Physiologic and Functional Adaptations of Insulin Sensitive Tissues

Study Overview
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Brief Summary
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The long-term goal is to understand the mechanisms of intestinal nutrient sensing and signal relays to insulin sensitive tissues (adipose, skeletal muscle, liver) in humans. The investigators hypothesize that human tissue biopsies (from obese surgery and non-surgery subjects as well as lean controls) can be used to understand the molecular mechanisms underlying intestinal nutrient sensing and signal relay in humans. The investigator will obtain tissue specimens from patients during scheduled upper endoscopies, colonoscopies and scheduled metabolic and bariatric surgeries or liver transplantation. A blood sample (4mL) will be obtained concurrent with these procedures. From metabolic and bariatric surgery subjects blood and tissues (liver, adipose, small intestine, omentum, skeletal muscle) can be collected at the time of surgery. From liver transplantation patients, excised liver tissue will be collected. Stool can be obtained preoperatively and at various time points after surgery. Some bariatric surgery subjects will participate in a mixed-meal tolerance test at their pre-operative visit and several post-operative visits to compare the whole-body metabolic alterations following bariatric procedures.

Detailed Description
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Upper endoscopy (subset) Intestinal biopsies will be obtained during scheduled upper endoscopy from the mid-duodenum and/or proximal jejunum. In the case that a patient requires an upper endoscopy after metabolic and bariatric surgery, biopsies will be obtained from the mid-jejunum. Blood will be collected from an IV placed in the arm used for administering anesthesia required for the indicated procedure. Colonoscopy (subset) Biopsies of the colon will be obtained during scheduled colonoscopy. Blood will be collected from an IV placed in the arm used for administering anesthesia required for the indicated procedure. Metabolic and bariatric surgery (subset) During the metabolic and bariatric surgical procedures, biopsy of the jejunum, liver and omentum (visceral adipose) may be obtained. Biopsies of skeletal muscle and subcutaneous adipose will be taken at the sites of trocar placement for laparotomy. Blood will be collected from an IV placed in the arm used for administering anesthesia required for the indicated procedure. Feces will be self-collected by the patient using a provided culture swab specimen container or FOB card. Liver transplantation (subset) • Tissue will be collected from excised disease liver

Official Title
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Physiologic and Functional Adaptations of Insulin Sensitive Tissues After Bariatric Surgery

Conditions
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Diabetes, Obesity, Insulin Resistance, Bariatric Surgery Candidate, Roux-en-y Gastric Bypass, Liver Diseases

Intervention / Treatment
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* Other: Endoscopy biopsy
* Other: Surgical biopsy
* Other: Mixed-meal tolerance test
* Other: Excised Liver Tissue Sampling


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: - Scheduled for upper endoscopy, colonoscopy or metabolic and bariatric surgery, or liver transplantation at Vanderbilt University Medical Center. Additional inclusion criteria for individuals scheduled for metabolic and bariatric surgery: Obese, ≥ 40 kg/m2 or ≥ 35 kg/m2 + one comorbidity (type 2 diabetes [fasting blood glucose ≥ 120 mg/dL; HbA1C ≥ 6.5%]; fatty liver disease, hypertension, cardiovascular disease, hyperlipidemia) Additional inclusion criteria for individuals scheduled for liver transplantation: diagnosis of nonalcoholic liver disease or nonalcoholic steatohepatitis Exclusion Criteria: Known history of intestinal diseases including, but not limited to, inflammatory bowel disease (e.g. ulcerative colitis, Crohn's disease) and celiac sprue. Smoking >7 cigarettes per day Malabsorptive syndromes Pregnant or breastfeeding Additional exclusion criteria for patients undergoing endoscopy/colonoscopy: Recent history of malignancy (<5 years ago) Previous lap band surgery Established renal disease Additional exclusion criteria for patients undergoing bariatric surgery: Previous lap band, sleeve gastrectomy, or gastric bypass surgery Recent history of malignancy (< 5 years ago) Established organ dysfunction Additional exclusion criteria for patients undergoing liver transplantation: Previous lap band, sleeve gastrectomy, or gastric bypass surgery Alpha 1 anti-trypsin disease, Wilson's disease, viral hepatitis, alcoholic liver disease

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Obese, surgery<br>Obese subjects recruited from the Center for Surgical Weight loss who are undergoing weight loss surgery as part of their standard of care. Tissue biopsies, blood, and fecal swabs will be collected at surgical visits. | Other: Surgical biopsy<br>* Biopsy of the liver is standard of care for diagnosing NAFLD. Biopsy of omentum, skeletal muscle and subcutaneous adipose (the latter two tissues taken at the site of trocar placement) will be collected intraoperatively at the time of Roux-en-Y gastric bypass (RYGB) or vertical sleeve gastrectomy (VSG).<br>Other: Mixed-meal tolerance test<br>* The mixed meal tolerance test (MMTT) shows how much insulin your body is making after drinking a liquid meal beverage that contains fats, protein and carbohydrates (sugar). Glucose, C-peptide, free fatty acids, triglycerides, incretins, pancreatic polypertide, bile aceis, and fatty acid amides can also be measured. A total of 9 tablespoons of blood is taken over a 255 minute period.<br>|
| Obese, nonsurgery<br>Obese subjects recruited from the Vanderbilt Endoscopy Clinic who are undergoing upper endoscopy or colonoscopy as part of their standard of care. Tissue biopsies, blood, and fecal swabs will be collected at day of procedure. | Other: Endoscopy biopsy<br>* Tissue samples will be collected from the jejunum, duodenum, and colon during the subject's standard of care procedure.<br>|
| Lean control<br>Lean control subjects recruited from the Vanderbilt Endoscopy Clinic who are undergoing upper endoscopy or colonoscopy as part of their standard of care. Tissue biopsies, blood, and fecal swabs will be collected at day of procedure. | Other: Endoscopy biopsy<br>* Tissue samples will be collected from the jejunum, duodenum, and colon during the subject's standard of care procedure.<br>|
| Liver transplant<br>Lean or obese subjects who are undergoing liver transplantation as part of their standard of care. Excised liver tissue will be collected the day of procedure. | Other: Excised Liver Tissue Sampling<br>* Tissue will be collected from the excised liver for research after the diseased liver has been removed as part of the standard of care procedure.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Ability to establish organoid cultures | Measure percent success rate of making organoid cultures from tissue biopsies | 12 months |