SMALL INTESTINAL L CELL DENSITY IN PATIENTS WITH SEVERE OBESITY AFTER ROUX-EN-Y GASTRIC BYPASS.

BACKGROUND: Enteroendocrine L cells can be found in the entire gastrointestinal tract and their incretins act on glycemic control and metabolic homeostasis. Patients with severe obesity and type 2 diabetes mellitus may have lower density of L cells in the proximal intestine. AIMS: This study aimed to analyze the density of L cells in the segments of the small intestine in the late postoperative of Roux-en-Y gastric bypass in diabetic patients with standardization of 60 cm in both loops, alimentary and biliopancreatic. METHODS: Immunohistochemistry analysis assays were made from intestinal biopsies in three segments: gastrointestinal anastomosis (GIA= Point A), enteroenteral anastomosis (EEA= Point B= 60 cm distal to the GIA) and 60 cm distal to the enteroenteral anastomosis (Point C). RESULTS: A higher density of L cells immunostaining the glucagon-1 peptide was observed in the distal portion (Point C) when compared to the more proximal portions (Points A and B). CONCLUSIONS: The concentration of L cells is higher 60 cm distal to enteroenteral anastomosis when comparing to proximal segments and may explain the difference in intestinal lumen sensitization and enterohormonal response after Roux-en-Y gastric bypass.

Small intestinal l cell density in patients with severe obesity after roux-en-y gastric bypass / Avaliação da densidade das células l no intestino delgado em obesos graves após gastroplastia em y-de-roux

ABSTRACT BACKGROUND: Enteroendocrine L cells can be found in the entire gastrointestinal tract and their incretins act on glycemic control and metabolic homeostasis. Patients with severe obesity and type 2 diabetes mellitus may have lower density of L cells in the proximal intestine. AIMS: This study aimed to analyze the density of L cells in the segments of the small intestine in the late postoperative of Roux-en-Y gastric bypass in diabetic patients with standardization of 60 cm in both loops, alimentary and biliopancreatic. METHODS: Immunohistochemistry analysis assays were made from intestinal biopsies in three segments: gastrointestinal anastomosis (GIA= Point A), enteroenteral anastomosis (EEA= Point B= 60 cm distal to the GIA) and 60 cm distal to the enteroenteral anastomosis (Point C). RESULTS: A higher density of L cells immunostaining the glucagon-1 peptide was observed in the distal portion (Point C) when compared to the more proximal portions (Points A and B). CONCLUSIONS: The concentration of L cells is higher 60 cm distal to enteroenteral anastomosis when comparing to proximal segments and may explain the difference in intestinal lumen sensitization and enterohormonal response after Roux-en-Y gastric bypass.

RESUMO RACIONAL: As células L enteroendócrinas podem ser encontradas na extensão de todo trato gastrointestinal e suas incretinas atuam no controle glicêmico e da homeostase metabólica. Estudos mostram que pacientes obesos graves com diabetes mellitus tipo 2 apresentam má sinalização entero-hormonal e baixa resposta da secreção do peptídeo glucagon-1, que poderia ser explicado por uma densidade menor de células L ou uma distribuição mais distal ao longo do intestino delgado. OBJETIVOS: Analisar a diferença da densidade de células L nos segmentos do intestino delgado de pacientes obesos graves submetidos à gastroplastia em Y de Roux, em período pós-operatório tardio, com padronização de alça alimentar e biliopancreática com extensão de 60 cm em ambas. MÉTODOS: Ensaios de análises de imuno-histoquímica foram feitos a partir de biopsias intestinais obtidas em três segmentos: junto à anastomose gastrointestinal (AGI= Ponto A), junto à anastomose entero-enteral (AEE= Ponto B= 60 cm distal à AGI) e 60 cm distalmente à anastomose entero-enteral (Ponto C). Os resultados foram obtidos por meio de imunomarcação do peptídeo glucagon-1 secretado pelas células L. RESULTADOS: Foi observada maior densidade de células L na porção mais distal do intestino delgado (Ponto C) quando comparada às porções mais proximais (Ponto A e B). CONCLUSÕES: Em pacientes no pós-operatório de gastroplastia em Y de Roux, identificou-se concentração maior de células L já na porção a 60 cm distalmente a entero-entero anastomose quando comparada aos segmentos proximais, o que pode explicar diferenças na sensibilização no lúmen intestinal e na resposta entero-hormonal.

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

INTRODUCTION: Vertical gastrectomy and different bowel functions. The wide net of physiological issues involved in metabolic surgery is extremely complex. Nonetheless, compared anatomy and phisiology can provide good clues of how digestive tracts are shaped for more or less caloric food, for more or less fiber, for abundance and for scarcity. OBJECTIVE: To review data from Compared Anatomy and Physiology, and in the Evolutionary Sciences that could help in the better comprehension of the metabolic surgery. METHOD: A focused review of the literature selecting information from these three fields of knowledge in databases: Cochrane Library, Medline and SciELO, articles and book chapters in English and Portuguese, between 1955 and 2019, using the headings "GIP, GLP-1, PYY, type 2 diabetes, vertebrates digestive system, hominid evolution, obesity, bariatric surgery ". RESULTS: The digestive tract of superior animals shows highly specialized organs to digest and absorb specific diets. In spite of the wide variations of digestive systems, some general rules are observed. The proximal part of the digestive tract, facing the scarcity of sugars, is basically dedicated to generate sugar from different substrates (gluconeogenesis). Basic proximal gut tasks are to proportionally input free sugars, insulin, other fuels and to generate anabolic elements to the blood, some of them obesogenic. To limit the ingestion by satiety, by gastric emptying diminution and to limit the excessive elevation of major fuels (sugar and fat) in the blood are mostly the metabolict asks of the distal gut. A rapid and profound change in human diet composition added large amounts of high glycemic index foods. They seem to have caused an enhancement in the endocrine and metabolic activities of the proximal gut and a reduction in these activities of the distal gut. The most efficient models of metabolic surgery indeed make adjustments in this proximal/distal balance in the gut metabolic activities. CONCLUSION: Metabolic surgery works basically by making adjustments to the proximal and distal gut metabolic activities that resemble the action of natural selection in the development the digestive systems of superior animals.

Does evolutionary biology help the understanding of metabolic surgery? a focused review / A biologia evolutiva ajuda na compreensão da cirurgia metabólica? uma revisão com foco

ABSTRACT Introduction: The wide net of physiological issues involved in metabolic surgery is extremely complex. Nonetheless, compared anatomy and phisiology can provide good clues of how digestive tracts are shaped for more or less caloric food, for more or less fiber, for abundance and for scarcity. Objective: To review data from Compared Anatomy and Physiology, and in the Evolutionary Sciences that could help in the better comprehension of the metabolic surgery. Method: A focused review of the literature selecting information from these three fields of knowledge in databases: Cochrane Library, Medline and SciELO, articles and book chapters in English and Portuguese, between 1955 and 2019, using the headings "GIP, GLP-1, PYY, type 2 diabetes, vertebrates digestive system, hominid evolution, obesity, bariatric surgery ". Results: The digestive tract of superior animals shows highly specialized organs to digest and absorb specific diets. In spite of the wide variations of digestive systems, some general rules are observed. The proximal part of the digestive tract, facing the scarcity of sugars, is basically dedicated to generate sugar from different substrates (gluconeogenesis). Basic proximal gut tasks are to proportionally input free sugars, insulin, other fuels and to generate anabolic elements to the blood, some of them obesogenic. To limit the ingestion by satiety, by gastric emptying diminution and to limit the excessive elevation of major fuels (sugar and fat) in the blood are mostly the metabolict asks of the distal gut. A rapid and profound change in human diet composition added large amounts of high glycemic index foods. They seem to have caused an enhancement in the endocrine and metabolic activities of the proximal gut and a reduction in these activities of the distal gut. The most efficient models of metabolic surgery indeed make adjustments in this proximal/distal balance in the gut metabolic activities. Conclusion: Metabolic surgery works basically by making adjustments to the proximal and distal gut metabolic activities that resemble the action of natural selection in the development the digestive systems of superior animals.

RESUMO Introdução: A rede de questões fisiológicas envolvidas na cirurgia metabólica é muito complexa. No entanto, a anatomia e fisiologia comparadas podem fornecer boas pistas sobre como o trato digestivo é moldado para alimentos mais ou menos calóricos, para mais ou menos fibras, para abundância e escassez. Objetivo: Selecionar e analisar dados de Ciências Evolucionárias e Anatomia e Fisiologia Comparadas que ajudam na compreensão da cirurgia metabólica. Método: Revisão focada da literatura, selecionando informações desses três campos de conhecimento em bancos de dados da Cochrane Library, Medline e SciELO, artigos e capítulos de livros em inglês e português, entre 1950 e 2019, usando como descritores "GIP, GLP-1, PYY, type 2 diabetes, vertebrates digestive system, hominid evolution, obesity, bariatric surgery". Resultado: O trato digestivo de animais superiores mostra órgãos altamente especializados para digerir e absorver dietas específicas..A parte proximal, diante da escassez de açúcares, é basicamente dedicada à geração de açúcar a partir de diferentes substratos (gliconeogênese). As tarefas básicas do intestino proximal consistem em fornecer proporcionalmente açúcares livres, insulina e outros combustíveis e gerar elementos anabólicos no sangue, alguns deles obesogênicos. Limitar a ingestão pela saciedade, por diminuir o esvaziamento gástrico e limitar a elevação excessiva dos principais combustíveis (açúcar e gordura) no sangue são principalmente as tarefas metabólicas do intestino distal. Mudança rápida e profunda na composição da dieta humana causa elevação nas atividades endócrinas e metabólicas do intestino proximal e redução no intestino distal. Os modelos mais eficientes de cirurgia metabólica fazem ajustes nesse equilíbrio proximal-distal das atividades metabólicas intestinais. Conclusão: A cirurgia metabólica funciona basicamente fazendo ajustes nas atividades metabólicas do intestino proximal e distal que se assemelham à ação da seleção natural no desenvolvimento dos sistemas digestivos de animais superiores.

Treating Severe GERD and Obesity with a Sleeve Gastrectomy with Cardioplication and a Transit Bipartition.

INTRODUCTION: Epidemiological data have demonstrated that obesity is an important risk factor for the development of gastroesophageal reflux disease (GERD). The proportion of subjects with GERD symptoms can be as high as 50% for BMI > 30. Although still controversial in the literature, there are several studies associating sleeve gastrectomy (SG) with an increase in GERD prevalence. The current video shows the technique of a SG with cardioplication associated with transit bipartition (TB) for the treatment of an obese patient with severe GERD. CASE REPORT AND MANAGEMENT: A 46-year-old male presented with obesity and GERD symptoms for several years. His BMI was 37.8 kg/m2 with mainly central obesity and several obesity-related comorbidities, including hypertension, dyslipidemia, severe insulin resistance, and obstructive sleep apnea. After a diagnostic evaluation, the patient was submitted to a sleeve gastrectomy with a transit bipartition. He presented satisfactory weight loss, reaching a BMI of 26 and remission of all comorbidities and complete remission of GERD symptoms. The current follow-up period is 2.5 years and the patient did not present any weight regain or return of the GERD symptoms. CONCLUSION: We presented a surgical alternative that is effective in both weight loss and remission of GERD. SG + TB is a potent intervention for metabolic syndrome and obesity. Furthermore, this alternative is capable of treating both obesity and GERD, in a simple way, avoiding mechanical restriction and the significant malabsorption related to excluded segments.

Early glycemic control and incretin improvement after gastric bypass: the role of oral and gastrostomy route.

BACKGROUND: Patients with obesity have a suppressed incretin effect and a consequent imbalance of glycemic homeostasis. Several studies have shown improved type 2 diabetes after Roux-en-Y gastric bypass (RYGB). The mechanisms of early action are linked to caloric restriction, improvement of insulin resistance, pancreatic beta cell function, and the incretin effect of glycogen-like protein 1 and gastric inhibitory polypeptide, but reported data are conflicting. OBJECTIVE: The objective of this study was to evaluate glycemic metabolism, including the oral glucose tolerance test and enterohormonal profile in the early postoperative period in severely obese patients who underwent RYGB with gastrostomy, comparing the preoperative supply of a standard bolus of nutrient against the postoperative administration through an oral and a gastrostomy route. SETTING: Clinics Hospital of University of São Paulo, Brazil. METHODS: Eleven patients with obesity and diabetes underwent RYGB with a gastrostomy performed in the excluded gastric remnant. Patients were given preoperative assessments of glycemic and enterohormone profiles and an oral glucose tolerance test; these were compared with early postoperative assessments after oral and gastrostomy route administrations. RESULTS: The mean preoperative body mass index of the group was 44.1 ± 6.6 kg/m2, mean fasting blood glucose of 194.5 ± 62.4 mg/dL, and glycated hemoglobin 8.7 ± 1.6%. In 77.7% of the patients, there was normalization of the glycemic curve in the early postoperative period as evaluated by the oral glucose tolerance test. Significant decreases in glycemia, insulinemia, and homeostatic model assessment-insulin resistance were also observed, regardless of the route of administration. There was significant increase in glycogen-like protein 1 by the postoperative oral route and reduction of gastric inhibitory polypeptide in both routes. Ghrelin did not change. CONCLUSION: Glycemia and peripheral insulin resistance reductions were observed in early-postoperative RYGB, independent of the oral or gastrostomy route. Incretin improvement, mediated by glycogen-like protein 1 increased was observed only in the postoperative oral route, while GIP reduced for both routes.

Resting metabolic rate and weight loss after bariatric surgery.

BACKGROUND: There is an increased interest in understanding how variation in body composition (BC) and energy expenditure is related to successful weight loss after surgery. It has been suggested that low resting metabolic rate (RMR) could be associated with poor weight loss. OBJECTIVES: To determine the relation among changes in BC, RMR, and weight loss after bariatric surgery. SETTING: University tertiary care hospital, Brazil. METHODS: A cohort of 45 patients submitted to bariatric surgery was prospectively studied. BC was evaluated by bioelectrical impedance analysis and RMR by indirect calorimetry before and 6 months after surgery. The RMR value was adjusted per kilogram of weight (RMR/kg). The patients were divided in 4 groups, based on patterns of change in the RMR/kg after surgery. The RMR/kg could decrease (group 1), remain stable (group 2), have a small increase (group 3), or have a major increase (group 4). RESULTS: A significant relation between fat-free mass and RMR for both pre- (P<.01) and postoperative periods (P<.01) was observed. Excess weight loss had a significantly correlation only with post-RMR/kg (P<.01). The pattern of change in RMR/kg was strongly correlated with weight loss, considering an excess weight loss>50% a successful weight loss: No patients achieved success in group 1; 61% of patients did in group 2; 80% di in group 3; and all patients in group 4 had successful weight loss. CONCLUSIONS: We demonstrate a clearly correlation between the postoperative RMR and weight loss. The increase in RMR/kg after surgery is a major factor related to a satisfactory excess weight loss after surgery.