Role of proximal gut exclusion from food on glucose homeostasis in patients with Type 2 diabetes.

AIMS: To report Type 2 diabetes-related outcomes after the implantation of a duodenal-jejunal bypass liner device and to investigate the role of proximal gut exclusion from food in glucose homeostasis using the model of this device. METHODS: Sixteen patients with Type 2 diabetes and BMI <36 kg/m(2) were evaluated before and 1, 12 and 52 weeks after duodenal-jejunal bypass liner implantation and 26 weeks after explantation. Mixed-meal tolerance tests were conducted over a period of 120 min and glucose, insulin and C-peptide levels were measured. The Matsuda index and the homeostatic model of assessment of insulin resistance were used for the estimation of insulin sensitivity and insulin resistance. The insulin secretion rate was calculated using deconvolution of C-peptide levels. RESULTS: Body weight decreased by 1.3 kg after 1 week and by 2.4 kg after 52 weeks (P < 0.001). One year after duodenal-jejunal bypass liner implantation, the mean (sem) HbA(1c) level decreased from 71.3 (2.4) mmol/mol (8.6[0.2]%) to 58.1 (4.4) mmol/mol (7.5 [0.4]%) and mean (sem) fasting glucose levels decreased from 203.3 (13.5) mg/dl to 155.1 (13.1) mg/dl (both P < 0.001). Insulin sensitivity improved by >50% as early as 1 week after implantation as measured by the Matsuda index and the homeostatic model of assessment of insulin resistance (P < 0.001), but there was a trend towards deterioration in all the above-mentioned variables 26 weeks after explantation. Fasting insulin levels, insulin area under the curve, fasting C-peptide, C-peptide area under the curve, fasting insulin and total insulin secretion rates did not change during the duodenal-jejunal bypass liner implantation period or after explantation. CONCLUSIONS: The duodenal-jejunal bypass liner improves glycaemia in overweight and obese patients with Type 2 diabetes by rapidly improving insulin sensitivity. A reduction in hepatic glucose output is the most likely explanation for this improvement.

Prevention of neoplastic port site implants in laparoscopy: an experimental study.

Enthusiasm about the application of videolaparoscopy to oncologic diseases has been limited by the growing number of port site implants. Adult Wistar rats were submitted to 6-7 mm Hg carbonic gas pneumoperitoneum. Rats were randomly divided into two groups: group I rats with tumor (200,000 viable cells of Walker tumor) and group 11 rats with no tumor. The pneumoperitoneum was deflated after 30 min. Group I was further randomized into five groups: no treatment; or abdominal irrigation with saline, heparin, chemotherapy (doxorubicin), or chemotherapy associated with heparin. After a period lasting no more than 18 days, the abdominal wall and intraperitoneal organs macroscopically affected were studied histologically. Chemotherapy groups had no port site implants and were significantly different (p < 0.05) than the no treatment, saline, and heparin solution groups, which had incisional implants at frequencies of 100%, 85.7%, and 82.5%, respectively. Intraperitoneal irrigation with chemotherapy solution was effective in preventing incisional implants in this animal model.

Transabdominal or totally extraperitoneal laparoscopic hernia repair?

Laparoscopic repair of inguinal hernias follows some principles that have already proven its efficiency, as a posterior approach and the prosthetic repair that allows a "tension-free" repair with consequent early return to work and low recurrence rate. To determine the most appropriate laparoscopic repair, we compared the transabdominal preperitoneal (TAPP) and the totally extraperitoneal (TEP) approach. Patients undergoing TAPP and TEP were compared regarding technical feasibility and difficulties, time until return to work and follow-up, including intraoperative and postoperative complications. Seventy-eight patients (108 hernias) were submitted to TAPP and 67 (100 hernias) were repaired through TEP. All data were analyzed by Yates-corrected chi-square test to qualitative analysis of each group and p < or = 0.05 was considered significant. Both procedures were indicated mainly for bilateral and/or recurrent hernias (68%). The operative time was shorter in TAPP (not statistically significant). Surgeons complained of more technical difficulties while performing the TEP approach (70% complaints of difficulty in TEP--four conversions to TAPP). There was no difference in hospital stay (mean of 30 h) and return to work (TAPP 7 days and TEP 5.5 days). Regarding the complication rate (TAPP = 20.5% and TEP = 13.5%; not significant), none were related to the pneumoperitoneum technique or its systemic effects. In the TAPP approach, two trocar site hernias occurred, and in the TEP approach, one severe cellulitis occurred, which was managed without surgical intervention. The mean follow-up period for each procedure was not the same, so the recurrence rates are not comparable statistically (rate of 1.85% in TAPP and 0 in TEP). Both techniques are safe and have the same advantages, but TAPP is easier: a better view of the anatomy is achieved, shortening the learning curve. We suggest that TAPP can be an adequate laparoscopic approach to groin hernias. A longer follow-up period and more cases are needed to determine recurrence rates.