RNY = Minimal Fat Malabsorption vs MGB = Major Fat Malabsorption
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Transcript of RNY = Minimal Fat Malabsorption vs MGB = Major Fat Malabsorption
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Malabsorption following the Roux-en-Y gastric bypass
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What is Roux-en-Y Gastric Bypass?
• Roux-en-Y Gastric Bypass both (?)
• Restrictive
• Malabsorptive (?)Components
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Malabsorption vs. Restriction after long-limb RNY gastric bypass
• Roux-en-Y gastric bypass (RNY) restricts food intake
• when the Roux limb is elongated to 150 cm
• IS the RNY malabsorptive?• Measure calorie reduction after RNY• Restriction vs Malabsorption• The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric
bypass, Elizabeth A Odstrcil, et al. Am J Clin Nutr October 2010 vol. 92 no. 4 704-7
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“The contribution of malabsorption to the reduction in
net energy absorption after long-limb
Roux-en-Y gastric bypass”
Elizabeth A Odstrcil, Juan G Martinez, Carol A Santa Ana, Beiqi Xue, Reva E Schneider, Karen J Steffer, Jack L
Porter, John Asplin, Joseph A Kuhn, and John S FordtranAm J Clin Nutr October 2010 vol. 92 no. 4 704-713
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The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass
• Results:• RNY:• No significant effect on • Protein or Carbohydrate
absorption
• “The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass”, Elizabeth A Odstrcil, et al. Am J Clin Nutr October 2010 vol. 92 no. 4 704-713
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RNY Malabsorption vs. Restriction
• 5 months after bypass, • Malabsorption reduced absorption by
124 kcal/d• Restriction of food intake reduced energy
absorption by 2,062 kcal/d• Restriction 16 times more important than
Malabsorption
• The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass, Elizabeth A Odstrcil, et al. Am J Clin Nutr October 2010 vol. 92 no. 4 704-713
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RNY Malabsorption vs. Restriction
• 14 months after bypass, • Malabsorption reduced absorption of
combustible energy by 172 kcal/d• vs• Restriction of food intake reduced energy
absorption by 1,418 kcal/d
• (Why: Restriction Beginning to Fail)• The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass, Elizabeth A Odstrcil,
et al. Am J Clin Nutr October 2010 vol. 92 no. 4 704-713
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Failure of RNYCaloric Effect
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RNY Malabsorption vs. Restriction
• Malabsorption ONLY 6%-11% reduction in calories
• RNY: Is Primarily a “Restrictive Procedure”
• Study Shows: Early signs of RNY caloric failure
• The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass, Elizabeth A Odstrcil, et al. Am J Clin Nutr October 2010 vol. 92 no. 4 704-713
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The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass
• Dietary intake and net intestinal absorption of fat, protein, and carbohydrate were measured
• Calculated the total reduction in fat, protein, carbohydrate, and calories after RYGB
• Extent to which these reductions were due to restriction or malabsorption
• The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass, Elizabeth A Odstrcil, et al. Am J Clin Nutr October 2010 vol. 92 no. 4 704-713
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The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass
• Fat absorption and malabsorption
• Average fat intake was
• 156 g/d before bypass,
• 50 g/d 5 mo after bypass, and
• 82 g/d 14 mo after bypass.
• The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass, Elizabeth A Odstrcil, et al. Am J Clin Nutr October 2010 vol. 92 no. 4 704-713
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Correlation between the length of jejunum in the biliopancreatic (BP) limb and the reduction in fat absorption
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Bile Acid Depletion:Fat Malabsorption &
Treatment of Diabetes
Most Bariatric surgeons DO NOT
Understand Bile/Bile Acids
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Bile Acids: Not Just for Fat Absorption
• Bile Acids Needed for Fat absorption (Decreased Bile Acids => Decreased Fat Absorption)
• Studies show that bile acids also play a large role in glucose homeostasis
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Bile Acids: Not Just DetergentsBile Acids as Hormones
• Bile acids as hormones act on several Critical receptors:
• Farnesoid X receptor (FXR) and • Pregnane X receptor (PXR), • Constitutive androstane receptor (CAR), • G-protein-coupled receptor TGR5. • Bile acids AS HORMONES regulate
Cholesterol, Glucose, and metabolism/energy homeostasis
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What Most Bariatric Surgeons Do Not Understand
• Bile Acids Critical to Fat and Glucose Control in the Body
• Decreased Bile Acids =>Decreased Fat absorptionLowered Blood Glucose Levels
• MGB (Billroth II) => Decreased Bile Acids
• RNY does NOT Affect Bile Acid Pool
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Study of long-limb Roux-en-Y gastric bypass
• Results: RNY does not cause bile acid malabsorption
• Fecal bile acid excretion average • Before: 0.8 g/d• Post Op 5 mo: 0.5 g/d • Post Op 14 mo: 0.7 g/d• Decreased Bile Acids Rx Diabetes• RNY Does Not Cause Loss of Bile
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Bile Acid Sequestration Reduces Glucose Levels by Increasing Metabolic Clearance
• Bile acid sequestrants (BAS) reduce plasma glucose levels in type II diabetics
• BAS induced plasma glucose lowering by increasing metabolic clearance rate of glucose in peripheral tissues
• RNY Does Not Cause Loss of Bile• MGB Does Cause Bile Acid Losses
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Bariatric Surgeons Forget History of GI Surgery
What have we learned from 100 years of GI Surgery?
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Post Gastrectomy Steatorrhea
• For over 75 years authors have noted that • Fat Malabsorption/Steatorrhea common
post gastrectomy syndrome in some patients
• More common & Greater degree with • Billroth II >> Billroth I
• EVERSON TC. Experimental comparison of protein and fat assimilation after Billroth II, Billroth I, and segmental types of subtotal gastrectomy. Surgery. 1954 Sep;36(3):525-37
• MACLEAN LD, PERRY JF, KELLY WD, MOSSER DG, MANNICK A, WANGENSTEEN OH. Nutrition following subtotal gastrectomy of four types (Billroth I and II, segmental, and tubular resections). Surgery. 1954 May;35(5):705-18
• WOLLAEGER EE, WAUGH JM, POWER MH. Fat-assimilating capacity of the gastrointestinal tract after partial gastrectomy with gastroduodenostomy (Billroth I anastomosis). Gastroenterology. 1963 Jan;44:25-32
• …
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100 Years of GI Surgery: Steatorrhea following Gastric Operations:
• What do we know:• Rare after gastro-jejunostomy or vagotomy
alone. • Rare after Billroth I• Especially Common after Polya gastrectomy
with BII. • (Butler, 1961)
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Polya Type Gastro-Jejunostomy
NOTE:Large
Wide OpenGastro-
jejunostomy
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Opinion Among BPD Surgeons
• Length of the Common Channel is the Critical Factor for Fat malabsorption & weight loss
• We review Animal studies and MGB results that suggest this is not the case
• Am J Surg. 2005 May;189(5):536-40, Common channel length predicts outcomes of biliopancreatic diversion alone and with the duodenal switch surgery, McConnell DB, O'rourke RW, Deveney CW
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NUTRIENT ABSORPTION in the SMALL INTESTINE: Remember the Basics
• Duodenum and Upper Jejunum: most minerals
• Jejunum and Upper Ileum: carbohydrates, amino acids, water-soluble vitamins
• Jejunum: absorbs most of lipids and fat-soluble vitamins
• Terminal Ileum: Bile,Vit B12
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Fat absorption and the Length of Billroth II Afferent Limb
• Experiment• Question: Increase length of
afferent limb associated with increased fat malabsorption
• Animals underwent a 50% distal gastrectomy with an antecolic
• Polya-type Billroth II anastomosis
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Fat absorption and the Billroth II Afferent loop
• 50% distal gastrectomy with an antecolic
• Polya-type Billroth II anastomosis
• Afferent limb of
• 30cm, 60cm, 90cm
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Fat absorption and the Billroth II Afferent Limb: RESULTS
• PreOp: Fecal excretion on a 127 Gm. diet 2.4% of the ingested fat.
• Similar results in dogs and in humans
• Animals with BII + 30cm afferent limbs
• Able to digest and absorb the dietary fat without any apparent difficulty
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Fat absorption and the Billroth II Afferent loop
• Average fecal excretion diet was 2.4% of the ingested fat.
• Longer Loops steatorrhea increased• 30 cm. limb fecal fat 2.4% (No Change)• 60 cm. limb fecal fat excretion 10.2%• 90 cm. limb 28.2%
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Fat MalabsorptionBillroth II (MGB) vs RNY
0
5
10
15
20
25
30
0 20 40 60 80 100
Bypass Limb Length
Fa
t L
os
t (%
)
MGBBillroth II
RNY
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Fat absorption and the Billroth II Afferent loop
• Average fecal excretion Pre Op 2.4% of ingested fat
• Longer Limb increased steatorrhea• 30 cm. limb fecal fat 2.4% (No Change)• 60 cm. limb fecal fat excretion 10.2%• 90 cm. limb 28.2%
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Fat MAL-absorption and the Billroth II Afferent LIMB
• Afferent limb most important factor post gastrectomy steatorrhea, “LENGTH”
• Animals with short afferent loops NO significant steatorrhea.
• As the length of the afferent limb increased, a concomitant and dramatic rise in fecal fat excretion was noted.
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Fat MAL-absorption and the Billroth II Afferent loop
• Malabsorption is NOT due to bypass of the upper jejunum ALONE
• Kremen’s Study:• Over half the jejunum can be
bypassed without producing steatorrhea.
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An Experimental Evaluation of the Nutritional Importance of Proximal and Distal Small
Intestine
• Arnold J. Kremen, et al.Ann Surg. 1954 September; 140(3): 439–447
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Kremen, et al.
• “Experimental studies in dogs reveal that animals can bypass
• 50 to 70 per cent of their small intestine
• and maintain a near normal nutritional status”
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Experimental Evaluation of the Nutritional Importance of Proximal and Distal Small Intestine
• Study showed that • Bypass of major lengths of the
proximal small intestine, • Weight is well maintained • No great interference with fat
absorption • NOTE:
Contradiction with Prior Study
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Experimental Evaluation of the Nutritional Importance of Proximal and Distal Small Intestine
• 50 - 70% of the small bowel bypassed
• Proximal and distal ends were exteriorized as a cutaneous stoma.
• Intestinal continuity was re-established by end-to-end anastomosis
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50% of Jejunum Bypassed:No Weight Loss!
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Massive bypass = No Effect
• The small intestine in adults is a long and narrow tube about 7 meters (23 feet) long
• 50% Bypass = 11.5 ft (3.5 meters)
• Minimal Weight Loss!
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70% Bowel BypassedMinimal Weight Loss
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Massive bypass = Little Effects!
• The small intestine in adults is a long and narrow tube about 7 meters (23 feet) long
• 70% Bypass = 16 ft (5 meters)
• 5% weight loss
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70% Bypass = Little Effect
• Group IV animals, which were similar to Group I except that 70% instead of 50% of proximal small bowel removed from intestinal continuity,
• Lost about five per cent of their preoperative weight and then stabilized at this level.
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Transit Time & Fat Absorption
• 50-70% Bypass
• Made Little Difference in
• Transit Time or
• Fat Absorption NOT affected
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Experimental Evaluation of the Nutritional Importance of Proximal and Distal Small Intestine
• CONCLUSIONS• The proximal 50 to 70 per cent of the small
intestine can be removed with no apparent ill effects.
• Weight is maintained, and protein and fat absorption are not significantly altered.
• Arnold J. Kremen, John H. Linner, and Charles H. Nelson
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Bypass of Jejunum; Experimental Results:No Fat Malbsorption or Major Fat
Malabsorption
• 2 Studies; 2 Different Findings• Massive Small Bowel Bypass
=> Minimal Effects• Moderate Small Bowel Bypass
=>Major Effects• What is the Difference?
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It’s the Billroth II
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Billroth II + Moderate Bypass=
Fat Malabsorption and Good Weight Loss
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RNY
• Primarily Restrictive
• Minor fat malabsorption
• No Malabsorption of Protein or Carbohydrate
• Restriction begins to fade early