Duodenal-Jejunal Bypass Liner for the management of Type 2 Diabetes Mellitus and Obesity: A Multicenter Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to examine the clinical efficacy and safety of the duodenal-jejunal bypass liner (DJBL) while in situ for 12 months and for 12 months after explantation. SUMMARY BACKGROUND DATA: This is the largest randomized controlled trial (RCT) of the DJBL, a medical device used for the treatment of people with type 2 diabetes mellitus (T2DM) and obesity. Endoscopic interventions have been developed as potential alternatives to those not eligible or fearful of the risks of metabolic surgery. METHODS: In this multicenter open-label RCT, 170 adults with inadequately controlled T2DM and obesity were randomized to intensive medical care with or without the DJBL. Primary outcome was the percentage of participants achieving a glycated hemoglobin reduction of ≥20% at 12 months. Secondary outcomes included weight loss and cardiometabolic risk factors at 12 and 24 months. RESULTS: There were no significant differences in the percentage of patients achieving the primary outcome between both groups at 12 months [DJBL 54.6% (n = 30) vs control 55.2% (n = 32); odds ratio (OR) 0.93, 95% confidence interval (CI): 0.44-2.0; P = 0.85]. Twenty-four percent (n = 16) patients achieved ≥15% weight loss in the DJBL group compared to 4% (n = 2) in the controls at 12 months (OR 8.3, 95% CI: 1.8-39; P = .007). The DJBL group experienced superior reductions in systolic blood pressure, serum cholesterol, and alanine transaminase at 12 months. There were more adverse events in the DJBL group. CONCLUSIONS: The addition of the DJBL to intensive medical care was associated with superior weight loss, improvements in cardiometabolic risk factors, and fatty liver disease markers, but not glycemia, only while the device was in situ. The benefits of the devices need to be balanced against the higher rate of adverse events when making clinical decisions. TRIAL REGISTRATION: ISRCTN30845205. isrctn.org; Efficacy and Mechanism Evaluation Programme, a Medical Research Council and National Institute for Health Research (NIHR) partnership reference 12/10/04.

Management of Malignant Small Bowel Obstruction: Is Intestinal Bypass Effective Palliation?

BACKGROUND/PURPOSE: Malignant small bowel obstruction (mSBO) is a common consequence of advanced malignancies. Surgical consultation is common, however data on the outcomes following an operation are lacking. We investigated a specific operative approach-intestinal bypass-to determine the outcomes associated with this intervention. METHODS: Patients with a preoperative diagnosis of mSBO who underwent intestinal bypass between 2015 and 2021 were included. Isolated colonic obstruction was excluded as was gastric outlet obstruction. Perioperative and postoperative outcomes were measured, including complications, overall survival, return to oral intake, and return to intended oncologic therapy. Patients were additionally grouped as to whether the operation was performed as elective or as inpatient. RESULTS: Overall, 55 patients were identified, with a mean age of 61.2 ± 14 years. The most common primary malignancy was colorectal cancer (65.5%) and 80% of patients had a preoperative diagnosis of metastatic disease. Small bowel to colon was the most common bypass procedure (51%). Severe complications occurred in 25.5% of patients with three in-hospital mortalities (5.5%). Survival rates at 30, 90, and 180 days were 91%, 80%, and 62%, respectively. The majority of patients were discharged to home (85.5%) and were tolerating an oral diet (74.6%). Twenty-seven patients (49.1%) returned to some form of oncologic treatment. CONCLUSIONS: Patients with mSBO face a potentially terminal condition. In this study, approximately 75% of patients who underwent intestinal bypass were able to regain the ability to eat, and 49% returned to oncologic therapy. Although retrospective, these data suggest the approach is efficacious for palliation of this difficult sequela of advanced cancer.

[Clinical analysis of 9 cases of a novel stent assisted intestinal bypass for preventing anastomotic leakage in laparoscopic assisted radical resection of rectal cancer].

Objective: To examine the safety and effectiveness of a novel stent assisted intestinal bypass for preventing anastomotic leakage in laparoscopic assisted radical resection of rectal cancer. Methods: The clinical data of 9 patients with rectal cancer who underwent laparoscopic radical resection and stent assisted intestinal bypass from September 2019 to June 2020 at the Department of Anus & Intestine Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University were retrospectively analyzed. There were 6 males and 3 females, aged (62.1±6.8) years (range: 53 to 75 years), underwent laparoscopic assisted radical resection of rectal cancer and stent assisted intestinal bypass. A degradable diverting stent was placed at the end of the ileum, and a drainage tube was placed at the proximal end of the stent to bypass the intestinal contents. After operation, the patients were given a diet with less residue. From the 14th day after operation, abdomen X-ray films were taken every 5 to 7 days to observe the destination of the stent dynamically. When the stent was observed to be disintegrated into pieces, the drainage tube was clamped for 3 days to observe any side effects before the tube was removed. The operation time, the time of removing the bypass tube and the total hospital stay were recorded. Results: Laparoscopic assisted radical resection of rectal cancer and stent assisted intestinal bypass were successfully performed in all patients. The operation time was (230.4±48.0) minutes (range: 150 to 318 minutes), and the time of removing shunt tube was (28.8±4.6) days (range: 22 to 34 days). The duration of hospitalization was (21.0±8.6) days (range: 9 to 34 days). Postoperative pathological examination showed 7 cases of moderately differentiated adenocarcinoma, 1 case of moderately well differentiated adenocarcinoma and 1 case of mucinous adenocarcinoma. There were 2 cases of T1, 4 cases of T2 and 3 cases of T3. The number of lymph node dissection was 13.4±3.5 (range: 6 to 18), 3 cases were positive and 6 cases were negative. The post-operation follow-up time was 6 to 16 months, no anastomotic leakage or stenosis was found. Conclusion: Stent assisted intestinal bypass for the prevention of anastomotic leakage in laparoscopic assisted radical resection of rectal cancer is safe and feasible, and shows good short-term effect.

Additional effects of duodenojejunal bypass on glucose metabolism in a rat model of sleeve gastrectomy.

PURPOSE: Sleeve gastrectomy with duodenojejunal bypass (SG-DJB) is expected to become a popular procedure in East Asia. The aim of this study was to evaluate the effects of duodenojejunal bypass on glucose metabolism in a rat model of sleeve gastrectomy (SG). METHODS: Twenty-four Sprague-Dawley rats were divided into two groups: SG-DJB and SG alone. 6 weeks after surgery, body weight, feed intake, and metabolic parameters were measured, and oral glucose tolerance tests (OGTT) were performed. The mRNA expression of factors related to gluconeogenesis and glucose transport was evaluated using jejunal samples. Protein expression of factors with significantly different mRNA expression levels was evaluated using immunohistochemistry. RESULTS: Body weight and metabolic parameters did not significantly differ between the two groups. During the OGTT, the SG-DJB group showed an early increase in serum insulin followed by an early decrease in blood glucose compared with the SG group. Expression levels of glucose transporter 1 (GLUT1) and sodium-glucose cotransporter 1 (SGLT1) mRNA and protein in the alimentary limb (AL) were greater in the SG-DJB group than in the SG group. CONCLUSIONS: The additional effects of duodenojejunal bypass on glucose metabolism after SG may be related to increased expression of GLUT1 and SGLT1 in the AL.

Resolution of late-onset heart and liver failures after reversion of jejuno-ileal bypass: a case report.

OBJECTIVES: Jejuno-ileal bypass (JIB) was a kind of bariatric surgery performed from 1960s to 1980s, able to induce sustainable weight loss by creating a surgical short bowel syndrome. MATERIALS AND METHODS: We report a case of an octogenarian woman who underwent in the early eighties this kind of surgery with consequent 40 kg weight loss. After 27 years, she first developed a reversible metabolic cardiomyopathy that began with signs and symptoms of heart failure. Thereafter, she was diagnosed with severe intractable liver insufficiency. RESULTS: Despite her old age, the patient underwent reversal of JIB with consequent early improvement of hepatic function. CONCLUSIONS: This case demonstrate that in case of long-term and life-threatening complications, it is possible to successfully reverse JIB surgery after upto 30 years. The hypothesis on pathophysiology of heart and liver insufficiency are discussed.

Ten years of follow-up of bilio-intestinal bypass: is malabsorption necessary for long-term metabolic results?

BACKGROUND: Bilio-intestinal bypass (BIBP) is an uncommon bariatric procedure. In 1999, a prospective trial was started at our institution to evaluate the effectiveness of BIBP. Trial was interrupted in 2006 due to high rate of complications. The aim of the present paper was to retrospectively review 10-year outcomes of BIBP. METHODS: Retrospective review of bariatric database was performed to find patients that had undergone BIBP from 1999 to 2006. Data collected were as follows: age, gender, body weight, body mass index (BMI), percentage of excess weight loss (%EWL), remission from weight-related diseases, complications, and deaths at 1,3, 5, 7, and 10 years. Quality of life was evaluated using "BAROS" questionnaire. RESULTS: From May 1999 to September 2006, 86 patients underwent BIBP. The mean age was 34.9 ± 22.4 years, and the initial weight and BMI were 141.2 ± 40.4 kg and 49.8 ± 15.5 kg/m2, respectively. After 10 years, the mean %EWL and BMI were 72.6 ± 18.7 and 31.2 ± 5.6 kg/m2. Almost all patients had diarrhea after surgery. Bloating syndrome occurred in 24% of patients, 48% had nephrolithiasis, and 20.9% had cholelithiasis. Remission from diabetes and hypertension was obtained in 75% and 80% of patients. Mortality was 3.2% and reoperation rate was 14.5%. CONCLUSIONS: Malabsorption plays a determinant role to obtain a long-lasting treatment for obese patients. However, BIBP is not recommendable due to high rate of complications and metabolic disorders.

Effect of the EndoBarrier Gastrointestinal Liner on obesity and type 2 diabetes: a systematic review and meta-analysis.

Compared with bariatric surgery, less invasive and reversible techniques to counteract obesity and type 2 diabetes (T2D) have been developed, including the EndoBarrier Gastrointestinal Liner [duodenal-jejunal bypass sleeve (DJBS)]. We conducted a systematic review and meta-analyses of eligible trials to evaluate the efficacy and safety of the DJBS. Five randomized controlled trials (RCTs; 235 subjects) and 10 observational studies (211 subjects) were included. The risk of bias was evaluated as high in all studies. The mean body mass index ranged from 30 to 49.2 kg/m(2) and 10-100% of the subjects had T2D. Meta-analysis showed that the DJBS was associated with significant mean differences in body weight and excess weight loss of -5.1 kg [95% confidence interval (CI) -7.3, -3.0; four trials; n = 151; I(2) = 37%] and 12.6% (95% CI 9.0, 16.2; four trials; n = 166; I(2) = 24%), respectively, compared with diet modification. The mean differences in glycated haemoglobin (-0.9%; 95% CI -1.8, 0.0) and fasting plasma glucose (-3.7 mM; 95% CI -8.2, 0.8) among subjects with T2D did not reach statistical significance. Adverse events consisted mainly of abdominal pain, nausea and vomiting. No deaths occurred. Future high-quality long-term RCTs are needed to further assess efficacy and safety.

Minimally invasive entero-enteral dual-path bypass using self-assembling magnets.

BACKGROUND: A minimally invasive method of entero-enteral bypass may be desirable for treatment of obstruction, obesity, or metabolic syndrome. We have developed a technology based on miniature self-assembling magnets which create large-caliber anastomoses (incisionless anastomosis system or IAS). The aim of this study was to assess (a) procedural characteristics of IAS deployment and (b) long-term integrity and patency of the resulting jejuno-ileal dual-path bypass. METHODS: Endoscopic jejuno-ileal bypass creation using IAS magnets was performed in 8 Yorkshire pigs survived 3 months. PROCEDURE: The jejunal magnet was endoscopically deployed. However, the ileal magnet required surgical delivery given restraints of porcine anatomy. A 5-mm enterotomy was created through which the ileal magnet was inserted using a modified laparoscopic delivery tool. Magnets were manually coupled. Pigs underwent serial endoscopies for anastomosis assessment. Three-month necropsies were performed, followed by pressure testing of anastomoses and histological analysis. RESULTS: Jejuno-ileal bypass creation using self-assembling IAS magnets was successful in all 8 pigs (100 %). Patent, leak-free bypasses formed in all animals by day 10. All IAS magnets were expelled by day 12. Anastomoses were widely patent at 3 months, with mean maximal diameter of 30 mm. At necropsy, adhesions were minimal. Pressure testing confirmed superior integrity of anastomotic tissue. Histology showed full epithelialization across the anastomosis with no evidence of submucosal fibrosis or inflammation. CONCLUSIONS: Entero-enteral bypass using self-assembling IAS magnets is safe and technically feasible in the porcine model. IAS magnets can be rapidly delivered endoscopically or through a modified laparoscopic device. Expulsion of fused magnets avoids retention of prosthetic material. Anastomoses are widely patent and fully re-epithelialized. Three-month pressure testing reveals anastomotic tissue to be as robust as native tissue, while necropsy and histology suggests minimal/absent tissue inflammation. In human anatomy, a fully endoscopic jejuno-ileal bypass using IAS magnets may be feasible.

[Three Cases of Unresectable, Advanced, and Recurrent Colorectal Cancer Associated with Gastrointestinal Obstruction That Were Treated with Small Intestine-Transverse Colon Bypass Surgery].

Herein, we report 3cases of unresectable, advanced, and recurrent colorectal cancer associated with gastrointestinal obstruction. The patients were treated with small intestine-transverse colon bypass surgery, which improved the quality of life (QOL)in all cases. Case 1 was an 80-year-old woman who presented with subileus due to ascending colon cancer. After surgery, her oral intake was reestablished, and she was discharged home. Case 2 was an 89-year-old woman whose ileus was caused by cecal cancer with multiple hepatic metastases. After surgery, the patient was discharged to a care facility. Case 3 was an 83-year-old man whose ileus was caused by a local recurrence and small intestine infiltration after surgery for rectosigmoid cancer. He underwent surgery after a colonic stent was inserted. His oral intake was re-established and he was discharged home. Small bowel-transverse colon bypass surgery can be used to manage various conditions rostral to the transverse colon. It is still possible to perform investigations in patients whose general condition is poorer than that of patients who undergo resection of the primary lesion. This avoids creating an artificial anus and allows continuation of oral intake, which are useful for improving QOL in terminal cases.

[The results of treatment of gastric cancer in the Provincial Hospital in Zielona Góra]. / Wyniki leczenia raka zoladka w Szpitalu Wojewódzkim w Zielonej Górze.

INTRODUCTION: Gastric cancer is the third leading cause of death from cancer worldwide in both sexes, following lung and breast cancer. The incidence of gastric cancer in Poland is approximately 5% in men and approximately 2.5% in women, among the complete incidence of cancers. Deaths from gastric cancer in men in Poland in 2009 amounted to 6.6%, while in women--4.6%. The highest mortality rate in men is observed in the Lubuskie, Podkarpackie, Slaskie and Opolskie provinces. European average 5-year survival in the EUROCARE-4 study is 24.5%. AIM: The aim of this paper was to assess the treatment of gastric cancer in the Department of General and Oncological Surgery of the Provincial Hospital in Zielona Góra. MATERIALS AND METHODS: The retrospective analysis of 109 patients with gastric cancer, operated in the years 2003-2007, was performed. The analysis included patients scheduled for admission with the histopathological confirmation of adenocarcinoma, prepared to and subjected to laparotomy. The post-operative intrahospital deaths were estimated up to 30 days after surgery. The analysis of the survival rates was performed up to 1, 6, 12, 36 and 60 months since lapatoromy. All the continuous variables with the standard distribution were expressed as the mean ± standard deviation, while the total survival rates were assessed by means of the Kaplan-Meier method. RESULTS: 55 patients (50.5%) underwent the radical surgical procedure intended to cure them. The remaining 54 patients (49.5%) could not be qualified for the radical surgical procedures. In 35 cases (32%) underwent laparotomy with biopsy, in 19 cases (17%) palliative surgery (intestinal bypass, gastrostomy, palliative resection). Out of 55 patients underwent the radical surgical procedure 9 patients died after the procedure (16.4%). The survival rates calculated for all the patients revealed that 21.1% patients survived 5 years after the surgery. CONCLUSIONS: Almost a half of the patients (49.5%) who were admitted for treatment had an advanced stage of the disease that could not be qualified for the radical surgical procedures. The distant results of surgical treatment are non-satisfactory due to the fact that the disease was so advanced. 5-year-long survival rates (21.1% in our data) are higher that the ones listed in the EUROCARE-4 test for Poland (14.4%), but lower than the European average (24.5%).

The feasibility of delivering a duodenal-jejunal bypass liner (EndoBarrier) endoscopically with patients under conscious sedation.

BACKGROUND: The endoscopically placed duodenal-jejunal bypass liner (DJBL) or EndoBarrier gastrointestinal liner has been designed for the treatment of type 2 diabetes mellitus and simultaneous achievement of weight loss by obese patients. This study was performed to determine the safety, efficacy, and feasibility of delivering the DJBL with the patient under conscious sedation (CS). The primary end points of the study were safety and complications. The secondary end points were delivery time (min), amount of propofol (mg) used, and the total hospital stay (h). METHODS: This prospective study compared placement of the DJBL with the patient under propofol sedation and placement with the patient under general anesthesia (GA). The study included 56 patients, with 28 patients in each group. RESULTS: Both groups were comparable in terms of age, gender, and body mass index. All the devices were placed successfully, and no complications occurred in either group. Comparison of the CS group with the GA group respectively showed a mean total operation time of 29 versus 56 min, a mean propofol use of 170 versus 258 mg, and a mean hospital stay of 11 versus 22 h. CONCLUSION: Delivery of the DJBL to patients under CS is feasible, safe, and efficient in terms of time and cost. Because of possible complications during the procedure, the authors recommend placement of the DJBL with the patient under CS in proximity to the operating room.

[Comparative results of surgical treatment of patients with morbid obesity].

It was performed a comparative analysis of treatment of 62 patients who were operated for morbid obesity. Patients were divided into 3 groups depending on kind of surgery: jejunal-iliac intestinal bypass, restrictive operations and combined operations. The complications in early postoperative period were diagnosed in 16.6% of patients after jejunal-iliac intestinal bypass and in 10% of patients after combined operations. Regardless of the kind of surgery there was rapid reduction of the body mass in the first year of observation with gradual increase of weight by an average of 5% in the subsequent period. The highest rate of weight loss by the second year was revealed after combined operations (up to 73.4%). Thus it was 1.1 times more than after jejunal-iliac intestinal bypass and 1.3 times more than after restrictive operations.

Proximal Jejuno-Ileal Bypass as Revision of Roux-en-Y Gastric Bypass.

INTRODUCTION: Bariatric surgery is established as a possibility for the treatment of obesity, allowing weight reduction and remission of obesity comorbidities. Reported suboptimal clinical response rates are as high as 30-60% (insufficient weight loss or gain, defined as BMI greater than 35 kg/m2 or excess weight loss less than 50%). Proximal jejuno-ileal bypass (PJIBP) is a promising option when re-intervention is required. OBJECTIVES: To describe the standardization of a proprietary technique of modified PJIBP as a management procedure in patients with post-gastric bypass recurrent weight gain or insufficient post-intervention weight loss. METHODS: This study evaluated a case series of 10 Latin American patients requiring post-bariatric re-intervention, between February 2018 and 2023, in a single-metabolic surgery center in Cali-Colombia. RESULTS: Median age was 45 years (26-70 RIC), 60% female, and 40% male. Mean BMI at conversion was 36.7 kg/m2 (6.4 SD). Median follow-up was 22 months (RIC 16-30). Mean percentage of excess weight lost was 78% (22.4 SD). One hundred percent achieved glycemia control, only one patient persisted with dyslipidemia, and no patient presented hypoalbuminemia. At the end of follow-up, 100% received vitamin supplementation. CONCLUSION: PJIBP could be an effective procedure, associated with positive results in relation to weight loss and resolution of obesity comorbidities. Deficiencies of fat-soluble vitamins and protein malnutrition represent the main concern in the long term, so multidisciplinary management and continuous follow-up are required.

Usefulness and description of the intestinal bypass technique in children with short bowel syndrome: report of a Mexican cohort.

BACKGROUND: Short bowel syndrome (SBS) is one of the most frequent causes of intestinal failure, needing parenteral nutrition to maintain an energy-protein and water-electrolyte balance. At the Hospital Infantil de México Federico Gómez (HIMFG), the formation of two stomas is a technique used for intestinal rehabilitation, where the use of residue through the bypass technique (BT) helps to maintain gastrointestinal functionality, water-electrolyte, and nutritional stability. This study aimed to describe the technique of using intestinal residue through BT as a treatment strategy in intestinal rehabilitation and its effect on the biochemical and nutritional status of pediatric patients with SBS. METHODS: An analytical and retrospective cross-sectional study was performed in patients hospitalized at HIMFG with SBS who underwent BT during their hospital stay between 2019 and 2020 and then followed up for 8 weeks. RESULTS: A total of 10 patients were included in this study, with a mean age of 24 months; 50% were female. BT was able to reduce the inflammatory process in the liver caused by the continuous use of parenteral nutrition; enteral caloric intake increased from 25.32 kcal/kg/day to 72.94 kcal/kg/day, but it was insufficient to improve their nutritional status. CONCLUSIONS: BT is a safe and effective alternative in intestinal rehabilitation in patients with SBS to stimulate trophism and intestinal functionality, allowing a progression of enteral feeding and a decrease in the hepatic inflammatory process that occurs in these patients with prolonged parenteral nutrition.

INTRODUCCIÓN: El síndrome de intestino corto (SIC) es una de las causas más frecuentes de insuficiencia intestinal que requiere del uso de nutrición parenteral para mantener un balance energético-proteico e hidroelectrolítico. En el Hospital Infantil de México Federico Gómez (HIMFG) la formación de dos estomas es una técnica empleada para la rehabilitación intestinal, donde con el aprovechamiento de residuo mediante la técnica de puenteo (TP) se ayuda a mantener la funcionalidad gastrointestinal, equilibrio hidro-electrolítico y estabilidad nutricional. El objetivo de este estudio fue describir la técnica del aprovechamiento de residuo intestinal mediante TP como estrategia de tratamiento en la rehabilitación intestinal y su efecto en el estado bioquímico y nutricional de pacientes pediátricos con SIC. MÉTODOS: Se llevó a cabo un estudio transversal analítico y retrospectivo en pacientes hospitalizados en el HIMFG con SIC en quienes se realizó la TP durante su estancia intrahospitalaria entre 2019 y 2020. RESULTADOS: Se incluyeron 10 pacientes en este estudio, con una edad promedio de 24 meses, y el 50% de sexo femenino. La TP logró disminuir el proceso inflamatorio hepático ocasionado por el uso continuo de nutrición parenteral; la ingesta calórica por vía enteral incrementó de 25.32 kcal/kg/día a 72.94 kcal/kg/día, pero fue insuficiente para mejorar el estado nutricional. CONCLUSIONES: La TP es una alternativa segura y efectiva en la rehabilitación intestinal en pacientes con SIC para estimular el trofismo y funcionalidad intestinal, permitiendo una progresión de la alimentación enteral y disminución del proceso inflamatorio hepático que se presentan en estos pacientes con nutrición parenteral prolongada.

Efficacy and Safety of Sleeve Gastrectomy with Jejunoileal Bypass Compared with Roux-en-Y Gastric Bypass: Results from a Cohort Study.

Background: We previously described sleeve gastrectomy with jejunoileal bypass (SGJIB) as promising novel technique for the surgical treatment of obesity Methods: A retrospective analysis of a prospective database in a Private Practice of Alimentary Tract Surgery in São Paulo, Brazil. We analyzed 176 patients with 60 months of follow-up, 74 of whom underwent Vertical Sleeve Gastrectomy with Jejunoileal Bypass (VSG-JIB) (50 women and 24 men) with a mean age of 38 years and a mean body mass index (BMI) of 40 kg/m2, and 102 patients underwent Roux-en-Y gastric bypass (RYGB) (90 women and 12 men) with a mean age of 36.5 years and a mean BMI of 39.73 kg/m2. Results: There was no statistically significant difference in long-term weight loss between the two groups. The rate of postoperative complications immediately after surgery was similar, but there was a tendency toward less severe complications in the SGJIB cohort. Conclusion: Sleeve gastrectomy with jejunoileal bypass is a novel surgical procedure for weight loss with comparable efficacy and safety compared with laparoscopic RYGB.

Clinical application of a novel stent-assisted in situ intestinal bypass in preventing postoperative anastomotic leakage for low-mid rectal cancer: A retrospective study.

This study aimed to investigate the safety and feasibility of a novel stent-assisted in situ intestinal bypass for low-mid rectal cancer patients. Patients who were diagnosed with rectal cancer and received laparoscopic low anterior rectal resection plus a novel stent-assisted in situ intestinal bypass were respectively included from March 2022 to June 2022. Biofragmentable intestinal stent with a protective sleeve was placed in the proximal colon before anastomosis, and feces could be discharged through the protective sleeve without touching the anastomosis, which achieved an in situ bypass of feces. Perioperative characteristics and short-term outcomes were collected. Rectal imaging was performed each week after surgery for the first 3 weeks to surveil the stent and feces delivery. Follow-ups were conducted for more than 3 months. Thirty patients who successfully received surgery were included in this study. There were 18 (60.0%) males and 12 (40.0%) females. As for perioperative characteristics, operation time was 213.8 ± 43.0 minutes, blood loss was 53.3 ± 24.6 mL, time to first flatus via protective sleeve after surgery was 3.2 ± 1.1 days, postoperative hospital stay was 11.8 ± 1.6 days, and time to discharge stent was 22.4 ± 3.2 days. As for short-term outcomes, 6 patients suffered from pneumonia, urinary tract infection or incision infection. During the follow-up, there was no anastomotic leakage or mortality. This novel stent-assisted in situ intestinal bypass is safe and feasible, it might be an applicable way to prevent postoperative anastomotic leakage for patients with low-mid rectal cancer.

[Current evidence on loop length in intestinal bypass procedures]. / Aktuelle Evidenz zur Schlingenlänge bei intestinalen Bypassverfahren.

BACKGROUND: Intestinal bypass procedures are well recognized for their long-term weight reduction and control of metabolic comorbidities. The selection of the length of the small bowel loop has a significant influence on the positive and also negative effects of the chosen procedure but national and international standardization are missing. OBJECTIVE: The aim of this article is to give an overview of the current evidence on the various intestinal bypass procedures and the influence of the chosen small bowel loop length on the desired and adverse postoperative outcomes. The IFSO 2019 consensus recommendations on the standardization of bariatric surgery and metabolic procedures form the basis of these considerations. MATERIAL AND METHODS: The current literature was searched for comparative studies addressing the question of different small bowel loop lengths in a Roux-en­Y gastric bypass, one anastomosis gastric bypass, single anastomosis duodenoileal bypass with sleeve gastrectomy and biliopancreatic diversion (with duodenal switch). RESULTS: Due to the heterogeneity of currently available studies and interindividual differences in total small bowel lengths in humans, it is difficult to give definitive recommendations for the choice of small bowel loop lengths. The longer the biliopancreatic loop (BPL) or the shorter the common channel (CC), the higher is the risk of (severe) malnutrition. To prevent malnutrition, the BPL should not be longer than 200 cm and the CC should have a length of at least 200 cm. CONCLUSION: The intestinal bypass procedures recommended in the German S3 guidelines are safe and show good long-term outcomes. As part of the postbariatric follow-up, the nutritional status of patients following an intestinal bypass has to be followed-up on the long term in order to avoid malnutrition preferably prior to a clinical manifestation.

[Cholecystolithiasis and intestinal bypass procedures]. / Cholezystolithiasis und intestinale Bypassverfahren.

With the increasing number of surgical interventions for obesity, the numbers of associated complications, such as gallstones after bariatric surgery are also increasing. The incidence of postbariatric symptomatic cholecystolithiasis is 5-10%; however, the numbers of severe complications due to gallstones and the probability of a necessary extraction of gallstones are low. For this reason, a simultaneous or preoperative cholecystectomy should only be carried out in symptomatic patients. Treatment with ursodeoxycholic acid reduced the risk of gallstone formation in randomized trials but not the risk of complications related to gallstones in cases of pre-existing gallstones. The most frequently used access route to bile ducts after intestinal bypass procedures is the laparoscopic approach via the stomach remnants. Other possible access routes are the enteroscopic approach as well as the endosonography-guided puncture of the stomach remnants.

Enhanced glucose homeostasis via Clostridium symbiosum-mediated glucagon-like peptide 1 inhibition of hepatic gluconeogenesis in mid-intestinal bypass surgery.

BACKGROUND: The small intestine is known to play a crucial role in the development and remission of diabetes mellitus (DM). However, the exact mechanism by which mid-small intestinal bypass improves glucose metabolism in diabetic rats is not fully understood. AIM: To elucidate the mechanisms by which mid-small intestinal bypass improves glucose metabolism. METHODS: Streptozotocin (STZ) was used to induce DM in Sprague-Dawley (SD) rats at a dose of 60 mg/kg. The rats were then randomly divided into two groups: The mid-small intestine bypass (MSIB) group and the sham group (underwent switch laparotomy). Following a 6-wk recovery period post-surgery, the rats underwent various assessments, including metabolic parameter testing, analysis of liver glycogen levels, measurement of key gluconeogenic enzyme activity, characterization of the gut microbiota composition, evaluation of hormone levels, determination of bile acid concentrations, and assessment of the expression of the intestinal receptors Takeda G protein-coupled receptor 5 and farnesoid X receptor. RESULTS: The MSIB group of rats demonstrated improved glucose metabolism and lipid metabolism, along with increased hepatic glycogen content. Furthermore, there was a decrease in the expression of the key gluconeogenic enzymes phosphoenolpyruvate carboxykinase 1 and glucose-6-phosphatase. Importantly, the MSIB group exhibited a substantial increase in the abundances of intestinal Lactobacillus, Clostridium symbiosum, Ruminococcus gnavus, and Bilophila. Moreover, higher levels of secondary bile acids, such as intestinal lithocholic acid, were observed in this group. Remarkably, the changes in the gut microbiota showed a significant correlation with the expression of key gluconeogenic enzymes and glucagon-like peptide 1 (GLP-1) at 6 wk postoperatively, highlighting their potential role in glucose regulation. These findings highlight the beneficial effects of mid-small intestine bypass on glucose metabolism and the associated modulation of the gut microbiota. CONCLUSION: The findings of this study demonstrate that the introduction of postoperative intestinal Clostridium symbiosum in the mid-small intestine contributes to the enhancement of glucose metabolism in nonobese diabetic rats. This improvement is attributed to the increased inhibition of hepatic gluconeogenesis mediated by GLP-1, resulting in a favorable modulation of glucose homeostasis.

Bariatric surgery and bone disease: from clinical perspective to molecular insights.

The use of bariatric surgery for the treatment of morbid obesity has increased annually for the last decade. Although many studies have demonstrated the efficacy and durability of bariatric surgery for weight loss, there are limited data regarding long-term side effects of these procedures. Recently, there has been an increased focus on the impact of bariatric surgery on bone metabolism. Bariatric surgery utilizes one or more of three mechanisms of action resulting in sustained weight loss. These include restriction (gastric banding, vertical banded gastroplasty and sleeve gastrectomy), malabsorption surgery with or without associated restriction (Roux en Y gastric bypass, duodenal switch, biliopancreatic diversion and jejunoileal bypass) and changes in gut-derived hormones that control energy metabolism also referred to as neuro-hormonal control of energy metabolism (Roux en Y gastric bypass, duodenal switch, biliopancreatic diversion, jejunoileal bypass, surgical procedures as above and gastric sleeve). Weight reduction has been associated with increased bone resorption but the mechanisms behind this have not yet been fully elucidated. Each of the mechanisms of action of bariatric surgery (restriction, malabsorption, neuro-hormonal control of energy metabolism) may uniquely affect bone resorption. In this paper we will review the current state of knowledge regarding the relationship between bariatric surgery and bone metabolism with emphasis on possible mechanisms of action such as malnutrition, hormonal interactions and mechanical unloading of the skeleton. Further, we suggest a future research agenda.