Laparoscopic Roux-en-Y gastric bypass in Type 2 diabetes mellitus patient with low body mass index and gastric stromal tumor: A case report. / 低体重指数2åž‹ç³–å°¿ç— å¹¶èƒƒé—´è´¨ç˜¤æ‚£è€ è ¹è ”é•œä¸‹è¡ŒRoux-en-Y胃旁路术1例.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been proved to be a safe and effective treatment for Type 2 diabetes mellitus (T2DM) patients with body mass index (BMI) >27.5 kg/m2 in China. The incidence of gastrointestinal stromal tumor (GIST) is very low, whereas the relevant studies on GIST and LRYGB are few. This is the first report of GIST associated with LRYGB in low BMI Chinese patient with T2DM.A male patient with GIST and T2DM, whose body weight and height were 67 kg and 175 cm, respectively,and the calculated BMI was 21.9 kg/m2. He was diagnosed by gastroscopy and enhanced CT scan. We used LRYGB to treat GIST and T2DM at the same time. After the operation, the GIST was removed successfully. Both the blood glucose levels and glycosylated hemoglobin were normal at 4 months and 1 year later. The patient received follow-up gastroscopy and abdominal CT scan and did not find out local recurrence and metastasis. LRYGB may be the best choice in treating GIST in T2DM with low BMI.

Surgery-associated acquired hemophilia A: a report of 2 cases and review of literature.

BACKGROUND: Acquired Hemophilia A (AHA) is a rare bleeding diathesis in patients with no previous personal or family bleeding history. The diagnosis of this disease often delays due to unfamiliarity of physicians with it, which leads to its high mortality rate. CASE PRESENTATION: Two cases (one 12 years old female and another 18 years old male) were admitted for right upper abdominal mass and right upper abdominal pain respectively at different times. Pre-operative diagnosis of both cases was congenital choledochal cyst. They suffered continuous gastrointestinal bleeding (hematemesis and melena) with reduced hemoglobin to 54 g/L and 60 g/L after Roux-en-Y anastomosis respectively. To investigate the exact bleeding site, Digital subtraction angiography (DSA) of case 1 showed contrast overflow at small branch of proper hepatic artery but had unremarkable result for case 2, whereas gastroscopy of both cases showed unremarkable results. Multiple surgeries were also performed for hemostatic purpose but each time no active bleeding site was found. Finally, hematologists consultation was mandated in both cases and they were diagnosed as acquired haemophilia A. However, unfortunately case 1 patient could not survive because of sever hemorrhage and infection while Case 2 of 18 years old male survived after proper haemophilia treatment catalog. CONCLUSION: Awareness about surgery associated acquired haemophilia A (SAHA) can facilitate quick diagnosis and lifesaving management because the mortality rate in SAHA is high due to lake of knowledge or late recognition of the disease. Bleeding always occurs at surgical sites and it can occur immediately within few hours after surgery in some cases. Hemorrhage may be severe or even life threatening and it presents a special challenge for diagnosis and treatment in a patient who has just undergone a surgical procedure. The treatment strategies for AHA include resumption of hemostasis with either recombinant porcine factor VIII (rpFVIII) or bypassing agents and immunosuppressive therapy to suppress the production of the factor VIII inhibitor.

GLP1R Single-Nucleotide Polymorphisms rs3765467 and rs10305492 Affect ß Cell Insulin Secretory Capacity and Apoptosis Through GLP-1.

The increased secretion of glucagon-like peptide-1 (GLP-1) after Roux-en-Y gastric bypass (RYGB) is regarded as the main reason for the improvement of blood glucose. However, the single-nucleotide polymorphisms (SNPs) of GLP-1 Receptor (GLP1R) impair receptor function, subsequently affecting ß cell insulin secretion function, ultimately affecting the efficacy of RYGB. In this study, we revealed that two SNPs in GLP1R gene, rs3765467 and rs10305492, could significantly reduce the insulin secreted by ß cells and the cyclic AMP concentration, whereas promote ß cell apoptosis. Under high glucose exposure, rs3765467 and rs10305492 impaired ß cell secretion of insulin and ß cell viability in the same way; in other words, GLP1R rs3765467 and rs10305492 exert an effect on pancreatic ß cell glucose-stimulated insulin secretion. Moreover, GLP-1 antagonist Exendin (9-39) further enhanced, whereas GLP-1 agonist Exendin-4 partially attenuated the effects of SNPs on the functions and apoptosis of ß cells. In conclusion, the rs3765467 and rs10305492 SNPs in GLP1R show to exert a critical effect on regulating insulin secretory capacity of ß cells and ß cell mass. Through leading to the dysfunction and apoptosis of ß cells, GLP1R rs3765467 and rs10305492 might also impair GLP-1 interaction with GLP1R, therefore attenuating the therapeutic effect of RYGB.

Farnesoid X receptor interacts with cAMP response element binding protein to modulate glucagon-like peptide-1 (7-36) amide secretion by intestinal L cell.

Type II diabetes is a complex, chronic, and progressive disease. Glucagon-like peptide-1 (7-36) amide (GLP-1) is a gut hormone released from the L cells which stimulate insulin secretion and promotes insulin gene expression and ß-cell growth and differentiation. Elevated levels of hormones secreted by L cells are an essential reason for diabetes improvement. GLP-1 secretion has been reported to be regulated by farnesoid X receptor (FXR), a transcriptional sensor for bile acids which also acts on glucose metabolism. Herein, we attempted to evaluate the effect of FXR on GLP-1 secretion in mouse enteroendocrine L cell line, namely STC-1, and to investigate the underlying mechanism. FXR inversely regulated GLP-1 secretion in STC-1. A total of 24 nonredundant human proteins were shown to be related to FXR by BioGRID; KEGG pathway analysis revealed that FXR was related to glucagon signaling pathway, particularly with the transcriptional activators CREB, PGC1α, Sirt1, and CBP. CREB could positively regulate GLP-1 secretion in STC-1 cells. FXR combined with CREB to inhibit its transcriptional activity, thus inhibiting proprotein convertase subtilisin/kexin type 1 protein level and GLP-1 secretion. In the present study, we demonstrated a negative regulation of GLP-1 secretion by FXR in L cell line, STC-1; FXR exerts its function in L cells through interacting with CREB, a crucial transcriptional regulator of cAMP-CREB signaling pathway, to inhibit its transcriptional activity. Targeting FXR to rescue GLP-1 secretion may be a promising strategy for type II diabetes.

Farnesoid X Receptor (FXR) Interacts with Camp Response Element Binding Protein (CREB) to Modulate Glucagon-Like Peptide-1 (7-36) Amide (GLP-1) Secretion by Intestinal L Cell.

BACKGROUND/AIMS: Type II diabetes is a complex, chronic, and progressive disease. Glucagon-like peptide-1 (7-6) amide (GLP-1) is a gut hormone released from the L cells which stimulates insulin secretion, and promotes insulin gene expression and ß-cell growth and differentiation. Elevated levels of hormone secreted by L cells are an important reason for diabetes improvement. GLP-1 secretion has been reported to be regulated by farnesoid X receptor (FXR), a transcriptional sensor for bile acids which also acts on glucose metabolism. Herein, we attempted to evaluate the effect of FXR on GLP-1 secretion in mouse enteroendocrine L cell lines, STC-1 and GLUTag, and to investigate the underlying mechanism. METHODS: ELISA and Western blot assays were employed to examine the levels of GLP-1 and FXR, and the effect of FXR on GLP-1 secretion; online database, including BioGRID and KEGG were used to identify the potential interactions between FXR and proteins and involved pathways; GST pull-down and Co-Immunoprecipitation (Co-IP) assays were performed to validate FXR-CREB interaction; Luciferase reporter gene assays were used for CREB transcriptional activity determination. RESULTS: FXR inversely regulated GLP-1 secretion in the mouse enteroendocrine L cell lines, GLUTag and STC-1. A total of 24 nonredundant human proteins were shown to be related to FXR by BioGRID; KEGG pathway analysis showed that FXR was related to glucagon signaling pathway, particularly with the transcriptional activators CREB, PGC1α, Sirt1 and CBP. CREB could positively regulate GLP-1 secretion in GLUTag and STC-1 cells. FXR combined with CREB to inhibit its transcriptional activity, thus inhibiting proprotein convertase subtilisin/ kexin type 1 (PCSK1) protein level and GLP-1 secretion. CONCLUSION: In the present study, we demonstrated a negative regulation of GLP-1 secretion by FXR in L cell lines, GLUTag and STC-1; FXR exerts its function in L cells through interacting with CREB, a crucial transcriptional regulator of cAMP-CREB signaling pathway, to inhibit its transcriptional activity. Targeting FXR to rescue GLP-1 secretion may be a promising strategy for type II diabetes.

Outcomes of laparoscopic gastrectomy for gastric cancer in elderly patients.

PURPOSE: This study aimed to compare the short- and longterm outcomes of elderly and middle-aged patients with gastric cancer who underwent laparoscopic gastrectomy. METHODS: From January 2010 to February 2017, a total of 75 patients with gastric cancer aged ≥70 years (elderly group) underwent laparoscopic gastrectomy, and their short- and long-term outcomes were compared with those of 197 patients with gastric cancer aged 60-69 years (middleaged group) who underwent also laparoscopic gastrectomy during the same period. RESULTS: With respect to the patients' preoperative baseline characteristics, the elderly group had a higher Charlson comorbidity index score, rate of previous abdominal operations, and American Society of Anesthesiologists (ASA) classification score compared to middle-aged patient group. There were no significant differences in the other baseline characteristics. There were no significant between-groups differences in the duration of surgery, intraoperative blood loss, incidence and severity of 30-day postoperative complications, and pathological results. Long-term follow-up results showed that the tumor recurrence rates were similar between groups, as were the overall (OS) and disease-free survival (DFS) rates. Multivariate analysis showed that age was not an independent predictor of OS and DFS. CONCLUSION: In summary, laparoscopic gastrectomy in elderly patients with gastric cancer can achieve similar short- and long-term outcomes as those for middle-aged patients. Age is thus not a contraindication for laparoscopic gastrectomy.

From genetics and epigenetics to the future of precision treatment for obesity.

Obesity has become a major global health problem, epitomized by excess accumulation of body fat resulting from an imbalance between energy intake and expenditure. The treatments for obesity range from modified nutrition and additional physical activity, to drugs or surgery. But the curative effect of each method seems to vary between individuals. With progress in the genetics and epigenetics of obesity, personalization of the clinical management of obesity may be at our doorstep. This review presents an overview of our current understanding of the genetics and epigenetics of obesity and how these findings influence responses to treatments. As bariatric surgery is the most effective long-term treatment for morbid obesity, we pay special attention to the association between genetic factors and clinical outcomes of bariatric surgery. Finally, we discuss the prospects for precision obesity treatment.

Using the hyperinsulinemic euglycemic clamp to assess insulin sensitivity at 3 months following Roux-en-Y gastric bypass surgery in type 2 diabetes patients with BMI <35 kg/m2 in China.

BACKGROUND: The aim of this study was to describe short-time effect of Roux-en-Y gastric bypass (RYGB) on insulin sensitivity (IS) of Chinese diabetes patients with body mass index (BMI) <35 kg/m2 by hyperinsulinemic euglycemic clamp. MATERIALS AND METHODS: We studied 15 type 2 diabete mellitus (T2DM) patients with BMI <35 kg/m2, who underwent laparoscopical Roux-en-Y gastric bypass (LRYGB). Hyperinsulinemic-euglycemic clamp were performed at baseline and at 3 months after LRYGB. RESULTS: The glucose disposal rate (M value) increased significantly at 3 months after RYGB (from 3.36 ± 1.26 mg kg-1 min-1 to 6.30 ± 1.3 mg kg-1 min-1, p < 0.001). The time to reach euglycemia at the hyperinsulinemic euglycemic clamp reduced remarkably from baseline to 3 months after RYGB (from 114.40 ± 6.11 min to 97.93 ± 8.57 min, p < 0.001). There was a marked reduction in value of HOMA-IR (from 4.47 ± 2.20 mg kg-1 min-1 to 2.10 ± 0.75 mg kg-1 min-1, p < 0.001). The parameters of body fat distribution (body weight, BMI, waist circumference, waist to hip radio) changed obviously after surgery. RYGB caused a significant improvement in fasting and postprandial plasma glucose and insulin, HbAc1. Preoperative M value and the time to reach steady-state correlated with changes of M and the time to reach steady-state at 3 months after RYGB. CONCLUSION: Peripheral and hepatic IS improved remarkably at 3 months following RYGB, as an important mechanism for early improvement in T2DM patients with low BMI. And the time to reach euglycemia at the hyperinsulinemic euglycemic clamp may be an useful index of assessing insulin sensitivity. It is more reasonal to combine the time to reach euglycemia with M value for assessing IS.

Can low BMI Chinese patients with type 2 diabetes benefit from laparoscopic Roux-en-Y gastric bypass surgery?

BACKGROUND: The efficacy of laparoscopic Roux-en-Y gastric bypass (LRYGB) in type 2 diabetes mellitus (T2D) is closely associated with the preoperative body mass index (BMI) of the patient. There is a lack of long-term and large sampling evidence on the efficacy of LRYGB in T2D patients with low BMI in China. OBJECTIVES: This retrospective study aimed to evaluate the efficacy of surgical treatment in a Chinese population with T2D (especially patients with BMI<27.5 kg/m2). SETTING: University-affiliated hospital, China METHODS: Seventy-eight patients with T2D were included in the study and evaluated before and after LRYGB surgery. No patients were lost to follow-up at any time points. RESULTS: Thirty-eight T2D patients with BMI≥27.5 kg/m2 in group 1 (high BMI group) had significant improvements in waist circumference, blood glucose levels, homeostasis model assessment-insulin resistance index, and C-peptide levels after LRYGB (P<.05). Forty T2D patients with BMI<27.5 kg/m2 in group 2 (low BMI group, including 19 T2D patients with BMI<25 kg/m2) had significant improvements in waist circumference and waist-to-hip ratio after LRYGB (P< .05). CONCLUSIONS: LRYGB surgery may be beneficial in T2D patients with BMI<27.5 kg/m2 in China.

Retraction Note: Effects of Bariatric Surgery on Incidence of Obesity-Related Cancers: A Meta-Analysis.

In the article entitled, "Effects of Bariatric Surgery on Incidence of Obesity-Related Cancers: A Meta-Analysis" which was published in Medical Science Monitor 2015;21: 1350-1357, sections in the text have been directly copied from a previously published article, entitled, "The Effects of Bariatric Surgery on Colorectal Cancer Risk: Systematic Review and Meta-Analysis", Sorena Afshar, Seamus B. Kelly, Keith Seymour, Jose Lara, Sean Woodcock, John C. Mathers  in Obesity Surgery 2014; 24(10):1793-1799. Thus owing to duplicity of text, the article is being retracted. Reference: 1. Xiang-wu Yang, Peng-zhou Li, Li-yong Zhu, Shaihong Zhu Effects of Bariatric Surgery on Incidence of Obesity-Related Cancers: A Meta-Analysis Medical Science Monitor 2015;21: 1350-1357 DOI: 10.12659/MSM.893553.

Enterotoxigenic Escherichia coli infection alters intestinal immunity in mice.

Enterotoxigenic Escherichia coli (ETEC) is a major cause of diarrhea in humans and piglets. However, research regarding alterations of intestinal immunity following ETEC infection remains limited and the results controversial. The present study investigated the effects of ETEC on the expression levels of pro­inflammatory cytokines and innate immune regulators from plasma cells, goblet cells and Paneth cells, and the activation of toll­like receptor 4-nuclear factor (NF)­κB and mitogen­activated protein kinase (MAPK) pathways using reverse transcription­quantitative polymerase chain reaction and western blot analysis, in a mouse model infected with a porcine isolated ETEC strain. ETEC infection significantly reduced the expression of pro­inflammatory cytokines in the mouse jejunum (P<0.05). Additionally, ETEC infection significantly affected the expression of immune regulators of plasma cells, goblet cells and Paneth cells in the mouse intestine (P<0.05). ETEC influenced the intestinal immunity via the NF­κB and MAPK signaling pathways. In conclusion, ETEC colonization affects intestinal immunity as observed in a mouse model. This study provides a greater understanding of the pathogenesis of ETEC infection in animals and humans.

Impact of intermittent portal clamping on the early recurrence of hepatocellular carcinoma after surgery.

PURPOSE: To evaluate the impact of intermittent portal clamping (IPC) during surgery on the early recurrence of hepatocellular carcinoma (HCC). METHODS: The subjects of this retrospective study were 266 patients who underwent curative liver resection for HCC. The patients were grouped as follows: an intermittent portal clamping (IPC) group, n = 78; a continuous portal clamping (CPC) group, n = 128; and a non-portal clamping (NPC) group, n = 60. RESULTS: The median recurrence-free interval within 2 years of follow-up was significantly shorter in the IPC group (14.2 ± 4.6 months) than in the CPC group (18.0 ± 4.8 months, P = 0.008) or the NPC group (19.04 ± 4.1 months, P = 0.023). Moreover, 2-year recurrence-free survival was much lower in the IPC group than in the CPC group (63.6 vs. 75.8 %, P = 0.025) or the NPC group (63.6 vs. 78.0 %, P = 0.030). However, the 2-year OS rate among the three groups was comparable (72.7 vs. 79.9 %; P = 0.101) and 83.1 %, (P = 0.125). According to univariable analysis, tumor size (>5 cm), tumor number (≥2), tumor grade (low/undifferentiated), TNM stage (III), vascular infiltration, blood transfusion, and IPC were significantly associated with the early postoperative recurrence of HCC. After multivariate analysis, significance of tumor grade (low/undifferentiated) and TNM stage (III) disappeared, whereas tumor size (>5 cm), tumor number (≥2), vascular infiltration, blood transfusion, and IPC remained significant. CONCLUSIONS: IPC is an independent risk factor for the early recurrence of HCC after surgery.

The role of foregut exclusion in the deterioration of glucose and lipid metabolism induced by a high-fat diet.

AIM: The small intestine may be involved in the improvement of glucose and lipid metabolism after bariatric surgery; however, the role of the foregut in metabolic changes remains unclear. This study used normal rats fed a high-fat diet (HFD) after bariatric surgery to determine the role of the foregut in glucose and lipid metabolism. METHODS: Duodenum-jejunum bypass (DJB), gastrojejunostomy (GJ) and sham-operations were performed on Sprague-Dawley (SD) rats. Oral glucose tolerance, insulin sensitivity, ß-cell function, lipid profile, glucose-stimulated glucose-dependent insulinotropic polypeptide (GIP) levels and glucagon-like peptide-1 (GLP-1) levels were measured. The rats were observed for 24 weeks post-surgery. RESULTS: Food intake and body weight were similar between the groups during the study period (P>0.05). The DJB group exhibited better glucose and lipid metabolism than the other groups (P<0.05). Compared with the GJ group, the DJB group demonstrated superior oral glucose tolerance, insulin sensitivity and lipid profiles (P<0.05); ß-cell function in the two groups was similar (P>0.05). The GIP levels were decreased in the DJB group and increased in the GJ group (P<0.05), and the GLP-1 levels were increased in the DJB and GJ groups (P>0.05). CONCLUSIONS: We found that foregut exclusion can prevent disordered glucose and lipid metabolism. Additionally, decreased GIP secretion was associated with improvements in glucose tolerance and insulin sensitivity, particularly related to lipid metabolism. Increased GLP-1 benefited ß-cell function; however, it could not reverse the disordered glucose and lipid metabolism induced by a HFD.

Effects of bariatric surgery on incidence of obesity-related cancers: a meta-analysis.

BACKGROUND: The aim of this meta-analysis was to investigate possible relationships between bariatric surgery and incidence of obesity-related cancers. Obesity is an established risk factor for obesity-related cancers but the effects of bariatric surgery on incidence of obesity-related cancers are uncertain. MATERIAL/METHODS: We searched 4 electronic databases to identify eligible studies: PubMed, Embase, Web of Science, and Google Scholar. Five observational studies were eligible and included in this meta-analysis. Random-effects or fixed-effects odds ratio (OR) and its corresponding 95% confidence interval (CI) were pooled. RESULTS: Meta-analysis of these 5 observational studies revealed that bariatric surgery was associated with a significantly (p=0.0004) reduced incidence of obesity-related cancers (OR=0.43, 95%CI, 0.27-0.69) when compared with control individuals. Pooled estimated data showed that bariatric surgery is associated with a 24% lower colorectal cancer (CRC) risk. No publication bias was detected by Egger's or Begg's tests. CONCLUSIONS: Although bariatric surgery may significantly reduce incidence of obesity-related cancers, considering the limitations of these included studies, these findings should be confirmed by further well-designed studies.

Effect of laparoscopic Roux-en-Y gastric bypass on body composition and insulin resistance in Chinese patients with type 2 diabetes mellitus.

BACKGROUND: This study aims to assess the effect of laparoscopic Roux-en-Y gastric bypass (LRYGB) on body composition, fat distribution, and insulin resistance (IR) in Chinese type 2 diabetes mellitus (T2DM) patients. METHODS: Eighteen patients with T2DM were studied before and 3 months post LRYGB. Fasting plasma glucose (FPG), fasting insulin (FINS), and triglyceride (TG) were measured. IR index was determined using the homeostasis model assessment of insulin resistance (HOMA-IR). Body composition and fat distribution were measured by dual-energy X-ray absorptiometry (DXA). Fat mass (FM), muscle mass (MM), bone mineral content (BMC), and percent fat mass (%FM) at the whole body and five body regions including the arms, legs, trunk, android, and gynoid were obtained from DXA scans. RESULTS: HOMA-IR decreased from 5.02 at baseline to 1.43 3 months post LRYGB (p < 0.05). There was significant decrease in total and regional body mass and body fat (all p < 0.05). A significant reduction was observed in %FM at every tested body region (all p < 0.05). There was more fat mass loss (31.03 %) in android region than any other tested body region. Preoperative android %FM was significantly correlated with IR (r = 0.49, p < 0.05). Changes in android FM showed significant correlations with changes in IR, FPG, FINS, and TG (r = 0.54, 0.64, 0.54, and 0.67, respectively; all p < 0.05). CONCLUSIONS: Body composition in Chinese T2DM patients is rebalanced after LRYGB. Reduction of central obesity can result in improvement of IR, and android fat distribution may be a good indicator of postoperative benefits for LRYGB.

Effect of laparoscopic Roux-en-Y gastroenterostomy with BMI<35 kg/m(2) in type 2 diabetes mellitus.

BACKGROUND: Roux-en-Y gastric bypass (RGB) has been endorsed by the "First World Congress on International Therapies for Type 2 diabetes" as a possible therapeutic option in patients with type 2 diabetes with a body mass index (BMI) of less than 35 kg/m(2). In the present study, we assessed the improvement in clinical indicators associated with laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients with non-obese type 2 diabetes mellitus (T2DM). METHODS: LRYGB was performed in 30 T2DM patients with a BMI <35 kg/m(2). The patients were followed up for 1 year. Pre- and postoperative changes in BMI, waist circumference, and biochemical indicators including fasting plasma glucose and glycosylated hemoglobin were recorded. RESULTS: Significant reduction in glycosylated hemoglobin from 8.02 ± 1.77 to 5.59 ± 1.02 % (p < 0.05) at 12 months was noted. Diabetes was completely resolved in nine cases, resulting in discontinuation of diabetes-related medication. No significant surgical complications occurred. CONCLUSIONS: LRYGB is beneficial for non-obese T2DM patients in China.