Effect of different limb lengths on quality of life, eating patterns and gastrointestinal symptoms after Roux-en-Y gastric bypass in superobese patients: randomized study.

BACKGROUND: Distal Roux-en-Y gastrojejunal bypass (DRYGJB) gives better weight reduction than standard Roux-en-Y gastric bypass (RYGB) but at the risk of increased malnutrition side-effects. This study compared the effects of RYGB and DRYGJB on gastrointestinal symptoms, eating patterns and health-related quality of life (QoL). METHODS: This was a single-blind RCT from a university-affiliated obesity centre. Patients with a BMI of 50 kg/m2 or above were invited to participate. Treatment arms were standard gastric bypass with an alimentary limb of 150 cm and a biliopancreatic limb of 60 cm, with a variable common channel length, or DRYGJB with biliopancreatic limb of 200 cm, common channel limb of 150 cm and variable alimentary limb length. Baseline and follow-up data to 5 years on quality of life, obesity-related problems and gastrointestinal symptoms were collected using prospectively created and validated questionnaires. RESULTS: Some 140 patients were included. Those with a DRYGJB had better weight loss at 5 years (mean(s.d.) 68·3(21·8) kg versus 55·7(19·8) kg for standard RYGB; P = 0·011). Eating patterns improved, with no difference between the groups. Gastrointestinal symptoms (diarrhoea, indigestion) worsened significantly in both groups, but only patients with DRYGJB had significantly worse diarrhoea at the end of the study than at baseline (P = 0·006). Both groups had improved perceived generic QoL over baseline, and obesity-related problems were markedly reduced. CONCLUSION: Standard RYGB and both improved generic and disease-specific QoL and eating behavioural pattern. Diarrhoea was increased more following DRYGJB than after RYGB. Registration number: NCT01514799 (https://clinicaltrials.gov).

ANTECEDENTES: El bypass gastroyeyunal distal (distal gastrojejunal bypass, DRYGB) proporciona una mejor pérdida de peso que el RYGB estándar, pero con el riesgo de aumentar los efectos secundarios de malnutrición. El presente estudio comparó los efectos de RYGB y DRYGJB en los síntomas gastrointestinales, patrón alimentario y calidad de vida relacionada con la salud. MÉTODOS: Estudio aleatorizado simple-ciego y controlado efectuado en un centro de obesidad con afiliación universitaria. Se invitó a participar a pacientes con un IMC de ≥ 50 kg/m2 . Las ramas del tratamiento fueron el bypass gástrico estándar con asa alimentaria (alimentary lim, AL) de 150 cm y asa biliopancreática (biliopancreatic, BP) de 60 cm, con asa común (common cannel, CC) de longitud variable, o DRYGJB con asa BP de 200 cm, asa CC de 150 cm y AL variable. Se recogieron datos basales y de seguimiento a los 5 años respecto a la calidad de vida, problemas relacionados con la obesidad y síntomas gastrointestinales utilizando cuestionarios prospectivos creados y validados. RESULTADOS: Se incluyeron un total de 140 pacientes. Los pacientes con DRYGJB tuvieron una mayor pérdida de peso a los 5 años (media (DE) 68,3 kg (21,9) versus 55,7 (19,8); P = 0,011)). Los patrones alimentarios mejoraron sin diferencia entre grupos. Los síntomas gastrointestinales (diarrea, indigestión) empeoraron significativamente en ambos grupos, pero solo los pacientes con DRYGJB presentaron diarrea al final del estudio significativamente peor en comparación con la situación basal (P = 0,006). Ambos grupos presentaron una mejor percepción de la QoL genérica en comparación con el estado basal, y los problemas relacionados con la obesidad se redujeron considerablemente. CONCLUSIÓN: El bypass gástrico estándar (RYGB) y el bypass gastroyeyunal distal (DRYGJB) mejoraron la QoL, tanto genérica como la específica de la enfermedad, así como el patrón de comportamiento alimentario. El DRYGJB aumentó la diarrea más que el RYGJB.

Ghrelin suppresses insulin secretion in human islets and type 2 diabetes patients have diminished islet ghrelin cell number and lower plasma ghrelin levels.

It is not known how ghrelin affects insulin secretion in human islets from patients with type 2 diabetes (T2D) or whether islet ghrelin expression or circulating ghrelin levels are altered in T2D. Here we sought out to identify the effect of ghrelin on insulin secretion in human islets and the impact of T2D on circulating ghrelin levels and on islet ghrelin cells. The effect of ghrelin on insulin secretion was assessed in human T2D and non-T2D islets. Ghrelin expression was assessed with RNA-sequencing (n = 191) and immunohistochemistry (n = 21). Plasma ghrelin was measured with ELISA in 40 T2D and 40 non-T2D subjects. Ghrelin exerted a glucose-dependent insulin-suppressing effect in islets from both T2D and non-T2D donors. Compared with non-T2D donors, T2D donors had reduced ghrelin mRNA expression and 75% less islet ghrelin cells, and ghrelin mRNA expression correlated negatively with HbA1c. T2D subjects had 25% lower fasting plasma ghrelin levels than matched controls. Thus, ghrelin has direct insulin-suppressing effects in human islets and T2D patients have lower fasting ghrelin levels, likely as a result of reduced number of islet ghrelin cells. These findings support inhibition of ghrelin signaling as a potential therapeutic avenue for stimulation of insulin secretion in T2D patients.

Management of suspected anastomotic leak after bariatric laparoscopic Roux-en-y gastric bypass.

BACKGROUND: Anastomotic leak is one of the most serious complications following bariatric laparoscopic Roux-en-Y gastric bypass (LRYGB), and associated with high morbidity rates and prolonged hospital stay. Timely management is of utmost importance for the clinical outcome. This study evaluated the approach to suspected leakage in a high-volume bariatric surgery unit. METHODS: All consecutive patients who underwent LRYGB performed by the same team of surgeons were registered prospectively in a clinical database from September 2005 to June 2012. Suspected leaks were identified based on either clinical suspicion and/or associated laboratory values, or by a complication severity grade of at least II using the Clavien-Dindo score. RESULTS: A total of 6030 patients underwent LRYGB during the study period. The leakage rate was 1·1 per cent (64 patients). Forty-five leaks (70 per cent) were treated surgically and 19 (30 per cent) conservatively. Eight (13 per cent) of 64 patients needed intensive care and the mortality rate was 3 per cent (2 of 64). Early leaks (developing in 5 days or fewer after LRYGB) were treated by suture of the defect in 20 of 22 patients and/or operative drainage in 13. Late leaks (after 5 days) were managed with operative drainage in 19 of 23 patients and insertion of a gastrostomy tube in 15. Patients who underwent surgical treatment early after the symptoms of leakage developed had a shorter hospital stay than those who had symptoms for more than 24 h before reoperation (12·5 versus 24·4 days respectively; P < 0·001). CONCLUSION: Clinical suspicion of an anastomotic leak should prompt an aggressive surgical approach without undue delay. Early operative treatment was associated with shorter hospital stay. Delays in treatment, including patient delay, after symptom development were associated with adverse outcomes.