Could the intestinal epithelial alterations promoted by roux-en-y gastric bypass explain higher tendency for colonic diseases in bariatric patients? / As alterações epiteliais intestinais promovidas pelo bypass em y-de-roux podem explicar maior tendência a doenças colônicas em pacientes bariátricos?

ABSTRACT Background: Intestinal diversions have revolutionized the treatment of morbid obesity due to its viability and sustained response. However, experimental studies suggest, after these derivations, a higher risk of colon cancer. Aim: To analyze the histological and immunohistological changes that the jejunojejunal shunt can produce in the jejunum, ileum and ascending colon. Method: Twenty-four male Wistar rats were randomly divided into two groups, control (n=12) and experiment (n=12) and subdivided into groups of four. Nine weeks after the jejunojejunal shunt, segmental resection of the excluded jejunum, terminal ileum and ascending colon was performed. Histological analysis focused on the thickness of the mucosa, height of the villi, depth of the crypts and immunohistochemistry in the expression of Ki-67 and p53. Results: Significant differences were found between the experiment and control groups in relation to the thickness of the mucosa in the jejunum (p=0.011), in the ileum (p<0.001) and in the colon (p=0.027). There was also a significant difference in relation to the height of the villus in the ileum (p<0.001) and the depth of the crypts in the jejunum (p0.001). The results indicated that there is a significant difference between the groups regarding the expression of Ki-67 in the colon (p<0.001). No significant differences were found between the groups regarding the expression of Ki-67 in the jejunum and ileum. In the P53 evaluation, negative nuclear staining was found in all cases. Conclusion: The jejunojejunal deviation performed in the Roux-in-Y gastrojejunal bypass, predispose epithelial proliferative effects, causing an increase in the thickness of the mucosa, height of the villi and depth of the crypts of the jejunum, ileum and ascending colon.

RESUMO Racional: As derivações intestinais revolucionaram o tratamento da obesidade mórbida pela sua viabilidade e resposta sustentada. Porém, estudos experimentais sugerem, após estas derivações, risco maior de câncer de cólon. Objetivo: Analisar as alterações histológicas e imunoistológicas que a derivação jejunojejunal possa produzir no jejuno, íleo e cólon ascendente. Método: Foram utilizados 24 ratos Wistar machos randomicamente divididos em dois grupos, controle (n=12) e experimento (n=12) e subdivididos em grupos de quatro. Nove semanas após a derivação jejunojejunal procedeu-se a ressecção segmentar do jejuno excluso, íleo terminal e cólon ascendente. Análise histológica focou na espessura da mucosa, altura dos vilos, profundidade das criptas e a imunoistoquímica na expressão do Ki-67 e p53. Resultados: Foram encontradas diferenças significativas entre os grupos experimento e controle em relação à espessura da mucosa no jejuno (p=0,011), no íleo (p<0,001) e no cólon (p=0,027). Também houve diferença significativa em relação à altura dos vilos no íleo (p<0,001) e profundidade das criptas no jejuno (p<0,001). Os resultados indicaram que existe diferença significativa entre os grupos em relação à expressão do Ki-67 no cólon (p<0,001). Não foram encontradas diferenças significativas entre os grupos em relação à expressão do Ki-67 no jejuno e no íleo. Na avaliação do P53, foi encontrada coloração nuclear negativa em todos os casos. Conclusão: O desvio realizado na derivação gastrojejunal em Y-de-Roux, predispõem efeitos proliferativos epiteliais, causando aumento da espessura da mucosa, altura dos vilos e profundidade das criptas do jejuno, íleo e cólon ascendente.

Current status and prospects of the jejunoileal bypass in bariatric surgery / 中华消化外科杂志

Bariatric surgery is an effective treatment for obesity and the related metabolic diseases. At present, although the jejunoileal bypass is widely used in various types of bariatric surgery, the effect of reconstructed anatomy after the jejunoileal bypass on normal physiological function of obese patients has not been clarified. This leaves some controversy about the recommended limb lengths in jejunoileal bypass. At the same time, there is no consensus on the optimal biliary limb length and alimentary limb length in the standard gastric bypass. Lack of accurate measurement of common limb length and total small bowel length inevitably results in unsatisfactory percentage of excess body weight loss caused by short limb length, or malabsorption and malnutrition caused by long limb length. The authors discussed the effects of different length of biliary limb, alimentary limb and common limb on weight loss, and introduced the preliminary application and prospects of the jejunoileal bypass including measurement of total small bowel length in bariatric surgery.

Current status and prospects of the jejunoileal bypass in bariatric surgery / 中华消化外科杂志

Bariatric surgery is an effective treatment for obesity and the related metabolic diseases.At present,although the jejunoileal bypass is widely used in various types of bariatric surgery,the effect of reconstructed anatomy after the jejunoileal bypass on normal physiological function of obese patients has not been clarified.This leaves some controversy about the recommended limb lengths in jejunoileal bypass.At the same time,there is no consensus on the optimal biliary limb length and alimentary limb length in the standard gastric bypass.Lack of accurate measurement of common limb length and total small bowel length inevitably results in unsatisfactory percentage of excess body weight loss caused by short limb length,or malabsorption and malnutrition caused by long limb length.The authors discussed the effects of different length of biliary limb,alimentary limb and common limb on weight loss,and introduced the preliminary application and prospects of the jejunoileal bypass including measurement of total small bowel length in bariatric surgery.

Mechanism research of sleeve gastrectomy combined with modified jejunoileal bypass in improving blood glucose levels in Goto-kakizaki rats / 中华内分泌外科杂志

Objective To investigate the mechanism of sleeve gastrectomy combined with modified jejunoileal bypass (SG/MJIB) in improving the blood glucose of Goto-kakizaki (GK) rats.Methods According to the random meter method,the 28 GK rats were divided into 4 groups:sleeve gastrectomy with modified jejunoileal bypass (SG/MJIB),sleeve gastrectomy (SG),modified jejunoileal bypass (MJIB) and sham operation (SHAM).The changes of weight,food intake,fasting blood glucose,oral glucose tolerance test (OGTT),insulin tolerance test (ITT),plasma insulin and gastrointestinal hormonal (ghrelin and GLP-1) were monitored before and 16 weeks after surgery respectively.Results After surgery,the fasting blood glucose level in SG/MJIB group was obviously lower than that in SG,MJIB and SHAM groups (P＜0.05).From the 2nd week after surgery,OGTT of the SG/MJIB group was obviously improved compared to SG,MJIB,and SHAM groups (P＜0.02).In our post-op erative study,the insulin levels in SG/MJIB group were lower than those in SG,and SHAM groups (P＜0.05).Compared to MJIB and SHAM groups,ghrelin levels of SG/MJIB group were significantly decreased (P＜0.001),while GLP-1 levels of SG/MJIB group were higher than those of SG and SHAM groups (P＜0.01).Conclusions SG/ MJIB can improve insulin sensitivity and insulin secretion,and this effect is independent of the body weight and food intake.This study further validates that the gastrointestinal hormones play an important role in the pathogenesis and treatment mechanisms of type 2 diabetes mellitus.

Duodenal jejunal bypass attenuates non-alcoholic fatty liver disease in western diet-obese rats

PURPOSE:To evaluate the effects of duodenal-jejunal bypass (DJB) on serum and hepatic profiles of obese rats fed on a western diet (WD).METHODS:Twenty eight male Wistar rats were fed a standard rodent chow diet (CTL group) or WD ad libitum. After 10 weeks, WD rats were submitted to sham (WD SHAM) or duodenal-jejunal bypass (WD DJB). Body weight, fat pad depots, glycemia, insulinemia, HOMA-IR, TyG, lipids profile and hepatic analyses were evaluated two months after surgery.RESULTS:The WD SHAM group presented greater obesity, hyperglycemia, hyperinsulinemia, insulin resistance, hypertriglyceridemia and hepatic steatosis than the CTL group. WD DJB rats presented decreased serum glucose and insulin resistance, when compared to WD SHAM animals, without changes in insulinemia. In addition, DJB surgery normalized serum TG and attenuated TG accumulation and steatosis in the liver of the WD DJB group. Hepatic ACC and FAS protein expressions were similar in all groups.CONCLUSION:Duodenal-jejunal bypass attenuates hepatic parameters of non-alcoholic fatty liver disease in obese rats fed on a western diet.

Duodenal jejunal bypass attenuates non-alcoholic fatty liver disease in western diet-obese rats

PURPOSE: To evaluate the effects of duodenal-jejunal bypass (DJB) on serum and hepatic profiles of obese rats fed on a western diet (WD). METHODS: Twenty eight male Wistar rats were fed a standard rodent chow diet (CTL group) or WD ad libitum. After 10 weeks, WD rats were submitted to sham (WD SHAM) or duodenal-jejunal bypass (WD DJB). Body weight, fat pad depots, glycemia, insulinemia, HOMA-IR, TyG, lipids profile and hepatic analyses were evaluated two months after surgery. RESULTS: The WD SHAM group presented greater obesity, hyperglycemia, hyperinsulinemia, insulin resistance, hypertriglyceridemia and hepatic steatosis than the CTL group. WD DJB rats presented decreased serum glucose and insulin resistance, when compared to WD SHAM animals, without changes in insulinemia. In addition, DJB surgery normalized serum TG and attenuated TG accumulation and steatosis in the liver of the WD DJB group. Hepatic ACC and FAS protein expressions were similar in all groups. CONCLUSION: Duodenal-jejunal bypass attenuates hepatic parameters of non-alcoholic fatty liver disease in obese rats fed on a western diet. .

The jejunoileal bypass provokes morphological changes in the large intestine? An experimental study in rats / A derivação jejuno-ileal provoca alterações morfológicas no intestino grosso? Estudo experimental em ratos

PURPOSE: To analyse histopathological alterations characterized by the mitotic index in the mucosa of the large intestine in Wistar rats submitted to jejunoileal bypass operation after continued administration of sodium nitrite and vitamin C to different groups. METHODS: Eighty male Wistar rats were employed and separated into 12 groups. In the control group (20 rats): five animals ingested only water; five animals received vitamin C; five animals received sodium nitrite and five received sodium nitrite + vitamin C. In the sham group (20 rats), the animals were anesthetized and underwent midline laparotomy and only intestinal manipulation was performed: five animals ingested only water; five animals received vitamin C; five animals received sodium nitrite and five received sodium nitrite + vitamin C. In the operated group 40 rats underwent a jejunoileal bypass surgery: ten animals ingested only water; ten animals received vitamin C; ten animals received sodium nitrite and ten received sodium nitrite + vitamin C. The mean weight of the animals was measured weekly. The large intestine was subdivided into cecum (S1), ascending colon (S2), transverse colon (S3), descending colon (S4) and rectum (S5) for histopathological analysis and mitotic counts. The statistical analysis was used to compare the mitotic indices. The level of significance was 5%. RESULTS: The mean of all the segments indicates that the sodium nitrite+vitamin C group obtained the lowest mitotic index compared to the other treatments in the control group. The segments S1 and S2 showed a statistical difference with the vitamin C treatment: a higher mitotic index and better preservation of the mucosa in the operated group. In the sham group the main statistical difference occurred only in the sodium nitrite+vitamin C group between the means of the segments. CONCLUSIONS: The comparison of all the colonic segments of the various groups revealed a lower mitotic index in the animals treated with sodium nitrite+vitamin C. In addition, it was found that vitamin C did not present a statistically significant inhibiting effect on the preservation of the mucosa and the mitotic index.

OBJETIVO: Analisar as alterações histopatológicas caracterizada pelo índice mitótico na mucosa do intestino grosso em ratos Wistar submetidos a operação de bypass jejunoileal após a administração continuada de nitrito de sódio e vitamina C para diferentes grupos. MÉTODOS: Oitenta ratos Wistar foram utilizados e separados em 12 grupos. No grupo controle (20 ratos): cinco animais ingeriram apenas água; cinco animais receberam vitamina C, cinco animais receberam nitrito de sódio e cinco receberam nitrito de sódio + vitamina C. No grupo sham (20 ratos), os animais foram anestesiados e submetidos a laparotomia mediana e só a manipulação intestinal foi realizada: cinco animais ingeriram apenas água; cinco animais receberam vitamina C, cinco animais receberam nitrito de sódio e cinco receberam nitrito de sódio + vitamina C. No grupo operado 40 ratos foram submetidos a uma cirurgia de bypass jejunoileal: dez animais ingeridos apenas água; dez animais receberam vitamina C, dez animais receberam nitrito de sódio e dez nitrito de sódio + vitamina C. O peso médio dos animais foi medido semanalmente. O intestino grosso foi subdividido em ceco (S1), cólon ascendente (S2), cólon transverso (S3), cólon descendente (S4) e reto (S5) para análise histopatológica e contagem das mitoses. A análise estatística foi utilizado para comparar os índices mitóticos. O nível de significância foi de 5%. RESULTADOS: A média de todos os segmentos indica que o grupo que ingeriu nitrito de sódio + vitamina C obteve o menor índice mitótico em relação aos demais tratamentos no grupo controle. Os segmentos S1 e S2 mostraram uma diferença estatística com a vitamina C de tratamento: um maior índice mitótico e melhor preservação da mucosa no grupo operado. No grupo sham a principal diferença estatística ocorreu apenas no grupo que ingeriu nitrito de sódio + vitamina C entre as médias dos segmentos. CONCLUSÕES: A comparação de todos os segmentos do colon dos vários grupos revelaram um menor índice de mitose nos animais tratados com nitrito de sódio + vitamina C. Além disso, a vitamina C não apresentou efeito inibidor, estatísticamente significativo, na preservação da mucosa e do índice de mitoses.

Acrodermatitis due to zinc deficiency after combined vertical gastroplasty with jejunoileal bypass: case report / Acrodermatite por deficiência de zinco após associação de gastroplastia vertical com derivação jejuno-ileal: relato de caso

CONTEXT: Nutritional complications may occur after bariatric surgery, due to restriction of food intake and impaired digestion or absorption of nutrients. CASE REPORT: After undergoing vertical gastroplasty and jejunoileal bypass, a female patient presented marked weight loss and protein deficiency. Seven months after the bariatric surgery, she presented dermatological features compatible with acrodermatitis enteropathica, as seen from the plasma zinc levels, which were below the reference values (34.4 mg%). The skin lesions improved significantly after 1,000 mg/day of zinc sulfate supplementation for one week. CONCLUSIONS: The patient's evolution shows that the multidisciplinary team involved in surgical treatment of obesity should take nutritional deficiencies into consideration in the differential diagnosis of skin diseases, in order to institute early treatment.

CONTEXTO: Complicações nutricionais podem ocorrer após cirurgia bariátrica, pela restrição no consumo de alimentos e por comprometimento do processo digestivo e absortivo. RELATO DO CASO: Após ter sido submetida a gastroplastia vertical e derivação jejuno-ileal, uma paciente apresentou acentuada perda de peso e desnutrição proteica. Sete meses após a cirurgia bariátrica, manifestou-se quadro dermatológico compatível com acrodermatite enteropática, verificado a partir dos níveis plasmáticos de zinco (34,4 mg%), que se situavam abaixo dos valores de referência. As lesões cutâneas melhoraram significativamente após 1.000 mg/dia de suplementação de sulfato de zinco, por uma semana. CONCLUSÕES: A evolução da paciente mostra que a equipe multiprofissional envolvida no tratamento cirúrgico da obesidade deve considerar as deficiências nutricionais no diagnóstico diferencial das doenças cutâneas, a fim de instituir precocemente o tratamento.

Creation and analysis of the model of sleeve gastrectomy with modified jejunoileal bypass / 中国医师杂志

Objective To construct and analyze the model of the sleeve gastrectomy with modified jejunoileal bypass (SG/MJIB) on non-obese Goto - kakizaki (GK) rats. Methods GK rats were randomly divided into SG/MJIB, sham-SG/MJIB, pair-fed (PF) and controls group. Before and after surgery, the changes of weight, food intake, fasting glucose, oral glucose tolerance test (OGTT), insulin tolerance test (ITT), fasting plasma Insulin and the histological changes in islet were dynamically observed for 16 weeks. Results From the 4th week postoperative, the weight changes of SG/MJIB significantly decreased compared with sham-SG/MJIB and PF group (P＜0.01). Fasting glucose concentration of SG/MJIB animals was lower than sham-SG/MJIB, PF and controls group (P＜0.05). The OGTT of SG/MJIB rats was obviously improved compared with the sham-SG/MJIB, PF and controls group （P＜0.01). Two weeks after operation, glucose tolerance was better improved in SG/MJIB than preoperative, the area under the curve (AUC) of blood glucose concentration decreased by about 38.9% (P＜0.01). Postoperative insulin levels in SG/MJIB group were obviously lower than sham-SG/MJIB group throughout the experiment(P＜0.05). In the 16th week, the morph of pancreatic islet of SG/MJIB was obviously improved. In the SG/MJIB group, the number of positive β-cell and mature acinus was significantly increased, while sham surgery groups had no obvious changes as mentioned above. Conclusions SG/MJIB was directly linked to the reduction in glucose levels in GK rats, independently weight loss and caloric intake, and it can be served asa stable long-lasting hypoglycemic surgery model to research the mechanism for the treatment of type 2 diabetes.

Migrating motor complex changes after side-to-side ileal bypass in mouse ileum ex-vivo: mechanism underlying the blind loop syndrome? / 대한외과학회지

PURPOSE: This study was intended to investigate the migrating motor complex (MMC) changes after ileal bypass in ex-vivo mouse models. METHODS: Partial (side-to-side) and total bypass (occlusion of proximal part of bypassed loop) were performed on ileums of female Institute of Cancer Research mice. After 2 and 4 weeks, the bypassed segments were harvested and MMCs were recorded at 4 different sites ex-vivo. Amplitude, duration, interval, direction of propagation, and the area under the curve (AUC) of MMCs were measured and compared to those of the controls. RESULTS: In control mice (n = 7), most MMCs propagated aborally (91.1%). After 2 weeks of partial bypass (n = 4), there was a significant decrease in both amplitude and AUC, and orally-propagating MMCs increased significantly (45%, P = 0.002). Bidirectional MMCs (originating in the bypassed loop and propagating in both directions) were also observed (10%). The amplitude of the MMCs remained decreased at 4 weeks after partial bypass (n = 4), and neither the AUC nor the direction of propagation showed significant changes compared to 2 weeks. Similarly, in the total bypass model, both the amplitude and AUC of the MMCs decreased significantly compared to controls. In contrast to partial bypass, 95% of the MMCs within the bypassed loop propagated aborally after 2 weeks (n = 6), which was similar to the control state. After 4 weeks (n = 5), however, MMCs either lost their temporal relationship or completely disappeared. CONCLUSION: The changes in propagation direction of the MMCs in the partially bypassed loop may contribute to stagnation of bowel contents and the development of blind loop syndrome.

Effects of Sleeve Gastrectomy Surgery with Modified Jejunoileal Bypass on Body Weight, Food Intake and Metabolic Hormone Levels of Rats / 华中科技大学学报（医学）（英德文版）

This study examined the effects of a combined surgery of sleeve gastrectomy (SG) and modified jejunoileal bypass (JIB) on the body weight,food intake,and the plasma levels of active glucagon-like peptide-1 (GLP-1) and total ghrelin of rats.Rats were divided into 3 groups in terms of different surgical protocol:SG-JIB (n=12),SG (n=12),JIB (n=12) and sham surgery groups (n=10).In SG-JIB group,rats was subjected to sleeve gastrectomy and end to side anastomosis of part of the jejunum (25 cm from the ligament of Treitz) to the ileum 25 cm proximal to the cecum.The body weight and food intake were evaluated during 10 consecutive weeks postoperatively.The levels of active GLP-1 and total ghrelin in the plasma of the rats were measured by ELISA assay.The results showed that the SG-JIB treated rats relative to SG- or JIB-treated ones produced a sustained reduction in food intake and weight gain.The level of active GLP-1 was elevated and total ghrelin level decreased in SG-JIB-treated rats as compared with SG- or JIB-treated ones.It was concluded that SG-JIB could efficiently reduce the body weight and food intake,alter obesity-related hormone levels of the rats,indicating that SG-JIB may be potentially used for the treatment of obesity.

Banda gástrica com desvio jejunoileal: nova opção técnica em cirurgia bariátrica / Gastric band with jejunoileal by-pass: new option in bariatric surgery

RACIONAL: Os procedimentos cirúrgicos para tratamento da obesidade morbida têm sido eficientes na resolução desta afecção a curto e longo prazo. Com exceção da banda gástrica ajustável todos estes procedimentos de alguma forma são capazes de induzir a liberação de hormônios intestinais em função do desvio intestinal e desta forma exercerem um efeito metabólico. OBJETIVO: Com a intenção de obter efeitos semelhantes às operações que promovem um desvio intestinal, com as vantagens de baixa morbidade e mortalidade da BGA, foi proposto novo procedimento técnico associando à banda gástrica ajustável a um desvio jejunoileal. MÉTODO: O procedimento cirúrgico totalmente conduzido por videolaparoscopia, consiste na aplicação inicial da banda gástrica e a seguir a realização de anastomose látero-lateral a 80 cm do ângulo duodenojejunal e 120 cm da válvula ileocecal. RESULTADOS: Foram operados 10 pacientes com esta técnica, seis mulheres e quatro homens com IMC médio de 40 kg/m2. A perda média de excesso de peso nos seis primeiros meses foi de 51,56

. Em quatro pacientes diabéticos houve normalização dos níveis glicêmicos e suspensão do uso da medicação antidiabética. CONCLUSÃO: Adição de desvio jejunoileal látero-lateral à banda gástrica pode melhorar a perda de peso em pacientes portadores de obesidade mórbida e contribuir para o controle da diabete tipo II.

BACKGROUND: Current procedures for surgical treatment of morbid obesity have proved to be efficient in controlling the process in the short and long follow-up. The bariatric surgical procedures, with the exception of the adjustable gastric banding are capable, in one way or another, of inducing hormonal release due to the intestinal by-pass that they may promote and therefore offering a metabolic effect. AIM: With the intention to maintain the same results promoted by gastrojejunal diversion, while maintaining the lower mortality rates of the adjustable gastric banding technique, it is proposed a new procedure combining adjustable gastric banding with jejunoileal diversion. METHOD: The surgical procedure, performed completely through videolaparoscopy, consisted of the initial application of the adjustable gastric banding and then a jejunoileal laterolateral by-pass, 80 cm from the duodenojejunal angle, with the distal ileum, at 120 cm from the ileocecal valve. RESULTS: Ten patients were operated on, six women and four men, with mean BMI of 40 kg/m2. The average percentage of excess weight loss after the first six months was 51.56

. In four diabetic type II patients there was a normalization of glicemic and HbA1c levels with suspension of insulin and/or antidiabetic medications. CONCLUSION: The addition of a laparoscopic jejunoileal laterolateral by-pass to the adjustable gastric banding may enhance the efficacy of weight-loss and diabetes type II control in the treatment of morbid obesity and its resulting co-morbidities.

Alcoholic Type Cirrhosis Following Side to Side Ileo-Transverse Colon Anastomosis

A case of micronodular cirrhosis of the alcoholic type developed following an intestianl bypass surgery in a 47 year-old nonalcoholic male patient is presented. The patient denied any drug use of a long duration and had no diabetes mellitus. Five years before, a side to side ileo-transverse colon anastomosis had been performed for perforated intestinal tuberculosis at 1 m proximal to the ileocecal valve, bypassing a short segment of ileum (about 1.5 m) and transverse colon. The ileum distal to the perforated site had been found completely stenosed. He was severely lean with evidences of nutritional deficiency such as low serum levels of the albumin and vitamin B12. The liver biopsy showed a fatty change, Mallory bodies and perihepatocellular collagenosis within the cirrhotic nodules. The present case suggests that, when there are blind loop formation and nutritional deficiency, hepatic changes identical to those following jejunoileal bypass could develop even by reduction of a shore segment of the small intestine.