Bariatric Times

ICCDS-1 2016

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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Page 17 of 32

November 2016 • Supplement B • Bariatric Times B17 FIRST INTERNATIONAL CONSENSUS CONFERENCE ON DUODENAL SWITCH difference and a significant progress. Still, in the metabolic field, " unnatural" high glycemic index food, like pure refined sugar or white flour, allows a fast absorption, faster than what naturally would occur. Obviously, the proximal gut would be o verstimulated in these circumstances whereas the distal gut less stimulated. The result: an imbalance in the metabolic activities of Proximal X Distal Gut. 4 Proximal gut signals do not provoke strong satiety, because it is obviously too early; they provoke insulin secretion but no blockage of glucagon secretion; 5 they do not strongly block gastric empting. It is too early for all these changes.In comparison, distal gut signals provoke strong satiety, potentiate insulin secretion, block glucagon secretion, and strongly block gastric empting. 3,6 Indeed, the patients with obesity and diabetes present a tendency to high gastric inhibitory polypeptide or GIP 7 (mainly a proximal gut product). If they eat less, on a diet, GIP falls. 8 GIP is obesogenic and insulinotropic (contributing to hyperinsulinemia), and the therapeutic blockage of GIP seems to be beneficial for these patients. 9,10 The opposite is also very clear, as therapeutic additions of the distal gut products (GLP-1, PYY, oxyntomodulin or their agonists) are beneficial in patients with metabolic syndrome. Surgical procedures support this observation. The more you shift food from proximal to distal, the better the results in obesity and metabolic csyndrome, despite worse nutritional results when this is obtained by excluding proximal segments. There is an imbalance in gut neuroendocrine activity, and the introduction of easily absorbed food can justify that. Epidemiology, physiology, drugs, and surgical procedures point at the same direction Transit bipartition (TB) was developed to correct this imbalance (Figure 1). Added to a SG, a TB aims at obtaining earlier functional restriction and a correction of the Proximal-Distal Imbalance. It dismisses mechanical restriction and malabsorption towards a Pure Metabolic Surgery. 4, 10, 11,12 Since 2003, around 3,000 patients were submitted to a SG+TB in Brazil by different surgeons; 1,446 are registered in especially designed in- cloud software. After a SG, a gastro- ileal anastomosis is created in the antrum; the nutrient transit to duodenum is much diminished as a significant part of it goes to the ileum (See accompanying video at A partial biliopancreatic bypass (pBPD) is indeed constructed. The stomach remains with two exits (Figure 2 and Figure 3). Jejunum is laterally anastomosed to ileum at 80 to 180 cm of the ileocecal valve: constipated patients, those with severe metabolic diseases, and the heavier F i gur e 1. Transit Bipartition. Added to a sleeve gastrectomy, a transit bipartition aims at obtaining earlier functional restriction and a correction of the Proximal-Distal Imbalance. It dismisses mechanical restriction and malabsorption towards a pure metabolic surger y.

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