Stomachs: does the size matter? Aspects of intestinal satiety, gastric satiety, hunger and gluttony

IMMUNOHISTOCHEMICAL DETECTION OF L CELLS IN GASTROINTESTINAL TRACT MUCOSA OF PATIENTS AFTER SURGICAL TREATMENT FOR CONTROL OF TYPE 2 DIABETES MELLITUS

OBJECTIVE

Type 2 diabetes mellitus (T2DM) is a disease of global impact that has led to an increase in comorbidities and mortality in several countries. Immunoexpression of the incretin hormones such as glucagon-like peptide-1 (GLP-1) and peptide YY (3-36) (PYY3-36) can be used as a scorer in the gastrointestinal tract to analyze L-cell activity in response to T2DM treatment. This study aimed to investigate the presence, location, and secretion of L cells in the small intestine of patients undergoing the form of bariatric surgery denominated adaptive gastroenteromentectomy with partial bipartition.

METHODS

Immunohistochemical assays, quantitative real-time polymerase chain reaction (qPCR), and Western blot analysis were performed on samples of intestinal mucosa from patients with T2DM in both the preoperative and postoperative periods.

RESULTS

All results were consistent and indicated basal expression and secretion of GLP-1 and PYY3-36 incretins by L cells. A greater density of cells was demonstrated in the most distal portions of the small intestine. No significant difference was found between GLP-1 and PYY3-36 expression levels in the preoperative and postoperative periods because of prolonged fasting during which the samples were collected.

CONCLUSION

The greater number of L cells in activity implies better peptide signaling, response, and functioning of the neuroendocrine system.

Is duodeno-jejunal bypass liner superior to pylorus preserving bariatric surgery in terms of complications and efficacy?

PURPOSE

Based on recent scientific evidence, bariatric surgery is more effective in the management of morbid obesity and related comorbidities than conservative therapy. Pylorus preserving surgical procedures (PPBS) such as laparoscopic single-anastomosis duodeno-jejunal or duodeno-ileal bypass with sleeve gastrectomy are modified duodenal switch (DS) surgical techniques. The duodeno-jejunal bypass liner (DJBL) is a novel surgical method in the inventory of metabolism focused manual interventions that excludes duodeno-jejunal mucosa from digestion, mimicking DS procedures without the risk of surgical intervention. The aim of this article is to summarize and compare differences between safety-related features and weight loss outcomes of DJBL and PPBS.

METHODS

A literature search was conducted in the PubMed database. Records of DJBL-related adverse events (AEs), occurrence of PPBS-related complications and reintervention rates were collected. Mean weight, mean body mass index (BMI), percent of excess of weight loss (EWL%), percent of total weight loss (TWL%) and BMI value alterations were recorded for weight loss outcomes.

RESULTS

A total of 11 publications on DJBL and 6 publications on PPBS were included, involving 800 and 1462 patients, respectively. The baseline characteristics of the patients were matched. Comparison of DJBL-related AEs and PPBS-related severe complications showed an almost equal risk (risk difference (RD): -0.03 and confidence interval (CI): -0.27 to 0.21), despite higher rates among patients having received endoscopic treatment. Overall AE and complication rates classified by Clavien-Dindo showed that PPBS was superior to DJBL due to an excess risk level of 25% (RD: 0.25, CI: 0.01-0.49). Reintervention rates were more favourable in the PPBS group, without significant differences in risk (RD: -0.03, CI: -0.27 to 0.20). However, PPBS seemed more efficient regarding weight loss outcomes at 1-year follow-up according to raw data, while meta-analysis did not reveal any significant difference (odds ratio (OR): 1.08, CI: 0.74-1.59 for BMI changes).

CONCLUSION

Only limited conclusions can be made based on our findings. PPBS was superior to DJBL with regard to safety outcomes (GRADE IIB), which failed to support the authors' hypothesis. Surgical procedures showed lower complication rates than the incidence of DJBL-related AEs, although it should be emphasized that the low number of PPBS-related mild to moderate complications reported could be the result of incomplete data recording from the analysed publications. Weight loss outcomes favoured bariatric surgery (GRADE IIB). As the DJBL is implanted into the upper gastrointestinal tract for 6 to 12 months, it seems a promising additional method in the inventory of metabolic interventions.

DOES EVOLUTIONARY BIOLOGY HELP THE UNDERSTANDING OF METABOLIC SURGERY? A FOCUSED REVIEW

Introduction:

The wide net of physiological issues involved in metabolic surgery is extremely complex. Nonetheless, compared anatomy and phisiology can provide good clues of how digestive tracts are shaped for more or less caloric food, for more or less fiber, for abundance and for scarcity.

Objective:

To review data from Compared Anatomy and Physiology, and in the Evolutionary Sciences that could help in the better comprehension of the metabolic surgery.

Method:

A focused review of the literature selecting information from these three fields of knowledge in databases: Cochrane Library, Medline and SciELO, articles and book chapters in English and Portuguese, between 1955 and 2019, using the headings “GIP, GLP-1, PYY, type 2 diabetes, vertebrates digestive system, hominid evolution, obesity, bariatric surgery “.

Results:

The digestive tract of superior animals shows highly specialized organs to digest and absorb specific diets. In spite of the wide variations of digestive systems, some general rules are observed. The proximal part of the digestive tract, facing the scarcity of sugars, is basically dedicated to generate sugar from different substrates (gluconeogenesis). Basic proximal gut tasks are to proportionally input free sugars, insulin, other fuels and to generate anabolic elements to the blood, some of them obesogenic. To limit the ingestion by satiety, by gastric emptying diminution and to limit the excessive elevation of major fuels (sugar and fat) in the blood are mostly the metabolict asks of the distal gut. A rapid and profound change in human diet composition added large amounts of high glycemic index foods. They seem to have caused an enhancement in the endocrine and metabolic activities of the proximal gut and a reduction in these activities of the distal gut. The most efficient models of metabolic surgery indeed make adjustments in this proximal/distal balance in the gut metabolic activities.

Conclusion:

Metabolic surgery works basically by making adjustments to the proximal and distal gut metabolic activities that resemble the action of natural selection in the development the digestive systems of superior animals.

Pilot Study of a New Model of Bariatric Surgery: Laparoscopic Intestinal Bipartition-Safety and Efficacy Against Metabolic Disorders

BACKGROUND

Despite the availability of many gastric surgery techniques to reduce obesity and its associated comorbidities, most of these procedures can result in life-threatening conditions including lifetime chronic illnesses and death. Vertical sleeve gastrectomy and Roux-en-Y gastric bypass have been reported to improve obesity-related comorbidities such as T2DM, but the long-term efficacy of these two procedures is unknown, and their significant impact on long-term weight loss was diminished by complications as reported in previous studies. Recently, laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) was developed to achieve sustained weight loss (Buchwald et al. Am J Med. 122:248-56, 2009; Sjöström et al. N Engl J Med. 351:2683-93, 2004) as well as an improvement in comorbid conditions, such as T2DM and hypertension (Buchwald et al. in Am J Med. 122:248-56, 2009; Dorman et al. Surgery. 152:758-65, 2012). The malabsorptive strategy of bypassing portions of the small intestine and delivering nutrients directly to the ileum may promote weight loss by enhanced activation of a negative feedback mechanism known as the "ileal brake" (Näslund et al. J Gastrointest Surg. 5:556-67, 2001). The purpose of this pilot study was to evaluate the safety, reproducibility, and efficiency of a new surgical bariatric model of laparoscopic intestinal bipartition (LIB) in patients with a BMI between 35 and 40 kg/m². The setting was in university hospitals.

METHODS

Between January 2011 and September 2012, seven patients were enrolled in the study and underwent the LIB procedure. One patient was operated by LIB for morbid obesity with comorbidities, especially T2DM, without any previous bariatric or gastric surgery. Six patients underwent the surgery after a sleeve gastrectomy for ≥ 4 years with a recurrence of obesity and diabetes.

RESULTS

The comorbidity factors decreased to the normal values in all patients at 6 months, 1 year, and 5 years postoperatively. The percentage of total weight loss was 21.1% at 6 months, 22.6% at 1 year, and 15.6% at 5 years. Weight excess was significantly lower at 6-month, 1-year, and 5-year postoperatively compared with baseline (p < 0.001). Comparison of comorbidity values at 6 months, 1 year, and 5 years did not show any significant differences.

CONCLUSION

Laparoscopic intestinal bipartition produced a total recovery from obesity-related comorbidities, especially T2DM and EWL without any signs of nutritional deficiency, although the 5-year follow-up is ongoing in order to demonstrate the efficacy and long-term durability of this procedure.

Observed Variability in Sleeve Gastrectomy Volume and Compliance Does Not Correlate to Postoperative Outcomes

BACKGROUND

Restrictive bariatric procedures reduce gastric capacity as a primary mechanism of action. Intraoperatively, surgeons observe variability in size and compliance of specimens. We hypothesized that higher gastric specimen volume or tissue compliance would respond better to restrictive procedures.

MATERIALS AND METHODS

Consecutive patients undergoing laparoscopic sleeve gastrectomy between September 2012 and September 2013 were enrolled. Specimens were insufflated at graduated pressure points creating pressure volume curves, and compliance was calculated. Postoperative weight loss and a hunger scores were recorded. Correlations were determined by Spearman correlation.

RESULTS

Eighty-four patients consented to enrollment. Mean age, weight, and body mass index (BMI) were 45 ± 12 years, 126 ± 23 kg, and 45.4 ± 6 m/kg2, respectively. The resected specimens varied in insufflated capacity from 0.3 to 1.8 (0.71 ± 0.32) L and compliance varied from 14.3 to 85.7 (36.1 ± 14.7) cc/mm Hg. Male patients had a larger greater curvature length (GCL) (P < 0.001), staple line length (SLL) (P = 0.03), gastric volume (GV) (P = 0.002), and gastric compliance (GC) (P < 0.001). Neither GV nor GC correlated to excess body weight loss (EBWL%) as hypothesized. There was an inverse correlation between hunger score and GV (P = 0.010). The mean 1-month, 3-month, 6-month, and 12-month EBWL was 17.4%, 33.2%, 43.7%, and 54.1%, respectively. Follow-up was 71.4% at 1 month, 39.3% at 3 months, 54.8% at 6 months, and 42.9% at 12 months.

CONCLUSIONS

Sleeve gastrectomy specimens exhibit nearly 6-fold variability in both volume and compliance. A large GC is anticipated in male and tall subjects. These observations do not appear to be correlated to %EBWL.