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النشرة البريدية


 البريد الالكتروني


اشتراك
إلغاء الاشتراك


gastric bypass


الرئيسية   |   تكميم المعدة (السليف)   |   28 September 2012 م
Laparoscopic Sleeve Gastrectomy with Ileal Interposition: Outcomes
Laparoscopic Sleeve Gastrectomy with Ileal Interposition: Outcomes

2
Augusto Tinoco  MD, PhD
Introduction
Standard bariatric surgical procedures employed in the treatment of morbid obesity are considered a safe and effective treatment for Type 2 diabetes mellitus (T2DM), even in individuals with a BMI ≤ 35kg/m2. In a recent review, Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion/duodenal switch (BPD-DS) were reported to induce remission of T2DM in 83.7% and 98.9% of cases, respectively. This is in contrast to gastric banding which produced positive effects on T2DM in only 47.9% of cases1.
Since glycemic control can be observed prior to significant weight loss, it has been suggested that T2DM could be regulated by mechanisms involving a group of gastrointestinal hormones known as the incretins, which include gastric inhibitory polypeptide (GIP), peptide YY (PYY) and glucagon-like peptide-1 (GLP-1). These hormones, in conjunction with the central nervous system, influence glucose metabolism by increasing insulin secretion, suppressing post-prandial glucagon secretion and reducing gastric emptying. This results in diminution of food intake, promotion of pancreatic β-cell hypertrophy, differentiation of pancreatic duct cells into insulin-secreting β-cells, reduction of peripheral insulin resistance and suppression of pancreatic beta cell apoptosis.
The incretin effect, mediated by GIP and GLP-1, accounts for 50% to 70% of the insulin response that is essential for glucose homeostasis.2 Serum concentrations of GIP are near normal in T2DM patients, but tend to decrease as the disease progresses. In contrast, GLP-1 concentrations are low in T2DM patients but, if levels can be restored, the capacity of β-cells to secrete insulin can be re-established even in advanced stages of the disease.
Surgical procedures that facilitate early contact between the nutrients and the ileum stimulate the premature release of incretins and have been shown to promote efficient control of T2DM.3,4 Laparoscopic ileal interposition (II) is one such technique that involves introducing a segment of terminal ileum into the proximal jejunum and thus allows the premature exposure of nutrients to the interposed ileum. This results in stimulation of GLP-1 and PYY without disrupting intestinal transit and absorption.5 The raised level of these anorectic peptides and the delay in gastric emptying causes a reduction in hunger and induces prolonged satiety.6,7 Furthermore, a study involving experimental animals has demonstrated that application of the II procedure does not result in problems relating to malnutrition and nutrient absorption.5,8
The identificationof ghrelin, an orexigenic hormone (appetite stimulant), signaled the importance of mechanisms involved in the decision to eat. It was shown in patients undergoing RYGB that ghrelin levels did not rise before meals.9 However, ghrelin stimulates the secretion of counter-regulatory hypergylcaemic hormones such as glucagon, catecholamines, cortisol and growth hormone. Ghrelin also suppresses the secretion of the insulin-sensitizing hormone, adiponectin, by fat cells and, consequently, blocks insulin signaling in the liver and inhibits insulin secretion. In contrast to RYGB, sleeve gastrectomy (SG) foregoes intestinal re-routing but involves removal of the fundus, thus eliminating the diabetic effects of ghrelin.
Following this hybrid procedure (sleeve gastrectomy and ileal interposition), the presence of the terminal ileum near to the gastric outlet stimulates the premature production of incretin hormones, whereas gastric resection should reduce ghrelin levels and accelerate stomach emptying. The initial results obtained using this strategy have been very encouraging.7,10,11
Aim of Study
The aim of the present study was to evaluate the short and medium-term effects of laparoscopic SG/II in T2DM patients. The variables investigated were the feasibility of the procedure, remission/improvement of the disease, weight loss, morbidity and mortality.
Surgical intervention
A 32F Fouchet catheter was introduced into the stomach and devascularization of the greater curvature, inside the gastroepiploic arcade, with ultrasonic scissors, was done. The sleeve gastrectomy was performed with a linear stapler (green cartridge) beginning at the antrum–body transition, about 5–10 cm from the pylorus, according to the patient’s BMI. In patients with BMI30 kg/m2, the starting point was 5 cm from the pylorus. Completion of the gastric resection with a linear stapler (blue load up to the Angle of His was performed. A 3/0 prolene running suture was used to oversew the sleeve staple line. For the II, the ligament of Treitz was identified, and the jejunum was divided 30 cm distally. Then, the cecum was identified, and the distal ileum transected 30 cm proximal to the ileocecal valve. A 170 cm segment of ileum was measured proximally and transected (Figure 1).
الوصف: http://1.1.1.2/bmi/www.ibcclub.org/wp-content/uploads/2012/08/img_1.jpg
Figure 1: Schematic Diagram demonstrating the ileal segment (red) that will be interposed with the proximal jejunum
This segment of ileum was interposed in an isoperistaltic way into the proximal jejunum, previously divided. Next, we performed three side-to-side entero-anastomosis. The first one was the ileo-ileostomy, then the jejuno-ileostomy, and finally, the ileo-jejunostomy (Figure 2). All three mesenteric defects were closed with interrupted sutures.
الوصف: http://1.1.1.3/bmi/www.ibcclub.org/wp-content/uploads/2012/08/img_2.jpg
Figure 2: Schematic Diagram demonstrating the final re-construction of the ileal interposition
Results
The study population (n = 30) comprised 10 women (33.3%) and 20 men (66.7%) with an average age of 49.7 ± 8.9 years (median 49 years, range 33–68 years).The average BMI of the population was 30.8 ± 5.1 kg/m2 (median 31.1 kg/m2; range 19.9–40.1 kg/m2), and mean time from T2DM diagnosis was 9.9 ± 4.4 years (range 4–20 years).
The average duration of the surgical procedure was 181 ± 53 min, while the mean duration of post-operative hospital stay was 3.2 ± 0.8 days. There were no intra-operative complications and none of the patients required conversion to open surgery. There was no mortality.Patients were followed-up for a period of between 6 – 18 months (average 13±3.3 months) after surgery. All patients had an improvement in T2DM over the months that followed surgery: remission was observed in 80% of patients such that these subjects no longer required treatment with anti-diabetic drugs.
Pre-surgical BMI was not a determinant factor for the post-surgical remission of T2DM. There were no significant differences between patients in the two different outcome groups (i.e. BMI30 kg/m2) with respect to the pre-surgical duration of T2DM. In addition, there were no significant differences between the two groups of patients regarding duration of insulin usage prior to surgery.
Conclusions
The main benefits from application of the SG/II procedure to T2DM patients are adequate glycemic control, satisfactory weight loss and an absence of clinical signs of nutritional deficiencies. Such findings indicate that the surgical treatment, which interferes with the pathophysiology of T2DM, is a promising alternative for patients with non-morbid obesity. Laparoscopic SG/II is an effective, safe and reproducible technique that produces few short or medium-term complications. However, a much longer post-surgical follow-up is essential in order to answer the critical issues relating to the maintenance of glycemic control.
References
1. Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med. 2009;122:248-256
2. Vilsboll T, Holst JJ. Incretins, insulin secretion and Type 2 diabetes mellitus. Diabetologia. 2004;47:357-366.
3. Shikora SA, Kim JJ, Tarnoff ME. Nutrition and gastrointestinal complications of bariatric surgery. Nutr Clin Pract. 2007;22:29-40.
4. El-Kadre LJ, Rocha PRS, Tinoco AC, Tinoco RC. Calcium metabolism in pre- and postmenopausal morbidly obese women at baseline and after laparoscopic Roux-En-Y gastric bypass. Obes Surg. 2004:1062-1066.
5. Strader AD. Ileal transposition provides insight into the effectiveness of gastric bypass surgery. Physiol Behav. 2006;88:277-282.
6. DePaula AL, Macedo AL, Schraibman V, Mota BR, Vencio S. Hormonal evaluation following laparoscopic treatment of type 2 diabetes mellitus patients with BMI 20-34. Surg Endosc. 2009;23:1724-1732.
7. DePaula AL, Macedo A, Rassi N, et al. Laparoscopic treatment of type 2 diabetes mellitus for patients with a body mass index less than 35. Surg Endosc. 2008;22:706-716.
8. Strader AD, Clausen TR, Goodin SZ, Wendt D. Ileal interposition improves glucose tolerance in low dose streptozotocin-treated diabetic and euglycemic rats. Obes Surg. Jan 2009;19(1):96-104.
9. Kojima M, Hosoda H, Date Y, Nakazato M, Matsuo H, Kangawa K. Ghrelin is a growth hormone-releasing acylated peptide from stomach. Nature. 1999;402:656–660.
10. DePaula AL, Macedo AL, Mota BR, Schraibman V. Laparoscopic ileal interposition associated to a diverted sleeve gastrectomy is an effective operation for the treatment of type 2 diabetes mellitus patients with BMI 21-29. Surg Endosc. 2009;23:1313-1320.
11. Tinoco A, El-Kadre L, Aquiar L, Tinoco R, Savassi-Rocha P. Short-term and mid-term control of type 2 diabetes mellitus by laparoscopic sleeve gastrectomy with ileal interposition. World journal of surgery. Oct 2011;35(10):2238-2244.

الكاتب : Augusto Tinoco MD, PhD Introduction

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البريد الالكتروني
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كود التحقق 68311
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