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The contribution of malabsorption
to the reduction in net energy
absorption after long-limb Roux-
en-Y gastric bypass
What is Roux-en-Y Gastric Bypass
Surgery?
• Roux-en-Y Gastric
Bypass (RYGB)
combines both
• Restrictive and
• Malabsorptiv...
The contribution of malabsorption to the reduction in net
energy absorption after long-limb Roux-en-Y gastric bypass
• Rou...
The contribution of malabsorption
to the reduction in net energy
absorption after long-limb
Roux-en-Y gastric bypass
The c...
The contribution of malabsorption to the reduction in net
energy absorption after long-limb Roux-en-Y gastric bypass
• No ...
The contribution of malabsorption to the reduction in net
energy absorption after long-limb Roux-en-Y gastric bypass
• 5 m...
The contribution of malabsorption to the reduction in net
energy absorption after long-limb Roux-en-Y gastric bypass
• 14 ...
The contribution of malabsorption to the reduction in net
energy absorption after long-limb Roux-en-Y gastric bypass
• On ...
The contribution of malabsorption to the reduction in net
energy absorption after long-limb Roux-en-Y gastric bypass
• Die...
The contribution of malabsorption to the reduction in net
energy absorption after long-limb Roux-en-Y gastric bypass
• Fat...
Correlation between the length of jejunum in the
biliopancreatic (BP) limb and the reduction in coefficient of
fat absorpt...
The contribution of malabsorption to the reduction in net
energy absorption after long-limb Roux-en-Y gastric bypass
• RNY...
Post Gastrectomy Steatorrhea
• Several authors have noted that
• Fat malabsorption
• More common and to a Greater
degree w...
Steatorrhoea following
Gastric Operations:
• Rare after gastro-jejunostomy or vagotomy
alone.
• Rare after Billroth I
• Co...
Factors implicated as the cause of increased
Body fat loss following gastrectomy & Billroth II
• Decreased caloric intake
...
Factors implicated as the cause of increased
fat loss following partial gastrectomy & Billroth
II
• In a clinical study, S...
Factors implicated as the cause of increased
fat loss following partial gastrectomy & Billroth
II
• Waddell and Wang Abnor...
Fat absorption and the
Billroth II Afferent loop
• An experiment was designed first, to
determine whether progressive incr...
Polya Type Gastro-Jejunostomy
Fat absorption and the
Billroth II Afferent loop
• Animals underwent
a 50% distal
gastrectomy with
an antecolic
• Polya-ty...
Fat absorption and the
Billroth II Afferent loop
• Average fecal excretion on a 127 Gm. diet
was 2.4% of the ingested fat....
Fat absorption and the
Billroth II Afferent loop
• Average fecal excretion diet was
2.4% of the ingested fat.
• Longer Loo...
Fat absorption and the
Billroth II Afferent loop
• Average fecal excretion diet was
2.4% of the ingested fat.
• Longer Loo...
Fat MAL-absorption and the
Billroth II Afferent loop
• Afferent loop can be a most important factor
in the cause of post g...
Fat MAL-absorption and the
Billroth II Afferent loop
• The malabsorption is probably not
due to bypass of the upper jejunu...
• An Experimental Evaluation of the
Nutritional Importance of Proximal
and Distal Small Intestine
• Arnold J. Kremen, et a...
Kremen, et al.
• Experimental studies in dogs reveal
that animals also can, with
reasonable assurance,
• be deprived of fr...
Experimental Evaluation of the Nutritional
Importance of Proximal and Distal Small Intestine
• Study showed that after sac...
Experimental Evaluation of the Nutritional
Importance of Proximal and Distal Small Intestine
• 50- 70% of the mesenteric s...
50% of Jejunum Bypassed
Massive bypass = No Effect
• The small intestine in adults is a
long and narrow tube about
7 meters (23 feet) long
• 50% B...
70% Bowel Bypassed
Massive bypass = Little Effects!
• The small intestine in adults is
a long and narrow tube about
7 meters (23 feet) long
•...
70% Bypass = Little Effect
• Group IV animals, which were
similar to Group I except that 70%
instead of 50% of proximal sm...
Transit Time & Fat Absorption
• 50-70% Bypass
• Made Little Difference in
Transit Time
• Fat Absorption NOT affected
Experimental Evaluation of the Nutritional
Importance of Proximal and Distal Small Intestine
• CONCLUSIONS
• The proximal ...
Absorption studies after gastrojejunostomy
with and without vagotomy
• It is concluded that serious malabsorption does not...
Malabsorbtion vs Restriction Post RNY Bypass
Malabsorbtion vs Restriction Post RNY Bypass
Malabsorbtion vs Restriction Post RNY Bypass
Malabsorbtion vs Restriction Post RNY Bypass
Malabsorbtion vs Restriction Post RNY Bypass
Malabsorbtion vs Restriction Post RNY Bypass
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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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