hormones in the control of eating, meal-related glycemia, and obesity. Here we review the nutrient-sensing mechanisms that control the secretion of four of these hormones, ghrelin, cholecystokinin (CCK), glucagon-like peptide-1 (GLP-1), and peptide tyrosine tyrosine [PYY(3-36)], and their contributions to the controls of GI motor function, food intake, and meal-related increases in glycemia in healthy-weight and obese persons, as well as in RYGB patients. Their physiological roles as classical endocrine and as locally acting signals are discussed. Gastric emptying, the detection of specific digestive products by small intestinal enteroendocrine cells, and synergistic interactions among different GI loci all contribute to the secretion of ghrelin, CCK, GLP-1, and PYY(3-36). While CCK has been fully established as an endogenous endocrine control of eating in healthy-weight persons, the roles of all four hormones in eating in obese persons and following RYGB are uncertain. Similarly, only GLP-1 clearly contributes to the endocrine control of meal-related glycemia. It is likely that local signaling is involved in these hormones' actions, but methods to determine the physiological status of local signaling effects are lacking. Further research and fresh approaches are required to better understand ghrelin, CCK, GLP-1, and PYY(3-36) physiology; their roles in obesity and bariatric surgery; and their therapeutic potentials.
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Affiliation(s)
- Robert E Steinert
- University of Adelaide Discipline of Medicine and National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, Australia; DSM Nutritional Products, R&D Human Nutrition and Health, Basel, Switzerland; Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland; Department of Biomedicine and Division of Gastroenterology, University Hospital Basel, Basel, Switzerland; and Department of Psychiatry, Weill Medical College of Cornell University, New York, New York
| | - Christine Feinle-Bisset
- University of Adelaide Discipline of Medicine and National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, Australia; DSM Nutritional Products, R&D Human Nutrition and Health, Basel, Switzerland; Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland; Department of Biomedicine and Division of Gastroenterology, University Hospital Basel, Basel, Switzerland; and Department of Psychiatry, Weill Medical College of Cornell University, New York, New York
| | - Lori Asarian
- University of Adelaide Discipline of Medicine and National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, Australia; DSM Nutritional Products, R&D Human Nutrition and Health, Basel, Switzerland; Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland; Department of Biomedicine and Division of Gastroenterology, University Hospital Basel, Basel, Switzerland; and Department of Psychiatry, Weill Medical College of Cornell University, New York, New York
| | - Michael Horowitz
- University of Adelaide Discipline of Medicine and National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, Australia; DSM Nutritional Products, R&D Human Nutrition and Health, Basel, Switzerland; Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland; Department of Biomedicine and Division of Gastroenterology, University Hospital Basel, Basel, Switzerland; and Department of Psychiatry, Weill Medical College of Cornell University, New York, New York
| | - Christoph Beglinger
- University of Adelaide Discipline of Medicine and National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, Australia; DSM Nutritional Products, R&D Human Nutrition and Health, Basel, Switzerland; Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland; Department of Biomedicine and Division of Gastroenterology, University Hospital Basel, Basel, Switzerland; and Department of Psychiatry, Weill Medical College of Cornell University, New York, New York
| | - Nori Geary
- University of Adelaide Discipline of Medicine and National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, Australia; DSM Nutritional Products, R&D Human Nutrition and Health, Basel, Switzerland; Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland; Department of Biomedicine and Division of Gastroenterology, University Hospital Basel, Basel, Switzerland; and Department of Psychiatry, Weill Medical College of Cornell University, New York, New York
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Bariatric surgery and obesity: influence on the incretins. INTERNATIONAL JOURNAL OF OBESITY SUPPLEMENTS 2016; 6:S32-S36. [PMID: 28685028 DOI: 10.1038/ijosup.2016.8] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The gut hormone incretins have an important physiological role in meal-related insulin release and post-prandial glucose control. In addition to weight loss, the incretin hormones have a role in glucose control after bariatric surgery. The release of incretins, and specifically of glucagon-like peptide (GLP)-1, in response to the ingestion of nutrients, is greatly enhanced after gastric bypass (RYGBP). The rapid transit of food from the gastric pouch to the distal ileum is responsible for the greater GLP-1 release after RYGBP. The incretin effect on insulin secretion, or the greater insulin response to oral glucose compared to an isoglycemic intravenous glucose challenge, is severely impaired in patients with type 2 diabetes, but is recovered rapidly after RYGBP. The improvement in insulin secretion rate and β-cell sensitivity to oral glucose after RYGBP is mediated by endogenous GLP-1, and is abolished by exendin 9-39, a specific GLP-1 receptor antagonist. While calorie restriction and weight loss have major effects on the rapid and sustained improvement of fasted glucose metabolism, the enhanced incretin effect is a key player in post-prandial glucose control after RYGBP.
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Wright MR, Sharda R, Vaezi MF. Unmet needs in treating laryngo-pharyngeal reflux disease: where do we go from here? Expert Rev Gastroenterol Hepatol 2016; 10:995-1004. [PMID: 27137439 DOI: 10.1080/17474124.2016.1179576] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Many patients experience ear, nose and throat symptoms associated with their gastroesophageal reflux disease. These symptoms are purportedly caused by reflux of gastroduodenal contents into the larynx, which leads to laryngopharyngeal reflux (LPR). Various modalities are used to diagnose LPR, including ambulatory pH monitoring, laryngoscopy, and esophagogastroduodenoscopy, as well as a few new emerging diagnostic tests. However, there are still no established diagnostic criteria or gold standard methodologies that can reliably distinguish LPR from other conditions. AREAS COVERED In this review, we will evaluate currently available diagnostic tests and therapeutic options for patients with laryngeal signs and symptoms of reflux and briefly discuss the development and emergence of new treatments. Numerous studies have investigated the role of proton pump inhibitor therapy in this patient population, but have led to disparate and often inconsistent results. Expert commentary: While a subgroup of patients with LPR appears to respond to PPI therapy, many patients show no symptomatic improvement, particularly with respect to extraesophageal symptoms. As such, there is a vital need to explore alternative treatment options, including anti-reflux surgery, lifestyle changes, and other classes of medications to better address LPR.
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Affiliation(s)
- Meera R Wright
- a Department of Internal Medicine , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Rohit Sharda
- b Division of Gastroenterology, Hepatology and Nutrition , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Michael F Vaezi
- b Division of Gastroenterology, Hepatology and Nutrition , Vanderbilt University Medical Center , Nashville , TN , USA
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Gesquiere I, Hens B, Van der Schueren B, Mols R, de Hoon J, Lannoo M, Matthys C, Foulon V, Augustijns P. Drug disposition before and after gastric bypass: fenofibrate and posaconazole. Br J Clin Pharmacol 2016; 82:1325-1332. [PMID: 27367040 DOI: 10.1111/bcp.13054] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/24/2016] [Accepted: 06/22/2016] [Indexed: 01/11/2023] Open
Abstract
AIMS Roux-en-Y gastric bypass (RYGB) alters the anatomical structure of the gastrointestinal tract, which can result in alterations in drug disposition. The aim of the present study was to evaluate the oral disposition of two compounds belonging to the Biopharmaceutical Classification System Class II - fenofibrate (bile salt-dependent solubility) and posaconazole (gastric pH-dependent dissolution) - before and after RYGB in the same individuals. METHODS A single-dose pharmacokinetic study with two model compounds - namely, 67 mg fenofibrate (Lipanthyl®) and 400 mg posaconazole (Noxafil®) - was performed in 12 volunteers pre- and post-RYGB. After oral administration, blood samples were collected at different time points up to 48 h after administration. Plasma concentrations were determined by high-performance liquid chromatography in order to calculate the area under the concentration-time curve up to 48 h (AUC0-48 h ), the peak plasma concentration (Cmax) and the time to reach peak concentration (Tmax ). RESULTS After administration of fenofibrate, no relevant differences in AUC0-48 h , Cmax and Tmax between the pre- and postoperative setting were observed. The geometric mean of the ratio of AUC0-48 h post/pre-RYGB for fenofibrate was 1.10 [95% confidence interval (CI) 0.87, 1.40; P = 0.40]. For posaconazole, an important decrease in AUC0-48 h and Cmax following RYGB was shown; the geometric mean of the AUC0-48 h post/pre-RYGB ratio was 0.68 (95% CI 0.48, 0.96; P = 0.03) and the geometric mean of the Cmax pre/post-RYGB ratio was 0.60 (95% CI 0.39, 0.94; P = 0.03). The decreased exposure of posaconazole could be explained by the increased gastric pH and accelerated gastric emptying of fluids post-RYGB. No difference for Tmax was observed. CONCLUSIONS The disposition of fenofibrate was not altered after RYGB, whereas the oral disposition of posaconazole was significantly decreased following RYGB.
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Affiliation(s)
- Ina Gesquiere
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Clinical and Experimental Endocrinology, KU Leuven and Department of Endocrinology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Bart Hens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Bart Van der Schueren
- Clinical and Experimental Endocrinology, KU Leuven and Department of Endocrinology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Raf Mols
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Jan de Hoon
- Center for Clinical Pharmacology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Matthias Lannoo
- Clinical and Experimental Endocrinology, KU Leuven and Department of Endocrinology, University Hospitals Leuven/KU Leuven, Leuven, Belgium.,Department of Abdominal Surgery, KU Leuven/University Hospitals Leuven, Leuven, Belgium
| | - Christophe Matthys
- Clinical and Experimental Endocrinology, KU Leuven and Department of Endocrinology, University Hospitals Leuven/KU Leuven, Leuven, Belgium
| | - Veerle Foulon
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Patrick Augustijns
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
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Abstract
Obesity and its associated medical conditions continue to increase and add significant burden to patients, as well as health-care systems, worldwide. Bariatric surgery is the most effective treatment for severe obesity and its comorbidities, and resolution of diabetes is weight loss-independent in the case of some operations. Although these weight-independent effects are frequently described clinically, the mechanisms behind them are not well understood and remain an intense area of focus in the growing field of metabolic and bariatric surgery. Perceptions of the mechanisms responsible for the beneficial metabolic effects of metabolic/bariatric operations have shifted from being mostly restrictive and malabsorption over the last 10 to 15 years to being more neuro-hormonal in origin. In this review, we describe recent basic and clinical findings of the major clinical procedures (adjustable gastric banding, vertical sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion) as well as other experimental procedures (ileal interposition and bile diversion) that recapitulate many of the metabolic effects of these complex operations in a simpler fashion. As the role of bile acids and the gut microbiome on metabolism is becoming increasingly well described, their potential roles in these improvements following metabolic surgery are becoming better appreciated. Bile acid and gut microbiome changes, in light of recent developments, are discussed in the context of these surgical procedures, as well as their implications for future study.
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Affiliation(s)
- Vance L Albaugh
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, 37232, USA
| | - C Robb Flynn
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, 37232, USA
| | - Robyn A Tamboli
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, 37232, USA
| | - Naji N Abumrad
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, 37232, USA
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Baud G, Daoudi M, Hubert T, Raverdy V, Pigeyre M, Hervieux E, Devienne M, Ghunaim M, Bonner C, Quenon A, Pigny P, Klein A, Kerr-Conte J, Gmyr V, Caiazzo R, Pattou F. Bile Diversion in Roux-en-Y Gastric Bypass Modulates Sodium-Dependent Glucose Intestinal Uptake. Cell Metab 2016; 23:547-53. [PMID: 26924216 DOI: 10.1016/j.cmet.2016.01.018] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 11/29/2015] [Accepted: 01/27/2016] [Indexed: 12/22/2022]
Abstract
Gastro-intestinal exclusion by Roux-en-Y gastric bypass (RYGB) improves glucose metabolism, independent of weight loss. Although changes in intestinal bile trafficking have been shown to play a role, the underlying mechanisms are unclear. We performed RYGB in minipigs and showed that the intestinal uptake of ingested glucose is blunted in the bile-deprived alimentary limb (AL). Glucose uptake in the AL was restored by the addition of bile, and this effect was abolished when active glucose intestinal transport was blocked with phlorizin. Sodium-glucose cotransporter 1 remained expressed in the AL, while intraluminal sodium content was markedly decreased. Adding sodium to the AL had the same effect as bile on glucose uptake. It also increased postprandial blood glucose response in conscious minipigs following RYGB. The decrease in intestinal uptake of glucose after RYGB was confirmed in humans. Our results demonstrate that bile diversion affects postprandial glucose metabolism by modulating sodium-glucose intestinal cotransport.
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Affiliation(s)
- Gregory Baud
- University Lille, Inserm, CHU Lille, U1190 Translational research for diabetes, 59000 Lille, France; European Genomic Institute for Diabetes, EGID, 59000 Lille, France
| | - Mehdi Daoudi
- University Lille, Inserm, CHU Lille, U1190 Translational research for diabetes, 59000 Lille, France
| | - Thomas Hubert
- University Lille, Inserm, CHU Lille, U1190 Translational research for diabetes, 59000 Lille, France; European Genomic Institute for Diabetes, EGID, 59000 Lille, France
| | - Violeta Raverdy
- University Lille, Inserm, CHU Lille, U1190 Translational research for diabetes, 59000 Lille, France; European Genomic Institute for Diabetes, EGID, 59000 Lille, France
| | - Marie Pigeyre
- University Lille, Inserm, CHU Lille, U1190 Translational research for diabetes, 59000 Lille, France; European Genomic Institute for Diabetes, EGID, 59000 Lille, France
| | - Erik Hervieux
- University Lille, Inserm, CHU Lille, U1190 Translational research for diabetes, 59000 Lille, France; European Genomic Institute for Diabetes, EGID, 59000 Lille, France
| | - Magalie Devienne
- University Lille, Inserm, CHU Lille, U1190 Translational research for diabetes, 59000 Lille, France; European Genomic Institute for Diabetes, EGID, 59000 Lille, France
| | - Mohamed Ghunaim
- University Lille, Inserm, CHU Lille, U1190 Translational research for diabetes, 59000 Lille, France; European Genomic Institute for Diabetes, EGID, 59000 Lille, France
| | - Caroline Bonner
- University Lille, Inserm, CHU Lille, U1190 Translational research for diabetes, 59000 Lille, France; European Genomic Institute for Diabetes, EGID, 59000 Lille, France
| | - Audrey Quenon
- University Lille, Inserm, CHU Lille, U1190 Translational research for diabetes, 59000 Lille, France; European Genomic Institute for Diabetes, EGID, 59000 Lille, France
| | - Pascal Pigny
- University Lille, Inserm, CHU Lille, U1172 Jean-Pierre Aubert Research Center, 59000 Lille, France
| | - André Klein
- CHU Lille, Metabolism and Glycosylation Diseases, Biology Pathology Center, 59000 Lille, France
| | - Julie Kerr-Conte
- University Lille, Inserm, CHU Lille, U1190 Translational research for diabetes, 59000 Lille, France; European Genomic Institute for Diabetes, EGID, 59000 Lille, France
| | - Valery Gmyr
- University Lille, Inserm, CHU Lille, U1190 Translational research for diabetes, 59000 Lille, France; European Genomic Institute for Diabetes, EGID, 59000 Lille, France
| | - Robert Caiazzo
- University Lille, Inserm, CHU Lille, U1190 Translational research for diabetes, 59000 Lille, France; European Genomic Institute for Diabetes, EGID, 59000 Lille, France
| | - François Pattou
- University Lille, Inserm, CHU Lille, U1190 Translational research for diabetes, 59000 Lille, France; European Genomic Institute for Diabetes, EGID, 59000 Lille, France.
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Magkos F, Bradley D, Eagon JC, Patterson BW, Klein S. Effect of Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding on gastrointestinal metabolism of ingested glucose. Am J Clin Nutr 2016; 103:61-5. [PMID: 26607940 PMCID: PMC4691669 DOI: 10.3945/ajcn.115.116111] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 10/09/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Data from studies conducted in animal models suggest that intestinal glucose uptake and metabolism are upregulated after Roux-en-Y gastric bypass (RYGB) surgery, which contributes to a weight-loss-independent improvement in glycemic control. OBJECTIVE We conducted a cohort study to evaluate whether an increase in gastrointestinal metabolism of ingested glucose occurs in obese people who underwent RYGB compared with those who underwent laparoscopic adjustable gastric banding (LAGB). DESIGN A mixed meal containing stable isotope-labeled glucose was used to determine the gastrointestinal (small intestine and liver) retention, and presumably metabolism, of ingested glucose in obese subjects before and after matched weight loss (∼21%) induced by RYGB (n = 16) or LAGB (n = 9). RESULTS The total percentage of ingested glucose that appeared in the systemic circulation was slightly lower after than before RYGB (85% ± 9% and 90% ± 8%, respectively) but was slightly higher after than before LAGB (89% ± 3% and 85% ± 4%, respectively) (P-interaction < 0.05). Accordingly, gastrointestinal clearance of ingested glucose (cumulative percentage cleared over 6 h postprandially) increased after RYGB (from 10% ± 8% before to 15% ± 9% after surgery) but decreased after LAGB (from 15% ± 4% before to 11% ± 3% after surgery) (P < 0.05). Surgery-induced weight loss caused a similar decrease in the 6-h postprandial plasma glucose area under the curve in both RYGB and LAGB groups (-4% ± 9% and -6% ± 5%, respectively; P = 0.475). CONCLUSIONS These data support the notion that intestinal glucose disposal increases after RYGB surgery. However, the magnitude of the effect was small and did not result in weight-loss-independent therapeutic effects on postprandial glycemic control. This trial was registered at clinicaltrials.gov as NCT00981500.
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Affiliation(s)
- Faidon Magkos
- Center for Human Nutrition and Atkins Center of Excellence in Obesity Medicine, Washington University School of Medicine, St. Louis, MO; Singapore Institute for Clinical Sciences, Agency for Science, Technology, and Research (A*STAR), and Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - David Bradley
- Center for Human Nutrition and Atkins Center of Excellence in Obesity Medicine, Washington University School of Medicine, St. Louis, MO
| | - J Christopher Eagon
- Center for Human Nutrition and Atkins Center of Excellence in Obesity Medicine, Washington University School of Medicine, St. Louis, MO
| | - Bruce W Patterson
- Center for Human Nutrition and Atkins Center of Excellence in Obesity Medicine, Washington University School of Medicine, St. Louis, MO
| | - Samuel Klein
- Center for Human Nutrition and Atkins Center of Excellence in Obesity Medicine, Washington University School of Medicine, St. Louis, MO;
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Gesquiere I, Darwich AS, Van der Schueren B, de Hoon J, Lannoo M, Matthys C, Rostami A, Foulon V, Augustijns P. Drug disposition and modelling before and after gastric bypass: immediate and controlled-release metoprolol formulations. Br J Clin Pharmacol 2015; 80:1021-30. [PMID: 25917170 DOI: 10.1111/bcp.12666] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 04/17/2015] [Accepted: 04/23/2015] [Indexed: 12/15/2022] Open
Abstract
AIMS The aim of the present study was to evaluate the disposition of metoprolol after oral administration of an immediate and controlled-release formulation before and after Roux-en-Y gastric bypass (RYGB) surgery in the same individuals and to validate a physiologically based pharmacokinetic (PBPK) model for predicting oral bioavailability following RYGB. METHODS A single-dose pharmacokinetic study of metoprolol tartrate 200 mg immediate release and controlled release was performed in 14 volunteers before and 6-8 months after RYGB. The observed data were compared with predicted results from the PBPK modelling and simulation of metoprolol tartrate immediate and controlled-release formulation before and after RYGB. RESULTS After administration of metoprolol immediate and controlled release, no statistically significant difference in the observed area under the curve (AUC(0-24 h)) was shown, although a tendency towards an increased oral exposure could be observed as the AUC(0-24 h) was 32.4% [95% confidence interval (CI) 1.36, 63.5] and 55.9% (95% CI 5.73, 106) higher following RYGB for the immediate and controlled-release formulation, respectively. This could be explained by surgery-related weight loss and a reduced presystemic biotransformation in the proximal gastrointestinal tract. The PBPK values predicted by modelling and simulation were similar to the observed data, confirming its validity. CONCLUSIONS The disposition of metoprolol from an immediate-release and a controlled-release formulation was not significantly altered after RYGB; there was a tendency to an increase, which was also predicted by PBPK modelling and simulation.
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Affiliation(s)
- Ina Gesquiere
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Adam S Darwich
- Centre for Applied Pharmacokinetic Research, School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Manchester, UK
| | - Bart Van der Schueren
- Clinical and Experimental Endocrinology, KU Leuven and Department of Endocrinology, University Hospitals Leuven/KU Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Jan de Hoon
- Center for Clinical Pharmacology, University Hospitals Leuven/KU Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Matthias Lannoo
- Department of Abdominal Surgery, University Hospitals Leuven/KU Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Christophe Matthys
- Clinical and Experimental Endocrinology, KU Leuven and Department of Endocrinology, University Hospitals Leuven/KU Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Amin Rostami
- Centre for Applied Pharmacokinetic Research, School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Manchester, UK
| | - Veerle Foulon
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Patrick Augustijns
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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Nadaleto BF, Herbella FAM, Patti MG. Gastroesophageal reflux disease in the obese: Pathophysiology and treatment. Surgery 2015; 159:475-86. [PMID: 26054318 DOI: 10.1016/j.surg.2015.04.034] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Revised: 04/07/2015] [Accepted: 04/28/2015] [Indexed: 12/12/2022]
Abstract
Obesity is a condition that has increased all over the world in the last 3 decades. Overweight and gastroesophageal reflux disease (GERD) are related. GERD may have different causative factors in the obese compared with lean individuals. This review focuses on the proper treatment for GERD in the obese based on its pathophysiology. Increased abdominal pressure may play a more significant role in obese subjects with GERD than the defective esophagogastric barrier usually found in nonobese individuals. A fundoplication may be used to treat GERD in these individuals; however, outcomes may be not as good as in nonobese patients and it does not act on the pathophysiology of the disease. All bariatric techniques may ameliorate GERD symptoms owing to a decrease in abdominal pressure secondary to weight loss. However, some operations may lead to a disruption of natural anatomic antireflux mechanisms or even lead to slow gastric emptying and/or esophageal clearance and thus be a refluxogenic procedure. Roux-en-Y gastric bypass decreases both acid and bile reflux from the stomach into the esophagus. On the other hand, gastric banding is a refluxogenic operation, and sleeve gastrectomy may show different outcomes based on the anatomy of the gastric tube.
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Affiliation(s)
- Barbara F Nadaleto
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil.
| | - Marco G Patti
- Department of Surgery, Pritzker School of Medicine, University of Chicago, Chicago, IL
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Dutia R, Embrey M, O’Brien S, Haeusler RA, Agénor KK, Homel P, McGinty J, Vincent RP, Alaghband-Zadeh J, Staels B, le Roux CW, Yu J, Laferrère B. Temporal changes in bile acid levels and 12α-hydroxylation after Roux-en-Y gastric bypass surgery in type 2 diabetes. Int J Obes (Lond) 2015; 39:806-13. [PMID: 25599611 PMCID: PMC4422767 DOI: 10.1038/ijo.2015.1] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Revised: 11/26/2014] [Accepted: 12/25/2014] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Gastric bypass surgery (GBP) leads to sustained weight loss and significant improvement in type 2 diabetes (T2DM). Bile acids (BAs), signaling molecules which influence glucose metabolism, are a potential mediator for the improvement in T2DM after GBP. This study sought to investigate the effect of GBP on BA levels and composition in individuals with T2DM. METHODS Plasma BA levels and composition and fibroblast growth factor (FGF)-19 levels were measured during fasting and in response to an oral glucose load before and at 1 month and 2 years post GBP in 13 severely obese women with T2DM. RESULTS A striking temporal change in BA levels and composition was observed after GBP. During the fasted state, BA concentrations were generally reduced at 1 month, but increased 2 years post GBP. Postprandial BA levels were unchanged 1 month post GBP, but an exaggerated postprandial peak was observed 2 years after the surgery. A significant increase in the 12α-hydroxylated/non12α-hydroxylated BA ratio during fasting and postprandially at 2 years, but not 1 month, post GBP was observed. Significant correlations between BAs vs FGF-19, body weight, the incretin effect and peptide YY (PYY) were also found. CONCLUSIONS This study provides evidence that GBP temporally modifies the concentration and composition of circulating BAs in individuals with T2DM, and suggests that BAs may be linked to the improvement in T2DM after GBP.
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Affiliation(s)
- R Dutia
- New York Obesity Nutrition Research Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - M Embrey
- New York Obesity Nutrition Research Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - S O’Brien
- New York Obesity Nutrition Research Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - RA Haeusler
- Department of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - KK Agénor
- New York Obesity Nutrition Research Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - P Homel
- Department of Medicine, Albert Einstein School of Medicine, New York, NY, USA
| | - J McGinty
- Division of Bariatric and Minimally Invasive Surgery, Department of Surgery, Mount Sinai, St. Luke’s Roosevelt Hospitals, New York, NY, USA
| | - RP Vincent
- Department of Clinical Biochemistry, King's College Hospital NHS Foundation Trust Denmark Hill, London, UK
| | - J Alaghband-Zadeh
- Department of Clinical Biochemistry, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - B Staels
- European Genomic Institute for Diabetes (EGID), Université Lille 2, Inserm UMR 1011, Institut Pasteur de Lille, Lille, France
| | - CW le Roux
- Diabetes Complications Research Center, Conway Institute, University College, Dublin, Ireland
| | - J Yu
- New York Obesity Nutrition Research Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - B Laferrère
- New York Obesity Nutrition Research Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
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Remission of type 2 diabetes after Roux-en-Y gastric bypass or sleeve gastrectomy is associated with a distinct glycemic profile. Ann Surg 2015; 261:316-22. [PMID: 25569030 DOI: 10.1097/sla.0000000000000586] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGBP) and sleeve gastrectomy (SG) have been associated with a high remission rate of type 2 diabetes mellitus (T2DM). However, whether such remission is associated with full restoration of postprandial glucose profile and/or the potentially nonrestored glycemic profile is associated with altered beta cell function, and relapse of T2DM over time is unknown. METHODS Cross-sectional studies comparing (1) glucose and proinsulin/insulin response to a standardized liquid mixed meal (SLMM) challenge (n = 31), (2) glucose response in normal living conditions assessed using continuous glucose monitoring (CGM) (n = 16), and prospective observational study comparing (3) rates of relapse of T2DM after surgery (n = 232) in subjects with remission of T2DM ensuing RYGBP or SG. RESULTS In RYGB individuals, SLMM elicited faster and sharper rise in plasma glucose compared with SG, with 88.2% and 42.9% of the study subjects presenting respectively a peak glucose more than 180 mg/dL (all, P < 0.05). During CGM, average percent time in hyperglycemic and hypoglycemic range was larger in RYGBP (respectively, 4.6% and 12.7%) compared with SG subjects (respectively, 0.4% and 3.2%; both P < 0.05). However, (1) no differences were found in fasting or stimulated proinsulin/insulin ratio, and (2) higher rates of T2DM relapse were observed after SG (hazard ratio: 2.339; P = 0.034). CONCLUSIONS Remission of T2DM after RYGBP and SG is associated with distinct glycemic profiles. However, longer time spent in hyperglycemia and in hypoglycemia after RYGBP compared with SG is not associated with persistence of altered beta cell function or higher rates of relapse of T2DM over time.
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Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) interferes considerably with the anatomy and physiology of the gastrointestinal tract. The study of intestinal permeability can provide important information regarding changes in the structure and function of the mucosal barrier after the procedure. METHODS The urinary excretion rates of lactulose and mannitol after oral intake of both substances were evaluated. We also evaluated the lactulose/mannitol excretion ratio. Tests were performed during the preoperative period (T0), at the first postoperative month (T1), and at the sixth postoperative month (T6). RESULTS The study included 16 morbidly obese patients. The excretion rate of mannitol was significantly lower at T1 compared with T0 and T6 (p = 0.003). There was no significant difference in the excretion rates of lactulose or in the lactulose/mannitol ratio during the three periods. Six patients (37.5%) exhibited a considerable increase in the excretion rate of lactulose at T6 (4-73 times higher than the preoperative value), accompanied by proportional variations in the lactulose/mannitol ratio. CONCLUSIONS The significant increase in mannitol excretion rate from T1 to T6 most likely reflects the occurrence of intestinal adaptation (mucosal hyperplasia), which would tend to minimize the malabsorption of macronutrients. A subgroup of patients who undergo RYGB exhibit pronounced increase in their intestinal permeability (assessed by the lactulose/mannitol ratio and the lactulose excretion rate) at T6.
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Nguyen NQ, Debreceni TL, Bambrick JE, Chia B, Deane AM, Wittert G, Rayner CK, Horowitz M, Young RL. Upregulation of intestinal glucose transporters after Roux-en-Y gastric bypass to prevent carbohydrate malabsorption. Obesity (Silver Spring) 2014; 22:2164-71. [PMID: 24990218 DOI: 10.1002/oby.20829] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 05/23/2014] [Accepted: 06/13/2014] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To determine the effect of Roux-en-Y gastric bypass (RYGB) on the expression of intestinal sweet taste receptors (STRs), glucose transporters (GTs), glucose absorption, and glycemia. METHODS Intestinal biopsies were collected for mRNA expression of STR (T1R2) and GTs (SGLT-1 and GLUT2) from 11 non-diabetic RYGB, 13 non-diabetic obese, and 11 healthy subjects, at baseline and following a 30 min small intestinal (SI) glucose infusion (30 g/150 ml water with 3 g 3-O-methyl-d-glucopyranose (3-OMG)). Blood glucose, plasma 3-OMG, and insulin were measured for 270 min. RESULTS In RYGB patients, expression of both GTs was ∼2-fold higher at baseline and after glucose infusion than those of morbidly obese or healthy subjects (P < 0.001). STR expressions were comparable amongst the groups. Peak plasma 3-OMG in both RYGB (r = 0.69, P = 0.01) and obese (r = 0.72, P = 0.005) correlated with baseline expression of SGLT-1, as was the case with peak blood glucose in RYGB subjects (r = 0.69, P = 0.02). CONCLUSIONS The upregulated intestinal GTs in RYGB patients are associated with increased glucose absorption when glucose is delivered at a physiological rate, suggesting a molecular adaptation to prevent carbohydrate malabsorption from rapid intestinal transit after RYGB.
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Affiliation(s)
- Nam Q Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, 5000, Australia; Discipline of Medicine, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, 5000, Australia
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Nguyen NQ, Debreceni TL, Bambrick JE, Bellon M, Wishart J, Standfield S, Rayner CK, Horowitz M. Rapid gastric and intestinal transit is a major determinant of changes in blood glucose, intestinal hormones, glucose absorption and postprandial symptoms after gastric bypass. Obesity (Silver Spring) 2014; 22:2003-9. [PMID: 24829088 DOI: 10.1002/oby.20791] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 04/10/2014] [Accepted: 05/02/2014] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the effect of modulating pouch emptying (PE) and SI transit of glucose after Roux-en-Y gastric bypass (RYGB) on blood glucose, incretin hormones, glucose absorption and gastrointestinal (GI) symptoms. METHODS Ten RYGB patients were studied twice in random order, receiving either a 150 ml glucose drink (200 kcal) or the same solution infused into the proximal Roux-limb at 4 kcal/min. Data were compared with 10 healthy volunteers who received a 4 kcal/min duodenal infusion. PE, cecal arrival time (CAT), blood glucose, plasma 3-O-methylglucose (3-OMG), insulin, glucose-dependent insulinotropic polypeptide (GIP), and glucagon-like peptide-1 (GLP-1), and GI symptoms were measured. RESULTS In RYGB subjects, the glucose drink emptied very rapidly (PE t50 = 3 ± 1 min) and intestinal glucose infusion was associated with higher blood glucose and plasma 3-OMG, but lower plasma GLP-1, GIP, insulin, and GI symptoms than oral glucose (all P < 0.001), and comparable to volunteers. In RYGB subjects, CAT correlated inversely with peak GLP-1 (r = -0.73, P = 0.01), and plasma 3-OMG correlated tightly blood glucose (r = 0.94, P < 0.0001). CONCLUSIONS After RYGB, reducing intestinal glucose delivery to 4 kcal/min is associated with higher blood glucose, greater glucose absorption, lower incretin responses, and less GI symptoms, supporting rapid transit contribution to the exaggerated incretin responses and "dumping symptoms".
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Affiliation(s)
- Nam Q Nguyen
- Department of Gastroenterology and Hepatology, Level 7, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000, Australia; Discipline of Medicine, University of Adelaide, Royal Adelaide Hospital, Level 6 Eleanor Harrold Building, North Terrace, Adelaide, South Australia, 5000, Australia
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Overduin J, Tylee TS, Frayo RS, Cummings DE. Hyperosmolarity in the small intestine contributes to postprandial ghrelin suppression. Am J Physiol Gastrointest Liver Physiol 2014; 306:G1108-16. [PMID: 24789208 PMCID: PMC4059977 DOI: 10.1152/ajpgi.00072.2014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Plasma levels of the orexigenic hormone ghrelin are suppressed by meals with an efficacy dependent on their macronutrient composition. We hypothesized that heterogeneity in osmolarity among macronutrient classes contributes to these differences. In three studies, the impact of small intestinal hyperosmolarity was examined in Sprague-Dawley rats. In study 1, isotonic, 2.5×, and 5× hypertonic solutions of several agents with diverse absorption and metabolism properties were infused duodenally at a physiological rate (3 ml/10 min). Jugular vein blood was sampled before and at 30, 60, 90, 120, 180, 240, and 300 min after infusion. Plasma ghrelin was suppressed dose dependently and most strongly by glucose. Hyperosmolar infusions of lactulose, which transits the small intestine unabsorbed, and 3-O-methylglucose (3-O-MG), which is absorbed like glucose but remains unmetabolized, also suppressed ghrelin. Glucose, but not lactulose or 3-O-MG, infusions increased plasma insulin. In study 2, intestinal infusions of hyperosmolar NaCl suppressed ghrelin, a response that was not attenuated by coinfusion with the neural blocker lidocaine. In study 3, we reconfirmed that the low-osmolar lipid emulsion Intralipid suppresses ghrelin more weakly than isocaloric (but hypertonic) glucose. Importantly, raising Intralipid's osmolarity to that of the glucose solution by nonabsorbable lactulose supplementation enhanced ghrelin suppression to that seen after glucose. Hyperosmolar ghrelin occurred particularly during the initial 3 postinfusion hours. We conclude that small intestinal hyperosmolarity 1) is sufficient to suppress ghrelin, 2) may combine with other postprandial mechanisms to suppress ghrelin, 3) might contribute to altered ghrelin regulation after gastric bypass surgery, and 4) may inform dietary modifications for metabolic health.
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Affiliation(s)
- Joost Overduin
- University of Washington School of Medicine, Seattle, Washington; and Veterans Affairs Puget Sound Health Care System Seattle, Washington
| | - Tracy S. Tylee
- University of Washington School of Medicine, Seattle, Washington; and Veterans Affairs Puget Sound Health Care System Seattle, Washington
| | - R. Scott Frayo
- University of Washington School of Medicine, Seattle, Washington; and Veterans Affairs Puget Sound Health Care System Seattle, Washington
| | - David E. Cummings
- University of Washington School of Medicine, Seattle, Washington; and Veterans Affairs Puget Sound Health Care System Seattle, Washington
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O'Brien CS, Wang G, McGinty J, Agénor KK, Dutia R, Colarusso A, Park K, Koshy N, Laferrère B. Effects of gastrogastric fistula repair on weight loss and gut hormone levels. Obes Surg 2014; 23:1294-301. [PMID: 23549962 DOI: 10.1007/s11695-013-0917-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Weight regain after gastric bypass (GBP) can be associated with a gastrogastric fistula (GGF), in which a channel forms between the gastric pouch and gastric remnant, allowing nutrients to pass through the "old route" rather than bypassing the duodenum. To further understand the mechanisms by which GGF may lead to weight regain, we investigated gut hormone levels in GBP patients with a GGF, before and after repair. MATERIALS AND METHODS Seven post-GBP subjects diagnosed with GGF were studied before and 4 months after GGF repair. Another cohort of 22 GBP control subjects without GGF complication were studied before and 1 year post-GBP. All subjects underwent a 50-g oral glucose tolerance test and blood was collected from 0-120 min for glucose, insulin, ghrelin, PYY3-36, GIP, and GLP-1 levels. RESULTS Four months after GGF repair subjects lost 6.0 ± 3.9 kg and had significantly increased postprandial PYY3-36 levels. After GGF repair, fasting and postprandial ghrelin levels decreased and were strongly correlated with weight loss. The insulin response to glucose also tended to be increased after GGF repair, however no concomitant increase in GLP-1 was observed. Compared to the post-GBP group, GLP-1 and PYY3-36 levels were significantly lower before GGF repair; however, after GGF repair, PYY3-36 levels were no longer lower than the post-GBP group. CONCLUSIONS These data utilize the GGF model to highlight the possible role of duodenal shunting as a mechanism of sustained weight loss after GBP, and lend support to the potential link between blunted satiety peptide release and weight regain.
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Affiliation(s)
- Ciaran S O'Brien
- New York Obesity Nutrition Research Center, Department of Medicine, St Luke's Roosevelt Hospital Center, 1111 Amsterdam Avenue, New York, NY 10025, USA
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Miras AD, le Roux CW. Can medical therapy mimic the clinical efficacy or physiological effects of bariatric surgery? Int J Obes (Lond) 2014; 38:325-33. [PMID: 24213310 PMCID: PMC3950585 DOI: 10.1038/ijo.2013.205] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 08/12/2013] [Accepted: 11/03/2013] [Indexed: 12/24/2022]
Abstract
The number of bariatric surgical procedures performed has increased dramatically. This review discusses the clinical and physiological changes, and in particular, the mechanisms behind weight loss and glycaemic improvements, observed following the gastric bypass, sleeve gastrectomy and gastric banding bariatric procedures. The review then examines how close we are to mimicking the clinical or physiological effects of surgery through less invasive and safer modern interventions that are currently available for clinical use. These include dietary interventions, orlistat, lorcaserin, phentermine/topiramate, glucagon-like peptide-1 receptor agonists, dipeptidyl peptidase-4 inhibitors, pramlintide, dapagliflozin, the duodenal-jejunal bypass liner, gastric pacemakers and gastric balloons. We conclude that, based on the most recent trials, we cannot fully mimic the clinical or physiological effects of surgery; however, we are getting closer. A 'medical bypass' may not be as far in the future as we previously thought, as the physician's armamentarium against obesity and type 2 diabetes has recently got stronger through the use of specific dietary modifications, novel medical devices and pharmacotherapy. Novel therapeutic targets include not only appetite but also taste/food preferences, energy expenditure, gut microbiota, bile acid signalling, inflammation, preservation of β-cell function and hepatic glucose output, among others. Although there are no magic bullets, an integrated multimodal approach may yield success. Non-surgical interventions that mimic the metabolic benefits of bariatric surgery, with a reduced morbidity and mortality burden, remain tenable alternatives for patients and health-care professionals.
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Affiliation(s)
- A D Miras
- Molecular and Metabolic Imaging Group, Imperial College London, MRC Institute of Clinical Sciences, London, UK
| | - C W le Roux
- Department of Experimental Pathology, Conway Institute, School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
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Quercia I, Dutia R, Kotler DP, Belsley S, Laferrère B. Gastrointestinal changes after bariatric surgery. DIABETES & METABOLISM 2013; 40:87-94. [PMID: 24359701 DOI: 10.1016/j.diabet.2013.11.003] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 11/21/2013] [Accepted: 11/22/2013] [Indexed: 12/23/2022]
Abstract
Severe obesity is a preeminent health care problem that impacts overall health and survival. The most effective treatment for severe obesity is bariatric surgery, an intervention that not only maintains long-term weight loss but also is associated with improvement or remission of several comorbidies including type 2 diabetes mellitus. Some weight loss surgeries modify the gastrointestinal anatomy and physiology, including the secretions and actions of gut peptides. This review describes how bariatric surgery alters the patterns of gastrointestinal motility, nutrient digestion and absorption, gut peptide release, bile acids and the gut microflora, and how these changes alter energy homeostasis and glucose metabolism.
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Affiliation(s)
- I Quercia
- New York Obesity Nutrition Research Center, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, 1111, Amsterdam Avenue, 1034 New York, NY 10025, USA; Department of Medicine, St Luke's-Roosevelt Hospital Center, New York, NY 10025, USA
| | - R Dutia
- New York Obesity Nutrition Research Center, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, 1111, Amsterdam Avenue, 1034 New York, NY 10025, USA; Department of Medicine, St Luke's-Roosevelt Hospital Center, New York, NY 10025, USA
| | - D P Kotler
- Division of Gastroenterology and Liver Disease, St Luke's-Roosevelt Hospital Center, New York, NY 10025, USA; Department of Medicine, St Luke's-Roosevelt Hospital Center, New York, NY 10025, USA; Columbia University College of Physicians and Surgeons, New York, NY 10025, USA
| | - S Belsley
- Department of Surgery, St Luke's-Roosevelt Hospital Center, New York, NY 10025, USA; Columbia University College of Physicians and Surgeons, New York, NY 10025, USA
| | - B Laferrère
- New York Obesity Nutrition Research Center, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, 1111, Amsterdam Avenue, 1034 New York, NY 10025, USA; Division of Endocrinology, Diabetes and Nutrition, St Luke's-Roosevelt Hospital Center, New York, NY 10025, USA; Department of Medicine, St Luke's-Roosevelt Hospital Center, New York, NY 10025, USA; Columbia University College of Physicians and Surgeons, New York, NY 10025, USA.
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Abstract
The clinical efficacy of bariatric surgery has encouraged the scientific investigation of the gut as a major endocrine organ. Manipulation of gastrointestinal anatomy through surgery has been shown to profoundly affect the physiological and metabolic processes that control body weight and glycaemia. The most popular bariatric surgical procedures are gastric bypass, adjustable gastric banding and vertical sleeve gastrectomy. Even though these procedures were designed with the aim of causing restriction of food intake and nutrient malabsorption, evidence suggests that their contributions to weight loss are minimal. Instead, these interventions reduce body weight by decreasing hunger, increasing satiation during a meal, changing food preferences and energy expenditure. In this Review, we have explored these mechanisms as well as their mediators. The hope is that that their in-depth investigation will enable the optimization and individualization of surgical techniques, the development of equally effective but safer nonsurgical weight-loss interventions, and even the understanding of the pathophysiology of obesity itself.
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Affiliation(s)
- Alexander D Miras
- Molecular and Metabolic Imaging Group, Institute of Clinical Sciences, Imperial College London, Hammersmith Hospital, London W12 0NN, UK
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Saeidi N, Meoli L, Nestoridi E, Gupta NK, Kvas S, Kucharczyk J, Bonab AA, Fischman AJ, Yarmush ML, Stylopoulos N. Reprogramming of intestinal glucose metabolism and glycemic control in rats after gastric bypass. Science 2013; 341:406-10. [PMID: 23888041 PMCID: PMC4068965 DOI: 10.1126/science.1235103] [Citation(s) in RCA: 262] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The resolution of type 2 diabetes after Roux-en-Y gastric bypass (RYGB) attests to the important role of the gastrointestinal tract in glucose homeostasis. Previous studies in RYGB-treated rats have shown that the Roux limb displays hyperplasia and hypertrophy. Here, we report that the Roux limb of RYGB-treated rats exhibits reprogramming of intestinal glucose metabolism to meet its increased bioenergetic demands; glucose transporter-1 is up-regulated, basolateral glucose uptake is enhanced, aerobic glycolysis is augmented, and glucose is directed toward metabolic pathways that support tissue growth. We show that reprogramming of intestinal glucose metabolism is triggered by the exposure of the Roux limb to undigested nutrients. We demonstrate by positron emission tomography-computed tomography scanning and biodistribution analysis using 2-deoxy-2-[18F]fluoro-D-glucose that reprogramming of intestinal glucose metabolism renders the intestine a major tissue for glucose disposal, contributing to the improvement in glycemic control after RYGB.
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Affiliation(s)
- Nima Saeidi
- Center for Basic and Translational Obesity Research, Division of Endocrinology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Shriners Hospital for Children, Boston, MA 02114, USA
- Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Luca Meoli
- Center for Basic and Translational Obesity Research, Division of Endocrinology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Eirini Nestoridi
- Center for Basic and Translational Obesity Research, Division of Endocrinology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Nitin K. Gupta
- Center for Basic and Translational Obesity Research, Division of Endocrinology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Stephanie Kvas
- Center for Basic and Translational Obesity Research, Division of Endocrinology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - John Kucharczyk
- Center for Basic and Translational Obesity Research, Division of Endocrinology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Ali A. Bonab
- Shriners Hospital for Children, Boston, MA 02114, USA
| | | | - Martin L. Yarmush
- Shriners Hospital for Children, Boston, MA 02114, USA
- Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Nicholas Stylopoulos
- Center for Basic and Translational Obesity Research, Division of Endocrinology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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46
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Meillon S, Miras AD, Roux CWL. Gastric bypass surgery alters food preferences through changes in the perception of taste. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/cpr.13.32] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Bariatric surgery, and in particular, gastric bypass, is an increasingly utilized and successful approach for long-term treatment of obesity and amelioration of comorbidities. Nutrient deficiencies after surgery are common and have multiple causes. Preoperative factors include obesity, which appears to be associated with risk for several nutrient deficiencies, and preoperative weight loss. Postoperatively, reduced food intake, suboptimal dietary quality, altered digestion and absorption, and nonadherence with supplementation regimens contribute to risk of deficiency. The most common clinically relevant micronutrient deficiencies after gastric bypass include thiamine, vitamin B₁₂, vitamin D, iron, and copper. Reports of deficiencies of many other nutrients, some with severe clinical manifestations, are relatively sporadic. Diet and multivitamin use are unlikely to consistently prevent deficiency, thus supplementation with additional specific nutrients is often needed. Though optimal supplement regimens are not yet defined, most micronutrient deficiencies after gastric bypass currently can be prevented or treated by appropriate supplementation.
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Affiliation(s)
- Edward Saltzman
- Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA 02111, USA.
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Dirksen C, Damgaard M, Bojsen-Møller KN, Jørgensen NB, Kielgast U, Jacobsen SH, Naver LS, Worm D, Holst JJ, Madsbad S, Hansen DL, Madsen JL. Fast pouch emptying, delayed small intestinal transit, and exaggerated gut hormone responses after Roux-en-Y gastric bypass. Neurogastroenterol Motil 2013; 25:346-e255. [PMID: 23360316 DOI: 10.1111/nmo.12087] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2012] [Accepted: 12/11/2012] [Indexed: 01/17/2023]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) causes extensive changes in gastrointestinal anatomy and leads to reduced appetite and large weight loss, which partly is due to an exaggerated release of anorexigenic gut hormones. METHODS To examine whether the altered passage of foods through the gastrointestinal tract after RYGB could be responsible for the changes in gut hormone release, we studied gastrointestinal motility with a scintigraphic technique as well as the secretion of the gut hormones glucagon-like peptide (GLP)-1 and peptide YY3-36 (PYY3-36 ) in 17 patients>1 year after RYGB and in nine healthy control subjects. KEY RESULTS At meal completion, a smaller fraction of liquid and solid radiolabeled marker was retained in the pouch of RYGB patients than in the stomach of control subjects (P = 0.002 and P < 0.001, respectively). Accordingly, pouch emptying in patients was faster than gastric emptying in control subjects (P < 0.001 and P = 0.004, respectively liquid and solid markers). For the solid marker, small intestinal transit was slower in patients than control subjects (P = 0.034). Colonic transit rate did not differ between the groups. GLP-1 and PYY3-36 secretion was increased in patients compared to control subjects and fast pouch emptying of the liquid marker was associated with high gut hormone secretion. CONCLUSIONS & INFERENCES After RYGB, the bulk of foods pass without hindrance into the small intestine, while the small intestinal transit is prolonged. The rapid exposure of the gut epithelium contributes to the exaggerated release of GLP-1 and PYY3-36 after RYGB.
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Affiliation(s)
- C Dirksen
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark.
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Anderwald CH, Tura A, Promintzer-Schifferl M, Prager G, Stadler M, Ludvik B, Esterbauer H, Bischof MG, Luger A, Pacini G, Krebs M. Alterations in gastrointestinal, endocrine, and metabolic processes after bariatric Roux-en-Y gastric bypass surgery. Diabetes Care 2012; 35:2580-7. [PMID: 22923664 PMCID: PMC3507557 DOI: 10.2337/dc12-0197] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Obesity leads to severe long-term complications and reduced life expectancy. Roux-en-Y gastric bypass (RYGB) surgery induces excessive and continuous weight loss in (morbid) obesity, although it causes several abnormal anatomical and physiological conditions. RESEARCH DESIGN AND METHODS To distinctively unveil effects of RYGB surgery on β-cell function and glucose turnover in skeletal muscle, liver, and gut, nondiabetic, morbidly obese patients were studied before (pre-OP, five female/one male, BMI: 49 ± 3 kg/m(2), 43 ± 2 years of age) and 7 ± 1 months after (post-OP, BMI: 37 ± 3 kg/m(2)) RYGB surgery, compared with matching obese (CON(ob), five female/one male, BMI: 34 ± 1 kg/m(2), 48 ± 3 years of age) and lean controls (CON(lean), five female/one male, BMI: 22 ± 0 kg/m(2), 42 ± 2 years of age). Oral glucose tolerance tests (OGTTs), hyperinsulinemic-isoglycemic clamp tests, and mechanistic mathematical modeling allowed determination of whole-body insulin sensitivity (M/I), OGTT and clamp test β-cell function, and gastrointestinal glucose absorption. RESULTS Post-OP lost (P < 0.0001) 35 ± 3 kg body weight. M/I increased after RYGB, becoming comparable to CON(ob), but remaining markedly lower than CON(lean) (P < 0.05). M/I tightly correlated (τ = -0.611, P < 0.0001) with fat mass. During OGTT, post-OP showed ≥15% reduced plasma glucose from 120 to 180 min (≤4.5 mmol/L), and 29-fold elevated active glucagon-like peptide-1 (GLP-1) dynamic areas under the curve, which tightly correlated (r = 0.837, P < 0.001) with 84% increased β-cell secretion. Insulinogenic index (0-30 min) in post-OP was ≥29% greater (P < 0.04). At fasting, post-OP showed approximately halved insulin secretion (P < 0.05 vs. pre-OP). Insulin-stimulated insulin secretion in post-OP was 52% higher than before surgery, but 1-2 pmol/min(2) lower than in CON(ob)/CON(lean) (P < 0.05). Gastrointestinal glucose absorption was comparable in pre-OP and post-OP, but 9-26% lower from 40 to 90 min in post-OP than in CON(ob)/CON(lean) (P < 0.04). CONCLUSIONS RYGB surgery leads to decreased plasma glucose concentrations in the third OGTT hour and exaggerated β-cell function, for which increased GLP-1 release seems responsible, whereas gastrointestinal glucose absorption remains unchanged but lower than in matching controls.
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Bradley D, Conte C, Mittendorfer B, Eagon JC, Varela JE, Fabbrini E, Gastaldelli A, Chambers KT, Su X, Okunade A, Patterson BW, Klein S. Gastric bypass and banding equally improve insulin sensitivity and β cell function. J Clin Invest 2012. [PMID: 23187122 DOI: 10.1172/jci64895] [Citation(s) in RCA: 194] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Bariatric surgery in obese patients is a highly effective method of preventing or resolving type 2 diabetes mellitus (T2DM); however, the remission rate is not the same among different surgical procedures. We compared the effects of 20% weight loss induced by laparoscopic adjustable gastric banding (LAGB) or Roux-en-Y gastric bypass (RYGB) surgery on the metabolic response to a mixed meal, insulin sensitivity, and β cell function in nondiabetic obese adults. The metabolic response to meal ingestion was markedly different after RYGB than after LAGB surgery, manifested by rapid delivery of ingested glucose into the systemic circulation, by an increase in the dynamic insulin secretion rate, and by large, early postprandial increases in plasma glucose, insulin, and glucagon-like peptide-1 concentrations in the RYGB group. However, the improvement in oral glucose tolerance, insulin sensitivity, and overall β cell function after weight loss were not different between surgical groups. Additionally, both surgical procedures resulted in a similar decrease in adipose tissue markers of inflammation. We conclude that marked weight loss itself is primarily responsible for the therapeutic effects of RYGB and LAGB on insulin sensitivity, β cell function, and oral glucose tolerance in nondiabetic obese adults.
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Affiliation(s)
- David Bradley
- Center for Human Nutrition, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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