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

Silva

ABCD, arq. bras. cir. dig.

et al. 2010

DESCRITORES -Obesidade. Diabetes mellitus. Cirurgia Bariátrica.RESUMO -Introdução -Há evidências que os melhores resultados em termos de resolução do diabetes mellitus tipo 2 (DM2) em pacientes obesos mórbidos são atingidos com as derivações biliopancreáticas, em especial o duodenal switch. Essas operações caracterizamse por redução do estômago através de gastrectomia e o rápido trânsito dos alimentos para o íleo distal, através de expressiva derivação de segmentos do intestino delgado. A idéia da realização da técnica aqui apresentada baseou-se nestes princípios. Método -Os procedimentos são habitualmente realizados por via laparoscópica após pneumoperitônio com 12 a 15 mmHg e seis trocárteres. O paciente é inicialmente posicionado em proclive de 30º com o cirurgião à direita. Inicia-se a gastrectomia vertical tendo como referência anatômica a trifurcação distal do vago anterior. A desvascularização da grande curvatura é realizada e se estende até o ângulo esofagogástrico. Com um calibrador intra-gástrico de 20 mm posicionado ao longo da pequena curvatura gástrica inicia-se a ressecção gástrica no antro com grampeador linear e adicionalmente é feita uma sutura contínua. Para a realização da interposição ileal na altura do jejuno proximal o ângulo duodenojejunal é identificado e o jejuno seccionado 20 a 30 cm à jusante com grampeador linear. O ceco é identificado e o íleo distal seccionado a 30 cm no sentido proximal. Um segmento de 150 a 170 cm de íleo é medido em sentido proximal e seccionado com grampeador linear. O segmento de íleo é interposto de forma isoperistáltica no jejuno proximal previamente seccionado. Em seguida, são realizadas três enteroanastomoses: a primeira íleo-ileal próxima ao ceco; outra próxima ao ângulo duodenojejunal; a terceira íleo-jejunal. O procedimento pode também ser feito com interposição ileal na primeira porção do duodeno. Conclusão -Esta técnica demonstrou-se segura, com baixa morbidade e mortalidade, factível cirurgicamente pela via laparoscópica e passível de ser ofertada como opção operatória ao tratamento da diabetes mellitus tipo 2.ABSTRACT -Introduction -There is an evidence that the best results in terms of resolution of diabetes in morbidly obese patients are achieved with bilio-pancreatic bypass, especially the duodenal switch. These operations are characterized by partial gastrectomy and the rapid transit of food into the distal ileum through derivation of a significant segment of small intestine. The idea of performing the technique presented here was based on these principles. Method -The procedures are usually performed laparoscopically, after establishment of a pneumoperitoneum at 12-15 mmHg and introduction of six trocars. The patient is initially positioned in 30° reverse Trendelenburg with the surgeon on the right side of the patient. The sleeve gastrectomy is performed using the anatomical distal trifurcation of the anterior vagus nerve as a reference. The devascularization of the greater curvature is performed and extends to the oesophagogastric junction. Wit...

Section: Interposição Ileal Na Altura Do Jejuno Proximalunclassified

Aspectos técnicos da interposição ileal com gastrectomia vertical como possível opção ao tratamento do diabetes mellitus tipo 2

Silva

ABCD, arq. bras. cir. dig.

et al. 2010

“…The operation does more than just limit intake, but also removes most-or perhaps all-of the ghrelin-producing cells in the gastric mucosa. In addition, two new procedures-the duodenojejunal bypass stomach-sparing operation [26] and ileal transposition [27][28][29]-have been tested in attempts to induce remission of diabetes without weight loss in lean or only modestly overweight patients with T2DM. However, both are still in the early stages of human trials (see Perspectives below).…”

Section: Surgical Techniquesmentioning

confidence: 99%

“…Also, as an alternative approach, ileal transposition may result in significant endocrine changes in the gut, particularly by promoting secretion of GLP-1, an ileal-produced hormone with a well-known role in T2DM [27]. Promising results with ileal interposition (the so-called 'neuroendocrine break') combined with sleeve gastrectomy were recently reported in a small series of patients with T2DM and no obesity [28,29]. Adequate glycaemic control was obtained in > 90% of the patients and several hormonal changes were also observed, especially a marked increase in GLP-1 and GIP (glucose-dependent insulinotropic polypeptide).…”

Section: Perspectivesmentioning

confidence: 99%

Bariatric surgery in patients with Type 2 diabetes: benefits, risks, indications and perspectives

Scheen

Flines

Roover³

et al. 2009

Diabetes & Metabolism

Obesity plays a key role in the pathophysiology of type 2 diabetes (T2DM), and weight loss is a major objective, although difficult to achieve with medical treatments. Bariatric surgery has proven its efficacy in obtaining marked and sustained weight loss, and is also associated with a significant improvement in glucose control and even diabetes remission. Roux-en-Y gastric bypass appears to be more effective in diabetic patients than the restrictive gastroplasty procedure. This may be explained not only by greater weight reduction, but also by specific hormonal changes. Indeed, increased levels of glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) may lead to improved β-cell function and insulin secretion as well as reduced insulin resistance associated with weight loss. The presence of T2DM in obese individuals is a further argument to propose bariatric surgery, and even more so when diabetes is difficult to manage by medical means and other weight-related complications are present. Bariatric surgery is associated with a better cardiovascular prognosis and reduced mortality, even though acute and long-term complications may occur. The observation that surgical rerouting of nutrients triggers changes in the release of incretin hormones that, in turn, ameliorate the diabetic state in the absence of weight loss has led to the recent development of innovative surgical procedures. Thus, bariatric surgery may be said to be progressing towards so-called 'metabolic surgery', which merits further evaluation in patients with T2DM within a multidisciplinary approach that involves both surgeons and endocrinologists.Keywords : Bariatric surgery ; Gastric bypass ; Gastroplasty ; Obesity ; Type 2 diabetes ; Review RésuméChirurgie bariatrique chez les patients atteints de diabète de type 2: bénéfices, risques, indications et perspectives L'obésité joue un rôle-clé dans la physiopathologie du diabète de type 2 (DT2) et l'obtention d'une perte de poids est un objectif majeur, bien que difficile à atteindre avec les moyens médicaux. La chirurgie bariatrique a apporté la preuve de son efficacité pour induire un amaigrissement marqué et soutenu, qui s'accompagne d'une amélioration du contrôle glycémique et assez souvent d'une remission du diabète. La dérivation gastrique avec l'anse de Roux-en-Y apparaît être plus efficace chez les patients diabétiques que la simple technique restrictive qu'est la gastroplastie calibrée. Ceci peut s'expliquer non seulement par une perte pondérale supérieure, mais aussi par des modifications hormonales spécifiques. En effet, une augmentation des concentrations de GLP-1 (glucagon-like peptide-1) et de GIP (glucose-dependent insulinotropic polypeptide) avec la dérivation permet d'améliorer la fonction de la cellule β et la réponse insulinosécrétoire, en plus de la diminution de l'insulinorésistance consécutive à l'amaigrissement. La présence d'un DT2 chez un sujet obèse est un argument supplémentaire pour proposer une chirurgie bariatrique, d'autant plus qu...

“…In non-obese diabetic patients, this surgical technique has been shown to be effective in controlling diabetes mellitus type 2. [106][107][108][109][110][111] Interestingly, in the antidiabetic surgical interventions proposed by that team, [106][107][108][109][110][111] vertical gastrectomy was one of the prominent surgical techniques employed. Note that vertical gastrectomy is a restrictive (based on the marked reduction of the gastric reservoir capacity) metabolic procedure (based on the reduction of circulating levels of the orexigenic hormone ghrelin, which is produced by the fundus and greater gastric curvature) 82,91 that primarily aims to achieve weight loss.…”

Section: Introductionmentioning

confidence: 99%

Organic consequences of ileal transposition in rats with diet-induced obesity

et al. 2011

INTRODUCTION:The clinical management of metabolic syndrome -especially diabetes mellitus type 2 -is notoriously complex due to the progressive nature of this disease. At present, there is a need for a surgical procedure that is effective for the treatment of diabetes mellitus type 2, even in non-obese individuals. The isolated ileal transposition theory could lead to an effective alternative therapy. This intervention has not yet been performed in humans, and there are no reports of its use in an experimental model of diet-induced metabolic syndrome. OBJECTIVES:The objective of this study is to evaluate the physiological effects of ileal transposition in rats with diet-induced metabolic syndrome. The effects of this procedure on glucose and lipid metabolism will be assessed. METHODS:Forty 12-week-old male rats (albino Rattus norvegicus, Wistar, 2BAW, heterogeneous) will be divided into four groups of 10 animals each: the ileal transposition group (TG) comprising animals on a hypercaloric-hyperlipidic diet; the sham group (SG) containing animals that receive the same diet and undergo the sham surgery; control group 1 (CG1), which will receive a hypercaloric-hyperlipidic diet and will not undergo surgery; and control group 2 (CG2), which will consume standard feed and will not undergo surgery. The surgeries will be performed in 20-week-old animals.Blood samples for laboratory testing will be collected from 12-week-old animals on the day of surgery and after eight postoperative weeks, following determination of the weights of the animals and the administration of anesthesia. The levels of serum glucose, insulin, triglycerides, total cholesterol and fractions, glucagon-like peptide-1, C-peptide and glycated hemoglobin will be assessed in all of the animals. The insulin tolerance test will be performed using PRISMA software, and insulin resistance will be calculated by the HOMA-IR indirect test. On specific days, two 20-week-old rats will be separated and randomly distributed in TG and SG. These animals will be followed until the eighth postoperative week. Subsequently, they will be euthanized, and the retroperitoneal and periepididymal fat deposits will be collected and weighed using a precision scale. In addition, the pancreas, liver and intestinal segments will be sent for pathological and immunohistochemical studies.