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.

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.

The intestinal bypass: arthritis-dermatitis syndrome.

Of the 31 patients who developed polyarthritis following jejunoileal bypass for obesity, 24 had cutaneous vasculitis (urticarial, pustular, and nodular), 11 paresthesias, 10 Raynaud's phenomenon, and 1 pericarditis. Blind loop symptoms (14 of 26 patients), cryoglobulinemia (10 of 28), and immune deposits in biopsied skin lesions (5 of 7) support the theory of a relationship between bowel bacteria and immune complexes. Treating the blind loop with antibiotics and sphincteroplasty to prevent bacterial reflux into the blind loop helped 5 of 10 and 6 of 9 patients, respectively. A comparison is made to other bowel associated arthritides.

Jejunoileal bypass and the defunctioned bowel syndrome.

Sixty-six patients who had a jejunoileal bypass with ileosigmoidostomy for intractable obesity were reviewed. Thirty-three patients had sudden, severe, upper pain develop in the abdomen with distention from one to four years after the original operation. All 33 patients had a repeat laparotomy from one to six years after the initial bypass procedure. In every instance, a dilated, hypertrophied defunctioned ileum was found proximal to the ileosigmoidostomy. In 11 patients, an ileosigmoid volvulus was present. In every instance, the ileosigmoid anastomosis was dismantled and an end-to-side ileotransversostomy performed. In one patient, an ileal volvulus developed proximal to the ileotransversostomy because of an inadvertent technicality and this was corrected by reoperation. The remaining 32 patients have been asymptomatic since the ileosigmoidostomy was converted to ileotransversostomy. To date, in more than 200 primary operations for morbid obesity, the ileum has been drained into the transverse colon. None of these patients have had obstruction of the defunctioned small bowel develop.

Complications of surgery for morbid obesity.

From experience with 261 jejonoileal bypass operations performed by one surgeon with the assistance of an interested endocrinologist, many problems have been encountered and many apparently solved. However, there are still some unexplained complications requiring further study, and there must be a continuous follow-up of the patients for some years before the operation can be a completely acceptable treatment for morbid obesity.

Endobronchial lipoma: two cases and review of the literature.

Endobronchial lipoma is a benign tumour of the large bronchi occurring in middle-aged men. To the 38 successfully treated cases in the English literature a further 2 are added. The symptoms are those of obstructive pneumonitis mimicking bronchogenic carcinoma, and the result of delayed therapy may be bronchiectasis. Treatment includes local resection through a bronchoscope or a bronchotomy incision, or removal, if necessary, of the obstructed lobe or lung at thoracotomy. Smoking may be important in the pathogenesis of this tumour.