Caruana Joseph A, Monte Scott V, Jacobs David M, Voytovich Catherine, Ghanim Husam, Dandona Paresh
State University of New York at Buffalo School of Medicine, Buffalo, New York, USA.
State University of New York at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York, USA.
Surg Obes Relat Dis. 2015 Nov-Dec;11(6):1248-55. doi: 10.1016/j.soard.2015.08.001. Epub 2015 Aug 4.
For patients with poor weight loss (WL) after Roux-en-Y gastric bypass (RYGB) there are few well-tolerated and effective surgical options. Revision to distal bypass by shortening of the common channel (CC) induces significant WL but often produces protein calorie malnutrition (PCM) and severe diarrhea.
The aim of this study was to identify a safe and effective threshold for distal small bowel bypass when done for revision of gastric bypass.
Academic Institution, United States.
We performed revision of RYGB for WL in 20 patients by shortening the CC to a new length of 120-300 cm. The Roux limb length was unchanged. WL and PCM were monitored. A threshold for percent of small bowel bypassed at which PCM was avoided was retrospectively determined. WL was then compared in patients above and below this threshold. Five patients completed a 250-kcal mixed meal challenge before and 3 months after revision to determine selected gut hormone responses.
Bypassing ≥70% small bowel resulted in PCM in 4 of 10 patients but in none of 10 patients below that threshold. PCM was observed as late as 2 years after revision and necessitated rerevision by lengthening of the CC in 3 patients. Additionally, nocturnal diarrhea was more common and more intractable when ≥70% bypass was done. Both groups had significant excess body WL over 2 years, but it was greater in patients with ≥70% bypass (47±19 versus 26±17; P<.05). A favorable gut hormone response was observed with 3-hour decrease in glucose-dependent insulinotropic peptide (GIP) by 25% and increase in glucagon-like peptide-1 (GLP-1) by 25%, whereas fasting peptide-YY (PYY) increased by 71% (P<.05 for all).
Revision of RYGB to distal bypass when it is <70% of a patient's small bowel length results in an acceptable balance of WL and a positive safety profile. WL may be mediated through an enhanced gut hormone effect, an aversion to ingested fat, and possibly other mechanisms.
对于接受 Roux - en - Y 胃旁路术（RYGB）后体重减轻（WL）不佳的患者，几乎没有耐受性良好且有效的手术选择。通过缩短共同通道（CC）来改为远端旁路手术可显著减轻体重，但常导致蛋白质热量营养不良（PCM）和严重腹泻。
本研究的目的是确定在进行胃旁路术翻修时远端小肠旁路的安全有效阈值。
美国学术机构。
我们对 20 例因体重减轻而接受 RYGB 翻修手术的患者，将 CC 缩短至新长度 120 - 300 cm。Roux 袢长度不变。监测体重减轻和 PCM 情况。回顾性确定避免出现 PCM 时小肠旁路百分比的阈值。然后比较该阈值上下患者的体重减轻情况。5 例患者在翻修前和翻修后 3 个月完成了 250 千卡混合餐激发试验，以确定所选肠道激素反应。
旁路超过 70%小肠的 10 例患者中有 4 例出现 PCM，而低于该阈值的 10 例患者中无一例出现。PCM 在翻修后 2 年时仍有观察到，3 例患者因 PCM 需要通过延长 CC 进行再次翻修。此外，当旁路超过 70%时，夜间腹泻更常见且更难治疗。两组在 2 年内均有显著的多余体重减轻，但旁路超过 70%的患者体重减轻更多（47±19 与 26±17；P<.05）。观察到有益的肠道激素反应，葡萄糖依赖性促胰岛素多肽（GIP）在 3 小时内下降 25%，胰高血糖素样肽 -1（GLP -1）增加 25%，而空腹肽 YY（PYY）增加 71%（所有 P<.05）。
当 RYGB 翻修为远端旁路且旁路长度小于患者小肠长度的 70%时，可在体重减轻和良好安全性之间取得可接受的平衡。体重减轻可能通过增强的肠道激素作用、对摄入脂肪的厌恶以及可能的其他机制介导。
