Nonalcoholic fatty liver disease in Japanese patients with severe obesity who received laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) in comparison to non-Japanese patients

Background. The number of patients with morbid obesity is increasing worldwide. However, the prevalence of morbid obesity is still low in Japan, and therefore few systematic investigations of liver dysfunction in this population have so far been carried out. This study aimed to investigate the clinical characteristics in severe obese Japanese patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB). Methods. Eighty-four patients with severe obesity, including 61 Japanese and 23 non-Japanese patients, were analyzed. Results. The mean body mass index (BMI) was 43.7 ± 7.8 kg/m², and there was no difference between Japanese and non-Japanese patients. Nonalcoholic fatty liver disease (NAFLD) was observed in 45/59 (76.2%) of the Japanese patients. Although there were no differences in the BMI and body weight, serum ALT was higher in Japanese patients in comparison to non-Japanese patients (P < 0.05). The indices for insulin resistance were significantly higher in the Japanese patients in comparison to non-Japanese patients (P < 0.01). The liver/spleen computed tomography (CT) ratios were lower in Japanese patients (P < 0.05). The laboratory data and BMI significantly improved at 1 year after LRYGB in both groups. Conclusions. Racial difference may exist difference may exist in NAFLD in patients with severe obesity. When the BMI is similar, liver dysfunction among Japanese patients with severe obesity tends to be higher than in non-Japanese patients. Japanese patients with severe obesity must therefore reduce their body weight to a greater degree in comparison to non-Japanese patients with the same BMI. LRYGB can achieve effective weight control and lower ALT levels in Japanese patients with severe obesity.     

Regional fat changes following weight reduction from laparoscopic Roux-en-Y gastric bypass surgery

Fat accumulation in muscle (intermuscular, IM) and viscera plays a role in obesity comorbidities. This study examined the impact of Roux-en-Y gastric bypass (RYGB) surgery in morbid obesity on changes in regional fat and muscle depots, and these body composition markers were correlated with physical function. Women (n = 18) were assessed prior to (baseline) and 12 months following RYGB for regional body composition and physical function. Weight loss from baseline to 12 months was 33.7 (s.e.m. = 1.7)%; total body fat decreased from 86.8 (s.e.m. = 5.8) to 45.8 (s.e.m. = 3.9) kg during follow-up. Differential changes in regional body fat were apparent with a volume loss of 58.4% in visceral fat, 19.8% in abdomen IM fat and 50.7% in thigh IM fat. At baseline, abdomen IM fat volume was related to physical function. There was less loss of abdomen IM fat volume than other depots following surgery; furthermore its relationship with physical function is a novel finding.     

2型糖尿病胃转流术后胰高血糖素样肽-1的变化及其意义

目的 探讨2型糖尿病患者行胃转流术后血清胰高血糖素样肽-1 （GLP-1）的变化及意义.方法 对37例2型糖尿病患者行胃转流术,手术前后检测空腹血糖（FPG）、餐后2h血糖（2 h PG）、糖化血红蛋白（HbA1c）、空腹胰高血糖素样肽-1（FGLP-1）、餐后2h胰高血糖素样肽-1（2 h GLP-1）,并计算胰岛素敏感指数（（ISI）=1/FPG×FIns.结果 37例患者均获随访1年以上,29例达到完全缓解,5例部分缓解,3例无效,总有效率为91.9％.与术前比较,术后FPG、2 h PG、及HbA1c呈显著下降,FGLP-1、2 h GLP-1及ISI则较术前明显升高（P均＜0.05）;FGLP-1、2 h GLP-1与ISI呈正相关（r分别为0.64、0.58,P＜0.01或＜0.05）.结论 胃转流术治疗2型糖尿病有明显效果,其作用机制之一是术后患者肠源性GLP-1的分泌增加进而改善胰岛素敏感性.     

Beta-cell growth in the neonatal Goto-Kakisaki rat and regeneration after treatment with streptozotocin at birth

Aims/hypothesis. In the Goto-Kakisaki rat, a genetic model of non-insulin dependent diabetes, we have recently reported that as early as fetal age, there is a restriction of the beta-cell mass which is maintained in the adult animal and is detectable before the onset of hyperglycaemia. It is therefore important to investigate the beta-cell growth potential in young Goto-Kakisaki rats. Methods. We have studied in 4 and 7-day-old Goto-Kakisaki neonates: 1. the in vivo replication rate of the beta cell; 2. the occurrence of beta-cell apoptosis; 3. the effectiveness of beta-cell regeneration after damage caused by neonatal treatment with streptozotocin. Results. The replication rate in vivo of beta cells and the beta-cell apoptosis were similar in untreated Wistar and Goto-Kakisaki neonates on days 4 and 7 whereas the total beta-cell masses were reduced to 50 % in the Goto-Kakisaki groups. Treatment with streptozotocin reduced the total beta-cell mass to the same extent in both Wistar and Goto-Kakisaki rats on day 4 compared with the corresponding normal values in Wistar and Goto-Kakisaki neonates. From day 4 to day 7, spontaneous beta-cell regeneration was manifest in both groups. Compared with the Wistar streptozotocin group, the net value of the beta-cell mass added during this period was more limited in the Goto-Kakisaki streptozotocin group, despite the replication activity of the residual beta cells being increased in this group to the same extent as in the Wistar streptozotocin group. Conclusion/interpretation. We therefore suggest: 1. that the reduced beta-cell mass in the untreated neonatal Goto-Kakisaki rat does not appear to reflect a reduction in the rate of beta-cell replication or an increased beta-cell death by apoptosis but is potentially due to an impaired rate of beta-cell neogenesis, and 2. that beta-cell regeneration can be reactivated after streptozotocin insult in the neonatal Goto-Kakisaki rat, although to a lesser extent compared with that in streptozotocin-treated Wistar neonates. [Diabetologia (1999) 42: 1098–1106] Received: 8 January 1999 and in revised form: 26 February 1999     

Absence of luminal intrinsic factor after gastric bypass surgery for morbid obesity

Abnormally low serum cobalamin levels (<180 pg/ml) have been observed in 154 of 429 patients (36%) at an average of 22 months (range 3–64 months) after gastric bypass surgery for morbid obesity. Twenty-four patients underwent a Schilling test and retrograde endoscopy of the bypassed gastric segment to determine the presence of intrinsic factor (IF) in gastric aspirates and in mucosal biopsies at 22±4 months after surgery. Five patients had a normal cobalamin level (405±44 pg/ml), and gastric juice intrinsic factor was present in three of them (11±7 ng/ml). Nineteen patients had a low cobalamin level (113±8 pg/ml), and gastric juice IF was found in only two subjects of this group (10 ng/ml each). Basal gastric juice IF concentration of healthy control subjects was 24±5 ng/ml. Schilling test results were normal in all five patients of the first group and in only nine patients of the group with cobalamin deficiency after surgery. To assess whether IF was present within the parietal cells of subjects with absent luminal IF, we studied gastric biopsy material of 14 patients using a well-characterized indirect immunoperoxidase method. IF was identified in fundic mucosal biopsy specimens of all 14 patients with absent gastric juice IF. We conclude that cobalamin deficiency occurs in a significant number of patients after gastric bypass and is associated with absence of gastric juice IF. We propose that this abnormality might be caused by inadequate secretion of IF from the bypassed stomach.This work was presented in part at the annual meeting of the American Gastroenterological Association, San Francisco, California, May 1986, and has appeared in abstract form (Gastroenterology 90:1533, 1986).     

Comparison of short- and long-term outcomes of bariatric surgery methods: A retrospective study

The present study is intended to retrospectively compare the short- and long-term outcomes of 3 different treatment methods in patients undergoing bariatric surgery and the variances in weight and nutritional parameters during the preoperative and postoperative periods. In this study, 534 patients who underwent laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-En-Y gastric bypass (LRYGB), and laparoscopic one anastomosis gastric bypass (LOAGB) between 2014 and 2021 were included. The sociodemographic and biodemographic characteristics of these patients, their weight losses and nutritional changes in the preoperative and postoperative periods, operative times, hospital stays, complications, and morbidity and mortality rates were retrospectively compared. There was a statistically significant difference between the surgical methods in the percentages of excess weight loss and total weight loss in the 1st and 3rd months. There were significant differences in the homeostasis model assessment of insulin resistance, folic acid, vitamin D, iron, ferritin, and parathyroid hormone levels (P < .05). All 3 techniques were found to be successful in facilitating weight loss at the end of the first year. LRYGB and LOAGB were found to be superior to LSG in terms of remission from diabetes during the first 6 months, whereas LSG was superior to the other methods in terms of nutritional deficiencies. Despite being more advantageous in terms of operative time, LSG and LOAGB were disadvantageous compared with the LRYGB technique because of the higher rates of leakage and mortality in the LSG technique and the higher rate of bile reflux in the LOAGB technique.     

Role of vagal activation in postprandial glucose metabolism after gastric bypass in individuals with and without hypoglycaemia

Patients who have undergone gastric bypass surgery (GB) have enhanced postprandial hyperinsulinaemia and a greater incretin effect is apparent. In the present study, we sought to determine the effect of vagal activation, a neural component of the enteroinsular axis, on postprandial glucose metabolism in patients with and without hypoglycaemia after GB. Seven patients with documented post-GB hypoglycaemia, seven asymptomatic patients without hypoglycaemia post-GB, and 10 weight-matched non-surgical controls with normal glucose tolerance were recruited. Blood glucose, and islet hormone and incretin secretion were compared during mixed meal tolerance tests (MMTs) with and without prior sham-feeding on two separate days. Sham feeding preceding the MMT caused a more rapid increase in prandial blood glucose levels but lowered overall glycaemia in all three groups (P < 0.05). Sham feeding had a similar effect to increase early (P < 0.05), but not overall, meal-induced insulin secretion in the three groups. Prandial glucagon concentrations were significantly greater in the GB groups, and sham feeding accentuated this response (P < 0.05). The effect of vagal activation on prandial glucose and islet-cell function is preserved in patients who have undergone GB, in those both with and without hypoglycaemia.     

Changes in iron transporter divalent metal transporter 1 in proximal jejunum after gastric bypass

AIM:To describe the variation that divalent metaltransporter 1(DMT1)shows in patients after Rouxen-Y gastric bypass(RYGB)surgery.METHODS:Prospective and analytical study of DMT1level at the brush border of proximal jejunum in patients having undergone RYGB surgery.The mucosa of proximal jejunum forming the gastrojejunal anastomosis was biopsied during surgery and after 6 mo later with an endoscopic biopsy.All the patients received precise instructions regarding feeding and nutritional supplementation.Both samples were processed at the same time by immunohistochemistry and western blot.Samples were analysed by a pathologist.For statistical analysis,theχ2 and Wilcoxon tests were used.RESULTS:Sixteen patients were recruited,13 of whom completed the study.Twelve were women.Average age and body mass index(BMI)were 44.1 and 40.4,respectively.Both body weight and BMI decreased significantly during the study period,with an average percent excess weight loss(%EWL)of 60%±13.3%and an average percent excess BMI loss(%EBMIL)of 79.6%±21.6%.Only two patients presented with mild anaemia6 mo after surgery,but their ferritin levels stayed within normal ranges.Staining for DMT1 showed a significant increase in the cytoplasm of enterocytes located at the tips of the villi(χ2=6.03;P=0.049).Nevertheless,the total quantity of DMT1 decreased significantly(Z=2.04;P=0.04).Associated with these results,we observed a significant increase in goblet cells in the villi 6mo postoperatively(Z=-2.47;P=0.013).CONCLUSION:Six months after RYGB surgery,patients exhibit an increase in DMT1 expression in the enterocytes of the tips of the villi at the proximal jejunum.     

Bariatric surgery: Mechanisms,indications and outcomes

The rising problem of obesity is causing major health problems, reduced quality of life and reduced life expectancy. It now generates approximately 10% of all health costs. The progression of the problem indicates preventive measures have been unsuccessful so far. Only bariatric surgical treatments have been able to achieve substantial and durable weight loss. Gastric banding and gastric bypass are used in more than 90% of bariatric operations. The proportion of each varies from greater than 95% bands in Australia, about 50/50 in Europe and USA and nearly 100% bypass in South America. The availability of follow up is a prime determinant of choice. Understanding the mechanisms of effect for the bariatric procedures is central to optimizing their effect. The traditional narrow concepts of restrictive (blocking the transit of food) and malabsorptive (preventing the absorption of food) should be discarded and the importance of induction of satiety, change of taste, diversion of chyme, neural and hormonal mediation and the effects of aversion need to be included. The primary mechanism of effect for gastric banding is the generation of a background of satiety and early post‐prandial satiation via specifically structured vagal afferents at the level of the band. At five years after banding or bypass, there is typically a loss of 30–35 kg representing 50–60% of excess weight. This weight loss has been shown to be associated with major improvement or complete resolution of multiple common and serious health problems plus improvement in quality of life and in survival. Level 1 evidence supports the use of the gastric band over optimal lifestyle therapy. Randomized controlled trials has shown gastric banding to achieve better weight loss, health and quality of life than optimal lifestyle therapies for adults above a BMI of 30 and adolescents above a BMI of 35. In adults with mild to severe obesity and type 2 diabetes gastric banding leads to remission in three out of four individuals. Perioperative risk is significant with gastric bypass and late revisional procedures can be required after both procedures. Gastric banding is indicated in any adult who has a BMI over 30, has problems with their obesity and has made substantial effort to reduce their weight by lifestyle methods. Gastric bypass or biliopancreatic diversion should be considered in those with BMI greater than 35 if banding is contraindicated or has been unsuccessful.     

Weight loss and incretin responsiveness improve glucose control independently after gastric bypass surgery

Background: The aim of the present study was to determine the mechanisms underlying Type 2 diabetes remission after gastric bypass (GBP) surgery by characterizing the short‐ and long‐term changes in hormonal determinants of blood glucose. Methods: Eleven morbidly obese women with diabetes were studied before and 1, 6, and 12 months after GBP; eight non‐diabetic morbidly obese women were used as controls. The incretin effect was measured as the difference in insulin levels in response to oral glucose and to an isoglycemic intravenous challenge. Outcome measures were glucose, insulin, C‐peptide, proinsulin, amylin, glucagon, glucose‐dependent insulinotropic polypeptide (GIP), glucagon‐like peptide‐1 (GLP‐1) levels and the incretin effect on insulin secretion. Results: The decrease in fasting glucose (r = 0.724) and insulin (r = 0.576) was associated with weight loss up to 12 months after GBP. In contrast, the blunted incretin effect (calculated at 22%) that improved at 1 month remained unchanged with further weight loss at 6 (52%) and 12 (52%) months. The blunted incretin (GLP‐1 and GIP) levels, early phase insulin secretion, and other parameters of β‐cell function (amylin, proinsulin/insulin) followed the same pattern, with rapid improvement at 1 month that remained unchanged at 1 year. Conclusions: The data suggest that weight loss and incretins may contribute independently to improved glucose levels in the first year after GBP surgery.     

Life threatening bleeding from duodenal ulcer after Roux-en-Y gastric bypass: Case report and review of the literature

Acute upper gastrointestinal bleeding is a rare, but serious complication of gastric bypass surgery. The inaccessibility of the excluded stomach restrains postoperative examination and treatment of the gastric remnant and duodenum, and represents a major challenge, especially in the emergency setting. A 59-year-old patient with previous history of peptic ulcer disease had an upper gastrointestinal bleeding from a duodenal ulcer two years after having a gastric bypass procedure for morbid obesity. After negative upper endoscopy finding, he was urgently evaluated for gastrointestinal bleeding. At emergency laparotomy, the bleeding duodenal ulcer was identified by intraoperative endoscopy through gastrotomy. The patient recovered well after surgical hemostasis, excision of the duodenal ulcer and completion of the remnant gastrectomy. Every general practitioner, gastroenterologist and general surgeon should be aware of growing incidence of bariatric operations and coherently possible complications after such procedures, which modify patient’s anatomy and physiology.     

胃转流手术治疗2型糖尿病机制的研究进展

外科手术已被认可为治疗2型糖尿病（T2DM）的一种新型方式,其中胃转流术是目前备受关注的手术方式,并逐渐进入临床。胃转流术治疗T2DM效果显著,尤其适用于伴肥胖的T2DM患者,甚至可以达到有效控制血糖及缓解糖尿病并发症的目的。然而,其潜在作用机制复杂,主要包括胃肠激素分泌的变化、脂肪因子的作用、胆汁酸代谢等。     

Application of side-to-side anastomosis of the lesser curvature of stomach and jejunum in gastric bypass

AIM To evaluate the feasibility of side-to-side anastomosis of the lesser curvature of stomach and jejunum in laparoscopic Roux-en-Y gastric bypass(LRYGB).METHODS Seventy-seven patients received side-to-side anastomosis of the lesser curvature of stomach and jejunum by utilization of linear stapler in LRYGB from April 2012 to July 2015 were retrospectively analyzed.RESULTS All patients were successfully completed laparoscopic gastric bypass with the side-to-side anastomosis of the lesser curvature of stomach and jejunum. No patient was switched to laparotomy during operation. No early complications including gastrointestinal anastomotic bleeding, fistula, obstruction, deep vein thrombosis, incision infections, intra-abdominal hernia complications were found. One patient complicated with stricture of gastrojejunal anastomosis(1.3%) and six patients complicated with incomplete intestinal obstruction(7.8%). BMI and Hb A1 c determined at 3, 6, 12, 24 mo during follow up period were significantly reduced compared with preoperative baselines respectively. The percentage of patients who maintain HbA 1c(%) 6.5% without taking antidiabetic drugs reached to 61.0%, 63.6%, 75.0%, and 63.6% respectively. The outcome parameters of concomitant diseases were significantly improved too.CONCLUSION Present surgery is a safety and feasibility procedure. It is effective to lighten the body weight of patients and improve type 2 diabetes and related complications.     

Percutaneous revascularization strategies in a patient with previous coronary artery bypass surgery: Technical and patho-physiological insights

Occasionally, in post-coronary artery bypass patients multiple percutaneous revascularization choices (treatment of the native artery versus treatment of the bypass graft) are available in order to obtain adequate blood supply of the ischemic myocardial region and relief of the anginal symptoms. Once a strategy has been chosen, the possibility to switch to the alternative plan should be considered in case unpredictable complications occur during the first treatment choice. A step-by-step assessment and prediction of the possible acute and long-term outcomes and complications should always be performed in order to optimize the results.     

Cardiac arrhythmias during sleep in morbidly obese sleep-apneic patients before and after gastric bypass surgery

Fourteen morbidly obese patients scheduled for gastric bypass surgery were diagnosed preoperatively as suffering from sleep apnea syndrome. There were 13 males and 1 female aged 24 to 59 years. Mean preoperative excessive body weight was 222 +/- 38%; mean apnea index prior to surgery was 84 +/- 44. A whole night lead II ECG tracing was performed as part of the polyhypnographic recordings and was evaluated for cardiac arrhythmias. Studies were performed in all patients preoperatively and 6 months thereafter. Statistical analysis was done using the Student's paired t-test. In this group a high incidence of atrial and ventricular arrhythmias was found. Marked sinus arrhythmia was encountered in all patients and extreme sinus bradycardia in 4 of them. In a consecutive sleep study performed 6 months postoperatively most cardiac arrhythmias disappeared. Marked sinus arrhythmia persisted in only two patients and severe ventricular premature beats (Lown's grade III-IV), found preoperatively in all patients, were still present postoperatively in only two, although in a much milder form. Surgical weight reduction, therefore, is a valuable method in the abolishment of life-threatening cardiac arrhythmias of the morbidly obese sleep-apneic patient.     

Changes in fasting bile acid profiles after Roux-en-Y gastric bypass and sleeve gastrectomy

Background:Bile acid is an essential factor that plays a role in metabolic regulation, but how bile acid is regulated after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) remains unclear. This meta-analysis aimed to investigate changes in the levels of fasting bile acids following RYGB and SG.Methods:A systematic literature search of the PubMed, EMBASE, Cochrane Library and Web of Science databases through July 2020 was performed in accordance with the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The concentrations of bile acids were evaluated.Results:Thirteen studies with 289 patients were included. Our results showed that patients who underwent RYGB had increased levels of fasting total bile acids, primary bile acids, secondary bile acids, conjugated bile acids, and unconjugated bile acids, but no significant differences in all these bile acid levels were observed in patients who underwent SG. Furthermore, 12a-hydroxylated bile acid levels and the 12a-hydroxylated/non-12a-hydroxylated bile acid ratio also increased following RYGB.Conclusion:In this study, we found that fasting bile acid levels, especially 12a-hydroxylated bile acids levels, were increased after RYGB. However, no differences in fasting bile acid levels were observed following SG.