Study On Safety And Efficacy Of Sleeve Gastrectomy Plus Modified Jejunoileal Bypass

Objectives:To establish the Sleeve Gastrectomy plus Modified Jejunoileal Bypass in Wistar rat model and to explore its safety.Methods:(1) Groups:40Specific pathogen Free (SPF)Wistar rats were randomly divided into5groups:the Sleeve Gastrectomy plus Modified Jejunoileal Bypass group(SGMJIB, n=8); Sham group of SGMJIB (Sham-SGMJIB, n=8), MJIB group(MJIB, n=8); Sham group of MJIB (Sham-MJIB, n=8), control group (Control, n=8).(2) Operative model:The procedures of SGMJIB:The tissue from5mm above the pyloric to the gastric fundus was freed, the2microvascular clamp along the greater curvature of stomach side opposite clamp to determine the resection line, about70%～80%volume of the stomach was resected, including most of the fundal portion. The incision was disinfected and then Continuous full-thickness incision inverting suture, and end to side anastomosis of the part of jejunum (25cm from the ligament of Treitz) to the ileum25cm proximal to the cecum was then implemented. The procedure of MJIB:only end to side anastomosis of the part of jejunum (25cm from the ligament of Treitz) to the ileum25cm proximal to the cecum. The procedures of Sham-SGMJIB, Sham-MJIB:Sham operations involved the same abdominal incisions, transections and re-anastomosis of the gastrointetinal tract at corresponding sites were performed in SGMJIB and MJIB Groups, and Sham operation durations were prolonged to achieve similar operating times anesthetic influence as those casted on SGMJIB and MJIB.(3) Post-operative observations The success rate, survival rate, weekly changes of the body weight, general condition of the rats and postoperative complications were recorded.(4) Analysis of blood samples:Blood samples were collected from Ophthalmic vein at the time points of preoperative and postoperative4,12weeks and then were analyzed by the Automatic biochemical analyzer and the parameters include the levels of the blood biochemistry included alanine aminotransferase(ALT), aspartate arninotransferase(AST), creatinine(Cr), urea, albumin(ALB) and total protein(TP).(5) Tissue samples collection:the rats were sacrificed after blood collection in12weeks, morphology of the liver, stomach, post-operative intestinal were observed and then tissue samples were taken, after liver wet weighing, liver organ coefficient was calculated, then one piece of every liver samples was frozen immediately in the-80degrees refrigerator, another piece of the liver samples were immersed in4%paraformaldehyde solution, The forestomach, glandular stomach tissue, Anastomosis proximal5cm (nearly segments), remote5cm (distal segments), exclusion side5cm (exclusion segments) bowel lcm of SGMJIB group, Sham-SGMJIB group and Control group were taken respectively and fixed in formalin-solution, stomach, intestines, liver tissue samples were embedded in paraffin and sliced, followed by conventional HE staining.(6) Microscopic observation and measurement:HE staining slice of the forestomach, glandular stomach and the proximal, distal segment, the exclusion section of the intestinal mucosa in SGMJIB, Sham-SGMJIB and Control group were observed under the microscope, the thickness of the mucosa and submucosa of the forestomach, villus height, crypt depth, mucosal thickness of intestinal mucosa proximal, distal, exclusion segment were microscopic measurement, data was collected for statistical analysis, morphology micro-metrology change of tissue were compaered between different groups.(7) Masson staining and CYP2E1staining of liver tissue:Masson staining and CYP2E1antibody immunohistochemical staining were performed in paraffin-embedded liver tissue; the production of antibody immunofluorescence staining of CYP2E1was detected in frozen liver sections from the frozen tissue samples; CYP2E1antibody was detected by Western Blot in another part of the frozen liver tissue.Results:(1) The average operating time of SGMJIB group and MJIB group were72.2±9.64min and42.3±7.54min. Surgery success rate was100%in SGMJIB model, a rat in Sham-MJIB group died of anesthesia before blood collection, The survival rate of operative rats was97.5%untill the end of the experiment.2rats diarrhea within postoperative3days in SGMJIB group which recovered by itself, except for the times when rats from each group in addition to the duration of fasting, blood collection, surgical intervention, the spirit of reaction, behavior, fur color and feces were not found abnormal. During12weeks rats in SGMJIB group weight gain slowed down, which regained the preoperative body weight postoperative4weeks, body weight were significantly lower than Sham-SGMJIB group and Control group in all postoperative time points, the difference was statistically significant (P <0.01); starting postoperative week3, each time point afterwards body weight were lower than MJIB group, have significant difference (P<0.05). (2) collecting blood samples from Rats in each group before surgery and after4weeks,12weeks were examined and been found that ALT, AST, Cr, Urea, TP, Alb were varying degrees of difference between the surgery group, Sham group and Control group, but there was not any statistically significance (P>0.05).(3) When compared with corresponding Sham group and Control group Postoperative liver gross morphology comparison, SGMJIB group and MJIB group had no significant difference in addition to slightly daker color, the liver organ coefficient had no significant difference (P>0.05). The residual forestomach of SGMJIB rats display with decreased elasticity, wrinkle reduction, the microscopic morphology revealed that compared with the Sham-SGMJIB group and Control group, mucosa and muscularis mucosa of the forestomach in SGMJIB group thinning(P<0.05), tissue became loose under the layer of mucosal muscle layer. The glandular stomach in SGMJIB group and Sham-SGMJIB group presented inflammatory cell infiltration in local submucosal under the microscope, the gastric pits deepened and elongated, glands in the lamina propria expanded, partially visible gastric mucosal inflammatory foci (lymphocytes, plasma cells, neutrophils)were observed in SGMJIB group, no intestinal metaplasia change, villus height, crypt depth and mucosal thickness of the anastomosis stoma proximal and distal intestinal in the SGMJIB group increased significantly (P<0.01) as oppose to those in the corresponding Sham group and Control group, histological changes of the exclusion segment in SGMJIB group were atrophic, organizational compensatory changed significantly (P<0.01). The comparison within SGMJIB groups:villus height, crypt depth and mucosal thickness of the distal and proximal intestinal than the exclusion segment increased significantly (P<0.01), and compensatory changes in distal was more obviously than distal segment (P<0.01).(4) Liver sections were HE and Masson staining and observed under the microscopic, in addition to occasionally spotty necrosis foci, a small amount of inflammatory cell infiltration, no obvious focal necrosis, no liver steatosis, collagen fibers chromogenic increase, no significant fibrosis in SGMJIB group and MJIB group, and there was no obvious morphological changes be found in Sham-SGMJIB group, Sham-MJIB group and Control group. CYP2E1antibody immunohistochemistry in liver tissue slices and results showed that:there can be seen around the central vein (acinar zone III)2-3layers of cells positive express a small amount, there was no obvious expression in acinar zone Ⅱ and zone Ⅰ, meanwhile, CYP2E1expression intensity and distribution had a slight difference in different liver tissue slices from different groups. CYP2E1antibodies were expressed among the groups according to Tsutsumi’s method and the common scoring criteria to quantify, the difference between the groups was not statistically significant (P>0.05); frozen liver slices were stained by CYP2E1antibody immunofluorescence which showed:CYP2E1antibody was mainly expressed in the cytoplasm of hepatocytes, no expression in the nucleus, expressed mainly in the acinar zone III. fluorescence intensity difference between different group were slightly, the difference was no significant statistically(P>0.05). CYP2E1antibody detected by Western Blot in different liver sections showed that expression levels in the SGMJIB group increased slightly than the Control group, and its expression level’s difference was not significant statistically with Sham group and Control group (P>0.05), the difference of the CYP2E1antibody’s the relative expression level between different group was no significant statistically (P>0.05).Conclusions:SGMJIB Wistar rats model was easy to perform and economical, relatively safe; the results from this model showed postoperative body weight of rats in SGMJIB group were significantly lower, but subjects’ nutrition and relative metabolisms were not affected.. This is due to the compensatory structural change of the gastrointestinal tract, Postoperative liver showed no signs of compromised structural hence the safety of SGMJIB rat model was better during the postoperative12weeks. Objectives:To investigate efficacy of the Sleeve Gastrectomy plus Modified Jejunoileal Bypass (SGMJIB) on weight loss, commorbidities and its safety.Methods:7morbidly obese patients associated with commorbidities admitted in the Plastic and Reconstructive Surgery of Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology and underwent SGMJIB in Our department between March2009and July2011were followed-up and assessed. We collected data from all cases included general information, operative time, hospital-stay, Weight assessment related index(weight, height, BMI and%EWL), fasting blood glucose(FBG), serum triglycerides(TG), total cholesterol(TC), uric acid, Assessment pre-and post-operative examination results with the Comorbidity, postoperative complications and other related information and data. Count data expressed as a percentage. Measurement data to x±s, data processing Paired t-test and the Dunnett t-test (two-sided) using SPSS20.0statistical software.Results:7patients with conventional open SGMJIB operation, The mean operative time was (280.29±80.59) min, Follow-up ranged from10～39(mean27.13±11.33months), the mean postoperative length of stay was(18.57±4.69)d.%EWL was53.15±19.18%; Blood pressure or abnormal blood glucose levels returned to normal in4cases, the remission rate of100%; hyperlipidemia in two cases of7patients returned to normal,4cases had improved,1cases did not change significantly, the total effective rate was85.7%; fatty liver in4cases were improved,3cases did not change significantly, the total effective rate was57.1%; high uric acid hyperlipidemia2cases returned to normal,1case improved markedly, the total effective rate was100%; The symptoms relieved three cases among4cases with sleep apnea syndrome, sleep quality improved significantly; menstrual of1female patients become normal, uneventful pregnancy give birth; postoperative quality of sex life of1male patient had been significantly improved. Bleeding, anastomotic leakage, anastomotic stenosis, surgery-related complications had not occured in the group of patients.1case of the group occurred fat liquefaction and dehiscence whica local incision was sutured after routine dressing, weight of3patients rebound slightly postoperative1year, Several patients complained of increased flatus and eating too fast can induce vomiting in the early postoperative, no significant occurrence of diarrhea, no serious complications.Conclusions:The EWL%of the postopetive1year in the SGMJIB patients was53.15±19.18%which had been achieved a good weight loss efficacy, the effect of weight loss is more satisfactory, SGMJIB achieved better effect, efficiency of most obesity comorbidities was more than85%. wound dehiscence in1case.complications included postoperative anemia,severe hypoalbuminemia, malnutrition and liver and kidney dysfunction, diarrhea and other intestinal flora disturbance syndromes were not occurred in the follow-up period, the security of SGMJIB is better in the term, but cases in the group was too few, need to further study.