Reoperative surgery for the morbidly obese. A university experience.

Patients who undergo surgery for morbid obesity are often subjected to reoperation for a wide array of indications. To evaluate outcome following revisional procedures, we reviewed the records of 32 such patients treated at UCLA between April 1986 and May 1989. Twenty-five women (78%) and 7 men (22%) with a mean age of 44 years underwent 76 reoperations (2.4 per patient) for complications of prior obesity surgery. Indications for initial surgical revision consisted primarily of metabolic derangements (12 patients) and weight-related problems (11 patients). In contrast, indications for the patients' final surgical procedure were commonly for bowel obstruction (41%), intra-abdominal sepsis (12%), and gastrointestinal bleeding (6%). Following initial revision, 23 patients (71.8%) required further surgery for major complications and four patients died (12.5%). While initial revisions are frequently indicated for metabolic problems, final reoperations are more frequently undertaken for urgent, life-threatening complications. Revisional procedures for morbid obesity should be carefully considered, and the potential for major complications and/or death should be weighted heavily against proposed benefits.

Cure of arthritis-dermatitis syndrome due to intestinal bypass by resection of nonfunctional segment of blind loop.

Many complications that followed jejunoileal bypass operations performed for the relief of morbid obesity were caused by bacterial overgrowth in the excluded blind loop. The arthritis-dermatitis syndrome was one of the common distressing disorders. The pathogenetic mechanism was thought to be an immune-complex-mediated process related to bypass enteritis. Antiarthritic medication was ineffective in most instances, and the skin lesions were refractory to treatment. A 45-year-old woman was suffering from the disorder as described above. She also had diarrhea, a low hematocrit, an elevated white blood cell count, and an increased sedimentation rate. Her nutritional status was satisfactory, presumably because of adaptive hypertrophy of the short functioning small intestinal segment. The patient adamantly refused dismantling of the bypass or any gastric restriction operations. Therefore, the blind loop, the source of her disease, was excised with immediate relief of all ill effects and restoration of normal laboratory findings. The patient has been entirely well since, and her weight has remained stable for one year.

Sudden cardiac arrest in morbidly obese surgical patients unexplained after autopsy.

Sixty sudden and unexpected lethal cardiac arrests, with entirely negative findings on autopsy, were reported among 50,314 morbidly obese patients in the care of surgeons performing operations to achieve weight loss. This represented an extrapolated overall annual mortality rate of 65 deaths per 100,000 patients, about 40 times higher than the rate of unexplained cardiac arrests in a matched nonobese population. Eight sudden deaths occurred while waiting for obesity surgery and 22 had cardiac arrest within 10 days after the operation. Late postoperative deaths (more than 4 weeks postoperatively) occurred in 30 instances. A possible marker of a predisposition for sudden, unexpected cardiac arrest was an electrocardiographic abnormality; namely, a Q-Tc interval prolonged to greater than 0.43 seconds. This feature, present in 29 of 38 tracings, denoted increased susceptibility to malignant ventricular arrhythmias. The perioperative clustering of arrests implicated nonspecific stresses incident to otherwise uneventful operations as triggers of lethal dysrhythmias in the absence of organic cardiac disease. Anoxemia after abdominal surgery is an added hazard. Length of postoperative survival among the late deaths was found to be unrelated to degree of initial obesity or to magnitude of weight loss. Patients who died in the late postoperative phase were still grossly obese (mean weight 114.2 kg). Cardiac weights in patients who died within 10 postoperative days (12 patients) or after an average of 103 days (20 patients) were the same (464 and 469 g, respectively), indicating that myocardial mass had remained intact. The data do not suggest nutritional depletion or lean tissue loss as plausible explanations for the cardiac arrests. Screening and postoperative monitoring for Q-T interval prolongation is indicated. Prophylactic beta-blockade in this vulnerable subset of the morbidly obese population may be instituted in anticipation of obesity surgery. The attendant physiologic stresses should be minimized by appropriate measures.

Gastric bypass with biliopancreatic diversion.

Gastric bypass with biliopancreatic diversion (GBBPD) is a combined restrictive and malabsorptive procedure for the treatment of morbid obesity.

Microbial flora in the bypassed jejunum of patients with biliopancreatic bypass for obesity.

The microbial flora in the bypassed biliopancreatic intestinal segment was studied after obesity surgery. This procedure causes less diarrhea than jejunoileal bypass and appears to avoid extraintestinal complications. This report concerns type and quantity of bacteria colonizing the biliopancreatic segment and changes occurring after oral metronidazole treatment. Twelve specimens were aspirated in 10 patients via catheter inserted percutaneously during surgery. The specimens were plated immediately on selective and nonselective media under aerobic and anaerobic conditions. Essentially equal numbers of aerobes and anaerobes were recovered from the biliopancreatic segment with average counts of 10(4) cfu/mL and median counts of 10(5) cfu/mL. Four patients had counts of 10(7) cfu/mL. The most common aerobes were E. coli, Klebsiella, Gram-positive cocci, and Candida; among anaerobes, Clostridium and the Bacteroides fragilis group were most common. In three patients treated with metronidazole because of diarrhea, anaerobes were eliminated and diarrhea cleared.

Zinc and copper nutriture in obese men receiving very low calorie diets of soy or collagen protein.

Balance studies for Zn and Cu were conducted over 40 days in 10 obese men housed in a metabolic balance unit. Two weight reduction diets providing 400 kcal and 100 g protein daily were administered; to five subjects, a collagen diet which was severely deficient in both Zn and Cu, and to another five subjects, a soy diet which provided a marginal intake of Zn and an adequate intake of Cu. Zn and Cu content of diets, plasma, red blood cells, urine, and feces were determined during eight 5-day periods. Balances were corrected for lean tissue catabolism or deposition. Holter ECG monitoring and measurement of the QTc interval were done on days 0 and 40. Both diets resulted in elevated plasma and red blood cell concentrations of Zn and Cu and in high urinary and fecal losses of Zn. By day 40, 6 of 10 subjects were in negative Zn balance. Urinary Zn was inversely correlated with measures of lean tissue catabolism. During each period, Cu balance was markedly positive in the soy-diet group and negative in the collagen-diet group. Shortening of prolonged QTc intervals was related to the Cu but not Zn status of the individual.

Metabolic and hormonal factors as predictors of nitrogen retention in obese men consuming very low calorie diets.

The ability to conserve body protein during very low calorie diets in ten obese men was observed to correlate with plasma free amino acid concentrations, urinary N tau-methylhistidine: creatinine ratios, resting oxygen consumption, and serum triiodothyronine levels. A diet consisting of only protein, 1.3 g/kg ideal body weight/24 h, was given for 40 days. Cumulative nitrogen deficit ranged from -64 g to -227 g. Nitrogen balance on days 36 to 40 ranged from + 1.37 g/24 h to -3.30 g/24h. Nitrogen balance during this period had a significant direct correlation with pre-diet concentrations of branched-chain amino acids (r = 0.69 to 0.89), methionine (r = 0.85), histidine (r = 0.66), alanine (r = 0.73), arginine (r = 0.70), ornithine (r = 0.66), total essential (r = 0.87, and nonessential (r = 0.68) amino acids, with initial serum levels of triiodothyronine (r = 0.66) and with the fall in triiodothyronine over the 40 days (r = 0.79). Initial resting oxygen consumption was directly correlated (r = 0.78) with final nitrogen balance and inversely with total nitrogen loss (r = -0.81). On day 0, triiodothyronine levels also correlated positively (r ranging from 0.71 to 0.93) with plasma concentrations of several essential and nonessential amino acids. These correlations suggest that individuals who ultimately will or will not achieve nitrogen equilibrium during very low calorie diets can be identified prior to dieting. These data are consistent with the hypothesis that individuals with higher initial protein flux and triiodothyronine levels are better able to adjust the balance between synthesis and degradation to attain nitrogen equilibrium during hypocaloric dieting.

Plasma concentration of amino acids in obese men consuming very-low-calorie diets composed of soy or collagen protein.

The effects of soy or collagen protein, 1.3 g/kg desirable body weight per day, on fasting and postprandial plasma free amino acid concentrations were evaluated in eight obese men during a 40-day very-low-calorie reducing regimen. The interrelationships among individual plasma amino acids were also examined. In both protein-fed groups, fasting plasma histidine, phenylalanine, tyrosine, threonine and alanine levels decreased by day 40 whereas glycine increased. The decrease in plasma threonine and increase in plasma glycine were more pronounced in the collagen-fed group (n = 4) than in the soy-fed group (n = 4). Serine increased only in the collagen-fed group. The postprandial increases of all essential amino acids, with the exception of valine and phenylalanine, were less on day 26 than on day zero. Except for threonine levels, plasma amino acid profiles were similar during very-low-calorie dieting and during prolonged fasting. However, essential amino acid levels were better maintained by soy than by collagen protein diets.

Relationship between the changes in serum thyroid hormone levels and protein status during prolonged protein supplemented caloric deprivation.

The relationship between the changes in serum thyroid hormone levels and nitrogen economy during caloric deprivation were investigated in ten obese men during a 40 d, 400 kcal protein-supplemented weight-reducing diet. This regimen induced increases in the serum levels of total T4, free T4 and total rT3, and decreases of total T3, while serum TSH remained unchanged. There were progressive decreases in total body weight and urinary losses of total nitrogen and 3-methylhistidine, with the early negative nitrogen balance gradually returning towards basal values during the 40 days. Subjects with the largest weight loss had the most increase in the serum levels of total T4 and free T4 index and the greatest decrease in T3. The magnitude of the increase of the nitrogen balance from its nadir was correlated with the extent of the reduction of T3 and increase of T3 uptake ratio and free T4 levels. The decrease in the urinary excretion of 3-methylhistidine correlated with the increase in free T4 and rT3 levels. Nadir serum transferrin values were directly related to peak rT3 values, and the lowest albumin concentrations occurred in subjects with the highest total T4 and free T4 index values. Further, the maximum changes in the serum thyroid hormone levels preceded those of the nutritional parameters. These relationships suggest that: (1) increases in serum rT3 and free T4 and reductions in T3 concentrations during protein supplemented weight reduction may facilitate conservation of visceral protein and reduce muscle protein turnover; and (2) the variation in the magnitude of these changes may account for the heterogeneity of nitrogen economy.

Calcium, magnesium, and phosphate balances during very low calorie diets of soy or collagen protein in obese men: comparison to total fasting.

In 30 obese men, calcium, magnesium, and phosphate balances were measured for 40 days using one of four weight reducing regimens: 1) 400 kcal soy protein; 2) 400 kcal collagen protein; 3) total fasting with potassium; and 4) total fasting without potassium. Relationship of the minerals to each other and to nitrogen and to the QTc interval was also examined. All groups were in negative cumulative calcium balance but the protein-fed groups lost less calcium (soy, -3.0 +/- 2.1 g; collagen -4.9 +/- 3.2 g) than the total fasting groups (with potassium supplement, -9.2 +/- 3.4 g; without potassium supplement, -5.8 +/- 2.1 g) (p less than 0.01). The soy-fed group attained positive cumulative magnesium (0.7 +/- 0.5 g) and phosphate balances (6.9 +/- 3.9 g). The other three groups had significantly more negative magnesium (p less than 0.0005) and phosphate (p less than 0.0005) balances, (collagen, magnesium balance, -1.1 +/- 1.0 g, and phosphate balance, -7.6 +/- 3.7 g; total fasting without potassium, magnesium balance, -1.4 +/- 0.6 g, and phosphate balance, -5.4 +/- 2.7 g). Potassium supplementation during fasting increased urinary losses of calcium and fecal losses of magnesium. High phosphate intake reduced urinary calcium. Nitrogen losses predicted only magnesium losses. Serum mineral levels did not reflect tissue mineral status. Shortening in the QTc interval as an indicator of reduced myocardial instability was related to the increase in serum phosphate in the protein-fed subjects.

Nitrogen economy during very low calorie reducing diets: quality and quantity of dietary protein.

Controversy exists whether protein quantity or quality affect "nitrogen sparing" or physical health while subsisting on very low calorie diets. Therefore, in 38 obese men, nitrogen economy was evaluated over 2 months periods using one of five regimens: 1) 400 kcal high quality protein: 2) 400 kcal low quality protein; 3) 500 kcal 55 g protein natural food; 4) total fasting with potassium; and 5) total fasting without potassium. Up to the 20- and 40-day intervals, mean cumulative nitrogen deficity for all three diet groups was the same but 60% lower than with total fasting. However, within groups, individual capability to conserve nitrogen varied over as much as 2.8-fold. All 10 subjects of diet groups 1 and 2 had negative nitrogen balances to day 21, and six of these subjects were still negative by day 40. The improvement in nitrogen conservation and the ability to attain nitrogen equilibrium was unrelated to the differences in protein quantity and quality. Intake of essential or branched-chain amino acids was also unrelated to the efficiency of nitrogen conservation, as were insulin, glucagon, and 3-hydroxybutyrate levels. The only indicator correlating positively with nitrogen deficit was a fall in complement C3 (r = 0.87). Despite the extent of overall nitrogen loss, no cardiac arrhythmias were observed with either the high or low quality protein diet.

Intestinal bypass complications involving the excluded small bowel segment.

We have examined complications involving the defunctionalized bowel in 119 intestinal bypass patients. In this group, we found a 66% of incidence of bypass enteropathy. Pneumatosis cystoides intestinalis was present in three patients, severe blood loss in three, localized ulcerations in two, intermittent or chronic intussusception of the proximal jejunal stump in 10, and extensive stenosis relating to tight fibrous adhesions in one patient. The stenosis may become manifest as an obstructive process only after reconstitution of normal bowel continuity. Bacterial overgrowth in the bypassed small bowel was the primary cause for most of the lesions. A consistent diagnostic finding, suggesting disease in the excluded bowel, was ileal distention and the presence of gas-fluid levels on upright abdominal x-rays. Definitive diagnoses of ulceration, intussusception, and/or obstruction were sometimes possible only during laparotomy. Because the bypassed bowel cannot be examined with conventional techniques, these various abnormalities must be suspected when ill-defined abdominal complaints are observed in bypass patients. Metronidazole, to suppress anaerobic organisms, or suitable broad spectrum antibiotics can relieve the various lesions of the inflammatory process, whereas appropriate surgical procedures may be required for some of the chronic or recurrent complications.

Risk of obesity and surgical indications.

Morbid obesity, defined arbitrarily as greater than 100 percent excess weight, is only rarely the immediate or sole cause of illness or death. In addition to the Pickwickian syndrome, localized adiposity can cause obstruction and/or organ compression resulting in clinical disorders. Most of the obesity-associated risk factors interact to (a) diminish quality of life, (b) impair health, and (c) shorten survival. Severe obesity in childhood and adolescence impairs scholastic achievement and final educational levels are lower than in the nonobese. For the adult, opportunities and promotions are fewer, the quality of jobs and pay are lower. Unemployment is more common. The obese are more apt to remain single or to lose their marriage partners. Sexual adjustment and reproductive capabilities may be impaired. Regarding morbidity, the obese are "high-cost patients'. The specific and common complications or morbid obesity have been extensively examined and are the major factors causing more severe, more prolonged and more frequently recurring illness. Some obscure risk factors are related to "sudden death', to serious hazards of various medical treatment regimens, and to complication arising out of rapid or repeated regain. Excess mortality has been documented in the morbidly obese to be greatest in the younger age categories while morbidity increases with age in the surviving obese population. The dismal results of non-surgical treatment require an alternative approach. Indications for surgery in a particular patient have to be individualized. Rigid criteria are not practical, but in general, surgery is indicated and justified if the benefits expected from surgical treatment can prevent or reverse the hazards arising from unrelieved obesity. Therefore, the resulting weight losses have to be sufficient to reduce the patients to within 30 or 40 percent of desirable weight. The potential surgical complications must not equal or surpass the hazards of chronic obesity.

Cutaneous lesions after intestinal bypass.

Twenty-three of 81 intestinal bypass patients with episodes of bypass enteropathy had papulopustular or nodular skin lesions. Histologic examination of the dermal lesions showed various forms of vasculitis in nine of 14 subjects. In six of 11 patients examined by immunofluorescent microscopy, both the lesions and uninvolved sun-exposed skin areas had immunoglobulin and complement deposits in linear or granular patterns in the dermoepidermal line, giving the appearance of a positive lupus band test. Skin lesions resolved with spontaneous improvement of bypass enteropathy or in response to metronidazole therapy. After the bypass was dismantled, the eruptions disappeared permanently, and previously positive lupus band tests became negative. The skin lesions were frequently observed in association with arthritis, suggesting an immune-complex mechanism, probably originating in "blind loop" bacterial overgrowth.