A randomized controlled trial of Roux-en-Y gastrojejunostomy vs. gastroduodenostomy with respect to the improvement of type 2 diabetes mellitus after distal gastrectomy in gastric cancer patients

<div><p>The purpose of this study is to compare the effect of diabetes control induced by Roux-en-Y gastrojejunostomy(RY) vs Billroth-I reconstruction(BI) after distal gastrectomy in patients with early gastric cancer(EGC) and type 2 diabetes(T2DM). Forty EGC patients with T2DM, aged 20–80 years, who were expected to undergo curative distal gastrectomy were randomized 1:1 to RY(n = 20) or BI(n = 20). Diabetes medication status, biochemical and hormonal data including blood glucose, HbA1c, insulin, C-peptide, HOMA-IR, ghrelin, leptin, GLP-1, PYY, and GIP were evaluated for 12 months after surgery. Although pre- and postoperative 12-month fasting and postprandial glucose levels did not show a significant difference, HbA1c, C-peptide, and HOMA-IR levels were significantly improved at 12 months after surgery in both BI and RY groups. Sixty percent of RY patients and 20% of BI patients decreased their medication satisfying FBS<126 mg/dL and HbA1c<6.5% and 5% of BI patients stopped their medication satisfying the criteria of FBS<126 mg/dL and HbA1c<6.0%. The improvement patterns were more sustainable with less fluctuation in RY than in BI. On hormonal analysis, ghrelin and leptin levels were decreased and PYY and GIP levels were increased at 12 months after surgery in both groups without significant difference according to the reconstruction type and diabetic improvement status except ghrelin. In gastric cancer surgery, RY reconstruction showed better and more durable diabetes control compared to BI during the first year after surgery. Gastric cancer surgery led to decreased ghrelin and leptin and increased PYY and GIP, which might have a role in improving insulin resistance and glucose homeostasis.</p></div

Diabetic control status and medication changes after surgery.

<p>Diabetic control status and medication changes after surgery.</p

Gut hormone changes after surgery by reconstruction types.

<p>RY, subtotal gastrectomy with Roux-en-Y gastrojejunostomy; BI, subtotal gastrectomy with gastroduodenostomy; GLP-1, glucagon-like peptide-1; GIP, glucose-dependent insulinotropic polypeptide; PYY, Peptide YY.</p

Serial changes in biochemical data reflecting glucose intolerance after surgery.

<p>RY, subtotal gastrectomy, Roux-en-Y gastrojejunostomy; BI, subtotal gastrectomy, gastroduodenostomy, BMI, body mass index; PP2, postprandial 2 hour; HOMA-IR, homeostasis model assessment-estimated insulin resistance.</p

Functional 3D Human Primary Hepatocyte Spheroids Made by Co-Culturing Hepatocytes from Partial Hepatectomy Specimens and Human Adipose-Derived Stem Cells

<div><p>We have generated human hepatocyte spheroids with uniform size and shape by co-culturing 1∶1 mixtures of primary human hepatocytes (hHeps) from partial hepatectomy specimens and human adipose-derived stem cells (hADSCs) in concave microwells. The hADSCs in spheroids could compensate for the low viability and improve the functional maintenance of hHeps. Co-cultured spheroids aggregated and formed compact spheroidal shapes more rapidly, and with a significantly higher viability than mono-cultured spheroids. The liver-specific functions of co-cultured spheroids were greater, although they contained half the number of hepatocytes as mono-cultured spheroids. Albumin secretion by co-cultured spheroids was 10% higher on day 7, whereas urea secretion was similar, compared with mono-cultured spheroids. A quantitative cytochrome P450 assay showed that the enzymatic activity of co-cultured spheroids cultured for 9 days was 28% higher than that of mono-cultured spheroids. These effects may be due to the transdifferentiation potential and paracrine healing effects of hADSCs on hHeps. These co-cultured spheroids may be useful for creating artificial three-dimensional hepatic tissue constructs and for cell therapy with limited numbers of human hepatocytes.</p> </div

Co-cultured spheroids had higher viability and aggregated more rapidly than mono-cultured spheroids.

<p>Spheroidal formation and viability of cells in mono-cultured spheroids cultured for (A) 3 days, (B) 7 days and in co-cultured spheroids cultured for (C) 3 days and (D) 7 days in concave microwells. Scale bars, 500 µm, (E) Diameter analysis of mono-cultured spheroids and co-cultured spheroids in 500 µm concave microwells. Data represent the means ± standard deviations of 10 independent experiments (*p<0.0001, two-tailed test).</p

hADSCs in co-cultured spheroids exhibited hepatocyte-like features.

<p>(A) The expression of mRNA for the co-cultured spheroids on day 3, day 7, and hADSC mono-cultured spheroids on day3. (B) Quantification of the relative gene expressions to GAPDH. Data represent the means ± standard deviations of 3 independent experiments. (*p<0.1, **p<0.05, ***p<0.001, two-tailed test).</p

Co-cultured spheroids showed higher liver specific function and more stable metabolic function than mono-cultured spheroids.

<p>Analysis of metabolic function of mono-cultured spheroids and co-cultured spheroids, measured as secretion of (A) albumin and (B) urea. Data represent means ± standard deviations of eight independent experiments. Immunostaining for cytochrome P450 reductase (red) in (C) mono-cultured spheroids and (D) co-cultured spheroids cultured for 9 days. Nuclei were stained with DAPI (blue). Scale bars, 50 µm. (E) Luminescence assay of cytochrome P450 activity in mono-cultured and co-cultured spheroids. Cytochrome P450 3A enzyme activity were measured based on the degree of luminescence emitted by adding detection reagent and measured with a luminometer. Data represent means ± standard deviations of 3 independent experiments.</p

Co-cultured spheroids showed healthy hepatocytic ultrastructure.

<p>Ultrastructural feature of the co-cultured spheroids by transmitting electron microscopy (TEM) on day 7 of culture. The spheroids are characterized by tight junctions (Tj) between adjacent cells, distinct nuclei (N), abundant mitochondria (M), peroxisomes (P), rough endoplasmic reticulum (rER), collagen accumulation (Col), glycogen vesicles (Gl), and bile canaliculi (B).</p

Only co-cultured model can form compact spheroidal shape.

<p>SEM images of mono-cultured spheroids cultured for (A) 3 days, (B) 9days and co-cultured spheroids cultured for (C) 3 days and (D) 9 days. Scale bars, 10 µm. Immunostaining for AE-2 (green) and actin (red) in (E) mono-cultured spheroids and (F) co-cultured spheroids cultured for 9 days. Scale bars, 50 µm. Scanning electron microscopy images of sectioned co-cultured spheroids cultured for (G) 3 days and (H) 9days. Inner structure of co-cultured spheroids is porous which involves good diffusion of nutrient and oxygen into the spheroid. Scale bars, 10 µm.</p