Structural changes in intestinal enteroendocrine cells after ileal interposition in normal rats

INTRODUCTION: No therapeutic approach has significantly impacted the progression of diabetes. As early improvement of glicaemic control is observed after bariatric surgeries, there is currently a search for surgical procedures that can promote euglycemia also in non-obese patients. Glicaemic control can be achieved by increasing the blood concentration of GLP-1, a hormone produced by L cells that are more densely concentrated in the terminal ileum. The interposition of ileal segment to a more anterior region (proximal jejunum) can promote a greater stimulation of the L cells by poorly digested food, increasing the production of GLP-1 and reflecting on glicaemic control.
AIMS: To investigate long-term histological modifications of intestinal mucosa of rats submitted to interposition of ileum segment to a proximal region (jejunum).
METHODS: Forty 8-week old male Wistar-EPM1 rats (Rattus norvegicus albinus) were randomly distributed into 3 groups: the Interposition Group (IG) was subjected to ileal interposition, the Sham Group (SG) was subjected to sham operations, and the Control Group (CG) was not subjected to surgery. All animals were followed until the 60th postoperative day (8 postoperative week) when they were euthanized. Segments of jejunum and ileum from all groups were collected and analyzed by optical microscopy and immunohistochemistry.
RESULTS: No structural nor histological changes in intestinal L cells in the interposed intestinal segment and other intestinal segments were noted after ileal interposition surgery. 
CONCLUSION: As L cells endocrine characteristics were likely maintained, the use of metabolic surgical techniques for the treatment of metabolic diseases, especially diabetes, seems to be justified

Organic consequences of ileal transposition in rats with diet-induced obesity

INTRODUCTION: The clinical management of metabolic syndrome - especially diabetes mellitus type 2 - is notoriously complex due to the progressive nature of this disease. At present, there is a need for a surgical procedure that is effective for the treatment of diabetes mellitus type 2, even in non-obese individuals. The isolated ileal transposition theory could lead to an effective alternative therapy. This intervention has not yet been performed in humans, and there are no reports of its use in an experimental model of diet-induced metabolic syndrome.
 OBJECTIVES: The objective of this study is to evaluate the physiological effects of ileal transposition in rats with diet-induced metabolic syndrome. The effects of this procedure on glucose and lipid metabolism will be assessed. 
METHODS: Forty 12-week-old male rats (albino Rattus norvegicus, Wistar, 2BAW, heterogeneous) will be divided into four groups of 10 animals each: the ileal transposition group (TG) comprising animals on a hypercaloric-hyperlipidic diet; the sham group (SG) containing animals that receive the same diet and undergo the sham surgery; control group 1 (CG1), which will receive a hypercaloric-hyperlipidic diet and will not undergo surgery; and control group 2 (CG2), which will consume standard feed and will not undergo surgery. The surgeries will be performed in 20-week-old animals. Blood samples for laboratory testing will be collected from 12-week-old animals on the day of surgery and after eight postoperative weeks, following determination of the weights of the animals and the administration of anesthesia. The levels of serum glucose, insulin, triglycerides, total cholesterol and fractions, glucagon-like peptide-1, C-peptide and glycated hemoglobin will be assessed in all of the animals. The insulin tolerance test will be performed using PRISMA software, and insulin resistance will be calculated by the HOMA-IR indirect test. On specific days, two 20-week-old rats will be separated and randomly distributed in TG and SG. These animals will be followed until the eighth postoperative week. Subsequently, they will be euthanized, and the retroperitoneal and periepididymal fat deposits will be collected and weighed using a precision scale. In addition, the pancreas, liver and intestinal segments will be sent for pathological and immunohistochemical studies.
&#xa

Isolated ileal interposition in enteroendocrine L cells differentiation

INTRODUCTION: 
Due to the progressive nature of type 2 diabetes, its complexity and drug treatment perpetuity, there is currently a search for surgical procedures that can promote euglycemia also in non-obese patients. Diabetic patients glycemic control can be achieved by increasing the blood concentration of GLP-1, a hormone produced by L cells that are more densely concentrated in the terminal ileum. Early and extended improvement of diabetes in patients submitted to bariatric surgeries awakened the necessity of investigating the isolated ileal interposition as a surgical alternative for the treatment of diabetes. The interposition of this ileal segment to a more anterior region (proximal jejunum) can promote a greater stimulation of the L cells by poorly digested food, increasing the production of GLP-1 and reflecting on glycemic control. However, in order to consolidate the ileal interposition as a surgical treatment of diabetes it is necessary that the interposed ileum keep the same differentiation rate into L cells for a long period to justify the intervention.

AIMS: 
To investigate the isolated ileal interposition influence on the differentiation of intestinal precursor cells into enteroendocrine L cells over time.

METHODS: 
Twelve 12-week-old male Wistar rats (Rattus norvegicus albinus) of the WAB strain (heterogeneous) will be used. All animals will receive a high-calorie, high-fat diet for 16 weeks or more until they develop glucose dysmetabolism confirmed by glycemic test. They will be divided into two groups of 10 animals each: the isolated ileal interposition group (GI) and the control group (GC), comprising animals that will not be submitted to any surgical intervention. Blood samples will be collected under anesthesia at the weeks 12, 26, 36 and 44 for the determination of serum levels of glucose, insulin, GLP-1, glucagon, C-peptide and glycosilated hemoglobin. The insulin tolerance test will be performed and insulin resistance will be calculated. For the comparative analysis of the ileal precursor cells differentiation into enteroendocrine cells among the two groups, the following intestinal fragments will be collected after euthanasia: interposed ileum and remaining ileum from GI, jejunum and ileum from GC. These fragments will be analyzed by imunofluorescence and also by Real Time PCR using PCR Arrays for target genes including the main ones related to stem cell, stem cell signaling, diabetes, Wnt and Notch signaling pathways and other genes and pathways involved in the differentiation of intestinal precursor cells into enteroendocrine cells, especially GLP-1-producing L cells that play important role in euglycemia

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Organic repercussions and morphological alterations of the endocrine pancreas after isolated ileal interposition in normal rats

Introdução: Fatores neurohormonais e metabolicos associados aos procedimentos bariatricos sao o foco no tratamento cirurgico do diabetes mellitus tipo 2 (DM2), com efeitos sobre a producao de insulina e no metabolismo glicidico e lipidico. Apesar de niveis glicemicos mais baixos apos Interposicao Ileal Isolada (III), em ratos euglicemicos, as alteracoes morfologicas do pancreas nao foram estudadas. O objetivo deste estudo foi avaliar os efeitos ponderais, metabolicos e na morfologia pancreatica apos III. Metodos: Estudo experimental com 24 ratos machos adultos Wistar, normais, distribuidos no Grupo Interposicao (GI), submetidos a III e no grupo Simulado (GS), submetidos a operacao simulada. Foram mensurados a massa corporal e o consumo alimentar da 13a a 21a semana de vida, 8 semanas de pos-operatorio(PO), quando foi realizada a eutanasia. Parametros bioquimicos e o teste de tolerancia insulinica (ITT) foram mensurados antes da cirurgia e na eutanasia. Foram efetuadas as medidas de tecido pancreatico e de ilhotas de Langerhans, alem da contagem de celulas beta e nao marcadas por imunohistoquimica. Resultados: Nao houve diferenca entre os grupos na evolucao da massa corporal, no consumo alimentar, nas dosagens bioquimicas e no ITT. Na analise dos momentos em cada grupo, na eutanasia, o GI apresentou niveis mais elevados de insulinemia (p=0,01) e HDL-colesterolemia (p<0,01) e colesterolemia total mais baixa (p=0,04), enquanto o GS apresentou glicemia (p=0,01) e trigliceridemia (p<0,01) mais elevadas. O ITT nao apresentou diferenca. Observou-se resultados semelhantes para os dois grupos na relacao entre a area de ilhotas e area de pancreas (p=0,37), na relacao do numero de celulas beta por area de ilhota (p=0,18) e area de pancreas (p=0,47) e no percentual de celulas beta (p=0,38). Discussao: Nao foi demonstrado que a III tem efeitos adversos sobre a morfologia do pancreas endocrino e foi benefico para o metabolismo glicidico e lipidico. Conclusao: Em ratos normais, a interposicao ileal nao influencia na populacao de celulas beta e induz alteracoes beneficas no metabolismo da glicose e lipidios. Assim, a III poderia representar uma tecnica operatoria para o tratamento de DM2 em pacientes com IMC normalBV UNIFESP: Teses e dissertaçõe

Injuries caused by Veress needle insertion for creation of pneumoperitoneum: a systematic literature review

Background the aim of this study was to assess the prevalence, risks, and outcomes of injuries caused by the Veress needle described in the literature.Methods Iatrogenic injuries caused by Veress needle insertion during diagnostic or therapeutic laparoscopies in humans were researched, with no language restriction, in the Medline, Lilacs, Embase, Scielo, and Cochrane Library databases. the following words were combined: Veress'' or insufflation needle'' or pneumoperitoneum needle,'' and complications'' or injuries'' or lesions.'' the bibliographic references of the selected articles were also analyzed. We considered the following: (1) number of injuries described in the literature, (2) relationship between number of injuries and number of patients who underwent Veress needle insertion in the studies that reported Veress needle injury, (3) organs and structures injured (retroperitoneal vessels, digestive tract, and self-limited, minor injuries), and (4) outcome (death, conversion to laparotomy, laparoscopic repair, spontaneous resolution).Results Thirty-eight selected articles included 696,502 laparoscopies, with 1,575 injuries (0.23%), 126 (8%) of which involved blood vessels or hollow viscera (0.018% of all laparoscopies). of the 98 vascular injuries, 8 (8.1%) were injuries to major retroperitoneal vessels. There were 34 other reported retroperitoneal injuries, but the authors were not specific as to which vessel was injured. of the 28 injuries to hollow viscera, 17 were considered major injuries, i.e., 60.7% (0.0024% of the total cases assessed).Conclusion the insertion of the Veress needle in the abdominal midline, at the umbilicus, poses serious risk to the life of patients. Therefore, further studies should be conducted to investigate alternative sites for Veress needle insertion.Universidade Federal de São Paulo, Div Operat Tech & Expt Surg, Dept Surg, BR-04023900 São Paulo, BrazilUniversidade Federal de São Paulo, Div Operat Tech & Expt Surg, Dept Surg, BR-04023900 São Paulo, BrazilWeb of Scienc

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

Background: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit