the surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition,...
TRANSCRIPT
![Page 1: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/1.jpg)
The Surgical: proximal and distal intestine, partial removal of the
stomach, ileal transposition, others
Alper Çelik, M.D.Associate Professor of Surgery
Yeni Yüzyıl University Medical Faculty& Taksim German Hospital
Metabolic Surgery Unitwww.metabolicsurgeryistanbul.com
![Page 2: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/2.jpg)
1st Question?
• Did initial vertebrates have an appendix epiploica?
![Page 3: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/3.jpg)
![Page 4: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/4.jpg)
Herbivore Carnivore
Gastrointestinal adaptation to fiber-poor diets
![Page 5: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/5.jpg)
Who consumes the diet with higher caloric index?
![Page 6: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/6.jpg)
The goat has a bigger stomach that than the dog’s stomach.
And longer intestines also.
the dog is not restricted.
The dog is adapted!
Is Sleeve gastrectomy a restrictive or adaptive procedure? Reflections o the concept of Restriction and Adaptation.
![Page 7: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/7.jpg)
Change in Food Industry
• Refined food• Saccharification• Coca-colanisation!!!• And their metabolic outcomes.
![Page 8: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/8.jpg)
Obesity and Metabolic Syndrome
DuodenojejunalHyperactivity
High GIP
Ileal Hypoactivity
Low PYY, GLP-1 and OXM
A Proximal – Distal Imbalance
![Page 9: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/9.jpg)
By bringing the ileum proximal
We will obtain an Adaptive andNeuroendocrine support
How about pathophysiology?
![Page 10: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/10.jpg)
TRIUNVIRATO1. Inadequate insulin release
from beta cells, disrupted early phase insulin effect
2. Insulin Resistance (IR) in peripheral tissues
3. Increased endogenous glucose production (hepatic / intestinal glucose output)
4. Adipocytes
OCTETO
5. Gastrointestinal tractus
(incretin insufficiency /
resistance)
6. Alpha cell (hyperglucagonemia)
7. Kidney (glucose reabsorption)
8. CNS (insulin resistance - others)
Diabetes 2009:58; 773-95.
![Page 11: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/11.jpg)
Steps for Success in Metabolic Surgery1) Caloric restriction and weight adjustments based on “hormonal
thermostat” mechanism.2) Increased gastric emptying and decreased ghrelin levels 3) Early term food contact with the ileal mucosa, increase in GLP-1 and
correction of the first phase insulin release (“jejuno ileal nutrient sensing”)
4) Correction of first + second phase (20-120 min) glucose dependent plasma insulin response due to GIP effect
5) Correction of late phase inadequate glucagon supression 6) Decrease in Hepatic and peripheral insulin resistance7) Decrease in Hepatic Glucose Output
• *Breen DM, et al. Nature Med 2012; 18: 950-955.
![Page 12: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/12.jpg)
1) Caloric Restriction
Sleeve Gastrectomy
causes functional
restriction and endocrine
adjustments
![Page 13: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/13.jpg)
2) Increased gastric emptying and decreased ghrelin levels
It reduces Ghrelin(Now we know it also enhances
GLP1 and PYY)
12
0,00
100,00
200,00
300,00
400,00
500,00
600,00
700,00Ghrelin
Pre-op Post-op
![Page 14: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/14.jpg)
What is Ghrelin?
• Hormone?
![Page 15: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/15.jpg)
GHRELIN
• Growth Hormone Receptor Ligand• Ghrelin deficiency may not be innocent!• Keep an eye on Journal of Bone & Mineral
Research!
![Page 16: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/16.jpg)
3-4-5) Incretin Effect & Glucagon Supression
• In patients with T2DM insulin release and beta cell functions are altered.
• Insulin has a biphasic release pattern from pancreas.• Early phase occuring within first 30 min• Late phase that platoes after 2nd hour
• The earliest possible sign of beta cell dysfunction is the disrupted early phase insulin release.
Kahn SE Int J Clin Pract 2001;123:13-18
![Page 17: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/17.jpg)
Early Phase Insulin Release -1
• If early phase insulin release is disrupted; 1 – Insulin sensitive tissues fail to adequately
perform glucose transport.2 – Glucagon secretion, FFA release and Hepatic
Glycogenolysis can not be prevented.3 – Circulating glucose load and glycemic
variability will increase.
Luzi L et al Am J Physiol 1989;257:E241-E246
![Page 18: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/18.jpg)
Early Phase Insulin Release -2
• The reason for these changes is intrinsic beta cell defect + Defective changes in factors promoting postprandial insulin secretion (Incretin Resistance & Insufficiency).
• There are two forms of basic physiologically active incretins (Intestinal İnsulinomimetic Polipeptides):
• GIP and GLP-1.
![Page 19: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/19.jpg)
GIP (Glucose-Dependent Insulinotropic Polypeptide )
• Is GIP a good hormone or a bad hormone?
![Page 20: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/20.jpg)
GIP
• The answer is “both” (depending on the situation).• It is mainly released from the K cells in the duodenum.• Especially in pts with IGT its levels increase in parallel
to hyperinsulinemia. Oral glucose load exeggerates this increase.
RESULT: • K cell desensitisation to oral glucose• GIP receptor desensitisation• Beta cell GIP Resistance
Theodorakis MJ, et al Diabetes Care 2004; 27: 1692-98.
![Page 21: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/21.jpg)
GIP & Trivial Pattern
LiverLiver / / MuscleMuscle AdipoAdipocycyttee
Insulin
GIP – trivial effect
FatFat
![Page 22: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/22.jpg)
GIP & Decreased insulin
Fat
LiverLiver / / MuscleMuscle
AdipoAdipocycyttee
Decreased insulin activity
GIP – effective
![Page 23: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/23.jpg)
GIP & Corrected Insulin
Fat
LiverLiver / / MuscleMuscle
AdipoAdipocycyttee
Corrected insulin activity
GIP – inhibition
![Page 24: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/24.jpg)
“Vicious Cycle” of GIP Molecule
Hyperphagia K-cell hyperplasia
GIP Increased
Beta-cell hyperplasia
Insulin Resistance
Hyperinsulinemia
Hyperglycemia
Glucose Intolerance
Beta-cell stimulation
Gault, VA et al (2005). Diabetes 54:2436-2446.
![Page 25: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/25.jpg)
GLP-1 (Glucagon Like Peptide 1)
• It is mainly released from L cells in Ileum.• It leads to Receptive Partial Antagonism with
Glucagon (“dysinhibition”).• GLP-1 shows a secretion kinetic based on the
oligosaccharides within ileum and is the main factor in adjusting early phase insulin release.
• GLP-1 secretion is altered in T2DM.
![Page 26: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/26.jpg)
p<0.001 - preoperative vs postoperativea p<0.05 - 1-12months vs 25-38 months
* * *
**
Time Based Evaluation (3 years) of Insulin Sensitivity After II-SG in T2DM Patients with BMI<35
Vencio S. Endocrine Reviews 2010;31(3):S1-257
*a
![Page 27: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/27.jpg)
Surgical Success – Things To Do!
• Sleeve gastrectomy• Correction of disrupted GIP secretion (Duodenal
Exclusion)• GLP-1 effect (ileal proximalisation)• Glucagon Suppression• Decrease in hepatic glucose output• Without long term malapsorption.
![Page 28: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/28.jpg)
BPD + Duodenal SwitchBPD + Duodenal Switch
Bypassed duodenum Bypassed duodenum and jejunum for a and jejunum for a Malabsorptive Malabsorptive componentcomponent
Neuroendocrine Neuroendocrine componentcomponentby enhancing entero-by enhancing entero-hormoneshormones
![Page 29: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/29.jpg)
Is the answer BPD/DS?
• If we want to end one form of addiction and give our patients a new form of addiction (vitamins, minerals, calcium, iron, and trace elements); than the answer is YES.
![Page 30: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/30.jpg)
One possible option: transit bipartition
IntentionalNeuroendocrine component
Easier and saferanastomosis
NO excluded segmentTOTAL endoscopic accessNO Nutritional problems
Santoro et al. Obes Surg 2006; 16:1371-79
Obes Surg 2008; 18:1343–1345 Ann Surg. 2012 Jul;256(1):104-10.
![Page 31: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/31.jpg)
Bipartition
Gastroileoanastomosis 240 to 260 cm from the cecum
![Page 32: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/32.jpg)
A very flexible procedure
A Smaller gastric remnant
“More bariatric procedure”
A Bigger remnant
“More metabolic procedure”
80 to 130cm
Shorter Common segment“More bariatric procedure”Longer common segment“More metabolic procedure”
L cells of distal gut are
very close anyway
![Page 33: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/33.jpg)
Transit Bipartition
PylorusPylorusGastro-ileal AnastomosisGastro-ileal Anastomosis
![Page 34: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/34.jpg)
And the second option could be: DS-II
Sleeve resection/ Gastric fundectomy
Duodenal Transection
Ileo – Jejunal Interposition
![Page 35: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/35.jpg)
![Page 36: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/36.jpg)
-cell glucose sensitivity
* p<0.001 vs corresponding group before surgery
0
10
20
30
40
50
60
70
pre post
ß-G
S p
mol
/min
/m2/
mM
)
lean OW OB pre
*
*
*
Mechanisms of action in insulin sensitivity and beta cell functions after II-SG
DePaula AL, Ferranninni E, et al. – J Gastrointest Surg 2011;15(8):1344-1353
![Page 37: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/37.jpg)
Evaluation of Insulin Sensitivity and Secretion by Eauglycemic Hyperinsulinemic Clamp + IVGTT
in patients with BMI<35
*
Glucose dependent C-peptide release
*p<0.001 – preoperatif vs postoperatif
Vencio S et al.- Diabetes 2010;59:S1
![Page 38: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/38.jpg)
26
Insulin Sensitivity
50
150
250
350
450
pre post
OG
IS -m
l/m
in/m
2
lean OW OB
* *
*
* p<0.001 vs corresponding group before surgery
Increase in Insulin Sensitivity According to BMI Values
DePaula AL, Ferranninni E, et al. – J Gastrointest Surg 2011;15(8):1344-1353
![Page 39: The Surgical: proximal and distal intestine, partial removal of the stomach, ileal transposition, others Alper Çelik, M.D. Associate Professor of Surgery](https://reader036.vdocument.in/reader036/viewer/2022070411/56649cc05503460f94987804/html5/thumbnails/39.jpg)
Without long term Nutritional Effects