GASTRIC MUCOSAL CHANGES IN DUODENAL SWITCH OPERATION IN MANAGEMENT OF MORBID OBES

Atef mohamed abdel latif, mokhtar fareed abuelhoda, yaser ali elsayed, tamer youssef mohammed, ehab atef abdel latif and amr esam el-ok da. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 09 September 2018 Final Accepted: 11 October 2018 Published: November 2018 Objectives: Duodenal switch has proved to be the most effective procedure in management of morbid obesity as it has long-term weight loss outcome and co-morbidity improvement.It is important to study the types of abnormal histopathologic pattern in the gastric mucosa in patients with duodenal switch operation and follow up of those changes 6 month after the operation Methods: 25 morbid ly obese patients were included in this study. All patients were treated in the Endocrine Surgery Unit (ESU), Mansoura University Hospitals. ِ All patients did duodenal switch operation ( single anastomosis duodeno-ileal bypass with sleeve gastrectomy) and a biopsy from their gastric mucosa was taken at the time of the operation.Follow up of those patient was done six month after surgery regarding body weight, body mass index, weight loss and a biopsy was taken by upper gastro intestinal endoscope and compared with the previous data Result:The mean body weight six month after the operation was 116.2 ±15.2 kilo grams in comparison with 156.8 ±14.9 kilo grams at time of surgery with mean weight loss about 40.6 kilo grams and the mean body mass index six month after the operation is 40.7 ±4.4 in comparison with 55.0 ±4.7 at t ime of surgery with mean body mass index loss about 14. Normal gastric mucosa increased to 12 cases (48%) six month postoperative in comparison to seven cases (28%) at time of operation and Pathologic gastric mucosa decreased to 13 cases (52%) six month postoperative in comparison to 18 cases (72%) at time of operation Conclusion: Open duodenal switch operation (Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy) for morb idly obese patients gives very good results in weight loss and control of diabetes mellitus type II and hypertension. As regards the epithelial changes after surgery it was noticed that there were improvement of the gastric mucosal pathology.


ISSN: 2320-5407
Int. J. Adv. R es. 6 (11), 790-797 791 When a person gains weight, the fat cells increase in size at the first and then in number. (1). Obesity is a serious health problem all over the world where there is more than 1.9 b illion adults who are overweight, of which 600 million are obese. (2). In the Eastern Mediterranean region, there are the highest levels of overweight persons (BMI ≥ 25) were in Kuwait, Egypt, Saudi Arabia, Un ited Arab Emirates, Jordan and Bahrain, where the incidence of overweight and obesity for those aged more than 25 years was between 74%-86% for wo men and 69%-77% for men (3). The et iology of morbid obesity is multifactorial and is those include genetic, metabolic, socio-cultural, physiological, and psychological factors (4). With mo rbid obesity there is increased risk of co-mo rbidit ies as: type two diabetes, hypertension, hyperlipidemia, coronary artery disease, and shorter lifespan (5). Non surgical treatment of obesity (physical activity, d iet control, life style modification and pharmacotherapy ) seems to be ineffect ive with morb idly obese patients (body mass index more than 40), or those with body mass index 35-39.9 with associated co-mo rbidit ies. Such patients should undergo bariatric surgery either restrictive (as laparoscopic sleeve gastrectomy or malabsorptive surgery (as single anastomosis duodeno-ileal bypass and Roux-en-Y gastric bypass). (6). In recent years,bariatric surgery is the most powerful tool for management of obesity and related co -morbid ities. (7). Bariatric surgical procedures are divided into restrictive, malabsorptive, and combined (both restrictive and malabsorptive procedures). Co mmonly performed techniques include: Adjustable Gastric Banding (LA GB), Laparoscopic Sleeve Gastrectomy, Rou x-en-Y Gastric Bypass, Bilio -pancreatic Diversion , and Bilio-pancreatic Diversion with Duodenal Switch (8). Laparoscopic sleeve gastrectomy was first done in 2000, as part of a duodenal switch operation. (9). Long-term results of sleeve gastrectomy alone indicate that up to 64% of patient present insufficient weight reduction and 70% of them present with weight regain, despite proper preoperative management and selection (10). Single anastomosis duodeno-ileal bypass with sleeve gastrectomy wh ich is done by single loop duodenal switch with a 200-250 co mmon channel. It has benefits over Roux-en-Y Gastric Bypass (which is considered by many authors to be the gold standard bariatric surgery) :half number of anastomo sis, preserved pylorus that controls gastric emptying, no dumping syndrome, reduction of operative time and possible lower rate of postoperative complications (11). Duodenal switch operation has proved to be the most effective bariatric operation in terms of the long-term weight loss outcome and high cure rate for co-mo rbidit ies. Ho wever, its technical difficulty has limited its widespread use.

Patients and Methods:-
Atotal number of 25 mo rbid ly obese patients were included in this study Between march 2014 and November 2017. Males and females were included in the study. All patients were treated by Endocrine Surgery Team in the Endocrine Surgery Unit (ESU), Mansoura University Hospitals. Inclusion criteria were: (1)Age between 12 -55 years, (2)BMI mo re than 40 kg/ m 2 , (3) Patients were morbid ly obese for more than 5 years with failure of med ical treatment modalit ies, (4)Mentally stable, (5)Cooperative and motivated patient, (6)Presence of obesity related complications e.g. hypertension diabetes, osteoarthritis, and hyperlip ide mia (if BM I between 35 -40 kg / m 2 ). The exclusion criteria were: (1)Lack of motivation, (2) Mental and psychological instability, (3) Drug or alcohol addicts, (4)Patients unfit for general anesthesia. All patients wrote in formed consent for inclusion in the study after explanation of the nature of the operation and possible complicat ions. The study was approved by Mansoura Faculty of Medicine ethical co mmittee.
Preoperatively our patients were subjected to Complete history taking regarding age, sex, obesity associated comorbid ities, Other methods used for weight reduction and their effectiveness and Family h istory of obesity. General and abdominal examination, body Weight , Height ,body mass index and preoperative investigations.

Operati ve Techni que:
All patients were in supine position. Sterilizat ion of the abdominal wall was done. Upper midline incision was done. Linea A lba was identified and incised. The abdominal cavity was entered and abdominal and pelvic exploration was done in every patient. Devascularization of greater curvature of the stomach was performed. The duodenum is sectioned at the level of the gastroduodenal artery, warranting a 2 to4 cm pro ximal duodenal stump and avoiding damage to the common bile duct . The dis tal duodenal stump is over sutured . we start by duodenal transaction before sleeve gastrectomy to facilitate sleeve gastrectomy as reported in Abdlatif Modification (12). A 36 French bougie is passed into the stomach along the lesser curve to the Pylorus. Then stapling was done. Then the entire staple line is then oversewn with a continuous suture. The ileocecal junction is identified, and 200 cm is measured upwards. The s elected loop is ascended up to the proximal duodenal stump and anastomosed in an isoperistaltic way by hand-sewn anastomosis . The anastomosis was tested for leaks with methylene blue through the nasogastric tube. Tube drain was inserted near to gastrojujenal anastomosis. Then closure of the abdomen in layers. Gastric mucosal b iopsy was taken from resected stomach and sent for pathology.
Follow up of all patients done six months after the operation for body weight, body mass index and associated comorb idit ies ( diabetes mellitus and hypertension. Upper gastrointestinal endoscopy was done in that visit and gastric mucosal biopsy was taken and sent for pathology.
Co mparing the histo-pathological examination between pre-operative and six month after surgery in duodenal switch operation group shown in table 3: Normal gastric mucosa increased to 12 cases (48%) six month postoperative in co mparison to s even cases (28%) at time of operation and Pathologic gastric mucosa decreased to 13 cases (52%) six month post-operative in co mparison to 18 cases (72%) at time of operation

Discussion:-
The female gender comprised the majo rity of cases (72%), while female gender comprised 80% in Abd-Elatif A, et al. (12) . The females may be susceptible for obesity or more to seek for med ical and surgical advice because they are more interested with their shape .
. And in our study we did this modification as it is observed that starting with duodenal transection facilitates the sleeve gastric resection.
Our results consistently demonstrated the presence of a link between morbid obesity and sweet eating and which is defined by the Dutch Sweet Eating Questionnaire as an eating behavior in which at least 50% of daily con sumed carbohydrates consist of simple carbohydrates and which can be triggered by emotional factors (i.e., stress), This was proved by Van den Heuvel et al. (16). So in our study we did duodenal switch operation to sweet eater patients and it is exclusion criteria for laparoscopic sleeve gastrectomy operation.
Gastric mucosal changes in group II ( open duodenal switch operation) show that normal gastric mucosa increase to 12 cases (48%) 6 month post-operative in co mparison to 7 cases (28%) at time of operation Pathological gastric mucosa decrease to 13 cases (52%) 6 month post-operative in comparison to 18 cases (72%) at time of operat ion and those include the following: 1. Mild superficial gastritis decrease to 6 cases (24%) 6 month post-operative in comparison to 7 cases (28%) at time of operat ion 2. Mild chronic gastritis increase to 4 cases (16%) 6 month post-operative in comparison to 3 cases (12%) at time of operation 3. Helicobacter gastritis decrease to 2 cases (8%) 6 month post-operative in comparison to 6 cases (24%) at time of operation 4. Severe chronic superficial gastritis decrease to 1 case (4%) 6 month post-operative in comparison to 2 cases (8%) at time of operation.
And up to our knowledge there is no studies comparing the intra operative and post operative gastric mucosal changes in patients who underwent Duodenal switch operation (Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy) and this is the first study. In

Conclusion:-
open duodenal switch operation (Single Anastomosis Duodeno -Ileal Bypass with Sleeve Gastrectomy) for mo rbid ly obese patients gives very good results in weight loss as there was statistically significant reduction of weigt and body mass index 6 months after the operation.
Better results after surgery was noticed in our patients as regards control of diabetes mellitus type II and hypertension indicating an improvement in the quality of life of these patients..
As regards the epithelial changes after surgery it was noticed that , there was marked increase in the normal gastric mucosa and decrease in the presence of superficial gastritis and helicobacter pylori gastritis.
So our advice is :Open duodenal switch operation (Single Anastomosis Duodeno -Ileal Bypass with Sleeve Gastrectomy) is the best to be done in morbid ly obese patients because of marked sustained reduction of body weight and control of diabetes mellitus( type two) and hypertension.