Clinical efficacy of laparoscopic biliopancreatic diversion with duodenal switch for obesity / 中华消化外科杂志

Objective:To investigate the clinical efficacy of laparoscopic biliopancreatic diversion with duodenal switch (BPD-DS) for obesity.Methods:The retrospective and descriptive study was conducted. The clinical data of 10 patients with obesity who were admitted to the China-Japan Union Hospital Affiliated to Jilin University from September 2019 to January 2020 were collected.There were 7 male and 3 females, aged (32±9)years. Patients underwent laparoscopic BPD-DS. Observation indicators:(1) intraoperative and postoperative situations;(2) follow-up.Follow-up was performed by telephone interview and wechat up to July 2020, to detect complications, physical index, remission of preoperative comorbidity and blood biochemical index at 3 months and 6 months after operation. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Repeated data were analyzed using the repeated ANOVA and pariwise comparison was done using the LSD method. Measurement data with skewed distribution were represented as M(range). Count data were represented as absolute numbers, and comparison between groups was analyzed using the chi-suqare test. Results:(1) Intraoperative and postoperative situations:10 patients underwent successfully laparoscopic BPD-DS, including 1 patient undergoing concomitant cholecystectomy due to gallstone disease. There was no obvious hemorrhage, conversion to open surgery or perioperative death for the 10 patients. The operation time and duration of postoperative hospital stay were (256±28)minutes and 11 days(range, 4-38 days). Two patients had postoperative complications. (2) Follow-up: 10 patients were followed up for 6 months. During the follow-up, 3 patients had increased frequency of defecation, with 3-5 times per day, 7 patients had defecation frequency of 1-2 times per day. Of 10 patients, 4 cases had postoperative cholestasis, 2 cases development to gallstone, and the remaining 4 patients had no abnor-mality. The body weight, body mass index, waist circumference of 10 patients were (139±22)kg, (46±10)kg/m 2,(139±14)cm before operation, (107±19)kg, (35±8)kg/m 2, (118±17)cm at 3 months after operation, and (92±17)kg, (30±6)kg/m 2, (104±12)cm at 6 months after operation, showing significant differences ( F=170.01, 104.42, 120.25, P<0.05). The excess body mass reduc-tion rates at 3, 6 months after operation of 10 patients were 58%±36% and 81%±42%, showing a significant difference ( t=73.00, P<0.05). Of 10 patients, cases with type 2 diabetes, hypertriglyceri-demia, hypercholesteremia, elevated low density lipoprotein cholesterin level, hyperuricemia, hypertension were 5, 4, 6, 8, 9, 9 before operation, cases with complete remission were 4, 2, 5, 5, 1, 1 at 3 months after operation, and cases with complete remission were 5, 3, 4, 6, 7, 5 at 6 months after operation. Cases with partial remission of hypertension were 8 and 4 at 3, 6 months after operation. For 5 patients with type 2 diabetes, the fasting blood glucose and hemoglobin Alc were (11.4±3.1)mmol/L and 9.3%±1.6% before operation, (5.6±1.0)mmol/L and 5.5%±0.5% at 3 months after operation, (4.9±0.5)mmol/L and 4.8%±0.5% at 6 months after operation, showing significant differences ( F=14.55, 39.84, P<0.05). Of 10 patients, the retinal-binding protein, vitamins E, serum iron, serum zinc were normal before operation, cases with deficiency of above indicators were 5, 2, 1, 1 at 3 months after operation and 3, 3, 2, 4 at 6 months after operation. There was no clinical symptoms in patents with nutrient deficiency. Cases with deficiency of vitamins A, hypocalcemia, folic acid deficiency were 2, 2, 0 before operation, 5, 0, 0 at 3 months after operation and 3, 0, 1 at 6 months after operation. No deficiency of vitamins D, vitamins B12, ferritin or anemia occurred to the 10 patients. Conclusion:Laparoscopic BPD-DS is safe and effective for obesity.

Modificaciones anatómicas de la derivación biliopancreática con cruce duodenal: ¿tienen algún rol futuro en la cirugía bariátrica y metabólica? / Anatomical modifications of the biliopancreatic diversion with duodenal switch: do they have a future role in bariatric and metabolic surgery?

La derivación biliopancreática con cruce duodenal (BPD-DS) es el procedimiento bariátrico que ha mostrado los mejores resultados en cuanto a pérdida de peso y resolución de comorbilidades. Sin embargo, su adopción ha sido lenta, principalmente debido a sus complicaciones nutricionales y dificultad técnica. Dado esto, algunos autores han propuesto variaciones de este procedimiento. Estas están basadas en disminuir las anastomosis a solo una, y realizarla con un asa tipo loop (sin derivación biliopancreática). Estos cambios podrían reproducir las ventajas del BPD-DS, y eliminar algunas de sus desventajas. En este artículo, mostramos los resultados de estas variaciones comparadas con el BPD-DS, y cómo sus resultados prometedores pueden tener como consecuencia una nueva aproximación a la población que sufre de obesidad y sus comorbilidades

Biliopancreatic Diversion with duodenal switch (BPD-DS) is the bariatric surgery that has shown the better results regarding long-term weight loss and comorbidities resolution. Nevertheless, BPD-DS' adoption has been slow, mainly due to its nutritional complications, and technical complexity. Given this, some authors have proposed surgical variations of this effective procedure. These new procedures are based on reducing the anastomosis to only one, and doing it just a loop anastomosis (no biliopacreatic diversion). These changes might bring to us the advantages of BPD-DS, and eliminate some of its disadvantages. In this article, we show the results of these variations compared with BPD-DS, and how their promising results could be a new approach for obese population and bariatric surgery.

The clinical analysis of endoscopic pancreaticobiliary separation in the treatment of occult pancreaticobiliary reflux / 中华普通外科杂志

Objective To evaluate endoscopic pancreaticobiliary separation (EPBS) in patients with gallstone and occult pancreaticobiliary reflux (OPBR).Methods The clinical data of 47 cases with gallstone and OPBR from Oct 2013 to Oct 2016 was analyzed retrospectively.Results The mean gallbladder bile amylase (GBA) was (864 ± 575) U/L.40 cases have undergone the treatment of endoscopic retrograde cholangiopancreatography.26 cases were diagnosed as duodenal papillitis,16 cases as periampullary diverticula,14 cases as long nipple,5 cases as atrophic papilla,3 cases as ampulla stone and 2 cases as papillary tumor.9 were diagnosed as pancreaticobiliary maljunction in the 14 patients with long nipple.33 cases were performed with EPBS.GBA was tested in 16 cases,and the GBA of 15 cases returned to normal level.The difference of GBA was statistically significant [(1 161 ±764) U/L vs.(47 ± 17) U/L,(t =5.641,P ＜ 0.05)].Patients were followed up for 1 to 4 years,among 36 cases without cholecystectomy,there was no recurrence of cholecystolithiasis after EPBS in 27 cases,but 2 cases had recurrent gallstones in 9 cases without EPBS,and the difference of gallstone recurrence rate was statistically significant (x2 =21.340,P ＜ 0.05).Conclusions Pancreaticobiliary junction diseases is an important cause for gallstone formation and OPBR.EPBS can avoid pancreaticobiliary reflux and reduce the recurrence rate of gallstone after choledochoscopic lithotomy.

Clinical efficacy of laparoscopic stomach intestinal pylorus sparing surgery in the treatment of severe obesity / 中华消化外科杂志

Objective To investigate the clinical efficacy of laparoscopic stomach intestinal pylorus sparing surgery (SIPS) in the treatment of severe obesity.Methods The retrospective and descriptive study was conducted.The clinical data of 5 patients with severe obesity who were admitted to the China-Japan Union Hospital Affiliated to Jilin University from October to November 2018 were collected.There was 1 male and 4 females,aged from 18 to 55 years,with an average age of 33 years.All the 5 patients underwent laparoscopic SIPS.Observation indicators:(1) surgical situations;(2) postoperative situations;(3) follow-up.Follow-up was performed by outpatient examination,telephone interview and Wechat up to February 2019,including general condition,changes in body weight,body mass index,waistline,blood pressure,percentage of excess weight loss,fasting plasma glucose,glycosylated hemoglobin,blood lipid,and uric acid at 3 months after surgery.Measurement data with normal distribution were represented as Mean±SD,and they were tested with Hotelling T2 test.Measurement data with skewed distribution were represented as M (range).Results (1) Surgical situations:5 patients underwent successfully laparoscopic SIPS under clear surgical field,without obvious bleeding,conversion to open surgery or perioperative death.The operation time was 240 minutes (range,165-345 minutes).(2) Postoperative situations:the time to initial out-of-bed activity,time to first and flatus,and time to initial drinking and liquid intake were 2 days (range,2-3 days),3 days (range,2-3 days),and 3 days (range,3-4 days),respectively.On the third day after surgery,all the 5 patients were confirmed anastomotic patency,without gastric leakage,stenosis,or obstruction by upper gastrointestinal contrast.The abdominal drainage-tube was removed on the fourth day after feeding without obvious discomfort and foreign substances extraction from the drainage-tube.The duration of postoperative hospital stay was 6 days (range,6-7 days).(3) Follow-up:5 patients with severe obesity were successfully followed up for 3 months.During the follow-up,one patient had significantly increased frequency of defecation,roughly 5-8 times a day,especially after eating greasy food.According to the dietary guidance of the case manager,diarrhea was improved significantly after reducing the intake of oily food.Of the 5 patients with severe obesity,color doppler ultrasonography examination revealed that cholestasis was found in 2 patients at 3 months after operation,which may be related to significant weight loss,ratio imbalance of bile acid to and cholesterol,intestinal microbiota,injury of vagus nerve,significant increasing in mucin of gallbladder,and without oral ursodeoxycholic acid as prescribed by the doctor.The body weight,body mass index,waistline,systolic blood pressure,and diastolic blood pressure of 5 patients with severe obesity were (100± 15)kg,(36±4)kg/m2,(111±10)cm,(130±12)mmHg (1 mmHg=0.133 kPa),and (78±14)mmHg at 3 months after operation,respectively,showing significant differences compared with these of preoperation (F=61.631,75.558,87.045,9.501,16.248,P＜0.05).The percentage of excess weight loss was 44％±9％.Among the 5 patients with severe obesity,the fasting plasma glucose of 2 patients with type 2 diabetes mellitus decreased from 9.55 mmol/L and 13.49 mmol/L to 5.18 mmol/L and 5.62 mmol/L after operation,respectively.Level of glycated hemoglobin decreased from 10.0％ and 9.9％ to 5.2％ and 6.2％ after operation,respectively.In the 2 patients with hyperlipidemia,one patient with hypertriglyceride had level of triglyceride,total cholesterol,and low density lipoprotein increased from preoperative 2.24 minol/L,4.84 mmol/L and 2.92 mmol/L to 2.47 mmol/L,6.68 mmol/L and 5.51 mmol/L after operation,another patient with hypercholesterol had cholesterol level decreased from preoperative 5.97 mmol/L to postoperative 5.75 mmol/L after operation.In the 3 patients with hyperuricemia,two patients had the uric acid decreased from 404 μmol/L and 484 μmol/L to 319 μmol/L and 417 pmol/L after operation,respectively,one had the uric acid increased from 531 pmol/L to 674 μmol/L after operation.Conclusions Laparoscopic SIPS has a significant short-term effect on patients with severe obesity,but its long-term safety and efficacy need to be further followed up.

Clinical efficacy of laparoscopic stomach intestinal pylorus sparing surgery in the treatment of severe obesity / 中华消化外科杂志

Objective@#To investigate the clinical efficacy of laparoscopic stomach intestinal pylorus sparing surgery (SIPS) in the treatment of severe obesity.@*Methods@#The retrospective and descriptive study was conducted. The clinical data of 5 patients with severe obesity who were admitted to the China-Japan Union Hospital Affiliated to Jilin University from October to November 2018 were collected. There was 1 male and 4 females, aged from 18 to 55 years, with an average age of 33 years. All the 5 patients underwent laparoscopic SIPS. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up. Follow-up was performed by outpatient examination, telephone interview and Wechat up to February 2019, including general condition, changes in body weight, body mass index, waistline, blood pressure, percentage of excess weight loss, fasting plasma glucose, glycosylated hemoglobin, blood lipid, and uric acid at 3 months after surgery. Measurement data with normal distribution were represented as Mean±SD, and they were tested with Hotelling T2 test. Measurement data with skewed distribution were represented as M (range).@*Results@#(1) Surgical situations: 5 patients underwent successfully laparoscopic SIPS under clear surgical field, without obvious bleeding, conversion to open surgery or perioperative death. The operation time was 240 minutes (range, 165-345 minutes). (2) Postoperative situations: the time to initial out-of-bed activity, time to first and flatus, and time to initial drinking and liquid intake were 2 days (range, 2-3 days), 3 days (range, 2-3 days), and 3 days (range, 3-4 days), respectively. On the third day after surgery, all the 5 patients were confirmed anastomotic patency, without gastric leakage, stenosis, or obstruction by upper gastrointestinal contrast. The abdominal drainage-tube was removed on the fourth day after feeding without obvious discomfort and foreign substances extraction from the drainage-tube. The duration of postoperative hospital stay was 6 days (range, 6-7 days). (3) Follow-up: 5 patients with severe obesity were successfully followed up for 3 months. During the follow-up, one patient had significantly increased frequency of defecation, roughly 5-8 times a day, especially after eating greasy food. According to the dietary guidance of the case manager, diarrhea was improved significantly after reducing the intake of oily food. Of the 5 patients with severe obesity, color doppler ultrasonography examination revealed that cholestasis was found in 2 patients at 3 months after operation, which may be related to significant weight loss, ratio imbalance of bile acid to and cholesterol, intestinal microbiota, injury of vagus nerve, significant increasing in mucin of gallbladder, and without oral ursodeoxycholic acid as prescribed by the doctor. The body weight, body mass index, waistline, systolic blood pressure, and diastolic blood pressure of 5 patients with severe obesity were (100±15)kg, (36±4)kg/m2, (111±10)cm, (130±12)mmHg (1 mmHg=0.133 kPa), and (78±14)mmHg at 3 months after operation, respectively, showing significant differences compared with these of preoperation (F=61.631, 75.558, 87.045, 9.501, 16.248, P<0.05). The percentage of excess weight loss was 44%±9%. Among the 5 patients with severe obesity, the fasting plasma glucose of 2 patients with type 2 diabetes mellitus decreased from 9.55 mmol/L and 13.49 mmol/L to 5.18 mmol/L and 5.62 mmol/L after operation, respectively. Level of glycated hemoglobin decreased from 10.0% and 9.9% to 5.2% and 6.2% after operation, respectively. In the 2 patients with hyperlipidemia, one patient with hypertriglyceride had level of triglyceride, total cholesterol, and low density lipoprotein increased from preoperative 2.24 mmol/L, 4.84 mmol/L and 2.92 mmol/L to 2.47 mmol/L, 6.68 mmol/L and 5.51 mmol/L after operation, another patient with hypercholesterol had cholesterol level decreased from preoperative 5.97 mmol/L to postoperative 5.75 mmol/L after operation. In the 3 patients with hyperuricemia, two patients had the uric acid decreased from 404 μmol/L and 484 μmol/L to 319 μmol/L and 417 μmol/L after operation, respectively, one had the uric acid increased from 531 μmol/L to 674 μmol/L after operation.@*Conclusions@#Laparoscopic SIPS has a significant short-term effect on patients with severe obesity, but its long-term safety and efficacy need to be further followed up.

Application value of laparoscopic gastric plication combined with duodeno-jejunal omega switch in modified adjustable gastric banding / 中华消化外科杂志

Objective@#To explore the application value of laparoscopic gastric plication (LGP) combined with duodeno-jejunal omega switch (DJOS) in modified adjustable gastric banding.@*Methods@#The retrospective and descriptive study was conducted. The clinical data of a female 46-year-old patient who had failure to undergo the adjustable gastric banding in the Hospital of Ludwig Maximilian University from December 2016 to December 2018 were collected. LGP and DJOS were performed in two-stages after completion of preoperative examinations. Observation indicators: (1) surgical and postoperative situations; (2) follow-up. Follow-up using outpatient examiantion and telephone interview was performed to collect the information of body mass index (BMI), insulin therapy, and long-term complications until December 2018. Count data were represented as absolute numbers.@*Results@#(1) Surgical and postoperative situations: the patient underwent LGP in the first stage and DJOS in the second stage successfully. For the LGP, the operation time, time of intestinal reconstruction, volume of intraoperative blood loss, time to first flatus, time to drainage tube removal, time to resume to normal diet, and duration of postoperative hospital stay were 96 minutes, 58 minutes, 210 mL, 32 hours, 48 hours, 42 days, and 3 days, respectively. For the DJOS, the above indicators were 148 minutes, 117 minutes, 260 mL, 47 hours, 72 hours, 21 days, and 7 days, respectively. There was no complication occurred in either LGP or DJOS. (2) Follow-up: the patient was followed up for 24 months after LGP. The BMI of this patient decreased to 45.3 kg/m2 at 6 months after LGP, and decreased to 37.2 kg/m2 at 18 months after DJOS. Insulin therapy was discontinued. There was no long-term complication such as malnutrition, dumping syndrome, or biliary reflux.@*Conclusion@#LGP combined with DJOS can enrich treatment methods of obese patient with BMI >50 kg/m2, which offers a safer surgical procedure option for patients after gastric binding.

Application value of laparoscopic gastric plication combined with duodeno-jejunal omega switch in modified adjustable gastric banding / 中华消化外科杂志

Objective To explore the application value of laparoscopic gastric plication (LGP) combined with duodeno-jejunal omega switch (DJOS) in modified adjustable gastric banding.Methods The retrospective and descriptive study was conducted.The clinical data of a female 46-year-old patient who had failure to undergo the adjustable gastric banding in the Hospital of Ludwig Maximilian University from December 2016 to December 2018 were collected.LGP and DJOS were performed in two-stages after completion of preoperative examinations.Observation indicators:(1) surgical and postoperative situations;(2) follow-up.Follow-up using outpatient examiantion and telephone interview was performed to collect the information of body mass index (BMI),insulin therapy,and long-term complications until December 2018.Count data were represented as absolute numbers.Results (1) Surgical and postoperative situations:the patient underwent LGP in the first stage and DJOS in the second stage successfully.For the LGP,the operation time,time of intestinal reconstruction,volume of intraoperative blood loss,time to first flatus,time to drainage tube removal,time to resume to normal diet,and duration of postoperative hospital stay were 96 minutes,58 minutes,210 mL,32 hours,48 hours,42 days,and 3 days,respectively.For the DJOS,the above indicators were 148 minutes,117 minutes,260 mL,47 hours,72 hours,21 days,and 7 days,respectively.There was no complication occurred in either LGP or DJOS.(2) Follow-up:the patient was followed up for 24 months after LGP.The BMI of this patient decreased to 45.3 kg/m2 at 6 months after LGP,and decreased to 37.2 kg/m2 at 18 months after DJOS.Insulin therapy was discontinued.There was no long-term complication such as malnutrition,dumping syndrome,or biliary reflux.Conclusion LGP combined with DJOS can enrich treatment methods of obese patient with BMI ＞50 kg/m2,which offers a safer surgical procedure option for patients after gastric binding.

Bipartição de trânsito intestinal isolada: uma nova estratégia para cirurgia em estágios em superobesos / Isolated intestinal transit bipartition: a new strategy for staged surgery in superobesity

RESUMO Objetivo: o duodenal switch é um procedimento disabsortivo complexo, associado aos melhores resultados de perda de peso e controle metabólico. A cirurgia em etapas, com gastrectomia vertical como primeiro passo, é uma opção para reduzir complicações em pacientes superobesos. No entanto, alguns problemas persistem, como fígados grandes, que dificultam a abordagem cirúrgica, e complicações, como fístulas graves. A bipartição do trânsito intestinal é um modelo modificado e simplificado de desvio biliopancreático que complementa a gastrectomia vertical. É semelhante ao duodenal switch com menores complexidade e consequências nutricionais. Este estudo avaliou a viabilidade e a segurança da bipartição de trânsito isolada como o procedimento inicial para tratar a superobesidade. Métodos: foram incluídos 41 pacientes superobesos, com IMC médio de 54,5±3,5kg/m2. Uma bipartição de trânsito isolada laparoscópica foi realizada como o primeiro procedimento em uma nova abordagem em duas etapas. Perda de peso e complicações foram analisadas durante um ano de acompanhamento. Resultados: todos os procedimentos foram completados por laparoscopia. Após seis meses, a perda média de excesso de peso percentual foi de 28%, permanecendo estável até o final do estudo. Não houve dificuldades intraoperatórias. Metade dos pacientes apresentou diarreia precoce e três tiveram úlceras marginais. Não houve complicações cirúrgicas maiores ou mortes. Conclusão: a bipartição de trânsito isolada laparoscópica é uma nova opção para uma abordagem em estágios na superobesidade, que pode permitir um segundo procedimento mais seguro após a perda de peso ao longo de seis meses. Pode ser útil, particularmente, para pacientes com obesidade grave.

ABSTRACT Objective: biliopancreatic diversion with duodenal switch is a complex, malabsorptive procedure, associated with improved weight loss and metabolic control. Staged surgery with sleeve gastrectomy as the first stage is an option for reducing complications in superobese patients. However, some problems persist: large livers can hamper the surgical approach and complications such as leaks can be severe. Intestinal transit bipartition is a modified and simplified model of biliopancreatic diversion that complements sleeve gastrectomy. It is similar to the duodenal switch, but with less complexity and fewer nutritional consequences. This study assessed the feasibility and safety of isolated transit bipartition as the initial procedure in a two-step surgery to treat superobesity. Methods: this prospective study included 41 superobese patients, with mean BMI 54.5±3.5kg/m2. We performed a laparoscopic isolated transit bipartition as the first procedure in a new staged approach. We analyzed weight loss and complications during one year of follow-up. Results: we completed all the procedures by laparoscopy. After six months, the mean percent excess weight loss was 28%, remaining stable until the end of the study. There were no intraoperative difficulties. Half of the patients experienced early diarrhea, and three had marginal ulcers. There were no major surgical complications or deaths. Conclusion: isolated laparoscopic transit bipartition is a new option for a staged approach in superobesity, which can provide a safer second procedure after effective weight loss over six months. It may be useful particularly in the management of patients with severe obesity.

Effect of biliopancreatic diversion on sleep quality and daytime sleepiness in patients with obesity and type 2 diabetes

ABSTRACT Objective: The poor quality of sleep and the deprivation thereof have been associated with disruption of metabolic homeostasis, favoring the development of obesity and type 2 diabetes (T2DM). We aimed to evaluate the influence of biliopancreatic diversion (BPD) surgery on sleep quality and excessive daytime sleepiness of obese patients with T2DM, comparing them with two control groups consisting of obese and normal weight individuals, both normal glucose tolerant. Subjects and methods: Forty-two women were divided into three groups: LeanControl (n = 11), ObeseControl (n = 13), and ObeseT2DM (n = 18). The LeanC and ObeseC groups underwent all tests and evaluations once. The ObeseT2DM underwent BPD and were reassessed after 12 months. Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) were applied before and 12 months after BPD. Results: Before surgery, there was less daytime sleepiness in LeanC group (p = 0.013) compared with ObeseC and T2DMObese groups. The two obese groups did not differ regarding daytime sleepiness, demonstrating that the presence of T2DM had no influence on daytime sleepiness. After surgery, the daytime sleepiness (p = 0.002) and the sleep quality (p = 0.033) improved. The score for daytime sleepiness of operated T2DMObese group became similar to LeanC and lower than ObeseC (p = 0.047). Conclusion: BPD surgery has positively influenced daytime sleepiness and sleep quality of obese patients with T2DM, leading to normalization of daytime sleepiness 12 months after surgery. These results reinforce previously identified associations between sleep, obesity and T2DM in view of the importance of sleep in metabolic homeostasis, quality of life and health.

Twelve years of experience using cholecystojejunal by-pass for palliative treatment of advanced pancreatic cancer / Derivação colecistojejunal para o tratamento paliativo do câncer de pâncreas avançado

ABSTRACT Background: The cholecistojejunal bypass is an important resource to treat obstructive jaundice due to advanced pancreatic cancer. Aim: To assess the early morbidity and mortality of patients with pancreatic cancer who underwent cholecystojejunal derivation, and to assess the success of this procedure in relieving jaundice. Method: This retrospective study examined the medical records of patients who underwent surgery. They were categorized into early death and non-early death groups according to case outcome. Results: 51.8% of the patients were male and 48.2% were female. The mean age was 62.3 years. Early mortality was 14.5%, and 10.9% of them experienced surgical complications. The cholecystojejunostomy procedure was effective in 97% of cases. There was a tendency of increased survival in women and patients with preoperative serum total bilirubin levels below 15 mg/dl. Conclusion: Cholecystojejunal derivation is a good therapeutic option for relieving jaundice in patients with advanced pancreatic cancer, with acceptable rates of morbidity and mortality.

RESUMO Racional: A derivação colecistojejunal é um importante recurso para o tratamento de pacientes com icterícia obstrutiva secundária ao câncer de pâncreas avançado. Objetivo: Avaliar a morbimortalidade precoce dos doentes com câncer de pâncreas submetidos à derivação colecistojejunal, assim como avaliar o alivio da icterícia. Método: Estudo retrospectivo de prontuários de pacientes que foram operados. Eles foram categorizados de acordo com a resolução dos casos em: morte precoce e sem morte precoce. Resultados: 51,8% dos pacientes eram homens e 48,2% mulheres. A média etária foi de 62,3 anos. A mortalidade precoce foi de 14,5%. 10,9% evoluíram com complicações cirúrgicas. A colecistojejunostomia foi efetiva em 97% dos casos. Houve tendência à maior sobrevida em mulheres e pacientes com níveis séricos de bilirrubina total pré-operatório menor do que 15mg/dl. Conclusão: A derivação colecistojejunal constitui boa opção terapêutica para alívio da icterícia em pacientes com câncer de pâncreas avançado, apresentando morbimortalidade aceitável.

Cáncer de páncreas: epidemiología de su mal pronóstico / Pancreatic cancer: epidemiology of a bad prognosis

Introducción: el cáncer de páncreas se caracteriza por su agresividad biológica, mal pronóstico oncológico y diagnóstico tardío. La mayoría con baja tasa de resecabilidad (10% a 20%), por la presencia de factores de irresecabilidad al momento del diagnóstico. Objetivo: descripción epidemiológica de las características del cáncer de páncreas irresecable, los tratamientos paliativos realizados, la sobrevida global y en relación con los procedimientos realizados. Material y método: estudio descriptivo, multivariable, retrospectivo de los cánceres de páncreas irresecables, de enero de 2010 a diciembre de 2015, en la Clínica Quirúrgica 3 del Hospital Maciel. Resultados: de los 30 pacientes irresecables: igual distribución por sexo; edad promedio: 61 años, cefálicos en 67% de los casos. El 53% adelgazados al momento de la primera consulta; 52% presentaban compromiso ganglionar locorregional, y 50% presentaba metástasis hepáticas o ascitis. A 52% de los pacientes se les realizó algún tipo de derivación biliar; quirúrgica en 53% (63% coledocoduodenostomías) y el resto percutánea o endoscópica. El 31% de los pacientes, por lo avanzado de la enfermedad, no recibió tratamiento quirúrgico ni endoscópico. La sobrevida media del tratamiento paliativo quirúrgico o endoscópico fue de 3,7 meses. Conclusiones: al momento del diagnóstico, la mitad de los casos tenían metástasis y repercusión nutricional severa, con indicadores locorregionales de irresecabilidad o incurabilidad. Un tercio de los casos no recibió tratamiento oncológico por lo avanzado de la enfermedad. La sobrevida global fue escasa. Esto permite sugerir que son imprescindibles medidas sanitarias para su diagnóstico precoz e incremento de la tasa de resecabilidad.

Introduction: pancreatic cancer is a particularly aggressive cancer witha poor prognosis and it is typically diagnosed at a late stage. Most cases have a lower rate of resectability (10 to 20%) as a result of certain unresectable factors at the time of diagnosis. Objective: the study aims to provide an epidemiological description of the characteristics of unresectable pancreatic cancer, palliative treatment, global survival and procedures applied. Method: descriptive, multivariable, retrospective study of cases of unresectablecáncer from January 2010 to December 2015, at the 3rdSurgical Unit of Hospital Maciel, Montevideo, Uruguay. Results: considering the 30 unresectable patients: same sex distribution. Average age was 61 years old, cephalic in 67% of cases. 53 of patients had lost weight at the time of consultation, 52% of them evidencedlocoregionallymph node involvement and 50% liver metastases and/or ascites. In 52% of cases some kind of biliary bypass was performed, surgical in 53% (63% pancreaticoduodenectomy), while the rest underwent percutaneous or endoscopic surgery. 31% of patients did not receive surgical or endoscopic treatment given the advanced stage of the condition. Averagesurvival of surgicalorendoscopictreatmentwas 3.7 months. Conclusions: at the time of diagnosis, 50% of the cases of pancreatic cancer presented metastases and severe nutritional compromise, evidencing locoregional indicators of unresectability or incurability. One third of the cases did not receive oncological treatment given the advanced stage of the disease. Global survival was low. All of these findings suggest it is essential to devise health policies for an early diagnosis and to increase resectability rates.

Introdução: o câncer de pâncreas se caracteriza por sua agressividade biológica, mal prognóstico oncológico e diagnóstico tardio. A maioria tem baja taxa de ressecabilidade (10 a 20 %), devido a presença de fatores específicos que o impedem no momento do diagnóstico. Objetivo: descrição epidemiológica das características do câncer de pâncreas irresecable, os tratamentos paliativos realizados, a sobrevida global e em relação aos procedimentos realizados. Material e método: estudo descritivo, multivariável, retrospectivo dos cânceres de pâncreas irresecables, atendidos no período janeiro de 2010 a dezembro de 2015, na Clínica Quirúrgica "3" do Hospital Maciel em Montevidéu, Uruguai. Resultados: os 30 pacientes com câncer de pâncreas irressecáveis apresentavam uma distribuição igual por sexo, idade media: 61 anos, cefálicos em 67% dos casos. 53% dos pacientes haviam emagrecido no momento da primeira consulta; 52% apresentavam compromisso ganglionar locorregional e 50% metástases hepáticas e/ou ascite. 52% dos pacientes foram submetidos a algum tipo de derivação biliar; cirúrgica em 53% (63% coledocoduodenostomias) e nos demais percutânea ou endoscópica. 31% dos pacientes não recebeu tratamento cirúrgico nem endoscópico devido ao estado avançado da doença. A sobrevida media do tratamento paliativo cirúrgico ou endoscópico foi de 3,7 meses. Conclusões: no momento do diagnóstico do câncer de pâncreas a metade dos pacientes apresentavam metástases e repercussão nutricional severa, com indicadores locorregionais de irressecabilidade ou incurabilidade. Um terço dos casos não recebeu tratamento oncológico devido ao estado avançado da doença. A sobrevida global foi curta. Isto nos permite sugerir que são imprescindíveis medidas sanitárias para seu diagnóstico precoce e aumento da taxa de ressecabilidade.

Liver failure following biliopancreatic diversions: a narrative review / Falência hepática após derivações biliopancreáticas: uma revisão narrativa

ABSTRACT CONTEXT AND OBJECTIVE: Occurrences of liver failure following jejunoileal bypass were extensively reported in the past and were one of the main factors that led to abandonment of this procedure. The newer predominantly malabsorptive procedures called biliopancreatic diversions (BPDs) have also been implicated in several cases of acute and subacute liver failure. The aim here was to review the current available evidence on occurrences of liver failure following BPDs. DESIGN AND SETTING: Narrative review; bariatric surgery service of a public university hospital. METHODS: A review of the literature was conducted through an online search of medical databases. RESULTS: Associations between BPDs and liver failure have only infrequently been reported in the literature. However, they appear to be more than merely anecdotal. The pathophysiological mechanisms remain obscure, but they seem to be related to rapid weight loss, protein malnutrition, deficits of hepatotrophic factors, high circulating levels of free fatty acids and bacterial overgrowth in the bypassed bowel segments. Reversal of the BPD may ameliorate the liver impairment. CONCLUSIONS: Although infrequent, liver failure remains a concern following BPDs. Careful follow-up is required in individuals who undergo any BPD.

RESUMO CONTEXTO E OBJETIVO: A ocorrência de falência hepática após a derivação jejunoileal foi extensivamente descrita no passado e foi um dos principais fatores que levaram ao abandono do procedimento. Os procedimentos predominantemente malabsortivos mais modernos, chamados de derivações biliopancreáticas, também já foram implicados em diversos casos de falência hepática aguda e subaguda. O objetivo foi revisar a atual evidência disponível sobre a ocorrência de insuficiência hepática após derivações biliopancreáticas. TIPO DE ESTUDO E LOCAL: Revisão narrativa; Serviço de Cirurgia Bariátrica de hospital universitário. MÉTODOS: Revisão da literatura conduzida por meio de pesquisa online de bancos de dados médicos. RESULTADOS: A associação entre derivações biliopancreáticas e falência hepática na literatura é infrequente. Entretanto, ela aparenta ser mais do que meramente anedótica. Os mecanismos fisiopatológicos continuam pouco compreendidos, mas parecem estar relacionados à rápida perda de peso, desnutrição proteica e déficit de fatores hepatotróficos, altos níveis circulantes de ácidos graxos livres e supercrescimento bacteriano em segmentos intestinais excluídos do trânsito. A reversão da cirurgia pode melhorar o comprometimento hepático. CONCLUSÕES: Embora infrequente, a falência hepática continua sendo preocupante após as derivações biliopancreáticas. Seguimento cuidadoso é mandatório em indivíduos submetidos a essas cirurgias.

GLP-2: a poorly understood mediator enrolled in various bariatric/metabolic surgery-related pathophysiologic mechanisms / GLP-2: um mediador pouco compreendido envolvido em diversos mecanismos fisiopatológicos relacionados à cirurgia bariátrica/metabólica

ABSTRACT Introduction: Glucagon-like peptide-2 (GLP-2) is a gastrointestinal hormone whose effects are predominantly trophic on the intestinal mucosa. Aim: Critically evaluate the current literature on the influence of bariatric/metabolic surgery on the levels of GLP-2 and its potential clinical implications. Method s: Narrative review through online research on the databases Medline and Lilacs. There were six prospective human studies, two cross-sectional human studies, and three experimental animal studies selected. Results: There is evidence demonstrating significant increase in the levels of GLP-2 following gastric bypass, Scopinaro operation, and sleeve gastrectomy. There are no differences between gastric bypass and sleeve gastrectomy in regards to the increase in the GLP-2 levels. There is no correlation between the postoperative levels of GLP-2 and the occurrence of adequate or insufficient postoperative weight loss. Conclusion: GLP-2 plays significant roles on the regulation of nutrient absorption, permeability of gut mucosa, control of bone resorption, and regulation of satiety. The overall impact of these effects potentially exerts a significant adaptive or compensatory effect within the context of varied bariatric surgical techniques.

RESUMO Introdução: O peptídeo semelhante ao glucagon-2 (GLP-2) é hormônio gastrointestinal com efeitos predominantemente tróficos sobre a mucosa intestinal. Objetivo: Avaliar criticamente a literatura atual a respeito da cirurgia bariátrica/metabólica sobre os níveis de GLP-2 e suas potenciais implicações clínicas. Métodos: Revisão narrativa realizada através de pesquisa on-line nas bases de dados Medline e LILACS. Foram selecionados seis estudos prospectivos em humanos, dois transversais em humanos e três experimentais em animais. Resultados: Existem evidências demonstrando aumento significativo nos níveis de GLP-2 após o bypass gástrico, a operação de Scopinaro e a gastrectomia vertical. Não foram observadas diferenças entre o bypass gástrico e a gastrectomia vertical em relação ao aumento do GLP-2. Não há correlação entre os níveis de GLP-2 e a ocorrência de perda de peso pós-operatória adequada ou insuficiente. Conclusão: O GLP-2 desempenha importantes papel sobre a regulação da absorção de nutrientes, permeabilidade da mucosa intestinal, controle da reabsorção óssea e regulação da saciedade. O impacto combinado destes efeitos potencialmente exerce efeito adaptativo ou compensatório importante no contexto das diferentes técnicas bariátricas.

SADI-S WITH RIGHT GASTRIC ARTERY LIGATION: TECHNICAL SYSTEMATIZATION AND EARLY RESULTS / SADI-S COM LIGADURA DA ARTÉRIA GÁSTRICA: SISTEMATIZAÇÃO TÉCNICA E OS PRIMEIROS RESULTADOS

ABSTRACT Background: Bariatric surgery is performed all over the world with close to 500.000 procedures per year. The most performed techniques are Roux-en-Y gastric bypass and sleeve gastrectomy. Despite this data, the most effective procedure, biliopancreatic diversion with or without duodenal switch, represents only no more than 1.5% of the procedures. Technical complexity, morbidity, mortality, and severe nutritional adverse effects related to the procedure are the main fears that prevent most universal acceptance. Aim: To explain the technical aspects and the benefits of the SADI-S with right gastric artery ligation as an effective simplification from the original duodenal switch. Methods: Were included all patients undergoing this procedure from the November 2014 to May 2016, describing and analysing aspects of this technique, the systematization and early complications associated with the procedure. Results: A series of 67 patients were operated; 46 were women (68.7%); mean age of the group was 44 years old (33-56); and an average BMI of 53.5 kg/m2 (50-63.5). Surgical time was 115 min (80-180). A total of five patients (7.5%) had any complication and two (2.9%) had to be reoperated. There were two patients with leak, one at the duodenal stump and other at the esophagogastric angle. There was no mortality. Patients stayed at the hospital a median of 2.5 days (1-25). Conclusions: SADI-S with right gastric artery ligation is a safe procedure with few preliminary complications. The technical variations introduced to the classical duodenal switch are reproducible and may allow this procedure to be more popular. All the complications in this series were not related to the ligation of the right gastric artery.

RESUMO Racional: Cerca de 500.000 cirurgias bariátricas são realizadas a cada ano em todo o mundo. As técnicas mais realizadas são o bypass gástrico em Y-de-Roux e a gastrectomia vertical. A derivação biliopancreática, com ou sem duodenal switch, é considerada técnica mais eficaz no tratamento cirúrgico do paciente obeso mórbido; entretanto, representa não mais do que 1,5% dos procedimentos na atualidade, pois sua complexidade técnica, morbimortalidade e graves efeitos adversos nutricionais impedem aceitação mais universal. Objetivo: Descrever os aspectos técnicos e os benefícios do SADI-S com ligadura da artéria gástrica direita como um modo simplificado do duodenal switch original. Métodos: Foram incluídos todos os pacientes submetidos a este procedimento entre novembro 2014 e maio de 2016. Além da descrição da sistematização da técnica operatória, foram analisadas as complicações precoces associadas ao procedimento. Resultados: Uma série de 67 pacientes foi operada no período analisado; 46 eram mulheres (68,7%) e a média de idade foi de 44 anos (33-56). O IMC médio foi de 53,5 kg/m2 (50-63,5). O tempo cirúrgico médio foi de 115 min (80-180) e a permanência hospitalar média foi de 2,5 dias (1-25). Complicações foram observadas em cinco pacientes (7,5%) e dois (2,9%) tiveram de ser reoperados. Duas pacientes evoluíram com fístula, uma no coto duodenal e outra na junção esofagogástrica. Não houve mortalidade. Conclusão: SADI-S com ligadura da artéria gástrica direita é procedimento seguro com poucas complicações precoces. A simplificação técnica em relação ao duodenal switch clássico pode permitir que este procedimento se torne mais popular. Todas as complicações observadas nesta série não estavam relacionadas com a ligadura da artéria gástrica direita.

Predictors for eeight loss failure following roux-en-y gastric bypass / Preditores para perda de peso insuficiente após bypass gástrico em Y de Roux

Context Weight loss failure is a widely recognized occurrence following Roux-en-Y gastric bypass. Objectives This study aims to identify predictors associated with weight loss failure. Methods It is a retrospective cohort which enrolled 187 subjects who underwent RYGB. Comparisons were made between patients’ features at baseline and 24 months after surgery. Results A weight loss failure rate of 11.2% was found. Advanced age and diabetes were statistically associated with failure. Conclusions The results found were close to previous reports. As weight loss failure represents an important concern, there is the possibility to perform revisional surgeries, which may emphasize the restrictive or malabsorptive characteristics of RYGB, leading to varied results. It is reinforced that weight loss cannot be used as the unique outcome to evaluate the success of surgery. .

Contexto A perda insuficiente de peso após o bypass gástrico em Y de Roux é uma ocorrência amplamente reconhecida. Objetivos Identificar preditores associados à falha cirúrgica na perda ponderal. Métodos Estudo de coorte retrospectiva envolvendo 187 indivíduos submetidos ao bypass gástrico. As características pré-operatórias dos pacientes foram comparadas àquelas observadas 24 meses após a cirurgia. Resultados Perda de peso insuficiente ocorreu em 11.2% dos pacientes. Idade avançada e diabetes apresentaram associação estatisticamente significativa com a falha. Conclusões Os resultados encontrados foram próximos aos de relatos prévios. Como a perda insuficiente de peso representa uma preocupação relevante, existe a possibilidade de indicação de cirurgias revisionais, que podem enfatizar as características restritivas ou disabsortivas do bypass gástrico, levando a resultados variados. Ressalta-se que a perda de peso isoladamente não pode ser utilizada como desfecho único para avaliar o sucesso da cirurgia. .

Impact of bariatric surgeries on diabetes outcomes / Impacto da cirurgia bariátrica no resultado do diabetes

Obesity and type 2-diabetes (T2D) are associated to dramatically high morbidity and mortality, and their incidence and prevalence are increasing rapidly. Bariatric surgeries, including a variety of gastrointestinal surgical procedures achieve substantial and sustained weight loss in morbidly obese patients, strongly improves diabetes and hypertension control or prevalence, quality of life, decreases incidence of stroke, myocardial infarction and obstructive sleep apnea among other favorable clinical outcomes. Most important, mortality rates decreases. The objectives of this narrative review were the effectiveness of bariatric procedures on diabetes remission or improvement and the implicated mechanisms. It was found that bariatric surgeries induce high rates of short and long-term diabetes remission (from 60 to 95% or improved control), according to the surgical intervention, with low frequency of perioperative and postoperative complications. Rates of diabetes recurrence are not well known, but the time free-of-disease should ameliorate diabetes complications and mortality. The mechanisms are still not completely understood; encompass improved insulin action, better b-cell function, higher adiponectin, lower inflammation and complex changes of hormones of the entero-insular axis, GLP-1 and glucose dependent insulinotropic polypeptide (GIP). Insulin action improves proportionally to weight loss (WL), in most types of surgery, but normalizes after Bilio-pancreatic diversion even in still obese people. b-cell function improves more after bypass than after restrictive surgeries, but does not normalize and baseline function predicts diabetes remission. Efforts to understand mechanisms and predictive factors for diabetes remission may optimize surgical interventions for metabolic disorders even in less obese patients. Finally and more important, they might drive the development of new clinical approaches for T2D...

Efeito da derivação biliopancreática na função da célula-beta de mulheres obesas grau I e II portadoras de diabetes mellitus tipo 2 / Effect of biliopancreatic diversion in the beta-cell function of grade I and II obese women with type 2 diabetes mellitus

Objetivo: avaliar o efeito da cirurgia de derivação biliopancreática (DBP) na função da célula-beta de mulheres obesas grau I e II portadoras de diabetes mellitus tipo 2 (DM2), utilizando estímulos com glicose oral e intravenosa. Material e métodos: foram avaliadas 68 mulheres na menacme que compuseram três grupos: Controle magro - CMagro (n = 19, IMC = 23,0 ± 2,2 kg/m²), Controle obeso - CObeso: 18 mulheres obesas (IMC = 35,0 ± 4,8 kg/m²), ambos normotolerante à glicose; e Obeso com DM2 - ObesoDM2 (n = 31; IMC: 36,3 ± 3,7 kg/m²). No grupo ObesoDM2, 64% das mulheres foram submetidas à cirurgia de DBP (n = 20, IMC: 36,5 ± 3,7 kg/m²). Os 68 pacientes passaram por todas as avaliações uma única vez. Os pacientes submetidos à DBP foram reavaliados um mês após a cirurgia. A avaliação da célula-beta foi realizada por testes dinâmicos com estímulo oral (teste de tolerância à glicose oral) e intravenoso (clamp hiperglicêmico). Foram dosados glicose, insulina e peptídeo-C plasmáticos. A aplicação das técnicas de modelagem matemática aos dados possibilitou avaliar as secreções de insulina basal, dinâmica e estática (estímulo oral); a primeira e a segunda fase de secreção de insulina (estímulo intravenoso); a secreção de insulina total; a sensibilidade à insulina (SI), a extração hepática de insulina (EH) e o tempo de atraso ou tempo de atraso para a célula-beta recrutar novos grânulos de insulina para compor o reservatório de grânulos prontamente liberáveis em resposta a determinada glicemia. Resultados: após a DBP houve melhora substancial na SI no TTOG e no teste de clamp, com o grupo cirúrgico alcançando níveis semelhantes aos do grupo CMagro e mais elevados que do grupo CObeso (p < 0,05). A EH de insulina apresentou aumento significante após a DBP, com o grupo cirúrgico mantendo-se semelhante ao CMagro e com níveis aumentados em relação ao CObeso (p < 0,05)...

Objective: to assess the effect of biliopancreatic diversion surgery (BPD) in beta-cell function of obese grade I and II women with type 2 diabetes mellitus (T2DM), using an oral and an intravenous stimuli with glucose. Research Design and Methods: sixty eight premenopausal women were assessed and divided into three groups: lean control - LeanC (n = 19; BMI: 23.0 ± 2.2 kg/m²), obese control - ObeseC (n = 18; BMI: 35.0 ± 4.8kg/m²), both with normal glucose tolerance; and obese with type 2 diabetes - ObeseT2DM (n = 31; BMI: 36.3 ± 3.7 kg/m²). In ObeseDM2 group, 64% of women underwent BPD (n = 20, BMI: 36.5 ± 3.7 kg/m²). The 68 volunteers underwent all assessments once. The volunteers those underwent BPD were reassessed one month after surgery. The assessment of beta-cell function was performed by dynamic tests with an oral (oral glucose tolerance test) and an intravenous stimulation test (hyperglycemic clamp). Serum glucose, insulin and C-peptide were determined. The application of mathematical modeling techniques to data allowed to evaluate basal, dynamic and static (oral stimulus) insulin secretion; the first and second phase of insulin secretion (intravenous stimulus); the total insulin secretion; the insulin sensitivity (IS); the hepatic extraction of insulin (EH) and the delay time for the beta-cell to recruit new insulin granules to form the pool of readily releasable granules in response to a given plasma glucose. Results: after BPD, there was a dramatic improvement on IS during the OGTT and during the clamp test, with the surgical group reaching normalized levels compared to those observed in LeanC group and higher levels than ObeseC group (p < 0.05). The EH of insulin showed significant improvement after BPD, with the surgical group reaching similar levels to LeanC and with increased levels in comparison to ObeseC (p < 0.05)...

Efficacy Comparison among Three Kinds of Surgical Operation for Type 2 Diabetes Mellitus in Rats / 世界科学技术-中医药现代化

This study was aimed to compare the efficacy of gastric banding (GB), Roux en-Y gastric bypass (RYGBP) and biliopancreatic diversion (BPD) in the treatment of rats with type 2 diabetes mellitus (T2DM). Ani-mal models of T2DM were induced by streptozotocin (STZ) injection and high-sugar-fat diets. A total of 70 T2DM rats were randomly allocated into the GB group (G group, n = 20), RYGBP group (R group, n = 20), BPD group ( B group , n = 20 ) , and the sham operation group ( S group , n = 10 ) . The fasting blood glucose ( BG ) , triglyceride ( TG ) , total cholesterol ( TC ) and insulin ( INS ) content were determined before and 1 , 2 , 3 , 4 , 8 , 16 weeks after operation. The insulin sensitivity index (ISI) was calculated. The mortality and complications were ob-served in each group. The results showed that the fasting weight of the GB group, RYGBP group and BPD group were (324.4 ± 22.5) g, (338.9 ± 17.5) g, (333.3 ± 28.4) g, respectively. The BG content was (12.44 ± 1.29) mmol/L, (9.70 ± 0.81) mmol/L, (11.93 ± 2.39) mmol/L, respectively. The TC content was (2.32 ± 0.45) mmol/L, (2.22 ± 0.79) mmol/L, (2.13 ± 0.31) mmol/L, respectively. The TG content was (1.38 ± 0.32) mmol/L, (1.16± 0.41) mmol/L, (1.23 ± 0.35) mmol/L, respectively. The ISI were (-6.38 ± 0.29), (-6.67 ± 0.24), (-6.65 ±0.23), respectively. And the INS content of the RYGBP group were (69.43 ± 18.73) mU/L. There were signifi-cant differences between before and after operation on the 16th week ( P < 0 . 05 , P < 0 . 01 ) . The mortality rate was 5% in the GB group, 20% in the RYGBP group, and 35% in the BPD group. It was concluded that the GB, RYGBP and BPD are effective in reducing blood glucose and blood lipids in the treatment of rat with T2DM. The treatment effect is obvious in the improvement of insulin resistance ( IR ) .

Biliopancreatic diversion with duodenojejunal exclusion associated with truncal vagotomy: a new proposal for type 2 diabetes mellitus treatment / Derivação biliopancreática com exclusão duodeno-jejunal associada à vagotomia troncular: uma nova proposta para o tratamento do diabetes melito tipo 2

PURPOSE: To evaluate the effectiveness of the biliopancreatic diversion surgery with duodenojejunal exclusion in combination with truncal vagotomy in type 2 diabetes mellitus (T2DM) patients with overweight or class I or II obesity. METHODS: The study included ten patients with T2DM and class I or II obesity or overweight who were subjected to biliopancreatic diversion with duodenojejunal exclusion in combination with truncal vagotomy. The blood glucose levels during the pre- and postoperative periods were compared using the Friedman test. The significance level adopted was 5%. RESULTS: There were significant differences between preoperative and postoperative blood glucose levels at three months (p=0.01), six months (p=0.001) and 12 months (p=0.001). There was also a significant difference between one month postoperative blood glucose and six months postoperative blood glucose (p=0.01). Glycosylated hemoglobin levels decreased in 80% of patients, there was marked improvement in their lipid profiles, and the average BMI reduction was 7.0±1.5 kg/m² at 12 months after the surgery. CONCLUSION: In patients with type 2 diabetes mellitus associated with class I/II obesity or overweight, performing biliopancreatic diversion with duodenojejunal exclusion in combination with truncal vagotomy resulted in glycemic control, reduction of excess weight, and improvement of lipid profile 12 months after the surgery.

OBJETIVO: Avaliar a eficácia da operação de derivação biliopancreática com exclusão duodeno-jejunal associada com vagotomia troncular em doentes com diabetes tipo 2 com sobrepeso ou obesidade classe I ou II. MÉTODOS: Foram estudados dez doentes com diabetes melito tipo 2 e sobrepeso ou obesidade grau I ou II submetidos à derivação biliopancreática com exclusão duodeno-jejunal associada à vagotomia troncular. Os valores de glicemia no pré e no pós-operatório foram comparados pelo teste de Friedman. O nível de significância adotado foi de 5%. RESULTADOS: Houve diferença significante (p=0,01) nas glicemias pré e pós-operatórias de três meses, de seis meses (p=0,001) e de 12 meses (p=0,001). Houve diferença significante entre a glicemia pós-operatória de um mês e glicemia pós-operatória de seis meses (p=0,01). O nível de hemoglobina glicosilada reduziu-se em 80% dos doentes, houve melhora acentuada do perfil lipídico e a média da redução do IMC foi de 7,0±1,5 kg/m² após 12 meses da operação. CONCLUSÃO: No paciente com diabetes melito tipo 2 associado com sobrepeso ou obesidade grau I/II, a realização da derivação biliopancreática com exclusão duodeno-jejunal associada à vagotomia troncular proporcionou controle glicêmico, redução do excesso de peso e melhora do perfil lipídico após 12 meses da operação.

BPD surgery on type 2 diabetes mellitus in GK rats / 中华内分泌外科杂志

Objective To investigate the therapeutic effects and mechanism of biliopancreatic diversion (BPD) surgery on type 2 diabetes mellitus(T2DM) in GK rats.Methods 16 GK rats were randomly divided into 2 groups:BPD surgery group included 10 rats undergoing BPD surgery,sham-BPD group included 6 rats undergoing a sham operation.Fasting plasma glucose,insulin,glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide(GIP)were detected one week before BPD surgery and the 1st week,4th week,10th week,26th week after BPD surgery.Oral glucose tolerance test(OGTT) and insulin tolerance test(ITT) were done in the 10th week after BPD surgery.Results There was no statistical difference in fasting plasma glucose,insulin,plasma GLP-1 or GIP between the 2 groups before surgery.Plasma glucose had significant reduction in BPD group compared to that in the sham group(P ＜0.05) and insulin level had no significant difference between the 2 groups.Rats in BPD group had significant improvement in glucose tolerance and insulin sensitivity compared to those in the sham group.Serum level of GLP-1 was significantly elevated in BPD group compared to that before surgery (P =0.0337 at the 1st week after surgery; P =0.0002 at the 4th week after surgery,P ＜ 0.0001 at the 10th week after surgery,P ＜0.0001 at the 26th week after surgery) and that in sham-BPD group(P =0.0354 at the 1st week after surgery,P =0.0032 at the 4th week after surgery,P =0.0001 at the 10th week after surgery,P ＜0.0001 at the 26th week).Serum level of GIP was significantly lowered in BPD group compared to that before surgery(P =0.0189 at the 1st week after surgery; P =0.0007 at the 4th week after surgery,P =0.0003 at the 10th week after surgery,P ＜0.0001 at the 26th week after surgery) and that in sham-BPD group(P =0.0089 at the 1st week after surgery,P =0.0002 at the 4th week after surgery,P =0.0006 at the 10th week after surgery,P ＜0.0001 at the 26th week after surgery).The difference had statistical significance (P ＜0.05).Conclusion BPD surgery can significantly reduce fasting plasma glucose,improve glucose tolerance and insulin sensitivity.The change of serum levels of GLP-1 and GIP may play the major role in BPD treatment of diabetes mellitus.