Ileogastrostomy or jejunoileal bypass with drainage of the bypassed bowel into the stomach.

Ileogastrostomy was first performed for morbid obesity in 1982. In this review, the rationale and technique for the operation are described, and the results and complications discussed. An interesting aspect in a changing world is the lack of modification that has occurred in the surgery, and the possibility of long-term results which are rare in bariatric surgery. The techniques of wound closure have changed, however. The surgery is simple to perform and achieves excellent weight loss and reversal of co-morbid conditions such as non-insulin-dependent diabetes mellitus, but requires long-term follow-up. The principal long-term problem is calcium oxalate renal stones, with occasional patients having troublesome diarrhoea.

Determinants of weight loss following ileogastrostomy.

To examine the factors associated with weight loss following ileogastrostomy, (i) energy expenditure, (ii) body composition and (iii) urinary and fecal energy losses were examined in 11 morbidly obese subjects (36 +/- 3 y, 43.7 +/- 0.9 kg/m2 BMI, 47.0 +/- 1.3% body fat (BF) (mean +/- SEM) prior to and after this surgical procedure. Respiratory gas exchange analysis was used to measure changes in basal energy expenditure (BEE) and thermic effect of food (TEF). Total energy expenditure (TEE) was determined by doubly labeled water (DLW) method over 14 d during 6-8 weeks after surgery. Body composition was assessed using isotope dilution space (IDS) method. Illegastrostomy did not significantly influence BEE levels but TEF declined following surgery (p = 0.001). There was a significant decline (p < 0.0001) in fat-free mass (FFM) and fat mass (FM). Weight loss was closely associated with TEE (r = 0.719, p = 0.019, n = 10), and fecal energy content (r = 0.808, p = 0.052, n = 6) but not with urinary energy loss (r = 0.011, p = 0.983, n = 6). The results indicate that ileogastrostomy blunts TEF levels and both FFM and FM declined following surgery. Total energy expenditure and fecal energy losses appear to be important determinants in the extent of weight loss following ileogastrostomy.

The reliability of bioelectrical impedance analysis for measuring changes in the body composition of patients with anorexia nervosa.

OBJECTIVE: To determine whether bioelectrical impedance analysis (BIA) is a valid measure of change in body fat in anorexia nervosa (AN) patients during refeeding, as compared to skinfold calipers (SF). METHODS: Prospective cohort study with measures of BIA and SF performed once a month for 3 months on patients meeting the DSM-III-R criteria for AN who received treatment from the Eating Disorders Clinic of a university teaching hospital as inpatients or outpatients. RESULTS: Twenty patients completed the study. Comparison of the two methods by the Pearson correlation coefficient showed a weak negative correlation of r = -.305. Analysis by a graphical method confirmed the poor agreement that exists between the two methods. DISCUSSION: The inability of BIA to detect changes in body composition due to altered hydration, and to accurately assess the distribution of water between intracellular and extracellular compartments, limits its clinical usefulness in AN. It appears that SF measurements are preferable to BIA as a measure of body fat change in patients with AN.

Liver Biopsies Following Ileogastrostomy.

Patients who have had ileogastrostomy for the treatment of morbid obesity require close, long-term follow-up. One concern in patients undergoing any form of intestinal bypass surgery is that of possible liver damage. To assess for possible liver damage in morbidly obese patients undergoing ileogastrostomy, we undertook a prospective study of liver biopsies in 12 consecutive patients. Preoperative and 2-year postoperative biopsies of the liver were planned. There were six liver biopsies available for comparison both pre- and post-operatively. The biopsies showed changes of fatty infiltration both pro- and post-operatively. There were no differences in the degree of fatty infiltration, or of other histological parameters which we measured. There were no cases of cirrhosis of the liver recorded.

Morphological and functional alterations to a sub-group of regulatory peptides in human pancreas and intestine after jejuno-ileal bypass.

The effect of ileo-gastrostomy on insulin and cholecystokinin secretion and the endocrine cells containing cholecystokinin, somatostatin, motilin, secretin, neurotensin and enteroglucagon was studied. Fasting and postprandial plasma samples collected pre- and post-operation demonstrated significant changes in circulating insulin and cholecystokinin. Fasting and postprandial insulin levels decreased three months after ileo-gastrostomy (postprandial pre-operation 40 +/- 8 microU/ml compared to 15 +/- 24 microU/ml post-operation, P < 0.02). The postprandial levels of cholecystokinin were significantly increased (pre-operation 7.1 +/- 1.1 pg/ml compared to 12.2 +/- 1.7 pg/ml post-operation, P < 0.02). Quantification of the endocrine cell populations in the jejunum in-continuity three months after ileo-gastrostomy demonstrated an hyperplasia of cholecystokinin-, secretin-, gastric inhibitory polypeptide-, motilin- and somatostatin-containing cells. In samples of the ileum taken from within the bypass loop the neurotensin- and somatostatin-containing cells were unaffected while the enteroglucagon-containing cells were significantly increased in number. Ileo-gastrostomy resulted in significant alterations to the abundance of regulatory peptide-containing endocrine cells and to circulating levels of insulin and cholecystokinin. These changes are implicated in the dramatic weight loss associated with the operation.

Follow-up of patients who have undergone ileogastrostomy.

Patients who have had ileogastrostomy for the treatment of morbid obesity require close, long-term follow-up. From a prospective study of a large number of variables in 12 consecutive patients, and from experience with more than 200 patients who have undergone this procedure since 1982, a protocol has evolved. The authors outline the associated morbid conditions, operative complications and biochemical alterations that are important in the management of these patients.

Ileogastrostomy for morbid obesity.

Jejunoileal bypass procedures for morbid obesity have been associated with numerous side effects, due mainly to the blind-loop syndrome. To overcome this, the authors describe a new procedure, ileogastrostomy, that they have performed in 50 patients. All had good weight loss and returned to work. Patient satisfaction with the operation was high and self-esteem increased. There were no deaths or severe complications. Stool frequency and foul-smelling stools were still problems but improved with time. Stomal ulceration occurred at 3 months in three patients but resolved within 1 month when treated with H2 blocking agents and was not encountered later than 3 months in any patient.

Cimetidine therapy for gastroesophageal reflux disease.

In a Canadian multicenter trial, a new dosing regimen of cimetidine (Tagamet)-600 mg given twice a day-was compared with the standard regimen of 300 mg four times a day in 118 evaluable patients with endoscopically proved esophagitis. More than 90% of the patients evaluated had clinically moderate to severe esophagitis. After four weeks of therapy, both regimens had significantly reduced the number of episodes and the severity and duration of the worst episodes of daytime and nighttime heartburn, as evaluated by visual analogue scales. After eight weeks of therapy, this improvement persisted. There was no difference between the regimens. Healing was observed endoscopically in 57% of patients receiving cimetidine 300 mg four times a day and in 55% of those receiving 600 mg twice a day. Side effects were infrequent and minor.

Glucose handling in morbid obesity and the effects of surgically induced weight loss.

Morbid obesity is associated with glucose intolerance. We studied the rate of glucose turnover in 18 morbidly obese individuals and compared the results to 10 normal weight controls using the technique of the hyperglycemic clamp. Rate of glucose turnover (mg/kg/min) was defined as metabolic clearance of glucose and corresponding plasma immunoreactive insulin values were determined. The ratio of metabolic clearance of glucose to plasma insulin is a reflection of endogenous insulin sensitivity. Patients were studied again 3 months following jejunoileal bypass and gastroplasty. Fasting glucose was similar for all groups. Fasting immunoreactive insulin was 16.8 +/- 5 microU/ml in preoperative obese, 4.3 +/- 0.2 in controls, 6.8 +/- 0.6 in postoperative jejunoileal bypass, and 6.2 +/- 0.3 in postoperative gastroplasty. The difference between postoperative groups was not significant at 3 months. The jejunoileal bypass group at 1 yr gave similar results to the immediate postoperative findings. In normals the value of metabolic clearance of glucose was 3.9 +/- 0.7 mg/kg/min and in the obese it was 2.05 +/- 0.2 (p less than 0.05). No significant improvement occurred postoperatively. Mean of the immunoreactive insulin values from 60 to 120 min was greater in preoperative obese than controls, 44.0 compared to 13.6 microU/ml (p less than 0.05). A highly significant postoperative lowering occurred in both groups, jejunoileal bypass 20.7 microU/ml, gastroplasty 22.4 microU/ml, but the difference between the surgical groups (jejunoileal and gastroplasty) is not significant. The ratio of metabolic glucose clearance to plasma insulin followed a similar pattern the primarily to the substantial decrease in insulin levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Oral L-carnitine administration after jejunoileal by-pass surgery.

Jejunoileal bypass surgery was performed on 14 morbidly obese women. Seven were treated with 3/g/day oral L-carnitine for ten days before surgery and for another ten days at six weeks following surgery. The other seven were not treated with carnitine. Carnitine administration was found to be without effect on plasma lipids, free fatty acids and ketones and on all other tested indicators. However, plasma levels of carnitine and the rate of urinary elimination of carnitine both after treatment and after an acute oral load were increased before and after surgery, indicating that carnitine was well absorbed by the shortened gut. Rate of elimination of short chain carnitine esters via the urine was also elevated after treatment. Surgery resulted in a marked decrease of plasma lipids but in no change in apolipoprotein A and B concentrations.

Selective management of benign esophageal strictures.

Thirty-eight consecutive patients were treated for benign stricture of the esophagus secondary to reflux esophagitis. All patients were evaluated endoscopically. Mild strictures allowed passage of the adult fiberoptic endoscope with some resistance. Moderate strictures would only allow passage of the pediatric scope and severe strictures failed to allow passage of the pediatric endoscope. Two treatment groups were designed. Group I (20 patients) underwent dilatation and antireflex surgery. Group II (18 patients) consisted of high risk patients who underwent dilatation plus medical management. Sixteen patients were followed in each group for a mean of 2 yr. Good to excellent results occurred in 80% of group I. The only treatment failures occurred in patients with complex pathology. Two patients had Barrett's esophagus and one a concomitant motor disorder. Results in group II showed only one frank treatment failure but three unsatisfactory results. Symptomatic improvement is obtainable in 80% of patients with peptic stricture by dilatation and medical management. Columnar epithelium did not seem to regress after antireflux surgery in three patients.

Early detection of colorectal cancer: second feasibility study.

The second study undertaken to test the feasibility of wide-scale controlled trial of Hemoccult® as a useful means of early detection of colorectal cancer is described. Of eight physicians recruited for this study, five completed it; 260 patients were enrolled, and randomized to obtain 152 in the study group and 108 in the control group. Of patients in the study group, 71% complied with the protocol. A third feasibility study will have to be mounted to reassess physician compliance and also to reassess the predicted rate of patient enrollment to the study.

Metabolic effects of glucose, mannose, galactose, and fructose in man.

The effects of various hexoses upon immunoreactive insulin (IRI) secretion, glucose disposal, and gastric inhibitory polypeptide (GIP) release have been compared in 10 normal nonobese men. Rapid iv infusion (0.5 g/kg in 3 min) of D-mannose resulted in significant ITI release, the peak levels approaching those after D-glucose infusion. D-Galactose, however, was ineffective. The 60-min urine excretions of mannose, galactose, and glucose were 35 +/- 7%, 16 +/- 4%, and 5.5 +/- 0.7% (mean +/- SEM) of the administered dose, respectively. All subjects also received 50 g oral glucose, mannose, galactose, and fructose on different days, each followed by an iv glucose infusion 30 min later. The ingestion of glucose or galactose resulted in a similar increment of GIP (P less than 0.01), followed by a similar increment in the IRI response to iv glucose. Furthermore, the glucose disposal rate increased 2.5-fold compared to that after iv glucose alone (P less than 0.001). However, oral msnnose or oral fructose caused no significant GIP release, yet the IRI response to a subsequent iv glucose load was moderately augmented after oral mannose or oral fructose when compared to iv glucose alone. In addition, there was a similar enhancement of glucose disposal of the iv glucose load after both oral mannose and oral fructose (P less than 0.01). From these studies we conclude that 1) galactose does not elicit IRI secretion per se, yet, like glucose, potentiates GIP and IRI secretion; 2) mannose, despite weak transport across gut or kidney, evokes significant betacytotropic effects; and 3) mannose- and fructose-induced enhancement of glucose disposal might be mediated by a factor(s) other than GIP.

Zollinger-Ellison syndrome associated with parathyroid adenomas and ectopic gastric tissue in the lower esophageal mucosa.

A rare case of the Zollinger-Ellison syndrome associated with hyperparathyroidism and ectopic gastric tissue in the lower esophageal mucosa is reported. Preoperatively the patient, a 53-year-old woman, had hyperchlorhydria and her fasting serum gastrin concentration was mildly elevated. There was a considerable increase in the gastric acid output and concentration of serum calcium after secretin infusion. At operation the patient had a gastric ulcer 10 cm in diameter, an islet cell tumour of the pancreas 14 cm in diameter, and ectopic gastric mucosa in the distal third of the esophagus. A gastrectomy was perfomed, the pancreatic tumour excised and part of the distal esophagus removed through a left thoracotomy. Four months after the operation the gastrin concentration had returned to low normal, but the serum calcium values remained high. One month later two parathyroid adenomas were removed which effectively cured the hypercalcemia.