Metabolic Improvements in Obese Type 2 Diabetes Subjects Implanted for 1 Year with an Endoscopically Deployed Duodenal-Jejunal Bypass Liner

Background: The purpose of this study was to evaluate the effect of the duodenal-jejunal bypass liner (DJBL), a 60-cm, impermeable fluoropolymer liner anchored in the duodenum to create a duodenal-jejunal bypass, on metabolic parameters in obese subjects with type 2 diabetes. Methods: Twenty-two subjects (mean age, 46.2 +/- 10.5 years) with type 2 diabetes and a body mass index between 40 and 60 kg/m(2) (mean body mass index, 44.8 +/- 7.4 kg/m(2)) were enrolled in this 52-week, prospective, open-label clinical trial. Endoscopic device implantation was performed with the patient under general anesthesia, and the subjects were examined periodically during the next 52 weeks. Primary end points included changes in fasting blood glucose and insulin levels and changes in hemoglobin A1c (HbA1c). The DJBL was removed endoscopically at the end of the study. Results: Thirteen subjects completed the 52-week study, and the mean duration of the implant period for all subjects was 41.9 +/- 3.2 weeks. Reasons for early removal of the device included device migration (n = 3), gastrointestinal bleeding (n = 1), abdominal pain (n = 2), principal investigator request (n = 2), and discovery of an unrelated malignancy (n = 1). Using last observation carried forward, statistically significant reductions in fasting blood glucose (-30.3 +/- 10.2 mg/dL), fasting insulin (-7.3 +/- 2.6 mu U/mL), and HbA1c (-2.1 +/- 0.3%) were observed. At the end of the study, 16 of the 22 subjects had an HbA1c < 7% compared with only one of 22 at baseline. Upper abdominal pain (n = 11), back pain (n = 5), nausea (n = 7), and vomiting (n = 7) were the most common device-related adverse events. Conclusions: The DJBL improves glycemic status in obese subjects with diabetes and therefore represents a nonsurgical, reversible alternative to bariatric surgery.

Intestinal IgG uptake by small intestine of goat kid fed goat or lyophilized bovine colostrum

The immunoglobulin G (IgG) uptake and enterocyte nucleus position in the villous were studied in newborn goat kids fed goat or lyophilized bovine colostrum. Two groups of 15 newborn goat kids, each received 5% of body weight of goat colostrum (GC) or lyophilized bovine colostrum (LBC) containing 55 mg/mL of immunoglobulin G (IgG) at 0, 7 and 14 h of life. Three animals were sampled just after birth, receiving no colostrum intake, to be used as control. Samples of duodenum, medium jejunum and ileum were collected at 0, 18, 36 and 96 h of life. IgG vacuoles were not observed in the duodenum throughout the experiment regardless of all the experimental time points. In this segment, at 0, 18 and 36 h of life, nuclei were found in the apical, medial and basal positions in the enterocytes, and localized in the upper, medial and lower parts in the villous, respectively. At 96 h, a basal nuclei position was observed in the enterocytes, throughout the villous. In jejunum, IgG vacuoles were distributed along the villous at 18 and 36 h. In this segment at Oh the nuclei were positioned predominantly apically in the enterocytes, throughout the villous. At 18 and 36 h, no consistent nuclei pattern was verified: however at 96 h, the nuclei were positioned basally in the enterocytes, throughout the jejunal villous. In the ileum at 0, 18 and 36 h, a great number of vacuoles without IgG were verified in the medial-apical part of the villous. In this segment, at Oh of life and 96 h of life, the predominance of basal nuclei was observed. Nuclei were positioned in medial-apically part of the ileal enterocytes in the upper part of the villous at 18 and 36 h. It was found that the jejunal epithelium was the most important segment related to absorption process. The IgG absorption and nucleus position in the newborn goats were dependent on the small intestine segments and experimental time points, regardless of the colostrum source. GC or LCB. Considering the IgG uptake mechanism observed in the present study, the lyophilized bovine colostrum might be used instead of goat colostrum. (C) 2011 Elsevier B.V. All rights reserved.

Extreme bariatric endoscopy: stenting to reconnect the pouch to the gastrojejunostomy after a Roux-en-Y gastric bypass

Among the possible complications of bariatric surgery, fistula and partial dehiscence of the gastric suture are well known. Reoperation often is required but results in significant morbidity. Endoscopic treatment of some bariatric complications is feasible and efficient. A modified metallic stent was placed between the gastroaesophageal junction and the alimentary jejunal limb, allowing the passage of a nasoenteric feeding tube into the jejunal limb. Endoscopy showed disruption of nearly the entire staple line at the gastric pouch. The modified stent was placed and allowed wound healing. After 31 days, the stent had migrated and was removed endoscopically. Total clousure of the fistula was reported 30 days afterward. Endoscopic treatment of some bariatric surgery complications is feasible and has been reported previously. This report presents a case of a serious leakage treated by placement of a self-expandable metal stent to bridge the fistula.