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.

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.

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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

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

Obesity has grown to epidemic proportions, and in lack of efficient life-style and medical treatments, the bariatric surgeries are performed in rising numbers. The most common surgery is the Gastric Bypass (GBP) surgery, with the Biliopancreatic diversion with duodenal switch (DS) as an option for the most extreme cases with a BMI>50 kg/m2. In paper I 20 GBP-patients were examined during the first post-operative year regarding the natriuretic peptide, NT-ProBNP, which is secreted from the cardiac ventricles. Levels of NT-ProBNP quickly increased during the first post-surgery week, and later established itself on a higher level than pre-surgery. In paper II we report of 5 patient-cases after GBP-surgery with severe problems with postprandial hypoglycaemia that were successfully treated with GLP-1-analogs. The effect of treatment could be observed both symptomatically and in some cases using continuous glucose measuring systems (CGMS). In paper III three groups of subjects; 15 post-GBP patients, 15 post-DS, and 15 obese controls were examined for three days using CGMS during everyday life. The post-GBP group had high glucose variability as measured by MAGE and CONGA, whereas the post-DS group had low variability. Both post-operative groups exhibited significant time in hypoglycaemia, about 40 and 80 minutes per day <3.3mmol/l and 20 and 40 minutes < 2.8mmol/l, respectively, longer time for DS-group. Remarkably, only about 20% of these hypoglycaemic episodes were accompanied with symptoms. In Paper IV the hypoglycaemia counter regulatory system was investigated; 12 patients were examined before and after GBP-surgery with a stepped hypoglycaemic hyperinsulinemic clamp. The results show a downregulation of symptoms, counter regulatory hormones (glucagon, cortisol, epinephrine, norepinephrine, growth hormone), incretin hormones (GLP-1 and GIP), and sympathetic nervous response. In conclusion patients post bariatric surgery exhibit a downregulated counter regulatory response to hypoglycaemia, accompanied by frequent asymptomatic hypoglycaemic episodes in everyday life. Patients suffering from severe hypoglycaemic episodes can often be treated successfully with GLP-1-analogues.

Made available in DSpace on 2014-12-17T14:13:58Z (GMT). No. of bitstreams: 1 IramiAF.pdf: 656108 bytes, checksum: 1ac30916d2a3afe1a1b29b6e3fa7c51f (MD5) Previous issue date: 2007-08-15 / The biliopancretic diversion with duodenal switch is one of the mixing techniques used in the treatment of morbid obesity. The duodenal switch reduces the stomach capacity and leaves only 50-100 cm of small intestine for nutrition and absorption. The surgery produces hormonal, structural and biochemical changes, which can influence on the result of scintigraphic examinations in operated patients. With the objective of evaluate the postoperative biodistribution of sodium pertechnetate (Na99mTcO4) in brain, thyroid, heart, lung, liver, spleen, kidney, stomach, duodenum, pancreas, small intestine, bladder, muscle and bone of Wistar rats. The rats were randomly allocated into 3 groups of 7 rats each: the duodenal switch group (DS), the control group (C) and the sham group (S). They were operated under anesthesia and aseptic technique. In the tenth postoperative day, 0.1mL of sodium pertechnetate was injected via orbital plexus. After 30 min the animals were killed with overdose of anesthetic and samples of liver, spleen, pancreas, stomach, duodenum, small intestine, thyroid, lung, heart, kidney, bladder, muscle, bone and brain were harvested, washed with saline and weighed. The detention of radioactivity was made using the automatic Gamma Counter Wizard, PerkinElmer and the percentage of activity per gram of tissue (%ATI/g) was calculated. There was no early or late mortality in either rats groups. The values of percent radioactivity per gram of tissue (%ATI/g), showed no significant difference in liver, stomach, small bowel, duodenum, kidney, heart, bladder, bone and brain, when compared the DS rats with sham and controls rats. A postoperative significant increase in mean %ATI/g levels was observed in spleen, pancreas and muscle in group DS rats, as compared to group S and C rats (p<0.05). In the lung there was an increase and in thyroid a decrease in mean %ATI/g of DS rats, when compared to sham rats (p>0.05). In conclusion, the biliopancreatic diversion with duodenal switch in rats modified the biodistribution of sodium pertechnetate in thyroid, lung, pancreas, spleen and muscle. The study had the participation of the departments and laboratories researches, as Nucleus of Experimental Surgery, Department of Surgery, Laboratory of Radiobiology, Department of Pathology and Service of Nuclear Medicine, certifying the character of a multidisciplinary research / A cirurgia do desvio biliopancre?tico ? uma das t?cnicas mistas utilizada no tratamento da obesidade m?rbida. O Switch duodenal reduz o est?mago a ? de sua capacidade e deixa apenas 50-100 cm de intestino delgado para nutri??o e absor??o. Isso leva a altera??es estruturais, hormonais e bioqu?micas que podem influenciar no resultado de exames cintilogr?ficos de pacientes operados. Com o objetivo de avaliar a biodistribui??o p?s-operat?ria do pertecnetato de s?dio (Na99mTcO4) em ?rg?os de diversos sistemas como c?rebro, tire?ide, cora??o, pulm?o, f?gado, ba?o, rim, est?mago, duodeno, p?ncreas, intestino delgado, bexiga, m?sculo e f?mur de ratos Wistar submetidos ? t?cnica do switch duodenal, foram utilizados ratos com 3 meses de idade alocados aleatoriamente em: grupo tratado, submetido ? cirurgia de desvio biliopancre?tico, t?cnica do switch duodenal (SD), o grupo controle (C) e o grupo submetido a uma simula??o de cirurgia, denominado sham (S). No d?cimo dia de p?s-operat?rio, 0,1 mL do pertecnetato de s?dio (Na99mTcO4) foi injetado via plexo orbital (IV). Decorridos trinta minutos da administra??o do radiof?rmaco, os animais foram sacrificados e submetidos a toracolaparotomia mediana para retirada do f?gado, ba?o, p?ncreas, est?mago, duodeno, intestino delgado, tire?ide, pulm?o, cora??o, rim, bexiga, m?sculo, f?mur e c?rebro. A detec??o da radioatividade foi feita com Contador Gama (Wizard, PerkinElmer USA), autom?tico. Calculou-se em seguida o percentual de atividade por grama de tecido (%ATI/g) do pertecnetato de s?dio (Na99m TcO4) em cada ?rg?o. Os valores da biodistribui??o do pertecnetato no ba?o, p?ncreas e m?sculo nos animais do grupo switch tiveram uma diferen?a significativamente maior do que os dos grupos C e S (p<0,05). Na tire?ide dos animais do grupo SD o pertecnetato teve menor capta??o em rela??o aos demais grupos, sendo estatisticamente significante quando comparada ao grupo S (p<0,05). A biodistribui??o pulmonar nos animais do grupo SD s? foi significativamente maior quando comparada a do grupo S (p<0,05). N?o houve diferen?a significante, para os demais ?rg?os. Em conclus?o, a t?cnica do desvio biliopancre?tico com switch duodenal alterou a biodistribui??o p?s-operat?ria do Na99mTcO4 em ?rg?os como tire?ide, pulm?o, ba?o, p?ncreas e m?sculo de ratos operados, devido a prov?veis altera??es metab?licas e estruturais causadas por t?cnica cir?rgica mutilante. O trabalho teve um car?ter multidisciplinar com a participa??o de pesquisadores de diferentes departamentos e laborat?rios, como N?cleo de Cirurgia Experimental, Departamento de Cirurgia, Laborat?rio de Radiobiologia e o Servi?o de Medicina Nuclear da Liga Norte-Riograndense contra o C?ncer, atestando o car?ter multidisciplinar da pesquisa