Hemic micronutrients following vertical banded gastroplasty.

Serum iron, folate, B12 and total iron binding capacity (TIBC) were obtained preoperatively and at 6-month intervals in 40 morbidly obese patients who underwent VGB. Deficiencies of hemic micronutrients rarely occurred following VBG. Hemoglobin and hematocrit levels were within normal limits at all times. Some patients experienced transitory depression of nutrients at six months postoperatively, during the period of most rapid weight loss and lowest dietary intake. These levels return to normal by one year in almost all cases. Low B12 levels were observed in four patients at 1 year. All had been above 120 per cent overweight and had lost in excess of 100 pounds in the first postoperative year. These data indicate that hemic micronutrients remain at normal levels following VBG. B12 levels should be followed to determine possible need for supplementation other than that provided by usual daily multivitamin preparations in patients above 120 per cent ideal weight loss exceeding 100 lbs in the first postoperative year.

Idiosyncracies of the Hollander test in the obese patient.

The Hollander test of gastric secretion in response to acute hypoglycemia is a time-honored method of evaluating vagal integrity. In the course of performing gastric bypass procedures in 19 morbidity obese patients who were twice their weight for height, Hollander tests were included in the preoperative evaluation. Infusion of a standard dose of 20 units of regular insulin failed to produce a hypoglycemia of 35 mg/dl in 13 patients (68%). There was a positive response to hypoglycemia of even a moderate degree in gastric secretory volume, pH, and total acid output at 75 minutes postinsulin injection in all patients. They lagged well behind the peak of relative hypoglycemia which occurred at 30 minutes postinsulin injection. If the Hollander test is to be used in the evaluation of gastric secretion in obese patients weighing more than 100 kg, it is recommended that the insulin dosage be adjusted to body weight at 0.2 units (RI) per kilogram body weight. In addition, collections of gastric and serum specimens must be continued for a full 2 hours postinsulin injection in order to insure recognition of vagal response.

Influence of bariatric surgery on erythromycin absorption.

Seven adult, morbidly obese patients scheduled for bariatric surgery were studied in an identical manner preoperatively and postoperatively. Six patients underwent gastroplasties, and one patient underwent a gastric bypass procedure. A single 250-mg dose of erythromycin as a Filmtab was administered orally after an overnight fast. Multiple venous blood samples were collected over a 12-hour period. After surgery, each patient had a decrease in peak concentration and an increase in the time to reach peak concentration compared to presurgery values. Mean peak concentration was reduced from 1.04 micrograms/ml preoperatively to 0.55 micrograms/ml postoperatively, and the mean time to peak increased from 3.9 hours to 6.7 hours. Mean weight-corrected AUC was reduced 41 per cent, with two patients having no detectable serum levels postoperatively. The results suggest that the erythromycin product evaluated is of questionable value for use in bariatric surgery patients.

Basal and exercise tests on morbidly obese patients before and after gastric bypass.

The psysiologic responses of 13 morbidly obese patients (nine women and four men) were studied during basal and exercise conditions before and after gastric bypass. The mean age of the group was 33 +/- 2.3 years, the weight was 157 +/- 11.3 kg, and the body mass index (BMI = weight [kg]/height [m]2) was 54. Initial mean oxygen consumption (VO2) values were extraordinarily elevated, being 453 ml/min at rest and 2084 ml/min during level walking on a treadmill at 2 mph. The mean weight loss 6.9 months after operation was 41.6 +/- 4 kg (0.2 kg/day). Retesting revealed striking improvement in all measured parameters, with some values approaching the values of the matched control group of lean subjects. Spirometric results were normal for the nonsmokers (n = 8), although insignificant improvement occurred after weight loss. The basic requirement to be accepted for operation was that the patient must be able to exercise for 6 minutes on the treadmill at 2 mph, zero elevation, without developing metabolic acidosis and a respiratory quotient above 1.0. Three superobese men (BMI = 69) with hypercarbia failed to meet the exercise requirement. Their poor performance resulted in hospital treatment until they were in suitable condition upon retesting to undergo operation. Their elevated Paco2 values did not correct to normal until several months after operation. In this study, the basal and exercise VO2 values proved to be sensitive indicators for the amount of weight loss after gastric bypass (P = 0.01 and 0.001, respectively).

Bleeding from the bypassed stomach following gastric bypass.

Of 3,000 patients with gastric bypass, eight had bleeding develop from acid peptic disease in the bypassed segment. Bleeding was both acute and chronic and did not respond to nonoperative therapy. Endoscopy differentiated between stomal ulcers and distal pouch bleeding. Resection of the distal pouch was curative in all instances.

Pregnancy following gastric bypass for the treatment of morbid obesity.

Of the patients undergoing gastric bypass for treatment of morbid obesity, 75 per cent are female. A common question both pre-and postoperatively concerns the advisability of a pregnancy following surgically-induced weight loss. Of all patients, 45 became pregnant on 54 occasions following gastric bypass and 46 infants were delivered. There were two spontaneous abortions (4.0%) and six early terminations of an undesired pregnancy. Seven infants were delivered prematurely. One child was born microcephalic and has developed severe retardation in both growth and development. In contrast to reports of infants born to mothers with jejunoileal bypass, 12 of the babies that were born to mothers after gastric bypass were heavier at birth than older siblings. An additional ten infants were the first born to women who had lost more than 100 pounds following gastric bypass. All but one of the women became pregnant more than six months following surgery. This corresponds to the period of maximum weight loss and reversal of menstrual abnormalities associated with massive obesity. Pregnancies were well tolerated by the mothers, with no excessive increase in weight loss or development of metabolic deficiencies. Since the gastric bypass is modeled on the Billroth II gastrectomy, additional iron supplementation was recommended during the pregnancy. While we cannot recommend pregnancy during the period of rapid weight loss in the initial postoperative period, our data indicate that neither the mother nor the developing fetus is unduly endangered by a pregnancy which develops after the period of rapid postoperative weight loss.

Pancreatitis induced renal vasoconstriction.

The etiology of renal vasoconstriction in acute pancreatitis remains obscure. The canine model of bile pancreatitis was used to determine whether hypovolemia or increased circulating levels of catecholamines are responsible for this phenomenon. Treatment of the pancreatitis was either with volume loading or alpha adrenergic blockade with Prazosin given both before and after the induction of pancreatitis. Neither pretreatment nor post-treatment with either volume loading or Prazosin protected the kidneys from the standpoint of mitigating renal vasoconstriction. To the contrary, treatment with alpha blockade produced the greatest decreases in renal blood flow.

Increasing the efficacy of gastric operations for the control of morbid obesity.

Based upon observations with double application of the TA90 surgical stapler in a stapled-in-continuity gastroplasty, we recommend a double application of gastric partitioning in the treatment of morbid obesity. The staple application should be closer than 0.5 cm or at least 2.0 cm apart to prevent necrosis of the intervening stomach. Division of the stomach between two staple applications with oversewing of the cut edges would preclude either staple line disruption or the danger of necrosis in the stomach intervening between stapler applications.

Gastric bypass criteria for effectiveness.

Weight loss patterns and revision rates in three sequential groups of patients with gastric bypasses and loop gastroenterostomies between 1965 and 1978 demonstrate the importance of a 50 ml volume of the upper segment measured at 25 to 30 cm water luminal pressure and a 10 to 12 mm diameter stoma. The need for a secure partition is well known. Reinforcement of the stoma to prevent dilation has contributed greatly to the success of gastroplasty and should be studied in gastric bypass. The importance of quality control and of both revision rate and weight patterns over five to ten years is emphasized.

Thrombophlebitis in the elderly.

Treatment of the elderly patient can be significantly compromised by complications which are less troublesome in younger individuals. In the authors' experience this has been the case with septic thrombophlebitis secondary to intravenous infusion. Thirteen patients over 65 years of age presented with septic thrombophlebitis during the course of hospitalization for a variety of diseases. All infections occurred in an upper extremity site of polyethylene catheter insertion. Twenty-five per cent of patients had proven bacteremia and clinically recorded septicemia, with Staphylococcus aureus as the most common organism. Treatment consisted of either a full course of intravenous antibiotics or more commonly surgical therapy (either incision and drainage or resection of the involved vein). Three patients required extensive procedures including muscle debridement and fasciotomy. The mean hospital stay of 19 days was largely related to thrombophlebitis and not primary disease. There was one mortality. Prevention of this condition by meticulous attention to sites of intravenous infusion and frequent changing of these sites rather than treatment after the fact provides the safest mode of patient care.

Stomal ulcers after gastric bypass.

Introduction of gastric bypass as treatment for morbid obesity in 1966 caused over its ulcerogenic potential as an antral exclusion procedure. However, in only 20 of our 653 patients has marginal ulceration developed. Predominant symptoms were epigastric pain, occult gastrointestinal bleeding, and vomiting. Barium contrast roentgenography was as diagnostically accurate as endoscopy in these lesions. Objective measurement ensuring creation of a gastric reservoir of 50 mL maximum size reduced the incidence of marginal ulcer from 3.8% to 0.98%. Upper pouch size determined the mode of therapy. Nonoperative therapy was successful in patients with small pouches, but did not relieve symptoms of patients with large reservoirs. Truncal vagotomy and resection of redundant upper pouch was the preferred operative approach in these patients.

Gastric bypass in morbid obesity.

Gastric operations for the treatment of morbid obesity have been standardized. They require close adherence to specifications for success. The upper stomach volume should be measured intraoperatively and fashioned to a capacity of 50 ml at a pressure of 25 to 30 cm of saline. The outlet should be no larger than 12 mm in diameter. The necessity for bypassing the remainder of the stomach and duodenum has not been established. Early maintenance of gastric decompression and immediate supervision and education of patients regarding new eating habits are crucial in the prevention of gastric rupture. Long-term care is usually minimal, but patients should be followed at least at 6 weeks, 6 months, 1 year, and at yearly intervals thereafter. Increasing numbers of intestinal bypass operations are being replaced by gastric bypass or gastroplasty. Many surgeons who once used intestinal bypass have decided to use the stomach operations instead because of the much less complicated long-term care required after the gastric procedures.

Risk reduction in gastric operations for obesity.

Although nearly devoid of late complications, gastric operations for obesity have resulted in 4.7% early postoperative perforations. For patients over 39 years of age who perforated, the first 11 patients died and the last 9 survived. Perforations are equally common in upper stomach, anastomosis, and lower stomach. They have become more frequent with the 50 ml upper stomach volume and 12 mm stoma that are required to assure optimum weight control. Perforation is as common with gastroplasty as with gastric bypass. If it occurs, it is normally within the first ten postoperative days. Acute dilatation and rupture of the stomach can happen if all the nasogastric tube holes are in the jejunum after gastric bypass. Erosion of the stomach by the hard end of the nasogastric tube has occurred when the tube was positioned in the upper stomach. This paper is dedicated to the prevention of death by early recognition and aggressive management of perforation and by prevention of perforations through careful attention to the details of these operations and early postoperative care.

Utilization of D-methionine during total parenteral nutrition in postsurgical patients.

Utilization of intravenously administered D-methionine was measured by morbidly obese subjects fed parenterally after elective gastric bypass surgery. Five patients were infused with a 25% glucose--4.25% amino acid solution containing DL-methionine, and four were treated with a 25% glucose--3.5% amino acid solution containing only L-methionine. Mean (+/- SD) total daily methionine excretion was 0.06 +/- 0.04 mmoles (of 28 +/- 4 mmoles infused) in patients treated with the L-methionine containing solution, and was 15.2 +/- 4.2 mmoles/day (of 45.2 +/- 5 mmoles DL-isomer infused) in patients treated with the DL-methionine containing solution. In these latter patients, 90 to 98% of the excreted methionine was the D-isomer. The data indicate 64 +/- 23% of infused D-methionine is excreted in the urine. Four patients excreted between 70 to 85% of infused D-methionine in the urine, but one patient excreted only 35 to 55%, suggesting better utilization. Plasma methionine levels were higher (9.9 +/- 1.9 mumoles/100 ml) in patients infused with solutions containing DL-methionine than those infused with the L-methionine solution (4.5 +/- 1.0 mumoles/100 ml). In the former case, 49% of plasma methionine was the D-isomer. The data indicate poor D-methionine utilization by postsurgical patients during total parenteral nutrition when given as DL-methionine in the presence of other amino acids and glucose.

Vagal innervation of the bypassed stomach following gastric bypass.

Gastric bypass, a 90% gastric exclusion, has been used successfully for surgical treatment of morbid obesity since 1967. Early concern as to its ulcerogenic potential has not materialized, but the physiological activity of the excluded stomach has not been studied fully. To determine whether the excluded segment retained any vagal innervation, 25 patients underwent preoperative Hollander tests of their intact stomachs. The test was repeated after operation, after the patients had resumed normal oral intake. Postoperative specimens were collected from a gastrostomy placed in the excluded stomach at the time of the gastric bypass. Percentage changes in volume and total acid for both the intact and excluded stomachs followed the same pattern with insulin injection after 45 minutes at both testings, pH values were identical. These observations, which indicate vagal innervation of the excluded stomach, together with previously published histalog acid-response data and the observed marginal ulcer incidence of one per 193 years of patient follow-up, demonstrate that normal gastric physiology is maintained after bypass and confirm that it is not an ulcerogenic procedure.

Abdominoperineal resection in the octogenarian.

Traditionally, abdominoperineal resection has been the accepted surgical therapy for anorectal carcinoma. A review is presented of the experience with this procedure at the University of Iowa Hospitals, involving 52 patients (33 men, 19 women) over the age of 80 (median, 81 years). The most common symptoms were: rectal bleeding in 35 patients, change in character of stool in 35, weight loss in 13, and abdominal pain in 7. A rectal mass was palpable in 45 patients and visible by sigmoidoscopy in 3 others. Of the 52 patients, 23 percent (12/52) died before postoperative discharge from the hospital, and 32 percent of the survivors had significant postoperative complications. The most lethal complications were related to problems of surgical technique. The median survival time for patients discharged from the hospital was 22 months, with causes of death being equally distributed between recurrent carcinoma and other disorders. Abdominoperineal resection remains an acceptable method for treatment of anorectal carcinoma in the aged (80 or older) provided it is carried out with meticulous technique and careful selection of the patients.