Malabsorbtion vs Restriction Post RNY Bypass

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The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass
Comparison to Billroth II and MGB

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Malabsorbtion vs Restriction Post RNY Bypass

  1. 1. The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux- en-Y gastric bypass
  2. 2. What is Roux-en-Y Gastric Bypass Surgery? • Roux-en-Y Gastric Bypass (RYGB) combines both • Restrictive and • Malabsorptive • Components
  3. 3. The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass • Roux-en-Y gastric bypass (RYGB) restricts food intake, and • when the Roux limb is elongated to 150 cm, the procedure is believed to induce malabsorption • Objective measure reduction calories after RYGB • Restriction of food intake 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. 4 704-713
  4. 4. The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass 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 Fordtran Am J Clin Nutr October 2010 vol. 92 no. 4 704-713
  5. 5. The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass • No statistically significant effects of RYGB on • Protein or • Carbohydrate absorption coefficients • 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
  6. 6. The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass • 5 months after bypass, • Malabsorption reduced absorption of combustible energy by 124 ± 57 kcal/d, whereas • Restriction of food intake reduced energy absorption by 2062 ± 271 kcal/d • In RNY 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
  7. 7. The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass • 14 months after bypass, • Malabsorption reduced absorption of combustible energy by 172 ± 60 kcal/d, whereas • Restriction of food intake reduced energy absorption by 1418 ± 171 kcal/d • Restriction 8 times as important as Restriction • (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
  8. 8. The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass • On average, malabsorption accounted for 6% and 11% of the total reduction in ccaloric intake at 5 and 14 mo, respectively, after 150 RNY gastric bypass • RNY: Primarily a Restrictive Procedure • NOTE: Early signs of 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
  9. 9. 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
  10. 10. 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
  11. 11. Correlation between the length of jejunum in the biliopancreatic (BP) limb and the reduction in coefficient of fat absorption at 5 (A) and 14 (B) mo after long-limb Roux- en-Y gastric bypass (RYGB).
  12. 12. The contribution of malabsorption to the reduction in net energy absorption after long-limb Roux-en-Y gastric bypass • RNY does not cause bile acid malabsorption • Fecal bile acid excretion averaged • Before: 0.78 ± 0.08 g/d, • 5 mo: 0.50 ± 0.13 g/d, and • 14 mo: 0.68 ± 0.12 g/d • Decreased Bile Acids Rx Diabetes
  13. 13. Post Gastrectomy Steatorrhea • Several authors have noted that • Fat malabsorption • More common and to a 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
  14. 14. Steatorrhoea following Gastric Operations: • Rare after gastro-jejunostomy or vagotomy alone. • Rare after Billroth I • Common after Polya gastrectomy. • The addition of vagotomy to gastrectomy or gastrojejunostomy increased the fat • content of the stools. • (Butler, 1961)
  15. 15. Factors implicated as the cause of increased Body fat loss following gastrectomy & Billroth II • Decreased caloric intake • Gastrointestinal motility changes • Reservoir function are responsible for the steatorrhea.
  16. 16. Factors implicated as the cause of increased fat loss following partial gastrectomy & Billroth II • In a clinical study, Saxon and Ziese stated that • Loss of the reservoir function of the stomach was of primary cause. • Loss of body weight correlated significantly with the • amount of stomach removed at operation and with no other factors.
  17. 17. Factors implicated as the cause of increased fat loss following partial gastrectomy & Billroth II • Waddell and Wang Abnormal motility rather than lack of reservoir function was the basic physiologic disturbance involved. • Glazebrook and Welbourn 6 indicted intestinal hypermotility as the cause
  18. 18. Fat absorption and the Billroth II Afferent loop • An experiment was designed first, to determine whether progressive increase in the length of the afferent loop was predictably associated with increasing fat malabsorption • Animals underwent a 50% distal gastrectomy with an antecolic • Polya-type Billroth II anastomosis
  19. 19. Polya Type Gastro-Jejunostomy
  20. 20. Fat absorption and the Billroth II Afferent loop • Animals underwent a 50% distal gastrectomy with an antecolic • Polya-type Billroth II anastomosis • Afferent loops of • 30, 60, and 90 cm.
  21. 21. Fat absorption and the Billroth II Afferent loop • Average fecal excretion on a 127 Gm. diet was 2.4% of the ingested fat. • Similar to results both in dogs and in humans • Animals with 30 cm. afferent loops • Able to digest and absorb the fat diet without any apparent difficulty
  22. 22. 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. loop fecal fat 2.4% (No Change) • 60 cm. loop fecal fat excretion 10.2% • 90 cm. loop 28.2%
  23. 23. 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. loop fecal fat 2.4% (No Change) • 60 cm. loop fecal fat excretion 10.2% • 90 cm. loop 28.2%
  24. 24. Fat MAL-absorption and the Billroth II Afferent loop • Afferent loop can be a most important factor in the cause of post gastrectomy steatorrhea, depending upon the LENGTH of its construction. • Animals with short afferent loops did not demonstrate any significant steatorrhea. • As the length of the afferent loop increased, a concomitant and dramatic rise in fecal fat excretion was noted.
  25. 25. Fat MAL-absorption and the Billroth II Afferent loop • The malabsorption is probably not due to bypass of the upper jejunum • Kremen’s demonstration in dogs that • Over half the jejunum can be bypassed without producing steatorrhea.
  26. 26. • 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
  27. 27. Kremen, et al. • Experimental studies in dogs reveal that animals also can, with reasonable assurance, • be deprived of from 50 to 70 per cent of their small intestine and maintain a near normal nutritional status.
  28. 28. Experimental Evaluation of the Nutritional Importance of Proximal and Distal Small Intestine • Study showed that after sacrifice of major lengths of the proximal small intestine, • the animal's weight is satisfactorily maintained near preoperative levels, and • no great interference with fat absorption is observed.
  29. 29. Experimental Evaluation of the Nutritional Importance of Proximal and Distal Small Intestine • 50- 70% of the mesenteric small bowel bypassed • The bypassed bowel had its blood supply preserved and • proximal and distal ends were exteriorized as a cutaneous stoma. • Intestinal continuity was re-established by end- to-end anastomosis
  30. 30. 50% of Jejunum Bypassed
  31. 31. 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!
  32. 32. 70% Bowel Bypassed
  33. 33. 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
  34. 34. 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.
  35. 35. Transit Time & Fat Absorption • 50-70% Bypass • Made Little Difference in Transit Time • Fat Absorption NOT affected
  36. 36. 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
  37. 37. Absorption studies after gastrojejunostomy with and without vagotomy • It is concluded that serious malabsorption does not follow either gastrojejunostomy or vagotomy • but may occur quite often when these procedures are combined. • It seems that the addition of vagotomy to the G-J is responsible for steatorrhea. • Presumably vagotomy interferes with the gastric, intestine, or biliary response to food.

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