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.

Τα επίπεδα της γκρελίνης και του PYY μετά από χειρουργείο χολοπαγκρεατικής εκτροπής και Roux-en-Y γαστρικού bypass και μετά από χειρουργείο κολεκτομής: προοπτική συγκριτική μελέτη Οι ορμόνες του γαστρεντερικού γκρελίνη και PYY έχει αποδειχθεί ότι παίζουν κάποιο ρόλο στη ρύθμιση του μεταβολισμού και της όρεξης. Μελετάμε την επίδραση του χειρουργείου της χολοπαγκρεατικής εκτροπής και RYGBP (BPD-RYGBP) στα κυκλοφορούντα επίπεδα της γκρελίνης και του PYY άμεσα μετεγχειρητικά και τα συγκρίνουμε με την αντίστοιχη επίδραση μιας άλλης χειρουργικής επέμβασης της ίδιας βαρύτητας, την κολεκτομή. Μέθοδος. Μελετάμε τα επίπεδα νηστείας της γκρελίνης και του PYY σε 20 παχύσαρκους ασθενείς (super-obese) που υποβλήθηκαν σε BPDRYGBP και σε 13 ασθενείς που υποβλήθηκαν σε κολεκτομή για καρκίνο παχέος εντέρου. Οι μετρήσεις έγιναν προεγχειρητικά, και τις μετεγχειρητικές ημέρες 1,3,7,30 και 90 και στις δύο ομάδες, καθώς και στον 1 χρόνο στην ομάδα των παχυσάρκων. Αποτελέσματα. Προεγχειρητικά, τα επίπεδα και της γκρελίνης και του PYY ήταν χαμηλότερα στην ομάδα των παχυσάρκων. Μια προσωρινή μείωση των τιμών της γκρελίνης παρατηρήθηκε και στις δύο ομάδες άμεσα μετεγχειρητικά με σταδιακή επάνοδο στα προεγχειρητικά επίπεδα έως τον 3ο μήνα. Επιπλέον τα επίπεδα της γκρελίνης αυξήθηκαν 40%, σε σύγκριση με τα προεγχειρητικά, στην ομάδα των παχυσάρκων στον 1ο χρόνο παρακολούθησης. Τα επίπεδα του PYY στην ομάδα των κολεκτομών μειώθηκαν τις πρώτες 3 μετεγχειρητικές ημέρες και έπειτα επέστρεψαν στα προεγχειρητικά. Σε αντίθεση, τα επίπεδα του PYY στην ομάδα των παχυσάρκων δεν άλλαξαν άμεσα μετεγχειρητικά αλλά αυξήθηκαν σε επίπεδα 50% υψηλότερα στον 3ο μήνα και 170% υψηλότερα στον 1ο χρόνο, σε σύγκριση με τα προεγχειρητικά. Συμπεράσματα. Η μεγάλη μετεγχειρητική αύξηση των επιπέδων της ανορεξιογόνου ορμόνης PYY μετά από BPD-RYGBP μπορεί να παίζει ρόλο στην μειωμένη όρεξη που παρατηρείται μετά από αυτό τον τύπο βαριατρικής επέμβασης. Οι αλλαγές της γκρελίνης μετεγχειρητικά κάνουν τη συμμετοχή της ορμόνης αυτής στη μείωση της όρεξης λιγότερο πιθανή. / Ghrelin and Peptide YY levels anfter a variant of biliopancreatic diversion with Roux-en-Y gastric bypass versus after colectomy: A prospective comparative study Background. The gastrointestinal peptide hormones ghrelin and PYY, have been shown to play a role in the regulation of metabolism and apetite. We investigate the effect of the biliopancreatic diversion with Roux-en-Y gastric bypass (BPD-RYGBP) procedure on the circulating levels of ghrelin and PYY during the first 3 months postoperatively as compared to the effects of colectomy, an abdominal operation of similar severity. Methods. We determined the fasting plasma levels of ghrelin and PYY in 20 morbidly super obese patients that underwent BPD-RYGBP and in 13 subjects that underwent a colectomy because of large bowel cancer. Fasting plasma ghrelin and PYY levels were measured preoperatively and during the postoperative period on days 1,3,7,30 and 90 in all patients of both groups and at the 1 year for the patients who had attained 1-year follow up. Results. Preoperatively, both plasma ghrelin and PYY levels were lower in the BPD-RYGBP group of patients. A temporary decrease in plasma ghrelin levels was observed in both groups of patients during the immediate postoperative period with a gradual return to preoperative levels by the third month. In addition, ghrelin concentrations increased at one year to levels 40% higher than those in baseline, in ten of the BPD-RYGBP patients who had completed the one-year follow up (p=0.004). Plasma PYY levels in the colectomy group decreased the first three postoperative days and then returned to baseline. In contrast, PYY levels in the BPD-RYGBP group did not change during the early postopera¬tive period but increased to levels 50% higher at 3 months (p<0.001) and 170% higher at one year (p<0.001) than the baseline. Conclusions. The great postoperative increase of the levels of the anorexigenic peptide PYY following BPD-RYGBP may contribute to the reduced appetite observed after this type of bariatric surgery. The changes in ghrelin levels postoperatively make its contribution to the appetite suppression less likely.

Studies have shown that following bariatric surgery, there is an almost immediate reversal of type 2 diabetes. However, there still remains questions as to why this occurs and what possible explanations there may be. This paper aims to focus on several studies that have found a reversal of diabetes in obese patients who have undergone bariatric surgery. Furthermore, it explores several possibilities for the reasons behind this reversal including the role of AMP-activated protein kinase, the incretins gastric inhibitory peptide and glucagon-like peptide-1, and also looks at genetics. Bariatric surgery and a description of certain mechanisms are first described for an understanding. Following is a literature review of published studies on bariatric surgery, the reversal of diabetes following the procedure, and roles of AMPK and incretins. Because of the possibility that reduced caloric intake may not be the major factor in the diabetic reversal, it is suggested that further research be done on obese and normal weight patients and observe the levels of the mentioned mechanisms and also various genes to see if they offer a more thorough explanation.

Ο στόχος της παρούσας μελέτης ήταν η σύγκριση των αποτελεσμάτων και των μεταβολικών επιπλοκών της γαστρικής παράκαμψης Roux-en-Y και μιας εκδοχής της χολοπαγκρεατικής εκτροπής σε έναν αποκλειστικά non-superobese πληθυσμό. Τα κύρια χαρακτηριστικά της χολοπαγκρεατικής εκτροπής ήταν: γαστρικός θύλακος 15 ± 5 pml, χολοπαγκρεατική έλικα 200 cm, κοινό κανάλι 100 cm και διατροφική έλικα το λοιπό λεπτό έντερο. Τα κύρια χαρακτηριστικά της RYGBP ήταν: γαστρικός θύλακος 15 ± 5 ml, χολοπαγκρεατική έλικα 60 cm, Roux έλικα 100 cm και κοινό κανάλι το υπόλοιπο μήκος του λεπτού εντέρου. Από 130 ασθενείς με BMI 35-50 kg/m2, οι 65 υποβλήθηκαν σε RYGBP και οι 65 σε BPD. ΄Ολοι οι ασθενείς ολοκλήρωσαν το δεύτερο μετεγχειρητικό έτος. Η μέση απώλεια υπερβάλλοντος βάρους (excess weight loss, %EWL) ήταν καλύτερη μετά από BPD καθόλη τη διάρκεια του follow-up, ενώ στα 2 χρόνια η EWL ήταν > 50% στο 100% των ασθενών της BPD σε σύγκριση με το 88.7% της RYGBP. Η παθολογική ανοχή γλυκόζης, η υπερχοληστερολαιμία, η υπερτριγλυκεριδαιμία και η υπνική άπνοια παρουσίασαν πλήρη ύφεση και στις δύο ομάδες, αλλά τα μέσα επίπεδα ολικής χοληστερόλης ήταν σημαντικά χαμηλότερα μετά από BPD στα 2 χρόνια. Ο διαβήτης υποχώρησε πλήρως σε όλους τους ασθενείς της BPD και σε 7 στους 10 ασθενείς της RYGBP. Δεν παρατηρήθηκαν στατιστικά σημαντικές διαφορές στις πρώιμες και όψιμες μη μεταβολικές επιπλοκές. Υποαλβουμιναιμία παρατηρήθηκε σε 1 ασθενή της RYGBP (1.5%) και σε 6 ασθενείς της BPD (9.2%). Μόνο ένας ασθενής από κάθε ομάδα χρειάστηκε νοσηλεία και ολική παρεντερική διατροφή. Συμπεραίνουμε πως οι μεταβολικές επιπλοκές μετά από BPD δεν ήταν σοβαρές και δεν παρουσίαζαν στατιστικά σημαντική διαφορά ανάμεσα στις δύο ομάδες, οπότε και οι δύο επεμβάσεις είναι ασφαλείς και αποτελεσματικές σε non-superobese πληθυσμούς, αλλά η BPD είναι πιο αποτελεσματική στην απώλεια βάρους και στην επίλυση του διαβήτη και της υπερχοληστερολαιμίας. / The aim of the present study was the comparison of the effectiveness and the metabolic complications of Roux-en-Y gastric bypass (RYGBP) versus a variant of biliopancreatic diversion (BPD) in an exclusively non-superobese population. The main characteristics of the BPD were: gastric pouch 15 ± 5 ml, biliopancreatic limb 200 cm, common channel 100 cm and alimentary limb the remainder of the small intestine. The main characteristics of the RYGBP were: gastric pouch 15 ± 5 ml, biliopancreatic limb 60 cm, Roux limb 100 cm and common channel the remainder of the small intestine. Of 130 patients with BMI 35-50 kg/m2, 65 underwent RYGBP and 65 underwent BPD. All patients completed their second postoperative year. Mean excess weight loss (EWL) was better after BPD at all time periods, and the %EWL was > 50% in all BPD patients compared to 88.7% of RYGBP patients. Glucose intolerance, hypercholesterolemia, hypertriglyceridemia and sleep apnea completely resolved in all patients in both groups, although mean total cholesterol level was significantly lower in BPD patients at second year. Diabetes completely resolved in all BPD patients and in 7 of the 10 RYGBP patients. No statistically significant differences were observed between the two groups in early and late non-metabolic complications. Hypoalbuminemia occured in only 1 patient after RYGBP (1.5%) and in 6 patients after BPD (9.2%). Only 1 patient from each group was hospitalized and received total parenteral nutrition. We conclude that the metabolic complications that occured following this type of BPD were not severe nor significantly different between the two groups, therefore both operations can be considered safe and effective for non-superobese patients, but BPD is more effective in weight loss as well as the resolution of diabetes and hypercholesterolemia.

No description available.

Introdução: A obesidade é uma afecção com alta prevalência no Brasil e no mundo. É fator de risco para comorbidades como Diabetes tipo 2 (DM2), Hipertensão Arterial Sistêmica (HAS), Dislipidemia, Apneia Obstrutiva do Sono (AOS), entre outras. Seu tratamento é complexo e a cirurgia bariátrica, executada por diferentes técnicas, tem sido uma das opções. Objetivo: Analisar os resultados publicados na literatura em relação às técnicas cirúrgicas de Banda Gástrica Ajustável (BGA), Gastrectomia Vertical (GV), Gastroplastia com derivação em Y de Roux (GDYR) e Derivação Biliopancreática (DBP) - técnica de \"Scopinaro\" e de \"Duodenal Switch\" quanto às complicações operatórias, à mortalidade, à perda do excesso de peso (PEP) e ao reganho, e a resolução das comorbidades após a operação. Método: Foram analisados 116 estudos selecionados na base de dados MEDLINE por meio da PubMed publicados na Língua Inglesa entre 2003 e 2014. Para comparar as diferentes técnicas cirúrgicas (BGA, GV, GDYR e DBP), realizou-se estudo estatístico por meio da análise de variância (ANOVA) aplicando os testes de Duncan e de Kruskal Wallis avaliando: complicações pós-operatórias (fístula, sangramento e óbito); perda e reganho do excesso de peso, e resolução das comorbidades. Resultados: A ocorrência de sangramento foi de 0,6% na média entre todos os estudos, sendo 0,44% na BGA; 1,29% na GV; 0,81% na GDYR e 2,09% na DBP. Já a ocorrência de fístulas foi de 1,3% na média entre todos os estudos, 0,68% para BGA; 1,93% para GV; 2,18% para GDYR e 5,23% para DBP. A mortalidade nos primeiros 30 dias pós-operatórios foi de 0,9% na média entre todos os estudos, 0,05% na BGA; 0,16% na GV; 0,60% na GDYR e 2,52% na DBP. A PEP após cinco anos na média entre todos os estudos foi de 63,86%, especificamente na BGA, foi de 48,35%; 52,7% na GV; 71,04% na GDYR e 77,90% na DBP. A taxa de DM2 resolvida foi de 76,9% na média entre todos os estudos, sendo 46,80% na BGA; 79,38% na GV; 79,86% na GDYR e 90,78% na DBP. A taxa de Dislipidemia resolvida após a operação foi de 74,0% na média de todo o estudo, sendo 51,28% na BGA; 58,00% na GV; 73,28% na GDYR e 90,75% na DBP. A taxa de HAS resolvida após a operação foi de 61,80% na média de todo o estudo, sendo 54,50% na BGA; 52,27% na GV; 68,11% na GDYR e 82,12% na DBP. A taxa de AOS resolvida após a operação foi de 75,0% na média de todo o estudo, sendo 56,85% na BGA; 51,43% na GV; 80,31% na GDYR e 92,50% na DBP. Conclusão: quando analisadas e comparada as quatro técnicas observa-se que nos primeiros 30 dias pós-operatório a taxa de sangramento é superior nos pacientes submetidos à DBP e taxa de fístula inferior nos pacientes da BGA. Quanto à mortalidade observou-se taxa mais pronunciada nos pacientes submetidos à DBP e menos nos submetidos à BGA. Quanto à PEP observou-se uma uniformidade entre os pacientes submetidos à GV, GDYR E DBP até o terceiro ano. Após esse período observa-se reganho de peso nos submetidos à GV até o quinto ano de seguimento. Já nos pacientes submetidos à BGA observou-se taxas de PEP menos pronunciadas em relação às demais desde o início do seguimento. Quanto à resolução das comorbidades observou-se taxas de resolução de DM2 inferiores nos pacientes submetidos à BGA, e não houve diferença entre nenhuma técnica quanto à resolução das demais comorbidades: HAS, AOS e dislipidemia / Introduction: Obesity is a disease with high prevalence in Brazil and worldwide. It is a risk factor for comorbidities such as type 2 diabetes (T2D), hypertension, dyslipidemia, obstructive sleep apnea, among others. Treatment is complex and bariatric surgery, performed by different techniques, has been one of the options. Objective: To analyze the surgical the results presented in the literature related to techniques of Adjustable Gastric Banding (AGB), Sleeve Gastrectomy(SG), Roux-en-Y Gastric Bypass(RYGB) and Biliopancreatic Diversion(BPD) - (\"Scopinaro\" and \"Duodenal Switch\" procedures) as to the postoperative complications, mortality, excess weight loss (EWL) and regain, and resolution of the comorbidities after surgery. Method: 116 studies were selected in MEDLINE through PubMed published in the English language between 2003 and 2014. To compare the different surgical techniques (AGB, SG, RYGB, BPD), statistical analysis was performed by analysis of variance applying Duncan and Kruskal Wallis tests assessing: postoperative complications (leak, bleeding and death); EWL and regained, and resolution of comorbidities after surgery. Results: The incidence of bleeding was in average 0.6% from all studies; 0.44% in AGB; 1.29% for SG; 0.81% RYGB and 2.09% for BPD. The average incidence of leaks was 1.3% in all studies; 0.68% for AGB; 1.93% in SG; 2.18% RYGB and 5.23% for BPD. Average mortality in the first 30 postoperative days was 0.9% in all studies; 0.05% for AGB; 0.16% in SG; 0.60% in RYGB and 2.52% in BPD. The average percentage of EWL after five years in all studies was 63.86%, specifically in AGB it was 48.35%; 52.7% in SG; 71.04% in RYGB and 77.90% in BPD. The rate of T2D resolved was in average 76.9% across all studies, 46.80% for AGB; 79.38% for SG; 79.86% RYGB and 90.78% for BPD. The rate of dyslipidemia resolved was in average 74.00% across all studies, 51.28% for AGB; 58.00% for SG; 73.28% RYGB and 90.75% for BPD. The rate of hypertension resolved was in average 61.80% across all studies, 54.50% for AGB; 52.27% for SG; 68.11% for RYGB and 82.12% for BPD. The rate of apnea resolved was in average 75.00% across all studies, 56.85% for AGB; 51.43% for SG; 80.31% for RYGB and 92.50% for BPD. Conclusion: After analyzing and comparing the four techniques it was observed that in the first 30 postoperative days the bleeding rate is higher in patients undergoing BPD and lower fistula rate in patients undergoing AGB. Regarding mortality was observed higher rate in patients undergoing BPD and smaller in patients undergoing AGB. As for EWL there was uniformity among patients submitted to SG, RYGB and BPD until the third year. After this period there has been regained weight in the patients submitted to SG until the fifth year. The patients undergoing AGB have lower rates of EWL. As for the resolution of comorbidities, observed T2D resolution rates were lower in patients undergoing AGB, and there was no difference between the techniques regarding: hypertension, dyslipidemia and obstructive sleep apnea

Obesity is the fifth leading cause of global deaths. The efficacy and safety of obesity treatment is still controversial. The objective of the thesis is to evaluate the efficacy and safety of bariatric surgery, through a systematic review of the current evidence and meta- analysis of important outcomes. Nineteen (19) randomized controlled trials (RCTs) with 1346 participants were included. Bariatric surgery resulted in greater weight loss when compared to non-surgical treatment. Weight loss was also associated with resolution and/or improvement of obesity related comorbidites such as diabetes, hypertension, hyperlipidemia, and sleep apnea. Weight loss and safety varied across the surgical procedures. Biliopancreatic diversion/duodenal switch had the greatest weight loss, followed by sleeve gastrectomy and Roux-en-Y gastric bypass, purely restrictive procedures such as vertical banded gastroplasty and adjustable gastric banding resulted in the least weight loss. Long term, high quality, and adequately powered trials are still needed to support the available evidence

Η χολοπαγκρεατική εκτροπή αποτελεί την πιο αποτελεσματική μέθοδο της βαριατρικής χειρουργικής όσο αφορά την απώλεια του βάρους και την υποχώρηση του σακχαρώδους διαβήτη τύπου 2, συνοδεύεται όμως συχνά από σημαντική έλλειψη θρεπτικών συστατικών. Η επιμήκης γαστρεκτομή είναι μια σχετικά νέα επέμβαση, η οποία σύμφωνα με μελέτες προκαλεί σημαντικού βαθμού απώλεια βάρους και υποχώρηση του σακχαρώδους διαβήτη τύπου 2. Σκοπός: Η προοπτική εκτίμηση και σύγκριση της επίδρασης της χολοπαγκρεατικής εκτροπής μακρών ελίκων και της λαπαροσκοπικής επιμήκους γαστρεκτομής στην υποχώρηση του σακχαρώδους διαβήτη τύπου 2, της υπέρτασης και της δυσλιπιδαιμίας, καθώς επίσης και στα επίπεδα ινσουλίνης, γλυκαγόνης, γκρελίνης, PYY και GLP-1( σε νηστεία αλλά και μετά από τη λήψη γλυκόζης ) σε ασθενείς με κλινικά σοβαρή παχυσαρκία και σακχαρώδη διαβήτη τύπου2. Μέθοδος: Δώδεκα ασθενείς (ΔΜΣ 57.6±9.9 kg/m2) υποβλήθηκαν σε χολοπαγκρεατική εκτροπή μακρών ελίκων και δώδεκα (ΔΜΣ 43.7±2.1 kg/m2 ) σε λαπαροσκοπική επιμήκη γαστρεκτομή. Όλοι οι ασθενείς παρουσίαζαν σακχαρώδη διαβήτη τύπου 2 και μελετήθηκαν προεγχειρητικά και σε 1, 3 και 12 μήνες μετά το χειρουργείο. Σε όλους τους χρόνους υποβλήθηκαν σε από του στόματος δοκιμασία ανοχής γλυκόζης. Αποτελέσματα: Το σωματικό βάρος σημείωσε σημαντική και αναλόγου μεγέθους μείωση και στις δύο ομάδες (Ρ<0.001). Στους 12 μήνες η ποσοστιαία απώλεια του υπερβάλλοντος σωματικού βάρους ήταν παρόμοια στις δύο ομάδες (Ρ=0.8) και ο σακχαρώδης διαβήτης είχε υποχωρήσει σε όλους τους ασθενείς. Η γλυκόζη, η ινσουλίνη και η αντίσταση στη δράση της παρουσίαζαν σημαντική μείωση έπειτα και από τις δύο επεμβάσεις, όμως η ευαισθησία στην ινσουλίνη ενισχύθηκε περισσότερο έπειτα από τη χολοπαγκρεατική εκτροπή (Ρ=0.003). Η αρτηριακή πίεση, η ολική και η LDL χοληστερόλη μειώθηκαν σημαντικά έπειτα από τη χολοπαγκρεατική εκτροπή (Ρ<0.001), όχι όμως και μετά την επιμήκη γαστρεκτομή. Τα τριγλυκερίδια μειώθηκαν σημαντικά και στις δύο ομάδες, ενώ η HDL χοληστερόλη παρουσίασε σημαντική αύξηση μόνο μετά την επιμήκη γαστρεκτομή (Ρ<0.001). Τα επίπεδα γκρελίνης νηστείας δεν μεταβλήθηκαν σημαντικά μετά τη χολοπαγκρεατική εκτροπή (Ρ=0.2), ενώ σημείωσαν σημαντική μείωση μετά την επιμήκη γαστρεκτομή (Ρ<0.001). Η απόκριση των ΡΥΥ και GLP-1 ενισχύθηκε σημαντικά και στις δύο ομάδες ασθενών (Ρ=0.001). Συμπεράσματα: Η λαπαροσκοπική επιμήκης γαστρεκτομή οδήγησε σε αναλόγου βαθμού απώλεια σωματικού βάρους και υποχώρηση του σακχαρώδη διαβήτη τύπου 2 με τη χολοπαγκρεατική εκτροπή μακρών ελίκων. Η χολοπαγκρεατική εκτροπή όμως ήταν περισσότερο αποτελεσματική όσο αφορά τη βελτίωση της ευαισθησίας στην ινσουλίνη, της δυσλιπιδαιμίας και της αρτηριακής υπέρτασης. / Biliopancreatic diversion (BPD) is the most effective bariatric procedure in terms of weight loss and remission of diabetes type 2 (DM2) but it is accompanied by nutrient deficiencies. Sleeve gastrectomy (SG) is a relatively new restrictive operation that has shown promising results concerning DM2 resolution and weight loss. Objective: To evaluate and compare prospectively the effects of BPD long limb (BPDLL) and SG on remission of DM2, hypertension and dyslipidemia and also on fasting, and glucose-stimulated insulin, glucose, glucagon, ghrelin, PYY and glucagon-like peptide-1 (GLP-1) levels in morbidly obese patients with DM2. Methods: Twelve patients (BMI 57.6±9.9 kg/m2) underwent BPDLL and 12 (BMI 43.7±2.1 kg/m2) underwent SG. All patients had DM2 and were evaluated before and 1, 3 and 12 months after surgery. Oral glucose tolerance test and blood sampling were carried out after an overnight fast and 30, 60 and 120 minutes after glucose ingestion. Results: Body weight decreased markedly in both groups (P<0.001); excess weight loss was similar in both groups at 12 months (P=0.08) and DM2 resolved in all patients. Glucose, insulin and insulin resistance decreased significantly after both procedures, but the BPDLL group had higher insulin sensitivity than the SG group at 1 year (P=0.003). Blood pressure, total and LDL cholesterol decreased markedly after BPDLL (P<0.001) but not after SG. Triglycerides decreased significantly after both operations but HDL increased significantly after SG only (p<0.001). Fasting ghrelin did not change significantly after BPDLL (P=0.2), but decreased markedly after SG (P<0.001). Fasting GLP-1 and PYY increased significantly after BPDLL only (P=0.01), however GLP-1 and PYY responses to glucose were significantly enhanced in both groups (P=0.001). Conclusion: SG results in weight loss and resolution of DM2 comparable to BPDLL, but BPDLL is more effective in terms of dyslipidemia resolution and blood pressure reduction.

Introdução: A obesidade é uma afecção com alta prevalência no Brasil e no mundo. É fator de risco para comorbidades como Diabetes tipo 2 (DM2), Hipertensão Arterial Sistêmica (HAS), Dislipidemia, Apneia Obstrutiva do Sono (AOS), entre outras. Seu tratamento é complexo e a cirurgia bariátrica, executada por diferentes técnicas, tem sido uma das opções. Objetivo: Analisar os resultados publicados na literatura em relação às técnicas cirúrgicas de Banda Gástrica Ajustável (BGA), Gastrectomia Vertical (GV), Gastroplastia com derivação em Y de Roux (GDYR) e Derivação Biliopancreática (DBP) - técnica de \"Scopinaro\" e de \"Duodenal Switch\" quanto às complicações operatórias, à mortalidade, à perda do excesso de peso (PEP) e ao reganho, e a resolução das comorbidades após a operação. Método: Foram analisados 116 estudos selecionados na base de dados MEDLINE por meio da PubMed publicados na Língua Inglesa entre 2003 e 2014. Para comparar as diferentes técnicas cirúrgicas (BGA, GV, GDYR e DBP), realizou-se estudo estatístico por meio da análise de variância (ANOVA) aplicando os testes de Duncan e de Kruskal Wallis avaliando: complicações pós-operatórias (fístula, sangramento e óbito); perda e reganho do excesso de peso, e resolução das comorbidades. Resultados: A ocorrência de sangramento foi de 0,6% na média entre todos os estudos, sendo 0,44% na BGA; 1,29% na GV; 0,81% na GDYR e 2,09% na DBP. Já a ocorrência de fístulas foi de 1,3% na média entre todos os estudos, 0,68% para BGA; 1,93% para GV; 2,18% para GDYR e 5,23% para DBP. A mortalidade nos primeiros 30 dias pós-operatórios foi de 0,9% na média entre todos os estudos, 0,05% na BGA; 0,16% na GV; 0,60% na GDYR e 2,52% na DBP. A PEP após cinco anos na média entre todos os estudos foi de 63,86%, especificamente na BGA, foi de 48,35%; 52,7% na GV; 71,04% na GDYR e 77,90% na DBP. A taxa de DM2 resolvida foi de 76,9% na média entre todos os estudos, sendo 46,80% na BGA; 79,38% na GV; 79,86% na GDYR e 90,78% na DBP. A taxa de Dislipidemia resolvida após a operação foi de 74,0% na média de todo o estudo, sendo 51,28% na BGA; 58,00% na GV; 73,28% na GDYR e 90,75% na DBP. A taxa de HAS resolvida após a operação foi de 61,80% na média de todo o estudo, sendo 54,50% na BGA; 52,27% na GV; 68,11% na GDYR e 82,12% na DBP. A taxa de AOS resolvida após a operação foi de 75,0% na média de todo o estudo, sendo 56,85% na BGA; 51,43% na GV; 80,31% na GDYR e 92,50% na DBP. Conclusão: quando analisadas e comparada as quatro técnicas observa-se que nos primeiros 30 dias pós-operatório a taxa de sangramento é superior nos pacientes submetidos à DBP e taxa de fístula inferior nos pacientes da BGA. Quanto à mortalidade observou-se taxa mais pronunciada nos pacientes submetidos à DBP e menos nos submetidos à BGA. Quanto à PEP observou-se uma uniformidade entre os pacientes submetidos à GV, GDYR E DBP até o terceiro ano. Após esse período observa-se reganho de peso nos submetidos à GV até o quinto ano de seguimento. Já nos pacientes submetidos à BGA observou-se taxas de PEP menos pronunciadas em relação às demais desde o início do seguimento. Quanto à resolução das comorbidades observou-se taxas de resolução de DM2 inferiores nos pacientes submetidos à BGA, e não houve diferença entre nenhuma técnica quanto à resolução das demais comorbidades: HAS, AOS e dislipidemia / Introduction: Obesity is a disease with high prevalence in Brazil and worldwide. It is a risk factor for comorbidities such as type 2 diabetes (T2D), hypertension, dyslipidemia, obstructive sleep apnea, among others. Treatment is complex and bariatric surgery, performed by different techniques, has been one of the options. Objective: To analyze the surgical the results presented in the literature related to techniques of Adjustable Gastric Banding (AGB), Sleeve Gastrectomy(SG), Roux-en-Y Gastric Bypass(RYGB) and Biliopancreatic Diversion(BPD) - (\"Scopinaro\" and \"Duodenal Switch\" procedures) as to the postoperative complications, mortality, excess weight loss (EWL) and regain, and resolution of the comorbidities after surgery. Method: 116 studies were selected in MEDLINE through PubMed published in the English language between 2003 and 2014. To compare the different surgical techniques (AGB, SG, RYGB, BPD), statistical analysis was performed by analysis of variance applying Duncan and Kruskal Wallis tests assessing: postoperative complications (leak, bleeding and death); EWL and regained, and resolution of comorbidities after surgery. Results: The incidence of bleeding was in average 0.6% from all studies; 0.44% in AGB; 1.29% for SG; 0.81% RYGB and 2.09% for BPD. The average incidence of leaks was 1.3% in all studies; 0.68% for AGB; 1.93% in SG; 2.18% RYGB and 5.23% for BPD. Average mortality in the first 30 postoperative days was 0.9% in all studies; 0.05% for AGB; 0.16% in SG; 0.60% in RYGB and 2.52% in BPD. The average percentage of EWL after five years in all studies was 63.86%, specifically in AGB it was 48.35%; 52.7% in SG; 71.04% in RYGB and 77.90% in BPD. The rate of T2D resolved was in average 76.9% across all studies, 46.80% for AGB; 79.38% for SG; 79.86% RYGB and 90.78% for BPD. The rate of dyslipidemia resolved was in average 74.00% across all studies, 51.28% for AGB; 58.00% for SG; 73.28% RYGB and 90.75% for BPD. The rate of hypertension resolved was in average 61.80% across all studies, 54.50% for AGB; 52.27% for SG; 68.11% for RYGB and 82.12% for BPD. The rate of apnea resolved was in average 75.00% across all studies, 56.85% for AGB; 51.43% for SG; 80.31% for RYGB and 92.50% for BPD. Conclusion: After analyzing and comparing the four techniques it was observed that in the first 30 postoperative days the bleeding rate is higher in patients undergoing BPD and lower fistula rate in patients undergoing AGB. Regarding mortality was observed higher rate in patients undergoing BPD and smaller in patients undergoing AGB. As for EWL there was uniformity among patients submitted to SG, RYGB and BPD until the third year. After this period there has been regained weight in the patients submitted to SG until the fifth year. The patients undergoing AGB have lower rates of EWL. As for the resolution of comorbidities, observed T2D resolution rates were lower in patients undergoing AGB, and there was no difference between the techniques regarding: hypertension, dyslipidemia and obstructive sleep apnea

Orientador: Bruno Geloneze Neto / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-25T08:35:56Z (GMT). No. of bitstreams: 1 Osugue_FernandaSatakeNovaes_M.pdf: 1676622 bytes, checksum: 7191877ca5d0868820670be722afc0b1 (MD5) Previous issue date: 2014 / Resumo: Objetivo: Comparar o efeito incretínico de indivíduos normotolerantes à glicose e obesos portadores de diabetes tipo 2 e avaliar a melhora 1 e 12 meses após cirurgia bariátrica (técnica de derivação biliopancreática) em obesos portadores de diabetes tipo 2. Metodologia: Um estudo longitudinal prospectivo foi realizado com duração de um ano. O efeito incretiníco foi avaliado pela técnica de clamp isoglicêmico (teste intravenoso de infusão de glicose isoglicêmico). Foram avaliados 33 participantes , divididos em dois grupos : um grupo controle caracterizado por indivíduos saudáveis não obesos e obesos (n : 23, homens / mulheres : 2 /21, idade 42 ± 9 anos , IMC 27,7 ± 5,1 kg/m2 , A1C 5, 5 ± 0,4 %) e um grupo intervenção composto por pacientes diabéticos do tipo 2 (n : 10, homens / mulheres : 0/ 10 , idade 46 ± 9 anos , IMC 35,0 ± 3,6 kg/m2, A1C 7,7 ± 1,3% ) . O efeito incretínico foi calculado de acordo com a fórmula: 100% x [resposta secretora das células ? pancreáticas no de teste de tolerância oral à glicose - resposta secretora das células ? pancreáticas no teste intravenoso]/resposta secretora das células ? pancreáticas no de teste de tolerância oral à glicose. O índice HOMA ( do inglês, Homeostasis Model of Assessment) foi utilizado para avaliar a sensibilidade à insulina . Resultados: Foi detectado um aumento no efeito incretínico calculado pela taxa de secreção de insulina (TSI) no grupo de intervenção de um ano ( 65 ± 25%) após a cirurgia bariátrica em comparação com pré-operatório (49 ± 24%) e um mês de pós-operatório (52 ± 34%), estatisticamente significativa com p < 0,05 . A sensibilidade à insulina igualou-se ao grupo controle (HOMA -IR 1,3 ± 1,3) precocemente com um mês de pós-operatório (HOMA -IR 1,6 ± 1,2) e todos os pacientes estavam em remissão do diabetes após um ano pós-operatório. Com um mês pós-operatório, 10% do peso pré-operatório foi perdido e 20 % em 1 ano. Conclusão: A derivação biliopancreática é capaz de melhorar o efeito incretínico em pacientes diabéticos com alcance precoce da sensibilidade insulínica / Abstract: Objective: To compare the incretin effect of individuals with normal glucose tolerance and type 2 diabetes obese subjects and evaluate the improvement 1 and 12 months after bariatric surgery (biliopancreatic diversion technique) in type 2 diabetes obese group. Methodology: A prospective longitudinal study was performed lasting one year. The incretin effect was assessed by isoglycemic clamp technique (isoglycemic intravenous glucose infusion test). We assessed 33 participants divided among two groups: the control group characterized by healthy non obese and obese subjects (n: 23, men/women:2/21,age 42±9 years, IMC 27,7 ± 5,1 kg/m2 , A1C 5,5 ± 0,4 %) and the intervention group compound by type 2 diabetic patients (n: 10, men/women: 0/10, age 46 ± 9 years, IMC 35,0±3,6 kg/m2, A1C 7,7 ± 1,3%). The incretin effect was calculated according to the formula: 100% x [?-cell secretory response to oral glucose tolerance test ¿ intravenous ?-cell secretory response]/?-cell secretory response to oral glucose tolerance test. Homeostasis Model of Assessment (HOMA) was used to asses insulin sensitivity. Results: We reported an increase in incretin effect calculated by insulin secretion rate (ISR) in the intervention group one year (65± 25%) after bariatric surgery compared with preoperative (49± 24%) and one month postoperative (52± 34%), statistically significant with p < 0,05. The insulin sensitivity equaled to control group (HOMA-IR 1,3 ± 1,3) early with one month postoperative (HOMA-IR 1,6 ± 1,2) and all patients were in remission of diabetes one year postoperative. By one month postoperative, 10% of preoperative weight was lost and 20% at 1 year after surgery. Conclusion: The biliopancreatic diversion is able to improve incretin effect in diabetic patients with early insulin sensitivity range / Mestrado / Clinica Medica / Mestra em Clínica Médica