title: Digestive Adaptation with Intestinal Reserve: a neuroendocrine-based operation for morbid obesity.
abstract: BACKGROUND
  Mechanical obstacles to food ingestion, nutrient-excluded segments and malabsorption are common strategies of bariatric surgery which are a potential cause of symptoms or complications. We describe an operation "Digestive Adaptation with Intestinal Reserve" (DAIR) that does not utilize these tools, aiming fundamentally at neuroendocrine changes.
  
  
  METHODS
  The operation includes sleeve gastrectomy, omentectomy and enterectomy, maintaining the initial 40 cm of jejunum and final 260 cm of ileum (keeping the bowel length at the lower limit for adaptation to normal). Jejunum is laterally anastomosed to ileum 80 cm proximal to the cecum. A gastroileostomy creates a transit bipartition (ileum and proximal bowel in transit). 55 patients are presented whose follow-up is >12 months (12-34 months). Fasting ghrelin and resistin, and postprandial GLP-1 and PYY were measured.
  
  
  RESULTS
  Mean BMI reduction was 4.8, 9.5, 15.4 and 20.1 kg/m(2) respectively at 1, 3, 6 and 12 months. Patients have early satiety and major improvement in pre-surgical co-morbidities, especially diabetes and hypertension. GLP-1 and PYY response to food ingestion were enhanced; fasting ghrelin and resistin were significantly reduced (P<0.05). Radiographic studies show nutrient transit through the pylorus and through the gastroileostomy. Early surgical complications (2 in 55 patients) resolved without sequelae. There were no signals of malabsorption, no deaths, and most patients present no symptoms at all.
  
  
  CONCLUSIONS
  DAIR amplifies postprandial neuroendocrine response and provokes intense weight loss. DAIR reduces production of ghrelin and resistin and enables more nutrients to be absorbed distally enhancing GLP-1 and PYY secretion. Diabetes improved significantly without duodenal exclusion.
authors.affiliation: Department of Surgery, Hospital Israelita Albert Einstein, São Paulo, Brazil. sergio@santoro.med.br
authors.forename: Sérgio
authors.initials: S
authors.lastname: Santoro
authors.forename: Carlos E
authors.initials: CE
authors.lastname: Malzoni
authors.forename: Manoel C P
authors.initials: MC
authors.lastname: Velhote
authors.forename: Fábio Q
authors.initials: FQ
authors.lastname: Milleo
authors.forename: Marco A
authors.initials: MA
authors.lastname: Santo
authors.forename: Sidney
authors.initials: S
authors.lastname: Klajner
authors.forename: Durval
authors.initials: D
authors.lastname: Damiani
authors.forename: João G
authors.initials: JG
authors.lastname: Maksoud
mesh_terms: D000222:Adaptation, Physiological; D000293:Adolescent; D000328:Adult; D001066:Appetite / Q000502:physiology; D050110:Bariatric Surgery / Q000379:methods*; D015992:Body Mass Index; D015897:Comorbidity; D013505:Digestive System Surgical Procedures / Q000379:methods*; D005260:Female; D005743:Gastrectomy; D054439:Ghrelin; D006801:Humans; D007422:Intestines / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000453:epidemiology / Q000601:surgery; D009852:Omentum / Q000601:surgery; D036361:Peptide Hormones / Q000097:blood; D019518:Postprandial Period; D052243:Resistin / Q000097:blood
chemical_list: D054439:Ghrelin; D036361:Peptide Hormones; D052243:Resistin