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Digestive adaptation: A new surgical proposal to treat obesity ORIGINAL ARTICLE
Digestive adaptation: A new surgical proposal to treat obesity Adaptação digestiva: Uma nova proposta cirúrgica para tratar a obesidade com base em Sérgio Santoro 1, Manoel Carlos Prieto Velhote 2, Carlos Eduardo Malzoni 3, Alexandre Sérgio Gracia Mechenas 4, ABSTRACT
omentectomia e enterectomia que mantém os primeiros 150 cm Objective: To report on a new surgical technique to treat obesity -
de jejuno e os últimos 150 cm de íleo. Os três primeiros pacientes Digestive Adaptation - and to present its preliminary results.
obesos tratados por esta técnica são apresentados. Resultados:
Method: The technique includes a vertical (sleeve) gastrectomy,
Com seguimento mínimo de seis meses, todos os pacientes estão omentectomy and enterectomy maintaining the initial 150-cm- livres de sintomas, referem saciedade mais precocemente e já portion of the jejunum and the final 150-cm-portion of the ileum.
estão com IMC menor que 31 Kg/m2. Conclusões: Este procedi-
The three first obese patients operated on are described. Results:
mento evita criar subestenoses, colocar próteses, excluir With a minimum follow-up of 6 months, all patients refer early segmentos digestivos do trânsito de nutrientes, gerar malabsorção satiety, are free of symptoms and have a BMI <31 Kg/m2.
e fundamentalmente, evita prejudicar funções digestivas. O Conclusions: This procedure does not use prostheses and does
procedimento visa gerar uma restrição moderada, o que colabora not cause exclusion of gastrointestinal segments. It does not para a saciedade precoce por distensão gástrica com menores create subocclusions neither malabsorption nor blind endoscopic volumes e visa também modificar as circunstâncias neuroendó- areas and above all, it causes no harm to important digestive crinas, retardando o esvaziamento gástrico, e gerando saciedade functions. Conversely, it aims at moderate restriction with early precoce e prolongada, paralelamente a mudanças positivas no satiety by distension, and at interfering in the neuroendocrine perfil metabólico. Baseado em dados fisiológicos recentemente profile, resulting in slow gastric emptying, early and prolonged descobertos, o procedimento pretende diminuir a produção de satiety, as well as positive changes in the metabolic profile. Based grelina, do inibidor da ativação do plasminogênio 1 (PAI-1), da on recent physiological data, the procedure aims at decreasing resistina e finalmente promover a secreção mais efetiva do the production of ghrelin, plasminogen activator inhibitor-1 (PAI-1) glucagon-like peptide 1 (GLP-1). O paciente operado não necessita and resistin, and at raising the levels of glucagon-like peptide-1 de suporte nutricional nem de uso crônico de medicações por (GLP-1). The patients operated on do not need nutritional support causa do procedimento, que é simples e fácil de ser realizado.
or to take drugs because of the procedure, which is easy and safeto perform.
DESCRITORES: Obesidade mórbida/cirurgia; Inibidor 1 de ativador
de plasminogênio; Omento/fisiologia; Tecido adiposo/fisiopatologia;
Keywords: Obesity, morbid/surgery; Plasminogen activator
Gastrectomia/métodos; Hormônios peptídicos; Citocinas/fisiologia inhibitor 1; Omentum/physiology; Adipose tissue/physiopathology;Gastrectomy/methods, Peptide hormones; Citokines/physiology INTRODUCTION
In the 20th century, we observed a great increase in the
incidence of obesity, hypertension, diabetes, hypertrigly- Objetivo: Esta é a comunicação preliminar, com resultados iniciais,
ceridemia, hypercholesterolemia, and other conditions de uma nova técnica cirúrgica para tratar a obesidade: Adaptação associated with changes in human diet. Nutritional Digestiva. Método: A técnica inclui uma gastrectomia vertical, a
education and medical treatment have failed to avoid * Study carried out at Hospital da Polícia Militar do Estado de São Paulo.
1 Master’s degree in Medicine by the Medical School of Universidade of São Paulo (FMUSP), Fellow of Colégio Brasileiro de Cirurgia Digestiva.
2 Ph.D. in Medicine by FMUSP, Assistant Professor of the Discipline of Pediatric Surgery of FMUSP.
3 Master’s degree in Medicine by FMUSP, Full member of Colégio Brasileiro de Cirurgiões4 Fellow of Colégio Brasileiro de Cirurgia Digestiva, Fellow of Sociedade Brasileira de Cirurgia Lapaoscópica5 Ph.D. in Medicine by the Department of Surgery of FMUSP, Assistant Professor of Digestive Surgery of FMUSP.
6 Clinician, Researcher in Rheumatology-Immunology, Ph.D. by Boston University, Post-doctorate by USP.
Corresponding author: Sérgio Santoro - R. São Paulo Antigo, 500 - apto. 111 SD, São Paulo - SP 05684-010 BRAZIL - e-mail: ssantoro@ajato.com.brReceived on September 4, 2003 – Accepted on November 14, 2003 Santoro S, Velhote MCP, Malzoni CE, Mechenas ASG, Strassmann V, Scheinberg M obesity, and many surgical techniques to treat extreme increase food intake and decrease use of fat(11-13).
obesity have been presented although none has been Ghrelin production drops after a meal and later on, it satisfactory. Current surgical treatment causes “another increases - this has been demonstrated as taking part disease” to counterbalance obesity. Some techniques in the mechanism of hunger(14). High ghrelin levels are result in malabsorption, yet unspecific, leading to loss not a common cause of obesity since it was demonstrated of non-caloric nutrients, such as calcium, iron, folic that obese individuals present low levels of this acid, etc., and to diarrhea(1). Some procedures pose hormone. However in case of significant weight loss, obstacles to ingestion of food, and others use prosthesis the levels of ghrelin raise, resulting in hunger and, that may cause subocclusions(2), and consequently, probably, contributing in gaining weight again(15).
dysphagia, vomiting, stasis esophagitis, etc. Many current PAI-1: Plasminogen activator inhibitor 1 (PAI-1) is
procedures involve exclusion of digestive system the primary physiological inhibitor of plasminogen segments, which causes atrophy of mucosa with bacterial activation and has procoagulation activity. Circulating proliferation; this, in turn, leads to intense flatulence PAI-1 levels are elevated in patients with coronary heart and bacterial translocation to the portal system, which disease and play an important role in the development may be related to hepatic fibrosis(3). Additionally, of arterial thrombosis by decreasing fibrin degradation(16) .
exclusion of segments hinders endoscopy.
PAI-1 is produced by visceral fat tissue, mainly the We searched new surgical alternatives, which could be omentum and mesenteric fat(16-18). Procedures causing easy to perform, require no exclusion of any segment, decrease in PAI-1 levels have already been demonstrated prevent endoscopic blind areas, avoid strangling prosthesis as improving metabolic profile and reducing cardiovascular and cause no subocclusions. Moreover, the technique should avoid malabsorption and above all, not harm Resistin: It is clear today that adipose tissue is an
important digestive functions. We rather searched endocrine gland and it produces many substances that procedures that could positively interfere with the could act like hormones, such as leptin, interleukin-6, neuroendocrine control of hunger and satiety.
adiponectin (also called ACRP30 and adipoQ), Physiological Background
angiotensin II and resistin. Resistin acts on skeletal GLP-1: Glucagon-like peptide 1 (GLP-1) is a
muscle myocytes, hepatocytes, and adipocytes, reducing hormone released by the enteroendocrine L-cells of their sensitivity to insulin; thus, it is related to the gut in response to food ingestion. GLP-1 increases diabetes(21-22). Abdominal fat is the main source of both insulin secretion and insulin gene expression and growth of pancreatic beta-cells(4-6). GLP-1 is secreted Visceral obesity: Abdominal fat tissue was clearly
mainly by the distal intestine and the nutrients that related to the so-called plurimetabolic syndrome. The reach this point are a major stimulus to release this waist/hip ratio has been used to quantify cardiovascular risk and many epidemiological studies have indicated GLP-1 is a potent agent that could improve or even its relation with high blood pressure, hypertriglyceridemia, cure type II diabetes(4,8). When obese diabetic patients insulin resistance and arterial thrombosis. Visceral fat are submitted to biliopancreatic diversion (Scopinaro is insulin-resistant and therefore releases free fatty acids Technique)(9), the ileogastric anastomosis provides (FFA) to the portal system. It is believed that insulin nutrients straight into the ileum and just after the resistance of the liver derives from a relative increase operation, and diabetes is markedly improved or cured in delivery of FFA from the omental fat depot to the before patients lose any significant weight. Efficient liver (via portal vein)(24). Many extreme obese patients production of GLP-1 is thought to cause this major have quite good metabolic profile because they have mostly subcutaneous fat. Except for orthopedic and GLP-1 also has other important actions. It inhibits respiratory complications, as well as reflux, most metabolic gastric emptying(7) and crosses the blood-brain barrier complications of obesity are related to visceral fat.
causing satiety(4,10). In sum, after a big meal, when Evolutionary Background
nutrients reach the distal intestine, GLP-1 is produced, Primitive diet was raw, full of poorly digestible fiber increasing the release of insulin and delaying gastric and very hypocaloric. The stomachs had to be big emptying and causing central satiety.
enough to keep an amount of food and handle long Ghrelin: It is a 28-amino peptide, predominantly
fasting periods. Hence, the volume of food ingested produced by the stomach and it has intense growth had to be expressive. The intestines had to be very long hormone (GH) releasing activity. Moreover, it in order to take and process more food and to be stimulates gastric acid secretion, and can induce excess efficient and not loose nutrients. However, the human adipose tissue by activating a central mechanism to diet has deeply changed in few centuries. Fire control Digestive adaptation: A new surgical proposal to treat obesity made food more digestible. Agriculture gave us some a midgut enterectomy that leaves 150 cm of proximal abundance and increased the amount of carbohydrates.
small bowel and 150 cm of distal small bowel, totaling Refined sugar may be given to us in considerable 3 meters of small bowel, which is still considered a amounts, whereas nature could give us just minimal portions. Saturated fat and industrialized food made The Research Ethics Committee of Hospital da the picture even worse. The development of electricity Polícia Militar do Estado de São Paulo approved the has allowed us to eat also at night. Marketing, protocol. A detailed informed consent was signed by restaurants, cookies, and the other goodies of patients, and it stated weight loss could not be predicted civilization have represented a very quick change that our digestive system and our eating instincts could not Modern diet is hypercaloric, poor in fiber and easy to absorb. After a meal with these characteristics, Technique: the procedure may be performed either
absorption occurs in the proximal portions of the bowel, through a supraumbilical midline incision or laparoscopy.
resulting in a peak of nutrient absorption. Distal bowel The open technique is described here. The first step is tends to absorb less nutrients, and this reduces to release the great omentum from the colon. The production of GLP-1. Indeed, it was noticed that gastric fundus is released by cutting the short gastric diabetic(25) and obese people(26) have reduced postprandial vessels with a harmonic scalpel. Later, the gastroepiploic arcade is interrupted at 6 cm proximal to the pylorus.
It has also been shown that obese individuals tend Gastroepiploic vessels will remain intact in the antrum.
to have longer small bowel than slim patients, and this A 12-mm Fouchet tube is passed through the esophagus is not related to height but to weight(27). This fact until the duodenum by the lesser curvature. A linear probably contributes to smaller amounts of nutrients cutting stapler is used in order to resect the gastric reaching the distal bowel, implying in less signaling of fundus and most of the gastric body, leaving a gastric tube of 3 to 4 cm of diameter in the lesser curvature Nature now performs what it does best - selection.
(figure 1). Gastric specimen and the great omentum Individuals with strong eating instincts are being killed by lack of adaptation of their digestive system and its A protective continuous seromuscular polypropylene suture is performed over the gastric stapling line. The A new surgical proposal to treat obesity
procedure is completed with an enterectomy that We have been searching a manner to adapt the removes the midgut, at 150 cm away from Treitz angle digestive system and eating instincts to abundance,without causing damage to important digestivefunctions, like those performed by the stomach, pylorus, duodenum, ileum and colon. The duodenum and theproximal intestine have functions different from thedistal gut. Some current techniques to treat obesity resect or exclude the pylorus (Scopinaro´s biliopancreaticbypass(9), Fobi(28) or Capella(29) Roux-en-Y gastric bypass).
In biliopancreatic bypass, using Scopinaro´s technique or the Duodenal Switch technique(30), the entire proximalintestine is excluded and the procedure may causeunspecific malabsorption that leads to nutritional deficiencies(1). In gastric bypass, most of the stomach isexcluded. Other techniques involve no exclusion but maycause subocclusion, such as gastric banding(2).
In our point of view, the several digestive functions are essential, even to obese patients. However, we knowthat the gastric capacity is bigger than what modern diet requires(31). Even the intestines are too long tomodern diet(32). Therefore, we propose a vertical gastricresection (similar to the extensively used “Duodenal Switch” technique)(30,33) associated to omentectomy and Figure 1. Diagram of partial gastric resection
Santoro S, Velhote MCP, Malzoni CE, Mechenas ASG, Strassmann V, Scheinberg M Patient 2: RJSB, male, 40 years old, weight=143 kg
(315 pounds), height=182 cm (6ft), BMI=43.1 kg/m2,total cholesterol=247 mg/dl, triglycerides=295 mg/dl.
The patient had been on clinical treatment for ten years, and was taking Fenproporex. He complained of pain inthe knees and low back pain, and was submitted to surgeryin January 2003. In August 2003, he weighed 100 kg (220 pounds), BMI=30.1 kg/m2, cholesterol=197 mg/dl;triglycerides=102 mg/dl. The patient was still loosingwhen this article was submitted to publication.
Patient 3: WVBG, male, 44 years old, weight=123 kg
(271 pounds), height=178 cm (5ft10), BMI=38.6 kg/m2,total cholesterol=247 mg/dl, triglycerides= 295 mg/dl.
The patient had been on clinical treatment for tenyears, and had recently been in use of Orlistat, Figure 2. Specimen of gastroepiploic resection
Fenproporex and amphetamine. He complained of pain in the knees and low back pain. The patient wasoperated in February 2003. On the 23rd postoperativeday, he returned to hospital due to an abscess that was drained. In August 2003, he weighed 99 kg (218.2pounds), BMI=31.2 kg/m2, cholesterol=142 mg/dl;triglycerides= 67 mg/dl.
All patients received cefazolin for 24 hours as prophylaxis and were discharged on the thirdpostoperative day. They were oriented to take only liquids, a maximum volume of 150 ml each time, duringone week; later they were allowed to eat solid food.
They were recommended to start meals with a portion of salad; fruits, vegetables and fish and chicken werealso prescribed. No patient had diarrhea, and two ofthem had mild obstipation for eating less. All patients referred early satiety, had no symptoms and were verysatisfied.
Figure 3. Specimen of enterectomy. Small bowel of 150 cm in length (patient MZF)
and at 150 cm proximal to the ileocecal valve, with its Discussion
mesentery (figure 3). And end-to-end (entero-enteral) The procedure has many advantages and we believe it could adapt the digestive system to modern diet. Since First patients and results: We report the first three
current foods are much more caloric than primitive patients submitted to surgery and their follow-up of at diet, the gastric capacity is reduced by 1 to 1.8 liters.
However, there is no subocclusion, no stenosis and no Patient 1: MZF, female, 39 years old, weight=104 kg
use of prosthesis. The stomach is proportionally (229,27 pounds), height =169 cm (5ft7), BMI: 36.4 kg/m2, reduced, but keeping its general structure (cardia, body, total cholesterol=210 mg/dl, triglycerides=200 mg/dl.
antrum and pylorus) and innervation by the lesser She had been under clinical treatment for ten years.
curvature is intact. Early satiety by gastric distension When surgery was indicated she was taking Orlistat, tends to occur. When significant weight loss occurs, and had used sibutramine and others drugs before. She no raise in ghrelin production is expected since its major could not loose any weight and complained of pain related to disk herniation. The patient was operated The enterectomy presented does not aim at causing in October 2002. In August 2003, her weight was 69 kg malabsorption. There is no report of enteric insufficiency (152 pounds), BMI=24.1 kg/m2; cholesterol=174 mg/dl, with 300 cm of a proportional bowel (with duodenum, triglycerides=161 mg/dl. She used no medicine and back jejunum, ileum, ileocecal valve and colon). In fact, some normal people have just three meters of small bowel Digestive adaptation: A new surgical proposal to treat obesity (in humans, the small bowel length ranges from 3 to 8 surgeries that are physiologically aggressive. The technique reported may be a physiologically acceptable The intention of this procedure is to create a procedure to treat extreme obesity. It could also be proportionally smaller intestine that is still normal and used to prevent extreme obesity in cases it is eminent takes less contents; moreover, it takes nutrients to the and patients already have associated diseases.
ileum, resulting in a more effective secretion of GLP- This is the first surgical procedure that does not 1, which, in turn, reduces gastric emptying speed, aim at curing an affected or deficient organ, but it improves insulin secretion and promotes central satiety.
intends to adapt a system to modern circumstances in Triglycerides and cholesterol levels are usually reduced cases nutritional and medical treatment failed. In fact, this is an evolutionary and adaptative surgery that When enterectomy is performed, the mesentery is would not be necessary if we had not changed our excised and visceral fat is removed. Omentectomy primitive diet. It might become a very important promotes additional resection of visceral fat(17) and procedure since it can early prevent the development reduction of a source of PAI-1(22), reducing the risk of of obesity, hypertriglyceridemia, hypercholesterolemia, arterial thrombosis. It provides a reduction in the source type II diabetes, hypertension, arterial thrombosis and of resistin and free fat acids to the portal vein. Both other typical conditions of modern life.
events are thought to reduce hyperinsulinism andinsulin resistance (21,24). As the specimens removed arebulky and the intraabdominal pressure (IAP) is CONCLUSION
reduced. High IAP is related to respiratory and The procedure presented is the association of three well-known techniques: vertical gastrectomy, omentectomy These preliminary results are very encouraging since and enterectomy. All are very simple and safe. Together, patients achieved weight loss as expected and presented they produce a proportionally reduced digestive neither subocclusions nor malabsorption. We should system, however not changing its general structure as evaluate the drop in ghrelin, resistin, PAI-1 levels and observed in other obesity surgery techniques. No early raise in GLP-1 levels. Besides the benefits of stenosis, subocclusions, excluded segments, malabsorption, weight loss, we observed the expected fall in cholesterol blind endoscopic areas were created, and no prosthesis and triglycerides levels. However, improvement of was used. Above all, no harm was caused to important metabolic profile must be assessed in a larger sample digestive functions. The patient submitted to surgery need no nutritional support or chronic use of drugs Furthermore, very obese patients may not loose the due to the procedure. The preliminary results are very amount of weight required with this technique for it is not aggressive to digestive functions. However, mosttechniques previously mentioned may still be used after ACKNOWLEDGEMENTS
The current surgical procedures for obesity are so We would like to thank U.S. Surgical for donating the aggressive that may not be recommended to patients disposable surgical equipment used in the procedures who are not extremely obese. Hence, when these performed at Hospital da Polícia Militar de São Paulo.
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