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Gastrointestinal Physiology and Results following Bariatric Surgery
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery. (Ventrikel-Esofagus)
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The number of operations for morbid obesity is rising fast. We have examined aspects of postoperative physiology and results after bariatric surgery.

The pH in the proximal pouch after Roux-en-Y gastric bypass (RYGBP) was investigated with catheter-based and wire-less technique. Gastric emptying, PYY-levels in the fasting state and after a standardized meal was evaluated after biliopancreatic diversion with duodenal switch (DS). A clinical trial was undertaken, comparing DS to RYGBP in patients with BMI>48. Main outcome variables were safety and long-term weight results as well as abdominal symptoms and laboratory results.

Patients with stomal ulcer had significantly lower pH in their proximal gastric pouch as compared to asymptomatic control subjects. Long-time pH measurements with the wire-less BRAVO-system were feasible and demonstrated pH<4 in median 10.5% of the time in asymptomatic post-RYGBP patients. After DS, the T50 of gastric emptying was 28±16 minutes. PYY-levels were higher after DS than in age-matched control subjects. BMI-reduction was greater after DS (24 BMI-units) than after RYGBP (17 BMI-units) in median 3.5 (2.0-5.3) years after surgery (p<0.001). Fasting glucose and HbA1c levels were lower one and three years after DS as compared to RYGBP. On the other hand, DS-patients reported having more diarrhea and malodorous flatus.

This thesis has resulted in deepened knowledge. Acid produced in the proximal pouch is an important pathogenetic factor in the development of stomal ulcer after RYGBP. However, symptom-free patients have an acidic environment in the proximal Roux-limb as well. After DS, gastric emptying is fast, but not instantaneous, and PYY-levels are high. DS results in superior weight reduction and better glucose control as compared to RYGBP in patients with BMI>48. We believe that DS has a place in surgical treatment of the super-obese, even though symptoms of diarrhea and malodorous flatus are more common after DS.

 

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis , 2010. , p. 72
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 607
Keywords [en]
Bariatric surgery, gastric bypass, biliopancreatic diversion with duodenal switch, PYY, stomal ulcer, gastric emptying
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-131889ISBN: 978-91-554-7916-9 (print)OAI: oai:DiVA.org:uu-131889DiVA, id: diva2:356780
Public defence
2010-11-27, Grönwallsalen, Ing 70 Akademiska Sjukhuset, Uppsala, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2010-11-04 Created: 2010-10-09 Last updated: 2011-01-13Bibliographically approved
List of papers
1. Role of gastric acid in stomal ulcer after gastric bypass.
Open this publication in new window or tab >>Role of gastric acid in stomal ulcer after gastric bypass.
Show others...
2005 (English)In: Obes Surg, ISSN 0960-8923, Vol. 15, no 10, p. 1375-8Article in journal (Refereed) Published
Keywords
Adult, Aged, Angiography/*methods, Artifacts, Balloon Dilatation, Contrast Media/administration & dosage, Female, Humans, Imaging; Three-Dimensional, Kidney Transplantation/radiography, Male, Middle Aged, Renal Artery/*radiography/*transplantation, Renal Artery Obstruction/*radiography, Reproducibility of Results, Research Support; Non-U.S. Gov't, Rotation
Identifiers
urn:nbn:se:uu:diva-75443 (URN)16354514 (PubMedID)
Available from: 2006-06-29 Created: 2006-06-29 Last updated: 2011-01-11
2. Wire-less pH-metry at the gastrojejunostomy after Roux-en-Y Gastric Bypass: a novel use of the BRAVO™-system
Open this publication in new window or tab >>Wire-less pH-metry at the gastrojejunostomy after Roux-en-Y Gastric Bypass: a novel use of the BRAVO™-system
2011 (English)In: Surgical Endoscopy, ISSN 0930-2794, E-ISSN 1432-2218, Vol. 25, no 7, p. 2302-2307Article in journal (Refereed) Published
Abstract [en]

Background

The number of gastric bypass operations being preformed is increasing rapidly due to good weight loss and alleviation of co-morbidities in combination with low mortality and morbidity. Stomal ulcers are, however, a clinical problem after gastric bypass, giving patients discomfort, risk of bleeding or even perforation. To measure the acidity in the proximal jejunum, we adopted the wire-less pH-metry (BRAVO-system) developed for evaluating reflux esophagitis.

Methods

25 patients (4 men, median age 44 years, BMI 29.3) who had undergone RYGBP 4 years earlier were recruited. Twenty-one asymptomatic, non-PPI users and in addition, four symtomatic patients (ongoing or stopped PPI-treatment) were studied. The wire-less BRAVO-capsule was positioned at the level of the gastrojejunal anastomosis under visual control with the endoscope. pH was registered for up to 48 hours. Time with pH<4 was calculated. Two patients were studied with two capsules.

Results

Of the 25 recruited patients capsule placement was successful in all but 2 patients, and in 3 patients a constant neutral environment was seen before a premature loss of signal, indicating early loss of position, thus 20 successful measurements were made. The mean time of registration was 25.7 hours (6.1-47.4, n=20). In the 16 asymtomatic patients, median percentage of time with pH<4 at the gastrojejunostomy was 10.6% (range 0.4 -37.7%). When dividing the registration time in day (08.00-22.00) and night (22.00-06.00), the median percentage of time with pH<4 was 8.4 and 6.3, respectively, (p=0.08). The two double measurements gave similar results indicating consistency. No complications occurred.

Conclusion

Wire-less pH-measurements in the proximal jejunum after gastric bypass are feasible and safe. The acidity was significant (10.5% of the registration time) even in asymptomatic patients with small gastric pouches. The described method could be useful in evaluation of epigastralgia after gastric bypass and in appraisal of PPI treatment of stomal ulcer.

 

Keywords
Gastric bypass, Stomal ulcer, Ulcer, pH-metry, Acid
National Category
Medical and Health Sciences
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-131886 (URN)10.1007/s00464-010-1553-5 (DOI)000291690100034 ()21298531 (PubMedID)
Available from: 2010-10-09 Created: 2010-10-09 Last updated: 2017-12-12Bibliographically approved
3. Gastric Emptying and Postprandial PYY Response After Biliopancreatic Diversion with Duodenal Switch
Open this publication in new window or tab >>Gastric Emptying and Postprandial PYY Response After Biliopancreatic Diversion with Duodenal Switch
Show others...
2011 (English)In: Obesity Surgery, ISSN 0960-8923, E-ISSN 1708-0428, Vol. 21, no 5, p. 609-615Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Super-obesity (BMI > 50) is increasing rapidly. We use the biliopancreatic diversion with duodenal switch (BPD-DS) as one option in this patient category. The aim of the present study was to investigate the emptying of the gastric tube, PYY levels and dumping symptoms after BPD-DS.

METHODS: Emptying of the gastric tube was investigated with scintigraphy after an overnight fast. Twenty patients (median age 43 years, BMI 31.1 kg/m(2)) having undergone BPD-DS in median 3.5 years previously were included in the scintigraphic study. A technetium-labelled omelette was ingested and scintigraphic evaluation of gastric emptying was undertaken. Ten of the patients also underwent PYY measurements after a standardised meal and were compared to nine non-operated age-matched normal weight controls, both in the fasting state and after the test meal. Frequency of dumping symptoms was evaluated in all patients.

RESULTS: The half-emptying time was 28 ± 16 min. Lag phase was present in 30% of the patients. PYY levels were significantly higher in BPD-DS patients as compared to controls both in the fasting state (p < 0.001) and after the test meal (p < 0.001). Dumping symptoms were scarce and occurred in 17 of the 20 patients only few times yearly or less.

CONCLUSIONS: Although the pylorus is preserved in BPD-DS, the stomach emptying is faster than in non-operated subjects. PYY levels are elevated in the fasting state after BPD-DS and a marked response to a test meal is seen, likely due to the rapid stimulation of intraluminal nutrients in the distal ileum. In spite of this, dumping symptoms are uncommon.

Keywords
Duodenal switch, Gastric emptying, PYY, Scintigraphy, Morbid obesity, Dumping
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-131876 (URN)10.1007/s11695-010-0288-7 (DOI)000289114300011 ()20862615 (PubMedID)
Available from: 2010-10-08 Created: 2010-10-08 Last updated: 2017-12-12Bibliographically approved
4. Superior weight loss and lower HbA1c 3 years after duodenal switch compared with Roux-en-Y gastric bypass: a randomized controlled trial
Open this publication in new window or tab >>Superior weight loss and lower HbA1c 3 years after duodenal switch compared with Roux-en-Y gastric bypass: a randomized controlled trial
2012 (English)In: Surgery for Obesity and Related Diseases, ISSN 1550-7289, E-ISSN 1878-7533, Vol. 8, no 3, p. 338-343Article in journal (Refereed) Published
Abstract [en]

Background: Obesity is a rising threat to public health. The relative increase in the incidence of morbid obesity is most pronounced in the most severely obese. Roux-en-Y gastric bypass (RYGB) results in inferior weight loss in this group. Therefore, we have offered biliopancreatic diversion with duodenal switch (BPD/DS) as an alternative for this patient category. Our objective was to compare BPD/DS and RYGB in the surgical treatment of morbid obesity in patients with a body mass index (BMI) >48 kg/m(2). The setting was a university hospital in Sweden.

Methods: In a controlled trial (registration number 1SRCTN10940791), 47 patients (25 men, BMI 54.5 +/- 6.1 kg/m(2)) were randomized to RYGB (n = 23) or BPD/DS (n = 24). Biochemical data were collected preoperatively and 1 and 3 years postoperatively. A questionnaire addressing weight, general satisfaction, and gastrointestinal symptoms was distributed a median of 4 years postoperatively.

Results: Both procedures were safe. The duration of surgery and postoperative morphine consumption were greater after BPD/DS than after RYGB (157 versus 117 min and 140 versus 93 mg, respectively). BPD/DS resulted in greater weight loss than RYGB (-23.2 +/- 4.9 versus 16.2 +/- 6.9 BMI units or 80% +/- 15% versus 51% +/- 23% excess BMI loss, P < .001). BPD/DS yielded lower glucose and glycated hemoglobin levels at 3 years. More patients listed troublesome diarrhea and malodorous flatus in the questionnaire after BPD/DS, but no significant difference was seen (P = .078 and P = .073, respectively).

Conclusions: BPD/DS produced superior weight results and lower glycated hemoglobin levels compared with RYGB in patients with a BMI >48 kg/m(2). Both operations yield high satisfaction rates. However, diarrhea tended to be more common after BPD/DS.

Keywords
Duodenal switch, Roux-en-Y gastric bypass, Weight loss, Abdominal symptoms, Glucose control
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-131888 (URN)10.1016/j.soard.2012.01.014 (DOI)000304520900015 ()
Note
Manuscript title: Superior weight loss and glucose control three years after duodenal switch compared to Roux-en-Y gastric bypassAvailable from: 2010-10-09 Created: 2010-10-09 Last updated: 2017-12-12Bibliographically approved

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