Bariatric Times

JUL 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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23 Interview Bariatric Times • July 2017 without obesity. Six months following metabolic surgery, patients will undergo bone marrow harvesting for stem cell procurement and processing. How might the six- month outcomes of the metabolic surgery affect the stem cell regeneration? Drs. Varela & Chaux: The majority of patients with T1DM are either normal weight or overweight. Very seldom do they have obesity. We plan to study both diabetic groups. Bariatric surgery provides the best possible metabolic environment (by decreasing lipotoxicity, increasing incretins, and insulin sensitivity) for stem cell implantation and long-term survival. We believe that six months may be the right time for those metabolic changes to take place prior to stem cell implantation. After that time, prepped cells will be laparoscopically implanted at specific organ sites. In addition, adult stem cells, as compared to islet cell transplants, are readily available and less costly, without the need for life-long immunosuppression. What stage is the METASTEM protocol in currently? Drs. Varela & Chaux: We are currently conducting pilot studies and searching for additional funding. We envision stem cells being part of the bariatric surgeons' armamentarium along with lifestyle, pharmacologic, endoscopic microbiology and surgical interventions and as part of a simultaneous multimodal approach. REFERENCES 1. Chaux F, Torres F, Bolaños E, et al. Metabolic surgery and beta cell regeneration in type-1 diabetes: a novel hypothesis. CellR4. 2016;4(3):e2068 2. Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes—5-Year outcomes. N Engl J Med. 2017;376(7):641–651. 3. Shapiro AM, Pokrywczynska M, Ricordi C. Nat Rev Endocrinol. 2017;13(5):268–277. 4. Kamvissi V, Salerno A, Bornstein SR, Mingrone G, Rubino F. Incretins or anti-incretins? A new model for the "enteropancreatic axis." Horm Metab Res. 2015;47: 84–87. 5. Chaux F, Bolaños, E, Varela E. Lengthening of the biliopancreatic limb is a key step during revisional Roux-Y gastric bypass for weight regain and diabetes recurrence. Surg Obes Relat Dis. 2015;11(6):1411. FUNDING: No funding was provided in the preparation of this manuscript. FINANCIAL DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article. ADDRESS FOR CORRESPONDENCE: Esteban Varela, MD, FACS, FASMBS; E-mail: Can the foregut and hindgut theories have a synergistic effect? Commentary to manuscript: "Metabolic surgery and beta cell regeneration in type 1 diabetes: a novel hypothesis" by Raul J. Rosenthal, MD, FACS, FASMBS C linical Editor, Bariatric Times; Professor of Surgery and Chairman, Department of General Surgery; Director of Minimally Invasive Surgery and The Bariatric and Metabolic Institute; General Surgery Residency Program Director; and Director, Fellowship in MIS and Bariatric Surgery, Cleveland Clinic Florida, Weston, Florida R eprinted with permission from: CellR4. 2016;4(3):e2075 I commend the authors for their innovative concept of combining metabolic surgery with stem cell transplantation in order to treat type 1 diabetes mellitus. The hypothesis of this treatment modality is based on creating a more physiologic environment for transplanted adult stem cells to engraft and better function by allowing patients to lose weight and decrease insulin resistance and insulin levels by means of a metabolic procedure such as the gastric bypass. The authors contend that in addition to the above-mentioned benefits, this procedure will bypass the duodenum and proximal jejunum enhancing incretins and anti-incretin effects. 1 I would add to this hypothesis the potential effects and benefits of rapid emptying and transit time seen in patients undergoing gastric bypass. The latter will deliver undigested food to the ileum stimulating the L-Cells to the release of glucagon-like peptide 1 (GLP-1) and other gut hormones that might in turn not only further decrease insulin resistance, but also act as a growth factor enabling the transplanted stem cells to engraft better, differentiate, and function. 1 I very much look forward to the results of future clinical trials. REFERENCES 1. De Graaf C, Blom WA, Smeets PA, Stafleu A, Hendriks HF. Biomarkers of satiation and satiety. Am J Clin Nutr. 2004;79:946–961. Figure 1. Pancreatic islet as seen by light microscopy. Beta cells can be recognized by the green insulin staining. Glucagon is labeled in red and the nuclei in blue. Copyright Nepton S. Beta-cell function and failure. In: Escher A (ed.) Type 1 Diabetes, Rijeka, Croatia: InTech; 2013. Figure 2. Roux-en-Y gastric bypass reconstruction

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