Plasma Enteroglucagon after Jejunoileal Bypass with 3 : 1 or 1 :3 Jejunoileal Ratio J. J. HOLST, T. I. A. SaRENSEN, A. N. ANDERSEN, F. STADIL, B. ANDERSEN, K. B. LAURITSEN & H. C. KLEIN Institute of Medical Physiology C, The Panum Institute, Dept. of Surgical Gastroenterology D,
Herlev Hospital, University of Copenhagen, Denmark Holst, J. J., Serrensen,T. I. A., Andersen, A. N., Stadil, F., Andersen, B., Lauritsen, K. B.
Scand J Gastroenterol Downloaded from informahealthcare.com by University of Newcastle on 01/07/15 For personal use only.
& Klein H. C. Plasma enteroglucagon after jejunoileal bypass with 3 : 1 or 1 :3jejunoileal ratio. Scand. J . Gastroent. 1979, 14, 205-207.
Enteroglucagon concentration in peripheral blood was determined before and after a test meal in 24 morbidly obese patients. Eighteen had jejunoileal bypass, 6 with a 3 : 1 and 12 with a 1 :3 jejunoileal ratio of the functioning segment, and 6 were unoperated. All three groups exhibited an increment of enteroglucagon concentration after the meal. Both the fasting values and the postprandial integratedincrementswere higher in operated patients than in unoperated patients and higher after 1:3 bypass than after 3 : 1 bypass. The findings agree with the hypothesis that enteroglucagon secretion is stimulated by exposureof the lower bowel to upper-bowel content, and that the effect of enteroglucagon is, as seen after bypass operation, stimulation of growth and reduction of motility of the intestine. Keywords: Glucagon; intestmal bypass; obesity T. I. A. Sbrensen, M.D., Dept. of Surgery D, Herlev Hospital, DK-2730 Herlev, Denmark
Enteroglucagon probably originates from cells occurring throughout the gastrointestinal mucosa and most abundantly in the ileum and colon (10). The scanty observations on secretion and effect of enteroglucagon may be unified in the following, teleologically attractive, hypothesis ( 10, 13, 16): enteroglucagon secretion is stimulated by exposure of the distal bowel to components of the intestinal content which usually are absorbed in the proximal bowel; the stimulated enteroglucagon secretion enhances the intestinal absorption by accelerating the growth and reducing the motility of the intestine. According to this hypothesis, hypersecretion of enteroglucagon should follow jejunoileal bypass, which exposes the lower bowel to upper content and leads to increased growth ( 5 , 6) and slow transit (15). Furthermore, it may be implied that bypass with short jejunal and long ileal segment in continuity results in greater enteroglucagon secretion than bypass with a reversed jejunoileal ratio. The enteroglucagon concentration in peripheral blood of such
patients agrees with this hypothesis, as will be shown in the present report. MATERIAL A N D METHODS Twenty-four morbidly obese adult patients were examined, 6 before and 18 within 3- 15 months after end-to-side jejunoileostomy. The patients were randomized to bypass with a ratio of eitber 3 : 1 or 1 : 3 between the jejunal and ileal segment left in continuity. The shunt measured 50 cm along the mesenteric border. The patients fasted from 8 p m . and were given a test meal at 8.30 a.m. the following day. The meal comprised two parts: first a bouillon of 10 g of meat extract (Bovril) in 200 ml water and then a gruel of 69 g cane sugar, 63 g skim milk powder, 37 g corn oil, 10 g orange taste corrigent, and 500 ml water. Immediately before and for 150 min after the test meal, peripheral blood samples were drawn into heparinized 10-ml tubes to which 5000 units of aprotinin (Trasylol@, Bayer, G.F.R.) were added.
Scand J Gastroenterol Downloaded from informahealthcare.com by University of Newcastle on 01/07/15 For personal use only.
206
J. J. Hmlst, T. 1. A . SQrensen, A . N . Andersen, F. Stadil, B. Andersen, K . B . Lauritsen & H. C . KIein
The tubes were placed in ice-water, and the plasma was separated by centrifugation at 4OC within 1 h and stored at - 18°C until assay. Total glucagon and pancreatic glucagon were determined by radioimmunoassay ( 12). Concentration of enteroglucagon was calculated as the difference between total and pancreatic glucagon and expressed as mole equivalent to a pancreatic glucagon standard (10, 12). The statistical methods were the Friedmann and the Page tests for within-patient comparisons and the Kruskal-Wallis and the Jonckheere-Terpstra tests for between-group comparisons
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RESULTS
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After the meal, the enteroglucagon concentration increased in all three groups of patients (P < 0.0 1) (Fig. 1). The increase appeared to be composed of two phases, of which the first seemed identical with regard to both magnitude and duration in the three groups. 150
-
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Fig. 2. Individual values in the three patient groups (cf.
.
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Fig. 1) of the integrated increment of enteroglucagon concentration in peripheral plasma (enteroglucagon response) during the first 150 min after a test meal. The horizontal lines represent median values.
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Herlev Hospital, University of Copenhagen, Denmark Holst, J. J., Serrensen,T. I. A., Andersen, A. N., Stadil, F., Andersen, B., Lauritsen, K. B.
Scand J Gastroenterol Downloaded from informahealthcare.com by University of Newcastle on 01/07/15 For personal use only.
& Klein H. C. Plasma enteroglucagon after jejunoileal bypass with 3 : 1 or 1 :3jejunoileal ratio. Scand. J . Gastroent. 1979, 14, 205-207.
Enteroglucagon concentration in peripheral blood was determined before and after a test meal in 24 morbidly obese patients. Eighteen had jejunoileal bypass, 6 with a 3 : 1 and 12 with a 1 :3 jejunoileal ratio of the functioning segment, and 6 were unoperated. All three groups exhibited an increment of enteroglucagon concentration after the meal. Both the fasting values and the postprandial integratedincrementswere higher in operated patients than in unoperated patients and higher after 1:3 bypass than after 3 : 1 bypass. The findings agree with the hypothesis that enteroglucagon secretion is stimulated by exposureof the lower bowel to upper-bowel content, and that the effect of enteroglucagon is, as seen after bypass operation, stimulation of growth and reduction of motility of the intestine. Keywords: Glucagon; intestmal bypass; obesity T. I. A. Sbrensen, M.D., Dept. of Surgery D, Herlev Hospital, DK-2730 Herlev, Denmark
Enteroglucagon probably originates from cells occurring throughout the gastrointestinal mucosa and most abundantly in the ileum and colon (10). The scanty observations on secretion and effect of enteroglucagon may be unified in the following, teleologically attractive, hypothesis ( 10, 13, 16): enteroglucagon secretion is stimulated by exposure of the distal bowel to components of the intestinal content which usually are absorbed in the proximal bowel; the stimulated enteroglucagon secretion enhances the intestinal absorption by accelerating the growth and reducing the motility of the intestine. According to this hypothesis, hypersecretion of enteroglucagon should follow jejunoileal bypass, which exposes the lower bowel to upper content and leads to increased growth ( 5 , 6) and slow transit (15). Furthermore, it may be implied that bypass with short jejunal and long ileal segment in continuity results in greater enteroglucagon secretion than bypass with a reversed jejunoileal ratio. The enteroglucagon concentration in peripheral blood of such
patients agrees with this hypothesis, as will be shown in the present report. MATERIAL A N D METHODS Twenty-four morbidly obese adult patients were examined, 6 before and 18 within 3- 15 months after end-to-side jejunoileostomy. The patients were randomized to bypass with a ratio of eitber 3 : 1 or 1 : 3 between the jejunal and ileal segment left in continuity. The shunt measured 50 cm along the mesenteric border. The patients fasted from 8 p m . and were given a test meal at 8.30 a.m. the following day. The meal comprised two parts: first a bouillon of 10 g of meat extract (Bovril) in 200 ml water and then a gruel of 69 g cane sugar, 63 g skim milk powder, 37 g corn oil, 10 g orange taste corrigent, and 500 ml water. Immediately before and for 150 min after the test meal, peripheral blood samples were drawn into heparinized 10-ml tubes to which 5000 units of aprotinin (Trasylol@, Bayer, G.F.R.) were added.
Scand J Gastroenterol Downloaded from informahealthcare.com by University of Newcastle on 01/07/15 For personal use only.
206
J. J. Hmlst, T. 1. A . SQrensen, A . N . Andersen, F. Stadil, B. Andersen, K . B . Lauritsen & H. C . KIein
The tubes were placed in ice-water, and the plasma was separated by centrifugation at 4OC within 1 h and stored at - 18°C until assay. Total glucagon and pancreatic glucagon were determined by radioimmunoassay ( 12). Concentration of enteroglucagon was calculated as the difference between total and pancreatic glucagon and expressed as mole equivalent to a pancreatic glucagon standard (10, 12). The statistical methods were the Friedmann and the Page tests for within-patient comparisons and the Kruskal-Wallis and the Jonckheere-Terpstra tests for between-group comparisons
0
25
.-c
-E 5
0
d
\
20
0
I
4
0
-E z
x
0
15
0
v)
W
(9).
0 0 0
E
RESULTS
Z
10
0 (3
After the meal, the enteroglucagon concentration increased in all three groups of patients (P < 0.0 1) (Fig. 1). The increase appeared to be composed of two phases, of which the first seemed identical with regard to both magnitude and duration in the three groups. 150
-
a u
3
A (3
0 0
5
. .
W
I-
z
!U
0 UNOPERATED
3:l BYPASS
1:3 BYPASS
Fig. 2. Individual values in the three patient groups (cf.
.
-- >
e CT
;100-E
Fig. 1) of the integrated increment of enteroglucagon concentration in peripheral plasma (enteroglucagon response) during the first 150 min after a test meal. The horizontal lines represent median values.
9.
z
0 0
