Prospective controlled study of effect of laparoscopic sleeve gastrectomy on small bowel transit time and gastric emptying half-time in morbidly obese patients with type 2 diabetes mellitus

The Potential Mechanism of Remission in Type 2 Diabetes Mellitus After Vertical Sleeve Gastrectomy

In recent years, there has been a gradual increase in the prevalence of obesity and type 2 diabetes mellitus (T2DM), with bariatric surgery remaining the most effective treatment strategy for these conditions. Vertical sleeve gastrectomy (VSG) has emerged as the most popular surgical procedure for bariatric/metabolic surgeries, effectively promoting weight loss and improving or curing T2DM. The alterations in the gastrointestinal tract following VSG may improve insulin secretion and resistance by increasing incretin secretion (especially GLP-1), modifying the gut microbiota composition, and through mechanisms dependent on weight loss. This review focuses on the potential mechanisms through which the enhanced action of incretin and metabolic changes in the digestive system after VSG may contribute to the remission of T2DM.

Gut motility and hormone changes after bariatric procedures

PURPOSE OF REVIEW

Metabolic and bariatric surgery (MBS) and endoscopic bariatric therapies (EBT) are being increasingly utilized for the management of obesity. They work through multiple mechanisms, including restriction, malabsorption, and changes in the gastrointestinal hormonal and motility.

RECENT FINDINGS

Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) cause decrease in leptin, increase in GLP-1 and PYY, and variable changes in ghrelin (generally thought to decrease). RYGB and LSG lead to rapid gastric emptying, increase in small bowel motility, and possible decrease in colonic motility. Endoscopic sleeve gastroplasty (ESG) causes decrease in leptin and increase in GLP-1, ghrelin, and PYY; and delayed gastric motility.

SUMMARY

Understanding mechanisms of action for MBS and EBT is critical for optimal care of patients and will help in further refinement of these interventions.

The Evaluation of Gastric Emptying Using Nuclear Scintigraphy Compared to Three-Dimensional Multi-detector Computed Tomography (3D-MDCT) Gastric Volumetry in the Assessment of Poor Weight Loss Following Sleeve Gastrectomy

BACKGROUND

Poor weight loss and weight regain are principal challenges following laparoscopic sleeve gastrectomy (LSG). There is a lack of standardised assessments and diagnostic tests to stratify the status post-LSG and determine whether anatomical or physiological problem exists. We aimed to compare nuclear scintigraphy gastric emptying with CT volumetric analysis of sleeve anatomy and determine the impact of anatomy on physiological function and its correlation with weight loss.

MATERIALS AND METHODS

Patients greater than 12 months post-LSG were categorised into optimal weight loss (OWL) (n = 29) and poor weight loss groups (PWL) (n = 50). All patients underwent a protocolised nuclear scintigraphy and three-dimensional multi-detector computed tomography (3D-MDCT) gastric volumetry imaging.

RESULTS

Post-operative % total weight loss in OWL was 26.2 ± 10.5% vs. 14.2 ± 10.7% in the PWL group (p value < 0.0001). The PWL group had significantly more delayed gastric emptying half-time than OWL (34.1 ± 18.8 vs. 19.5 ± 4.7, p value < 0.0001). Gastric emptying half-time showed statistically significant correlations with weight loss parameters (BMI; r = 0.215, p value 0.048, %EWL; r =  - 0.336, p value 0.002 and %TWL; r =  - 0.379, p value < 0.001). The median gastric volume on 3D-MDCT did not differ between the OWL (246 (IQR 50) ml) and PWL group (262 (IQR 129.5) ml), p value 0.515. Nuclear scintigraphy gastric emptying half-time was the most highly discriminant measure. A threshold of 21.2 min distinguished OWL from PWL patients with 86.4% sensitivity and 68.4% specificity.

CONCLUSION

Nuclear scintigraphy is a potentially highly accurate tool in the functional assessment of sleeve gastrectomy physiology. It appears to perform better as a diagnostic test than volumetric assessment. Gastric volume did not correlate with weight loss outcomes. We have established diagnostic criteria of greater than 21 min to assess sleeve failure, which is linked to suboptimal weight loss outcomes.

Diagnosis and management of post-bariatric surgery hypoglycemia

INTRODUCTION

While bariatric surgery remains the most effective treatment for obesity that allows substantial weight loss with improvement and possibly remission of obesity-associated comorbidities, some postoperative complications may occur. Managing physicians need to be familiar with the common problems to ensure timely and effective management. Of these complications, postoperative hypoglycemia is an increasingly recognized complication of bariatric surgery that remains underreported and underdiagnosed.

AREA COVERED

This article highlights the importance of identifying hypoglycemia in patients with a history of bariatric surgery, reviews pathophysiology and addresses available nutritional, pharmacological and surgical management options. Systemic evaluation including careful history taking, confirmation of hypoglycemia and biochemical assessment is essential to establish accurate diagnosis. Understanding the weight-dependent and weight-independent mechanisms of improved postoperative glycemic control can provide better insight into the causes of the exaggerated responses that lead to postoperative hypoglycemia.

EXPERT OPINION

Management of post-operative hypoglycemia can be challenging and requires a multidisciplinary approach. While dietary modification is the mainstay of treatment for most patients, some patients may benefit from pharmacotherapy (e.g. GLP-1 receptor antagonist); Surgery (e.g. reversal of gastric bypass) is reserved for unresponsive severe cases. Additional research is needed to understand the underlying pathophysiology with a primary aim in optimizing diagnostics and treatment options.

Changes in Oesophageal Transit, Macro-Reflux Events, and Gastric Emptying Correlate with Improvements in Gastro-Intestinal Symptoms and Food Tolerance Early Post Sleeve Gastrectomy

PURPOSE

There are significant alterations in gastro-intestinal function, food tolerance, and symptoms following sleeve gastrectomy (SG). These substantially change over the first year, but it is unclear what the underlying physiological basis for these changes is. We examined changes in oesophageal transit and gastric emptying and how these correlate with changes in gastro-intestinal symptoms and food tolerance.

MATERIAL AND METHODS

Post-SG patients undertook protocolised nuclear scintigraphy imaging along with a clinical questionnaire at 6 weeks, 6 months, and 12 months.

RESULTS

Thirteen patients were studied: mean age (44.8 ± 8.5 years), 76.9% females, pre-operative BMI (46.9 ± 6.7 kg/m2). Post-operative %TWL was 11.9 ± 5.1% (6 weeks) and 32.2 ± 10.1% (12 months), p-value < 0.0001. There was a substantial increase of meal within the proximal stomach; 22.3% (IQR 12%) (6 weeks) vs. 34.2% (IQR 19.7%) (12 months), p = 0.038. Hyper-accelerated transit into the small bowel decreased from 6 weeks 49.6% (IQR 10.8%) to 42.7% (IQR 20.5%) 12 months, p = 0.022. Gastric emptying half-time increased from 6 weeks 19 (IQR 8.5) to 12 months 27 (IQR 11.5) min, p = 0.027. The incidence of deglutitive reflux of semi-solids decreased over time; 46.2% (6 weeks) vs. 18.2% (12 months), p-value < 0.0001. Reflux score of 10.6 ± 7.6 at 6 weeks vs. 3.5 ± 4.4 at 12 months, (p = 0.049) and regurgitation score of 9.9 ± 3.3 at 6 weeks vs. 6.5 ± 1.7, p = 0.021 significantly reduced.

CONCLUSIONS

These data demonstrate that there is an increase in the capacity of the proximal gastric sleeve to accommodate substrate over the first year. Gastric emptying remains rapid but reduce over time, correlating with improved food tolerance and reduced reflux symptoms. This is likely the physiological basis for the changes in symptoms and food tolerance observed early post-SG.

Gastroparesis: An Evidence-Based Review for the Bariatric and Foregut Surgeon

Gastroparesis is a gastric motility disorder characterized by delayed gastric emptying. It is a rare disease and difficult to treat effectively; management is a dilemma for gastroenterologists and surgeons alike. We conducted a systematic review of the literature to evaluate current diagnostic tools as well as treatment options. We describe key elements in the pathophysiology of the disease, in addition to current evidence on treatment alternatives, including nutritional considerations, medical and surgical options, and related outcomes.

Changes of Short-Chain Fatty Acids and Their Receptors in an Obese Rat Model After Sleeve Gastrectomy

BACKGROUND

Short-chain fatty acids (SCFAs) and gut microbiota have health-related effects and are associated with a wide range of disorders. However, the changes of SCFAs and their receptors after sleeve gastrectomy (SG) remain unclear. This study aimed to examine changes of SCFAs and their receptors after SG in an obese rat model.

METHODS

Thirty obese Sprague-Dawley rats eating a high-energy diet for 6 weeks were divided into three groups: sham-operated (SO) control, pair-fed (PF) control, and SG group. Six weeks after the surgery, metabolic parameters, SCFA levels in the blood and stool, mRNA and protein expression of SCFA receptors in the ileum and epididymal fat, and gut microbiota were examined.

RESULTS

Metabolic parameters in the SG group were significantly improved compared with the SO group. Acetic acid levels in the blood and stool were significantly higher in the SG group than the PF group. The butyric acid level in the stool was also significantly higher in the SG group than in the PF group. In the ileum and epididymal fat, mRNA and protein expression of GPR41 was significantly higher in the SG group than in the other two groups, and mRNA and protein expression of GPR43 was significantly higher in the SG group than in the PF group. Increases in the genera Enterococcus, Lactobacillus, Lactococcus, and Clostridium were observed in the stool after SG.

CONCLUSIONS

SG may activate SCFA pathways through a change in gut microbiota.

Antrum Preservation Versus Antrum Resection in Laparoscopic Sleeve Gastrectomy With Effects on Gastric Emptying, Body Mass Index, and Type II Diabetes Remission in Diabetic Patients With Body Mass Index 30-40 kg/m2: a Randomized Controlled Study

Background

Laparoscopic sleeve gastrectomy (LSG) is a widely performed procedure nowadays. There is a controversy on whether antrum resection (AR) or antrum preservation (AP) should be done and if this has an effect on BMI, gastric emptying, and associated medical conditions such as diabetes mellitus (DM).

Study Design

This randomized controlled trial included 56 patients in the AP group and 53 patients in the AR group with BMI 30–40 kg/m². Weight, BMI, fasting and postprandial blood glucose (FBS and PPBS), HbA1C, oral hypoglycemic drug use, and % gastric emptying by gastric scintigraphy at 30, 60, 90, and 120 min were recorded preoperatively and postoperatively at 3, 6, and 12 months. Postoperative % of total weight loss (TWL) and symptoms of de novo GERD were observed at 3, 6, and 12 months.

Results

The AR group had significantly lower BMI and HbA1C and higher %TWL than the AP group. There was a significant difference between the two groups regarding % of gastric emptying with the AP group showing higher values at 30, 60, 90, and 120 min. There were no significant differences regarding FBS, PPBS, and oral hypoglycemic use. The AR group had more incidence of GERD symptoms postoperatively yet with no significant difference.

Conclusion

LSG with antrum resection (2 cm from the pylorus) had significantly less postoperative BMI, higher %TWL, better control of type II DM, and more retention of gastric contents in patients with BMI 30–40 kg/m² in comparison with LSG with antral preservation with non-significant increase in incidence of GERD symptoms.

Graphical abstract

Nutrients handling after bariatric surgery, the role of gastrointestinal adaptation

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.

Bariatric Surgery in NAFLD

Currently, there are no approved medications to treat patients with nonalcoholic steatohepatitis (NASH) with fibrosis or cirrhosis. Although the management goal in these patients is weight reduction by 7-10% with lifestyle modifications, only less than 10% of patients achieve this target at 1-year, and fewer maintain the weight loss at 5 years. Bariatric surgery is an option that may be considered in those who fail to lose weight by lifestyle changes. Bariatric surgery has been shown to improve liver histology including fibrosis secondary to NASH, in addition to other benefits including an improvement or resolution of type 2 diabetes mellitus, dyslipidemia, and hypertension, and a reduction of cardiovascular morbidity or mortality. There are no guidelines of bariatric surgery indications for the management of NASH. The purpose of this review is to critically appraise the current knowledge of the role of bariatric surgery and the potential mechanisms for its perceived benefits in the management of patients with NASH-related liver disease.

Feasibility and diagnostic yield of small-bowel capsule endoscopy in patients with surgically altered gastric anatomy: the SAGA study

BACKGROUND AND AIMS

Little is known about small-bowel (SB) capsule endoscopy (CE) in patients with a history of gastric surgery. This study aims to evaluate the feasibility and diagnostic yield (DY) of orally ingested SB-CE in patients with surgically altered gastric anatomy.

METHODS

Twenty-four European centers retrospectively identified patients who had SB-CE after total or subtotal gastrectomy. The primary outcome was the DY of SB-CE (intermediate P1 to highly P2 relevant findings). Secondary outcomes were gastric and SB transit times, completion, cleanliness, and adverse event rates.

RESULTS

Studied were 248 procedures from 243 patients (mean age, 62 years) with a history of partial gastrectomy (Billroth I, 13.1%; Billroth II, 34.6%), total gastrectomy (7.4%), Whipple procedure (12.8%), sleeve gastrectomy (7.2%), or gastric bypass surgery (24.7%). Obscure GI bleeding was the most frequent indication (85.1%). SB completion rate was 84.3%. One capsule retention in the SB was noted (adverse event rate, .4%). Median SB transit time was 286 minutes (interquartile range [235; 387]). Cleanliness was rated as adequate in 92.1% of procedures. After exclusion of abnormalities found at the upper anastomotic site, the DY was 43.6%, with inflammatory/ulcerated lesions observed more frequently (23.4%) than vascular lesions (21.0%).

CONCLUSIONS

SB-CE seems to be feasible and safe in selected patients with a history of major gastric surgery and comes with a high DY. The spectrum of abnormal SB findings in these patients may be different from what is known from the literature in nonoperated patients.

Hill Modified, a Novel Approach: Technique Description and Experience in Patients with Laparoscopic Sleeve Gastrectomy

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common disease among patients with obesity, with an associated prevalence of 39 to 61% between the population who attends a bariatric surgery evaluation. Laparoscopic sleeve gastrectomy (LSG) has become a popular and valid option for obesity treatment, even though the literature is ambivalent regarding the increase or decrease in GERD after this surgery. Thus, it is necessary to propose new surgical techniques as a solution to GERD in patients with a concomitant LSG or with a history of it. Therefore, we present a modified technique based on Hill's gastropexy described originally in 1967.

OBJECTIVE

Describe and propose a surgical procedure for GERD management based on the Hill technique that can be applied in all patients who undergo an LSG or with a history of it.

METHODS

Retrospective observational study with a prospective database in which we described, Hill modified technique in a group of 16 patients with GERD who underwent this procedure concomitantly with an LSG or who presented with GERD after LSG with a 3-year follow-up. The surgical technique is based on an intra-abdominal esophageal length of a minimum of 3 cm and posterior fixation of the gastroesophageal junction to the crus.

RESULTS

Postoperative controls have shown satisfactory results in the control and management of GERD symptoms in this group of patients, with very few to no complications associated with the procedure and without reintervention or medication out of the standard protocol.

CONCLUSION

Hill modified technique can be used and presented as an option for GERD control in patients with LSG.

HIDA and Seek: Challenges of Scintigraphy to Diagnose Bile Reflux Post-Bariatric Surgery

INTRODUCTION

Oesophageal bile reflux after bariatric surgery may trigger development of Barrett's oesophagus. Gastro-oesophageal reflux of bile is captured by hepatobiliary iminodiacetic acid (HIDA) scintigraphy; however, anatomical and physiological changes after bariatric surgery warrant protocol modifications to optimise bile reflux detection.

METHODS

HIDA scintigraphy occurred 6 months after either sleeve gastrectomy, Roux-en-Y gastric bypass or one-anastomosis gastric bypass. Standard HIDA scanning involves (i) 6-h fast and 24-h abstinence from opioids; (ii) IV administration of 99mTc di-isopropyl iminodiacetic acid; and (iii) dual anterior/posterior 60-min dynamic scanning of the duodenum, stomach and oesophagus. Three challenges were identified, and modifications were implemented, namely, (1) anatomical localisation of refluxed bile on planar scintigraphy was improved by adding a SPECT/CT for 3D imaging; (2) impaired cholecystokinin-controlled gallbladder emptying, following bypassed duodenum, was addressed by ingestion of a 'fatty meal'; and (3) intestinal hypomotility after gastric bypass was counteracted by longer scan duration (75-90 min) to allow bile to pass beyond the gastro-jejunal anastomosis.

RESULTS

HIDA scan was undertaken in 18 patients, 13 of whom underwent the modified protocol. The tailored protocol ameliorated issues identified with the standard HIDA scan protocol; thus, accurate anatomical localisation was achieved in all patients, no delayed gallbladder emptying was observed, and bile was observed beyond the gastro-jejunal anastomosis in all gastric bypass patients. The modified technique was well tolerated by patients.

CONCLUSION

A tailored HIDA scan protocol with addition of a SPECT-CT scan, ingestion of a fatty meal and prolonged scanning duration results in enhanced bile reflux detection in post-bariatric surgical patients.

Gastric Sensory and Motor Functions and Energy Intake in Health and Obesity-Therapeutic Implications

Sensory and motor functions of the stomach, including gastric emptying and accommodation, have significant effects on energy consumption and appetite. Obesity is characterized by energy imbalance; altered gastric functions, such as rapid gastric emptying and large fasting gastric volume in obesity, may result in increased food intake prior to reaching usual fullness and increased appetite. Thus, many different interventions for obesity, including different diets, anti-obesity medications, bariatric endoscopy, and surgery, alter gastric functions and gastrointestinal motility. In this review, we focus on the role of the gastric and intestinal functions in food intake, pathophysiology of obesity, and obesity management.

Adaptations in gastrointestinal physiology after sleeve gastrectomy and Roux-en-Y gastric bypass

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.

Background characteristics and diabetes remission after laparoscopic sleeve gastrectomy in Japanese patients with type 2 diabetes stratified by BMI: subgroup analysis of J-SMART

Aim

The J-SMART study was the first national survey of Japanese patients undergoing laparoscopic sleeve gastrectomy (LSG). We performed a subgroup analysis of J-SMART focusing on the differences in patient background and diabetes remission between patients with BMI 32-34.9 kg/m² and those with higher BMI.

Methods

In this multi-institutional retrospective study at 10 certified bariatric institutions, 203 Japanese with type 2 diabetes (T2D) and BMI of 32 kg/m² or higher were analyzed (mean age: 49.2 years, BMI: 43.8 kg/m², HbA1c: 7.6%). Patients were stratified into five groups according to preoperative BMI.

Results

Background characteristics in BMI 32.0-34.9 group were higher adjusted HbA1c, higher visceral/subcutaneous fat area ratio, higher prevalence of diabetic retinopathy, higher frequency of insulin use and lower serum C-peptide. Although 2-year percent total weight loss (21.7%) and diabetes complete remission (CR) rate (52.4%) were lower in BMI 32.0-34.9 group, diabetes improvement rate was 81.0%, and the decrease in HbA1c and number of antidiabetic drugs were comparable or greater than those with higher BMI. Higher BMI and no insulin use were significant independent predictors of diabetes CR. No significant independent predictor was identified for diabetes improvement.

Conclusion

The patients with 32-34.9 kg/m² were characterized by more severe visceral obesity, T2D and the complications, and lower intrinsic insulin secretion capacity. LSG should be considered as a treatment option for patients with BMI 32-34.9 kg/m², to improve diabetes control.

Effects of Laparoscopic Sleeve Gastrectomy on Gastric Structure and Function Documented by Magnetic Resonance Imaging Are Strongly Associated with Post-operative Weight Loss and Quality of Life: a Prospective Study

BACKGROUND

This prospective study applied magnetic resonance imaging (MRI) to assess the effect of laparoscopic sleeve gastrectomy (LSG) on gastric structure and function. The impact of these changes on patient outcomes was analyzed.

METHOD

Obese patients without gastrointestinal symptoms referred for bariatric surgery were recruited prospectively. Pre-operative assessment included (i) high-resolution manometry and pH-impedance monitoring and (ii) magnetic resonance imaging (MRI) measurement of gastric capacity, accommodation, and emptying with the 400 ml liquid Nottingham test meal (NTM). Studies were repeated 6-7 months after LSG. Weight loss and changes in the Gastrointestinal Quality of Life Index (GIQLI) assessed patient outcomes.

RESULTS

From 35 patients screened, 23 (66%) completed the study (17 females, age 36 ± 10 years, BMI 42 ± 5 kg/m2). Mean excess weight loss was 59 ± 18% at follow-up. Total gastric volume (capacity) after the meal was 467 mL (455-585 ml) before and 139 mL (121-185 ml) after LSG (normal reference 534 (419-675) mL), representing a mean 70% reduction (p < 0.0001). Similar findings were present for gastric content volume indicating rapid early-phase gastric emptying (GE) post-LSG. Conversely, late-phase GE was slower post-LSG (2.5 ± 1.0 vs. 1.4 ± 0.6 mL/min; p < 0.0001; (reference 1.5(1.4-4.9) mL/min)). Patients with ≥ 80% reduction in gastric capacity had greater weight loss (p = 0.008), but worse gastrointestinal outcomes (p = 0.023).

CONCLUSIONS

MRI studies quantified the marked reduction in gastric capacity after LSG. The reduction in capacity was associated with rapid early- but slow late-phase GE after surgery. These changes were associated with weight loss; however, reductions in gastric capacity ≥ 80% were linked to increased acid reflux and impacted on gastrointestinal quality of life.

Efficacy of laparoscopic sleeve gastrectomy in obese patients with type 2 diabetes mellitus: A protocol of systematic review and meta-analysis

BACKGROUND

A numerous studies have reported that obese patients (OP) are easily to have type 2 diabetes mellitus (T2DM). Although a variety of managements are available to treat such disorder, their efficacy is still limited. Previous studies have reported that laparoscopic sleeve gastrectomy (LSGT) can benefit OP with T2DM. However, no study specifically and systematically explores this topic. Thus, this study will assess the efficacy and complications of LSGT for the management of OP with T2DM.

METHODS

The search strategy will be performed in the electronic databases from inception to the March 31, 2020 without limitations of language and publication time: PUBMED, EMBASE, Cochrane Library, Scopus, Web of Science, CINAHL, AMED, WANGFANG, VIP, and CNKI. Two authors will independently identify the articles, collect the data, and assess the risk of bias using Cochrane risk of bias tool. We will invite a third author to solve any differences between two authors. We will use RevMan 5.3 software to investigate the statistical analysis.

RESULTS

This study will supply a high-quality synthesis of randomized controlled trials (RCTs) on the analysis of LSGT for the management of OP with T2DM.

CONCLUSIONS

This study will help to build proposals that aim at providing high quality RCTs in the management of LSGT in OP with T2DM.

SYSTEMATIC REVIEW REGISTRATION

INPLASY202040128.

Does Reconstruction Type After Gastric Resection Matters for Type 2 Diabetes Improvement?

BACKGROUND

Gastrointestinal (GI) surgery involving gastric resection and bypass of intestinal segments was reported to facilitate glucose control in obese patients with type 2 diabetes (T2D).

AIM

Our aim was to assess whether the type of post-gastrectomy GI reconstruction also influences glucose control in T2D patients with BMI below 35 kg/m² submitted to gastrointestinal surgery without bariatric intention.

METHODS

A cohort of T2D Caucasian patients (n = 40) with upper GI malignancy (n = 33) or complicated reflux disease (n = 7) were submitted to either a gastrectomy plus Billroth II (BII) gastrojejunal anastomosis (n = 17), a gastrectomy plus Roux-en-Y gastrojejunostomy (RY) reconstruction (n = 18; subtotal gastrectomy n = 7 and total gastrectomy n = 11), or atypical gastrectomy without reconstruction (no-R) (n = 5). Patients were evaluated before and 2 years after surgery for body weight, Hb1Ac, need of glucose lowering drugs, and presence of diabetes.

RESULTS

Body mass index (BMI) decreased after every surgical procedure when compared to baseline (- 0.9 ± 0.8 kg/m² for BII vs - 4.3 ± 2.6 kg/m² for RY vs - 4.6 ± 2.5 kg/m² for no-R, p < 0.05), which was only significantly different after RY surgeries. Diabetes remission occurred in 5.9% of BII patients, in 27.8% of RY patients, and 0% of no-R patients, while in patients with persistent T2D, the needs for glucose-lowering drugs were significantly also decreased after RY (31.3% BII vs 66.7% RY vs 25% no-R, p = 0.03).

CONCLUSIONS

T2D Caucasian patients undergoing post-gastrectomy GI reconstructions without a bariatric intention experience a significant improvement of T2D, in a magnitude that could be influenced by the technical procedure performed in favor of RY reconstruction. Thus, presence of T2D should be taken into consideration when deciding for the type of post-gastrectomy GI reconstruction.

Impact of Laparoscopic Sleeve Gastrectomy on Gut Permeability in Morbidly Obese Subjects

BACKGROUND

Recent studies have suggested that obesity is associated with an increased intestinal permeability as well as an altered microbiota profile. These conditions can promote the translocation of lipopolysaccharide into the circulation and, subsequently, contribute to the observed systemic inflammation. Our aim was to assess gut permeability in patients with obesity compared to non-obese subjects as well as after excessive weight loss following laparoscopic sleeve gastrectomy (LSG).

METHODS

We analyzed the dietary intake, metabolic and inflammatory markers, gut permeability (four-probe sugar test), and microbiota composition in 17 morbidly obese patients before and after LSG as well as in 17 age- and gender-matched non-obese subjects. Additionally, we compared gut permeability and inflammatory markers in patients of different stages of obesity.

RESULTS

Patients with obesity showed elevated levels of C-reactive protein and lipopolysaccharide-binding protein as compared to non-obese subjects, but no differences were noted for gut permeability between these two groups. LSG led to improvements in metabolic and inflammatory parameters in the obese patients. Moreover, gastroduodenal as well as small intestinal permeability decreased, whereas colonic permeability increased after surgery. Regarding gut microbiota, differences were noted for main phyla and alpha-diversity between non-obese and obese subjects. After surgery, the composition of the microbiota showed a tendency toward the pattern of the non-obese group.

CONCLUSIONS

Gut permeability is not dependent on body mass index, whereas weight loss after LSG initiates distinct changes in gastroduodenal, intestinal, and colonic permeability. These changes do not seem to be associated with changes in the microbiota composition.

CLINICAL TRIAL REGISTRY NUMBER AND WEBSITE

The trials were registered at https://www.drks.de/drks_web/ with the number DRKS00009008 and DRKS00006210.

Bilio-enteric flow and plasma concentrations of bile acids after gastric bypass and sleeve gastrectomy

BACKGROUND/OBJECTIVES

Bile acids in plasma are elevated after bariatric surgery and may contribute to metabolic improvements, but underlying changes in bile flow are poorly understood. We assessed bilio-enteric flow of bile and plasma bile concentrations in individuals with Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) surgery compared with matched non-surgical controls (CON).

SUBJECTS/METHODS

Fifteen RYGB, 10 SG and 15 CON underwent ⁹⁹Tc-mebrofenin cholescintigraphy combined with intake of a high-fat ¹¹¹In-DTPA-labelled meal and frequent blood sampling. A ⁷⁵Se-HCAT test was used to assess bile acid retention.

RESULTS

After RYGB, gallbladder filling was decreased (p = 0.045 versus CON), basal flow of bile into the small intestine increased (p = 0.005), bile acid retention augmented (p = 0.021) and basal bile acid plasma concentrations elevated (p = 0.009). During the meal, foods passed unimpeded through the gastric pouch resulting in almost instant postprandial mixing of bile and foods, but the postprandial rise in plasma bile acids was brief and associated with decreased overall release of fibroblast growth factor-19 (FGF-19) compared with CON (p = 0.033). After SG, bile flow and retention were largely unaltered (p > 0.05 versus CON), but gastric emptying was accelerated (p < 0.001) causing earlier mixture of bile and foods also in this group. Neither basal nor postprandial bile acid concentrations differed between SG and CON.

CONCLUSIONS

Bilio-enteric bile flow is markedly altered after RYGB resulting in changes in plasma concentrations of bile acids and FGF-19, whereas bile flow and plasma concentrations are largely unaltered after SG.

Prospective study of the changes in pharmacokinetics of immunosuppressive medications after laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy induces weight loss via the creation of a restrictive gastric tube for early satiety and is associated with an accelerated gastric transit time. A prospective, single-dose pharmacokinetic study was performed, prior to and after laparoscopic sleeve gastrectomy, for tacrolimus, extended-release tacrolimus, mycophenolate mofetil, and enteric-coated mycophenolate sodium. The study included 12 morbidly obese patients in chronic renal failure. The median decrease in body mass index was 8.8 kg/m² with an excess body weight loss of 54.9%. The AUC₂₄ of all drugs were increased after laparoscopic sleeve gastrectomy by 46%, 55%, 77%, and 74%, respectively. The maximum concentrations were increased for tacrolimus, extended-release tacrolimus, and mycophenolate mofetil by 43%, 46%, and 65%. The apparent total clearances were decreased for tacrolimus, mycophenolate mofetil, and enteric-coated mycophenolate sodium by 36%, 57%, and 38%. Laparoscopic sleeve gastrectomy can be associated with significant changes in pharmacokinetics of the drugs evaluated. The mechanism is likely decreased apparent drug clearance due to an increased drug exposure (from a more distal site of intestinal absorption with decreased intestinal metabolism), or decreased clearance (liver metabolism). Adapting the monitoring of immunosuppression will be important to avoid overdosing and potential side effects.

Complications of bariatric surgery in adolescents

Over the past decade, outcomes data have demonstrated the benefit of bariatric surgery in achieving both sustained weight loss and reversal of co-morbidities. Comparing these data to contemporary known risks of adolescent bariatric surgery informs the patients and providers considering bariatric procedures and provides insight into potential ways to reduce and manage complications. The goal of this article is to review the common surgical and postoperative complications following bariatric procedures and discuss approaches to improve their safety. A systematic review identifying bariatric surgery complications in adolescents was conducted. The review focused on the data relevant to adolescent bariatric surgery. However, when necessary, adult studies were used to address the gaps in available pediatric information. The data pertaining to the intraoperative, short term, and long term surgically related and nutritional related complications show that complication are declining with increasing experience. Specific recommendations and strategies to avoid major complications of bariatric surgery in adolescents are offered.

A Higher Preoperative Glycemic Profile Is Associated with Rapid Gastric Emptying After Sleeve Gastrectomy for Obese Subjects

BACKGROUND

Recent reports have shown that sleeve gastrectomy (SG) accelerates gastric emptying (GE), but the etiology remains unclear. This study aimed to investigate the factors affecting GE before and after SG.

METHODS

We enrolled 35 normal weight healthy subjects and 23 obese patients receiving SG. The normal individuals and obese patients before and 3 months after SG received oatmeal-based scintigraphy to measure GE. Gastrointestinal symptoms and circulating levels of peptide YY (PYY) were also measured.

RESULTS

There were no differences in the GE parameters, including simple half-time at 3 h and percentage of gastric retention at 0.5, 1, 2, and 3 h between healthy controls and pre-SG obese subjects. SG led to accelerated GE, more gastrointestinal symptoms, and increased fasting PYY levels postoperatively. Based on our previously established normal GE values, 18 (78.3%) obese patients with rapid postoperative GE had higher levels of preoperative fasting glucose and glycated hemoglobin, and homeostasis model assessment of the insulin resistance index than those with normal postoperative GE. Twelve (52.2%) obese patients had preoperative diabetes mellitus (DM), and only four (17.4%) remained diabetic after SG. The post-SG gastric retention at 0.5 and 1 h was lower in patients with preoperative DM than in those without preoperative DM. Neither severity of gastrointestinal symptoms nor fasting PYY levels were associated with postoperative GE alterations.

CONCLUSION

Most of the obese patients had accelerated GE after SG. A higher preoperative glycemic profile was associated with rapid post-SG GE.

Correlation Between Symptomatic Gastro-Esophageal Reflux Disease (GERD) and Erosive Esophagitis (EE) Post-vertical Sleeve Gastrectomy (VSG)

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become the preferred bariatric procedure in many countries. However, there is one shortcoming of LSG in the long-term follow-up and this is the onset of GERD and erosive esophagitis (EE). Current evidence of the effect of SG on GERD did not consolidate to a consensus. In this study, we objectively evaluate the incidence of EE 1 year post-LSG with upper endoscopy (EGD) and try to identify the significant variables and possible underlying mechanisms of the EE post-LSG.

METHODS

Over a period of 5 years (2011-2016) at Singapore General Hospital, we retrospectively reviewed a prospectively collected database of a cohort of patients whom had LSG by a single surgeon who routinely performed EGD pre-operative and 1 year post-operative to assess EE and hiatal hernia. Patient's endoscopic findings and demographic and anthropometric data were analyzed.

RESULTS

We identified a total of 97 obese patients who underwent LSG at our hospital by studied surgeon. Sixty-three patients (64.9% of original sample) were finally evaluated in the present study, 40 (59.7%) of whom were female. The mean (range) age of patients was 38.2 (18-66) years, and mean BMI was 36.3 ± 4.1 kg/m². Median time to follow-up EGD was 13 months (range, 12-15). Following LSG, there was a significant decrease in both BMI (42.1 ± 1.2 vs. 29.9 ± 1.0 kg/m²) and percentage excess weight loss of 56.6 ± 3.6%. The prevalence of EE on endoscopy increased from 9 (14.3%) to 28 (44.4%) patients. Of which 15 (23.8%) were grade A, 11 (17.5%) were grade B, and 2 (3.2%) were grade C. There was no correlation between GERD symptoms with EE; however, our study found a trend suggesting higher prevalence of EE with a sleeve diameter measuring > 2 cm wide (p = 0.069).

CONCLUSION

Although LSG is effective in treating obesity and its metabolic syndromes, the prevalence of EE increased significantly 1 year after the surgery. Since we do not fully understand the long-term impact of chronic esophagitis in post-sleeve population, we recommend follow-up EGD assessment post-operatively and treat the esophagitis if present.

Proceedings of the 2017 ASPEN Research Workshop-Gastric Bypass: Role of the Gut

The goal of the National Institutes of Health-funded American Society for Parenteral and Enteral Nutrition 2017 research workshop (RW) "Gastric Bypass: Role of the Gut" was to focus on the exciting research evaluating gut-derived signals in modulating outcomes after bariatric surgery. Although gastric bypass surgery has undoubted positive effects, the mechanistic basis of improved outcomes cannot be solely explained by caloric restriction. Emerging data suggest that bile acid metabolic pathways, luminal contents, energy balance, gut mucosal integrity, as well as the gut microbiota are significantly modulated after bariatric surgery and may be responsible for the variable outcomes, each of which was rigorously evaluated. The RW served as a timely and novel academic meeting that brought together clinicians and researchers across the scientific spectrum, fostering a unique venue for interdisciplinary collaboration among investigators. It promoted engaging discussion and evolution of new research hypotheses and ideas, driving the development of novel ameliorative, therapeutic, and nonsurgical interventions targeting obesity and its comorbidities. Importantly, a critical evaluation of the current knowledge regarding gut-modulated signaling after bariatric surgery, potential pitfalls, and lacunae were thoroughly addressed.

Emergent Repair of Paraesophageal Hernias and the Argument for Elective Repair

Background and Objectives:

A feared complication of large paraesophageal hernias is incarceration necessitating emergent repair. According to previous studies, patients who require an emergent operation are subject to increased morbidity compared with patients undergoing elective operations. In this study, we detail patients who underwent hernia repair emergently and compare their outcomes with elective patients.

Methods:

A retrospective analysis was performed of the paraesophageal hernia repair operations between 2010 and 2016. Patients were divided into 2 groups: patients with hernias that were repaired electively and patients with hernias that were repaired emergently. Perioperative complications and follow-up data regarding morbidity, mortality, and recurrence were also recorded. A propensity analysis was used to compare emergent and elective groups.

Results:

Thirty patients had hernias repaired emergently, and 199 patients underwent elective procedures. Patients undergoing emergent repair were more likely to have a type IV hernia, have a partial gastrectomy or gastrostomy tube insertion as part of their procedure, have a postoperative complication, and have a longer hospital stay. However, propensity analysis was used to demonstrate that when characteristics of the emergent and elective groups were matched, differences in these factors were no longer significant. Having an emergent operation did not increase a patient's risk for recurrence.

Conclusion:

Patients who had their hernias repaired emergently experienced complications at similar rates as those of elective patients with advanced age or comorbid conditions as demonstrated by the propensity analysis. The authors therefore recommend evaluation of all paraesophageal hernias for elective repair, especially in younger patients who are otherwise good operative candidates.

Selection of Bypass vs Sleeve for the Management of Type-2 Diabetes in Severely Obese: Could Ethnicity Play a Role?

PURPOSE

Prospective data was evaluated to see whether bariatric procedure type made any difference to diabetes remission.

METHODS

One hundred eighty-six consecutive patients of Indian ethnicity (M:F 89:97) with type 2 diabetes mellitus (T2DM) and HbA1c > 6.5 were assessed before and at 1 year following surgery. Age, BMI, C-peptide and duration of diabetes (ABCD - described by WJ Lee), insulin use, baseline HbA1c, and % weight loss were tested as modifiers. We present remission rates (HbA1c ≤ 6.0%) and between group remission odds ratio (OR) and adjusted OR after controlling for key modifiers.

RESULTS

Patients selecting RYGB (n = 113) vs SG (n = 73) were older (50.7 vs 44.2 years), had a lower BMI (44.1 vs 46.7), lower C-peptide (3.5 vs 4.7 ng/ml), greater duration of diabetes (8 vs 3 years), and higher HbA1c (8.90 and 7.9%) respectively p < 0.05 for all (combined R² = 0.38). Weight loss at 1 year was 27 and 30% for RYGB and SG respectively (p = 0.01). Remission at 1 year was achieved by 37% of patient selecting RYGB and 74% for the SG (OR = 0.21, 95% CI 0.11-0.41, p < 0.001). After adjusting for ABCD, the adjusted OR (AOR) still favored the SG (AOR = 0.32, 0.14-0.74, p = 0.01), and adjustment for HbA1c and weight loss (AOR 0.4, 0.17-0.95, p = 0.038) attenuated the effect.

CONCLUSION

The analysis suggests SG may be superior to RYGB in this Indian population. Ethnicity may play a role in predicting the response to bariatric surgery and hence the choice of procedure. A randomized controlled trial is needed to clarify the relative benefit.

Gastric emptying scintigraphy results may influence the selection of the type of bariatric surgery: A cohort study

Bariatric surgery (BAS) may result in adverse outcomes that include appearance of gastrointestinal (GI) symptoms and/or failure to reach the weight reduction goal. This retrospective study tested the hypothesis that pre-operative gastric emptying (GE) abnormality is responsible for adverse post-surgical outcomes.Pre-operative GE was performed using the standard solid-meal GE scintigraphy (GES) in 111 consecutive patients (105 females and 6 males, mean age 46.2 years, range 20-70 years) who were evaluated for BAS. All underwent BAS - 93 had laparoscopic sleeve gastrectomy (LSG) and 18 had Roux-en-Y (ReY) gastric bypass. All had short-term (3-6 months) and long-term (up to 54 months) follow-up with review of symptoms, physical, and laboratory examinations. Chi-square analysis was performed. P-value < .05 was considered significant.Of the 111 patients, 83 had normal and 28 had abnormal pre-op GES. Sixty-eight were asymptomatic and 43 were symptomatic prior to surgery. Following surgery, 81 patients were asymptomatic and 30 were symptomatic at long-term follow-up. There was no significant difference between pre-op GE results and post-surgical adverse clinical outcome (p = ns). However, GES results seem to have guided the selection of surgical procedure significantly (P = .008).Pre-operative GE study was not a strong predictor of clinical outcome in BAS. Although, it influenced the type of surgery, as when the GES was abnormal, the patient was more likely to undergo ReY and when GES was normal, they favored LSG. Interestingly, many of our symptomatic patients at 6 months post-op were asymptomatic after long-term follow-up.

The investigation of diet recovery after distal gastrectomy

This study aims to investigate the adaptation process of the alimentary tract after distal gastrectomy and understand the impact of remnant stomach volume (RSV) on diet recovery.One year after gastrectomy, although patients' oral intake had increased, the RSV was decreased and small bowel motility was enhanced. Patients with a larger RSV showed no additional benefits regarding nutritional outcomes.We prospectively enrolled patients who underwent distal gastrectomy with Billroth II reconstruction to treat gastric cancer at a tertiary hospital cancer center between September 2009 and February 2012. Demographic data, diet questionnaires, computed tomography (CT), and contrast fluoroscopy findings were collected. Patients were divided into 2 groups according to the RSV calculated using CT gastric volume measurements (large vs small). Dietary habits and nutritional status were compared between the groups.Seventy-eight patients were enrolled. Diet volume recovered to 90% of baseline by the 36 postoperative month, and RSV was 70% of baseline at 6 months after surgery and gradually decreased over time. One year after surgery, small bowel transit time was 75% compared to the 1st postoperative month (P < .05); however, transit time in the esophagus and remnant stomach showed no change in any studied interval. Compared to patients with a small RSV, those with a large RSV showed no differences in diet volume, habits, or other nutritional benefits (P > .05).Diet recovery for distal gastrectomy patients was achieved by increased small bowel motility. The size of the remnant stomach showed no positive impact on nutritional outcomes.

The Effects of Bariatric Surgery on Islet Function, Insulin Secretion, and Glucose Control

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.

Late esophagogastric anatomic and functional changes after sleeve gastrectomy and its clinical consequences with regards to gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is described as a complication after sleeve gastrectomy. Most studies have used only clinical symptoms or upper gastrointestinal endoscopy for evaluation of reflux after surgery. Manometry, acid reflux tests, and esophageal barium swallow have not been commonly used. The objective of this study is to evaluate the short- and long-term incidence of clinical gastroesophageal reflux, the lower esophageal sphincter (LES) pressure, acid reflux, and endoscopic and radiological changes after sleeve gastrectomy (SG). A total of 315 patients were studied after SG; 248 (78.3%) completed more than 5 years of follow-up and 67 (21.4%) have more than 8 years (range 8-10 years) of follow-up. The preoperative weight was 106 + 14.1 kg with a mean body mass index 38.4 + 3.4 kg/m2. Patients with prior GERD were excluded for SG. During the follow-up patients were subjected to clinical, endoscopic, radiological, manometric, and 24-hour pH monitoring and duodenogastric reflux evaluations. Reflux symptoms were observed in 65.1% of patients at late follow-up. Patients without reflux symptoms presented an LES resting pressure of 13.3 ± 4.2 mmHg while patients with reflux symptoms presented an LES resting pressure of 9.8 + 2.1 mmHg. In patients with reflux symptoms, a positive acid reflux test was observed in 77.5% of patients with a mean DeMeester score of 41.7 ± 2.9 (range 14.1-131.7). During endoscopy, esophagitis was found in 29.4%, hiatal hernia in 5.7%, and Barrett's esophagus was diagnosed in 4.8%. Positive duodenogastric reflux was found in 31.8% of patients and 57.7% of our patients received proton pump inhibitor treatment after SG. Sleeve gastrectomy presents anatomic and functional changes that are associated with increased GERD.

Postprandial Nutrient Handling and Gastrointestinal Hormone Secretion After Roux-en-Y Gastric Bypass vs Sleeve Gastrectomy

BACKGROUND & AIMS

Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) induce substantial weight loss and improve glycemic control in patients with type 2 diabetes, but it is not clear whether these occur via the same mechanisms. We compared absorption rates of glucose and protein, as well as profiles of gastro-entero-pancreatic hormones, in patients who had undergone SG or RYGB vs controls.

METHODS

We performed a cross-sectional study of 12 patients who had undergone sleeve gastrectomy, 12 patients who had undergone RYGB, and 12 individuals who had undergone neither surgery (controls), all in Denmark. Study participants were matched for body mass index, age, sex, and postoperative weight loss, and all had stable weights. They received continuous infusions of stable isotopes of glucose, glycerol, phenylalanine, tyrosine, and urea before and during a mixed meal containing labeled glucose and intrinsically phenylalanine-labeled caseinate. Blood samples were collected for 6 hours, at 10- to 60-minute intervals, and analyzed.

RESULTS

The systemic appearance of ingested glucose was faster after RYGB and SG vs controls; the peak glucose appearance rate was 64% higher after RYGB, and 23% higher after SG (both P < .05); the peak phenylalanine appearance rate from ingested casein was 118% higher after RYGB (P < .01), but similar between patients who had undergone SG and controls. Larger, but more transient increases in levels of plasma glucose and amino acids were accompanied by higher secretion of insulin, glucagon-like peptide 1, peptide YY, and cholecystokinin after RYGB, whereas levels of ghrelin were lower after SG, compared with RYGB and controls. Total 6-hour oral recovery of ingested glucose and protein was comparable among groups.

CONCLUSIONS

Postprandial glucose and protein absorption and gastro-entero-pancreatic hormone secretions differ after SG and RYGB. RYGB was characterized by accelerated absorption of glucose and amino acids, whereas protein metabolism after SG did not differ significantly from controls, suggesting that different mechanisms explain improved glycemic control and weight loss after these surgical procedures. ClinicalTrials.gov ID NCT03046186.

Effects of Sleeve Gastrectomy on Blood Pressure and the Renal Renin-Angiotensin System in Rats with Diet-Induced Obesity

OBJECTIVE

Sleeve gastrectomy (SG) has been reported to decrease blood pressure (BP), although the reason has not been revealed. The present study aimed to establish the reason why SG decreases BP.

METHODS

Male Sprague-Dawley rats were subjected to surgical (sham operation or SG) and dietary interventions (fed a normal diet or high-fat diet ad libitum or fed by pair-feeding [PF]). Systolic BP (SBP), urinary sodium excretion, and endocrine parameters were examined 4 weeks after surgery.

RESULTS

Both SG and PF rats had reduced body weight compared with SO rats fed normal diet or high-fat diet ad libitum. SG rats exhibited a reduction in SBP compared with PF, which was associated with a reduction in renal renin, angiotensin II, and catechol-O-methyltransferase levels (P < 0.01 for each). SG increased plasma cholecystokinin (CCK) levels compared with PF (P < 0.0001 for each), whereas glucagon-like peptide 1 and peptide YY were not changed in fasting. Exogenous administration of CCK reduced renal catechol-O-methyltransferase (P = 0.0233), renin (P < 0.0001), and angiotensin II (P < 0.0001) levels and SBP (P = 0.0053).

CONCLUSIONS

SG reduced SBP, at least in part, through suppression of sympathetic nerve action by elevation of CCK, which was followed by suppression of the intrarenal renin-angiotensin system.

Sleeve Gastrectomy and Roux-en-Y Gastric Bypass Achieve Similar Early Improvements in Beta-cell Function in Obese Patients with Type 2 Diabetes

Bariatric surgery is a treatment option for obese patients with type 2 diabetes mellitus (T2DM). Although sleeve gastrectomy (SG) is growing in favor, some randomized trials show less weight loss and HbA1c improvement compared with Roux-en-Y gastric bypass (RYGB). The study objective was to compare changes in beta-cell function with similar weight loss after SG and RYGB in obese patients with T2DM. Subjects undergoing SG or RYGB were studied with an intravenous glucose tolerance test before surgery and at 5–12% weight loss post-surgery. The primary endpoint was change in the disposition index (DI). Baseline BMI, HbA1c, and diabetes-duration were similar between groups. Mean total weight loss percent was similar (8.4% ± 0.4, p = 0.22) after a period of 21.0 ± 1.7 days. Changes in fasting glucose, acute insulin secretion (AIR), and insulin sensitivity (Si) were similar between groups. Both groups showed increases from baseline to post-surgery in DI (20.2 to 163.3, p = 0.03 for SG; 31.2 to 232.9, p = 0.02 for RYGB) with no significant difference in the change in DI between groups (p = 0.53). Short-term improvements in beta-cell function using an IVGTT were similar between SG and RYGB. It remains unclear if longer-term outcomes are better after RYGB due to greater weight loss and/or other factors.

Mechanisms Underlying Type 2 Diabetes Remission After Metabolic Surgery

Type 2 diabetes prevalence is increasing dramatically worldwide. Metabolic surgery is the most effective treatment for selected patients with diabetes and/or obesity. When compared to intensive medical therapy and lifestyle intervention, metabolic surgery has shown superiority in achieving glycemic improvement, reducing number of medications and cardiovascular risk factors, which translates in long-term benefits on cardiovascular morbidity and mortality. The mechanisms underlying diabetes improvement after metabolic surgery have not yet been clearly understood but englobe a complex interaction among improvements in beta cell function and insulin secretion, insulin sensitivity, intestinal gluconeogenesis, changes in glucose utilization, and absorption by the gut and changes in the secretory pattern and morphology of adipose tissue. These are achieved through different mediators which include an enhancement in gut hormones release, especially, glucagon-like peptide 1, changes in bile acids circulation, gut microbiome, and glucose transporters expression. Therefore, this review aims to provide a comprehensive appraisal of what is known so far to better understand the mechanisms through which metabolic surgery improves glycemic control facilitating future research in the field.

A SIRT1 agonist reduces cognitive decline in type 2 diabetic rats through antioxidative and anti‑inflammatory mechanisms

Sirtuin 1 (SIRT1) is an NAD+‑dependent protein deacetylase that is involved in cell differentiation, aging, apoptosis, physiological rhythms, metabolic regulation, oxidative stress and numerous other important biological processes. In the present study, the ability of a sirtuin‑1 (SIRT1) agonist, SRT1720, to reduce cognitive decline in type 2 diabetes mellitus (T2DM) was investigated. Streptozotocin‑induced male Sprague‑Dawley rats were used to establish a T2DM model and the protective effect of SRT1720 and its underlying mechanisms were investigated. Body weight and fasting blood glucose (FBG) were recorded and cognitive function was measured with the Morris water maze. Levels of oxidative stress, inflammation, caspase‑3 activity and nuclear factor κB (NF‑κB) mRNA expression were detected with a series of commercial assay kits and reverse transcription‑quantitative polymerase chain reaction, respectively. Western blot analysis was performed to determine the protein expression of NF‑κB, endothelial nitric oxide synthase (eNOS), peroxisome proliferator‑activated receptor γ (PPARγ), AMP‑activated protein kinase (AMPK), heat shock 70 kDa protein (HSP70), SIRT1, nuclear factor erythroid 2‑related factor 2 (Nrf2) and heme oxygenase 1 (HO‑1). The results revealed that SRT1720 significantly increased body weight, decreased FBG, improved cognitive function and reduced the levels of proteins associated with oxidative stress and inflammation damage in T2DM rats. Additionally, SRT1720 significantly decreased NF‑κB p65 mRNA expression and increased eNOS and PPARγ expression. SRT1720 significantly reduced caspase‑3 activity and HSP70 protein expression, and increased p‑AMPK, SIRT1, Nrf2 and HO‑1 protein expression. Collectively, the results indicate that SRT1720 may reduce cognitive decline in T2DM rats through antioxidative and anti‑inflammatory action via NF‑κB and AMPK‑dependent mechanisms.

Greater curvature as a gastric pouch for sleeve gastrectomy: a novel bariatric procedure. Feasibility study in a canine model

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has serious complications, such as leaks, reflux, stenosis, and kinks, which are also consequences of shortcomings in the LSG technique.

OBJECTIVES

We evaluated the feasibility and weight loss of a novel bariatric procedure, using the greater curvature as the gastric pouch for sleeve gastrectomy (SG) in dogs.

SETTING

Animal house in Faculty of Medicine, Cairo University.

METHODS

Five 20- to 25-kg stray mongrel male dogs were subjected to open SG using the greater curve as the gastric pouch (GCSG group). The weight was monitored at day of surgery and at postoperative weeks 2, 4, 6, and 8; weight progression was compared with a sham and a standard SG group. By the end of the follow-up period autopsy was done.

RESULTS

The mean operative time in GCSG group was 39.6 ± 3.97 minutes. At the end of the study, dogs in the sham group had gained 8% of their preoperative weight, while the GCSG and standard SG groups lost 24.7% and 25% of their preoperative weight, respectively. At autopsy, the gastric sleeve in the GCSG group showed excellent healing with no stenotic areas, kinks, or mucosal ulcerations.

CONCLUSION

Greater curvature SG is technically feasible in a canine model. Larger studies with longer follow-up period will be needed to assess weight progression and resolution of the metabolic co-morbidities.

Gut adaptation after metabolic surgery and its influences on the brain, liver and cancer

Metabolic surgery is the best treatment for long-term weight loss maintenance and comorbidity control. Metabolic operations were originally intended to change anatomy to alter behaviour, but we now understand that the anatomical changes can modulate physiology to change behaviour. They are no longer considered only mechanically restrictive and/or malabsorptive procedures; rather, they are considered metabolic procedures involving complex physiological changes, whereby gut adaptation influences signalling pathways in several other organs, including the liver and the brain, regulating hunger, satiation, satiety, body weight, glucose metabolism and immune functions. The integrative physiology of gut adaptation after these operations consists of a complex mechanistic web of communication between gut hormones, bile acids, gut microbiota, the brain and both enteric and central nervous systems. The understanding of nutrient sensing via enteroendocrine cells, the enteric nervous system, hypothalamic peptides and adipose tissue and of the role of inflammation has advanced our knowledge of this integrative physiology. In this Review, we focus on the adaptation of gut physiology to the anatomical alterations from Roux-en-Y gastric bypass and vertical sleeve gastrectomy and the influence of these procedures on food intake, weight loss, nonalcoholic fatty liver disease (NAFLD) and cancer. We also aim to demonstrate the underlying mechanisms that could explain how metabolic surgery could be used as a therapeutic option in NAFLD and certain obesity-related cancers.

A comparison of rodent models of vertical sleeve gastrectomy

BACKGROUND

Although vertical sleeve gastrectomy (VSG) is fashioned in humans by applying multiple staple loads, rodent VSG is generally created through a single-staple load application.

OBJECTIVES

To investigate the impact of a 2-staple load VSG rat model more closely resembling the multistaple load operation done in humans on weight, metabolic outcomes, and the microbiome and how these compare with those obtained with the standard one-staple load model.

SETTING

University research facility, United States.

METHODS

High-fat diet-induced obese male rats were randomized to single-staple load VSG (VSG1), 2-staple load VSG (VSG2), or sham operation (Sham). Outcomes included weight and composition, food intake, glucose metabolism, lipids, bile acids, and intestinal microbiome. Statistical comparisons were performed using analysis of variance.

RESULTS

Both procedures resulted in substantial weight and body fat loss compared with Sham-treated animals. Weight loss was modestly greater for VSG2 compared with VSG1. Food intake was reduced in both procedures and accounted for the observed weight reduction. Glucose tolerance and plasma and hepatic lipid profiles were improved comparably in VSG1 and VSG2 relative to Sham. Bile acids were higher for VSG2 compared with Sham but not significantly different between VSG1 and VSG2. Neither procedure impacted intestinal microbiome richness and diversity compared with Sham across multiple intestinal sections. Colonic Actinobacteria was more abundant in VSG2 than in Sham. Relative abundances of bacterial phyla did not differ among VSG1, VSG2, and Sham across the remaining intestinal sections.

CONCLUSIONS

Although VSG1 or VSG2 offer effective and overall comparable platforms for the study of obesity, VSG2 resulted in superior weight loss.

Ghrelin and Obesity: Identifying Gaps and Dispelling Myths. A Reappraisal

The etiology of obesity is complex. Environmental and genetic causes have been implicated in the development of this disease. Ghrelin is a hormone known to stimulate appetite. There are numerous possible actions through which ghrelin exerts its effect in the body: a) Overproduction of ghrelin, b) reduced ghrelin following meals, and c) increased receptor sensitivity to ghrelin action. Sleeve gastrectomy, a bariatric procedure, leads to reduction of ghrelin levels and subsequently to weight loss. However, there are many limitations to measurement of the fasting plasma level of the active form of ghrelin. The establishment of the exact correlation between ghrelin, appetite and obesity could be vital for the fight against obesity.

Altered glucose metabolism after bariatric surgery: What's GLP-1 got to do with it?

Bariatric surgery is an effective treatment for obesity. The two widely performed weight-loss procedures, Roux-en-Y gastric bypass (GB) and sleeve gastrectomy (SG), alter postprandial glucose pattern and enhance gut hormone secretion immediately after surgery before significant weight loss. This weight-loss independent glycemic effects of GB has been attributed to an accelerated nutrient transit from stomach pouch to the gut and enhanced secretion of insulinotropic gut factors; in particular, glucagon-like peptide-1 (GLP-1). Meal-induced GLP-1 secretion is as much as tenfold higher in patients after GB compared to non-surgical individuals and inhibition of GLP-1 action during meals reduces postprandial hyperinsulinemia after GB two to three times more than that in persons without surgery. Moreover, in a subgroup of patients with the late complication of postprandial hyperinsulinemic hypoglycemia after GB, GLP1R blockade reverses hypoglycemia by reducing meal stimulated insulin secretion. The role of enteroinsular axis activity after SG, an increasingly popular alternative to GB, is less understood but, similar to GB, SG accelerates nutrient delivery to the intestine, improves glucose tolerance, and increases postprandial GLP-1 secretion. This review will focus on the current evidence for and against the role of GLP-1 on glycemic effects of GB and will also highlight differences between GB and SG.

Analysis of Gastric Physiology After Laparoscopic Sleeve Gastrectomy (LSG) With or Without Antral Preservation in Relation to Metabolic Response: a Randomised Study

INTRODUCTION

Laparoscopic sleeve gastrectomy is one of the most common techniques in bariatric surgery, but there is no consensus on the optimal distance from the pylorus to start the gastric transection. The aim of this study is to determine the differences in gastric emptying, gastric distension and metabolic response between two starting distances.

MATERIAL AND METHODS

This is a prospective randomised study of 60 patients (30 patients with the section at 3 cm and 30 patients at 8 cm from the pylorus). We calculate at 6 and 12 months from surgery gastric emptying by scintigraphy (T1/2 min), gastric volume by CT scan (cc) and metabolic response by blood sample analysis (glucose, HbA1c, insulin, HOMA-IR, GLP-1, GIP and C-peptide).

RESULTS

Gastric emptying increases the speed significantly in both groups but is greater in the 3-cm group (p < 0.05). Dividing groups into type 2 diabetic patients and non-diabetic patients, the speed in non-diabetic patients is significantly higher for the 3-cm group. Residual volume increases significantly in both groups, and there are no differences between them. One year after surgery, there are significant improvements in the hyperinsulinaemia in the patients of the 3-cm group with respect to the 8-cm group, but only in diabetic patients. No differences between groups are found regarding changes in GLP-1 or GIP.

CONCLUSIONS

Gastric emptying is faster in patients with antrum resection. The distance does not influence the gastric emptying of diabetic patients. Other mechanisms may explain metabolic response besides GLP-1 and its association with improvements in diabetes via gastric emptying.

Impact of Laparoscopic Sleeve Gastrectomy on Gastrointestinal Motility

Objective

Laparoscopic sleeve gastrectomy (LSG) was considered mainly as a restrictive procedure due to anatomic alterations in the upper gastrointestinal tract. Additionally, due to neurohormonal alterations, LSG modifies the gastrointestinal motility, which controls appetite and feeling of satiety.

Aim

The aim of the study was to review the impact of laparoscopic sleeve gastrectomy on gastrointestinal motility.

Material and Methods

A search of the medical literature was undertaken in Pubmed, Web of Science, and Cochrane library. Esophageal, gastric, bowel motility were assessed separately.

Results

Nine studies assessed esophageal motility. The data remain debatable attributing to the heterogeneity of follow-up timing, surgical technique, bougie size, and distance from pylorus. The stomach motility was assessed in eighteen studies. Functionally, the sleeve was divided into a passive sleeve and an accelerated antrum. All scintigraphic studies revealed accelerated gastric emptying after LSG except of one. Patients demonstrated a rapid gastroduodenal transit time. The resection of the gastric pacemaker had as a consequence aberrant distal ectopic pacemaking or bioelectrical quiescence after LSG. The bowel motility was the least studied. Small bowel transit time was reduced; opposite to that the initiation of cecal filling and the ileocecal valve transit was delayed.

Conclusion

Laparoscopic sleeve gastrectomy has impacts on gastrointestinal motility. The data remain debatable for esophageal motility. Stomach and small bowel motility were accelerated, while the initiation of cecal filling and the ileocecal valve transit was delayed. Further pathophysiological studies are needed to evaluate the correlation of motility data with clinical symptoms.

Predictive Value of Gut Peptides in T2D Remission: Randomized Controlled Trial Comparing Metabolic Gastric Bypass, Sleeve Gastrectomy and Greater Curvature Plication

BACKGROUND

Our aim was to determine the predictive value of gut hormone changes for the improvement of type 2 diabetes (T2D) following metabolic Roux-en-Y gastric bypass (mRYGB), sleeve gastrectomy (SG), and greater curvature plication (GCP) in a randomized controlled trial. Contradictory results have been obtained regarding the role of gastrointestinal hormones (in particular GLP-1) in beneficial metabolic bariatric surgery outcomes.

METHODS

Forty-five patients with T2D (mean BMI 39.4 ± 1.9 kg/m²) were randomly assigned to mRYGB, SG, or GCP. Anthropometric and biochemical parameters, fasting concentrations of PYY, ghrelin, glucagon, and area under the curve (AUC) of GLP-1 after a standard meal test were determined prior to and at months 1 and 12 after surgery.

RESULTS

Twelve months after surgery, total weight loss percentage was higher and HbA1c lower in the mRYGB group than in the SG and GCP groups (-35.2 ± 8.1 and 5.1 ± 0.6% vs. -27.8 ± 5.4 and 6.2 ± 0.8% vs. -20.5 ± 6.8 and 6.6 ± 1.3%; p = 0.007 and p < 0.001, respectively). Moreover, GLP-1 AUC at months 1 and 12 was greater and T2D remission was higher in mRYGB (80 vs. 53.3 vs. 20%, p < 0.001). Insulin treatment (odds ratio (OR) 0.025, p = 0.018) and the increase in GLP-1 AUC from baseline to month 1 (OR 1.021, p = 0.013) were associated with T2D remission.

CONCLUSIONS

mRYGB achieves a superior rate of weight loss and T2D remission at month 12. Enhanced GLP-1 secretion 1 month after surgery was a determinant of glucose metabolism improvement. Registration number ( http://www.clinicaltrials.gov ): NCT14104758.

The Effects of Sleeve Gastrectomy on Glucose Metabolism and Glucagon-Like Peptide 1 in Goto-Kakizaki Rats

PURPOSE

To investigate the effects of sleeve gastrectomy (SG) on glucose metabolism and changes in glucagon-like peptide 1 (GLP-1) in Goto-Kakizaki (GK) rats.

METHODS

GK rats were randomly assigned to one of three groups: SG, SG pair-fed plus sham surgery (PF-sham), and ad libitum-fed no surgery (control). Food intake, body weight, blood glucose, GLP-1 and insulin levels, and GLP-1 expression in the jejunum and ileum were compared.

RESULTS

The SG rats exhibited lower postoperative food intake, body weight, and fasting glucose than did the control rats (P < 0.05). SG significantly improved glucose and insulin tolerance (P < 0.05). Plasma GLP-1 levels were higher in SG rats than in control or PF-sham rats in the oral glucose tolerance test (OGTT) (P < 0.05). Blood glucose levels expressed as a percentage of baseline were higher in SG rats than in control rats after exendin (9-39) administration (P < 0.05). The levels of GLP-1 expression in the jejunum and ileum were higher in SG rats than in PF-sham and control rats (P < 0.05).

CONCLUSIONS

Improvement of glucose metabolism by SG was associated with increased GLP-1 secretion. SG contributes to an increase in plasma GLP-1 levels via increased GLP-1 expression in the mucosa of the jejunum and/or ileum.