Weight loss after gastroplasty: psychological sequelae in relation to clinical and metabolic observations.

Twenty-one grossly obese patients were studied before and repeatedly after gastroplasty. Eighteen months after surgery, three groups of patients were identified which had similar preoperative weights but showed significantly different patterns of weight loss. About one third of the patients were considered unsuccessful (less than 20% weight loss). Psychological assessment, using the meta-contrast technique, showed that signs of regressive defense and of immature identity decreased postoperatively. Mild to moderate depressive reactions were found in two thirds of the patients postoperatively and were significantly more frequent among the successful patients. Acute depressive episodes, severe enough to require professional intervention, occurred in four patients, three of whom belonged to the successful group. No correlation could be found between surgical complications or metabolic alterations after gastroplasty and postoperative depression, implying that these factors do not primarily influence the patient's postoperative psychological status. Rather, we suggest that the marked weight loss as such leads to problems of adaptation which in turn may trigger depressive reactions.

A controlled randomized trial of budesonide versus prednisolone retention enemas in active distal ulcerative colitis.

Sixty-four patients with active distal ulcerative colitis participated in a multicentre, randomized, investigator-blind trial to compare the effect of budesonide enema, 2 mg/100 ml, with prednisolone disodium phosphate enema, 31.25 mg/100 ml. Budesonide is a new potent corticosteroid with a rapid first-pass elimination. The patients were treated for 4 weeks, and the efficacy of the drugs were evaluated by sigmoidoscopy, histology, and subjective symptoms after 2 and 4 weeks. After 4 weeks of treatment 16 of 31 patients (52%) receiving budesonide enema had healed endoscopically, compared with 8 of 33 (24%) (p = 0.045) receiving prednisolone enema. Budesonide was superior to prednisolone in terms of both significantly improved sigmoidoscopic and histologic scores and subjective symptoms evaluated by visual analogue scales. The patients receiving prednisolone had a significant depression of endogenous cortisol levels during the treatment period, but not the patients receiving budesonide. Budesonide enema seems to be a promising therapy for active distal ulcerative colitis and causes no adverse reactions.

Surveillance colonoscopy and biopsy in patients with ureterosigmoidostomy.

Colonoscopy with biopsy was included in the surveillance of 19 patients with ureterosigmoidostomy, because of the high incidence of colonic carcinoma reported in such cases. The patients were examined 1-6 times, at intervals of 1-2 years, 4-36 years after the urinary diversion. Random biopsies from the distal colon and rectum showed only discrete changes, and no dysplasia. Polyps with dysplastic changes were found close to ureteral anastomoses in three patients. For routine check-up of the rectosigmoid region and the ureteral implantation sites, examination with a flexible sigmoidoscope seems to be adequate and preferable, giving easy access to the risk zone for the development of cancer. Caution should be exercised, however, when performing biopsy close to the ureteral orifices.

Intestinal xylose degradation and bile acid deconjugation in patients with continent or conventional ileostomy.

Intestinal bacterial overgrowth was investigated in ten patients with continent ileostomy and in eight with conventional ileostomy, using the bile acid deconjugation test and the (14C)xylose test. Bile acid deconjugation was significantly greater in the continent ileostomy than in the conventional ileostomy group. There was a positive correlation between fecal 14C after oral administration of cholyl-(14C)glycine and the extent of bile acid deconjugation, suggesting that deconjugation occurred in the distal ileum. There was no difference in (14C)xylose degradation rate between the two groups of patients, supporting the view that the (14C)xylose breath test reflects microbial activity in the proximal small intestine.

Continent ileostomy. A follow-up study of 60 patients.

Sixty patients underwent proctocolectomy and received a continent ileostomy because of ulcerative colitis (50 cases) familial polyposis (7) or Crohn's disease (3), with no deaths at surgery or during follow-up (mean 4.5 years, range 3 months-10 years). Early complications were few and insignificant. Late complications (nipple-valve sliding and pouch ileitis) were more common, and 15 patients with valve sliding causing leakage had to undergo altogether 22 reoperations. Three reservoirs had to be removed because of refractory pouch ileitis. Modifications in nipple-valve construction in the last 40 cases diminished the problem of sliding. More than 90% of the patients reported improved quality of life after conversion of conventional to continent ileostomy. Continent ileostomy remains an excellent alternative to ileoanal anastomosis with proximal reservoir for patients who cannot accept conventional ileostomy or when an ileoanal anastomosis with reservoir functions unsatisfactorily or is otherwise unsuitable.

Recurrence and survival after anterior resection of the rectum using the end to end anastomotic stapler.

With the introduction of the end to end anastomotic stapler there has been an increase in the number of sphincter saving resections for carcinoma of the middle and distal part of the rectum. The results of earlier reports have indicated an increasing number of local recurrences possibly due to less extensive dissection of the lower pelvic area. Ninety-six patients, 46 males and 50 females, with a median age of 68 years (a range in age of 33 to 86 years) were operated upon between 1978 and 1981 for carcinoma of the rectum with anterior resection and stapled anastomosis have been analyzed. All patients were observed for more than three years (a median of 65 months and a range of 36 to 82 months). The hospital mortality rate was 5 per cent. The median distal margin was 2.5 centimeters (a range of 1 to 10 centimeters). Local recurrences occurred in 17 patients. No correlation between the grade of malignant disease and classification according to Dukes' staging and local recurrence was found. The median time between operation and the diagnosis of a local recurrence was 14 months (two to 62 months). Distant metastases developed in 14 of 83 patients who underwent operation for cure. The over-all five year survival rate was 64 per cent. The survival rate for 83 patients who underwent operation for cure was 71 per cent (96 per cent of Dukes' A, 72 per cent for Dukes' B, 45 per cent for Dukes' C and zero per cent for Dukes' D). It is concluded that the use of stapling devices has not been followed by a higher rate of local recurrence or a decreased five year survival rate and that this new technique can be used whenever technically possible.

Patient's and doctor's delay in carcinoma of the colon and rectum.

Despite sophisticated diagnostic equipment and modern surgical therapy, the prognosis for patients with colorectal carcinoma has not improved during the last few decades. One of the factors, possibly contributing to the prognosis, is the time between the patient's visit to the doctor and the final therapy. In order to estimate patients' and doctors' delay and to investigate the factors which may influence the time of delay, a prospective study was designed including 50 patients with carcinoma of the rectum or the sigmoid colon and 50 patients with colonic carcinoma above this level. All patients were interviewed by a doctor using a standard questionnaire, and initial symptoms, duration of symptoms, and type of clinical examination leading to diagnosis were recorded. The results show that 16% of the patients in the recto/sigmoid group suffered from patient's delay as opposed to 20% in the group of patients with carcinoma above 25 cm from the anal verge. Doctor's delay was found in 27% of all cases, being evenly distributed in the two groups. The reason for doctor's delay was usually the doctor's neglecting to perform rectosigmoidoscopy or rectal palpation, and in some cases a false-negative X-ray. No significant correlation was found between tumor stage and doctor's or patient's delay.

Adipocyte heat production before and after weight reduction by gastroplasty.

Fifteen grossly obese patients were studied before and 6-8 months after gastroplasty. Their mean body weight decreased by 30% (from 127 +/- 13 to 97 +/- 14 kg, mean +/- SD). The preoperative hyperinsulinemia, hyperglucosemia and hyperglucagonemia were significantly reduced at follow up. Liproprotein lipase activity, measured in post-heparin plasma, was slightly reduced and did not change after weight reduction. Variables reflecting thyroid function were within the reference ranges; small but statistically significant reductions in serum thyroxine and reverse triiodothyronine levels were recorded. Adipocyte heat production, reflecting total cellular metabolic activity and registered by microcalorimetry, was significantly decreased before surgery (by about 60 per cent when expressed per g tissue and by about 20 per cent when expressed per cell) and increased significantly at follow-up; expressed per cell, the heat production was normalized, but expressed per g tissue the values were still about 15 per cent before those of a control group. The results indicate that the reduced adipocyte heat production in obese individuals is a consequent rather than a cause of severe obesity.

Gastroplasty as a treatment for massive obesity. A clinical and biochemical evaluation.

Twenty-four grossly obese patients were operated on with horizontal gastroplasty. One patient died postoperatively of pulmonary embolism. The remaining 23 were extensively studied before and repeatedly after surgery. Eighteen months postoperatively the average weight loss was 34.4 kg (range, 1-71 kg). Seven patients had a weight reduction of less than 20% after 18 months. Postoperatively, biochemical variables reflecting glucose and lipid metabolism and liver function improved. B-hemoglobin, S-iron levels, and serum concentrations of folate and cobalamins decreased significantly. No negative histological changes could be found in the gastric mucosa during the follow-up period. Although only positive metabolic changes have been registered, we feel that gastroplasty, which is not without early postoperative complications and has a failure rate of about 30%, cannot be generally recommended until the problem of postoperative dilation of the stoma has been successfully solved.

Effects of weight reduction after gastroplasty on glucose and lipid metabolism.

We have studied effects of weight reduction after gastroplasty on glucose and lipid metabolism in 15 grossly obese subjects. Their body weight decreased from 127 +/- 13 to 97 +/- 14 kg 6 months after surgery and remained essentially stable 8 months later. There was a marked improvement of lipid and carbohydrate metabolism with significant reductions in blood glucose, plasma insulin and glucagon levels, and in glucose tolerance. Lipoprotein lipase activity in adipose tissue was in the upper reference range and lipoprotein lipase activity in postheparin plasma tended to be low. Plasma triglyceride, cholesterol and low-density lipoprotein cholesterol concentrations decreased significantly, while high-density lipoprotein cholesterol levels tended to rise. Concomitantly, there was an increase in triglyceride clearance rate. Most of these changes were significantly correlated to the reduction in body weight/body fat, indicating that the metabolic improvements are due to body fat reduction as such.

Single versus multiple dose doxycycline prophylaxis in elective colorectal surgery.

One hundred and two patients undergoing elective colorectal surgery were randomized in a prospective but "non-blind" way into two groups. The first group received 0.4 g of doxycycline preoperatively and the second group 0.2 g of doxycycline preoperatively and 0.1 g of doxycycline on the first, second and third postoperative day. All doxycycline was administered by intravenous infusion. The infection rate was 10% in the "one-dose" treatment group and 10% in the "four-dose" treatment group. It is thus concluded that 0.4 g of doxycycline preoperatively results in an acceptable rate of postoperative infections, which may be explained by the satisfactory concentration of doxycycline up till three days after administration. The advantage of "one-dose" treatment compared to "four-dose" treatment from practical and economical standpoints are obvious.

Weight reduction after gastroplasty: the predictive value of surgical, metabolic, and psychological variables.

Twenty-one grossly obese patients (mean body weight 126 kg, range 93-190 kg) were treated with gastroplasty ad modum Gomez. Eighteen months after surgery the average weight loss was 30.4 kg (range 1-71 kg); about 80 per cent of this weight loss represented loss of body fat. Mean weight loss of the entire programme, including preoperative weight reduction was 34.4 kg (range 1-71 kg). Dilation of the pouch and/or channel occurred in 14 patients and was generally discovered 6-12 months after operation. The wide range in weight reduction could not be unequivocally attributed to technical-surgical factors. Although the patients with the least weight reduction had all developed channel dilation, several patients with excellent weight loss also showed dilation of the pouch and/or channel. An extensive psychological investigation performed before surgery demonstrated more signs of sensitivity and denial in the unsuccessful patients; the successful ones were more dependent and tended to live in a supportive social environment. The unsuccessful patients were younger and their estimated alcohol consumption was higher. A number of morphological and biochemical variables including body weight, fat cell size, and variables reflecting thyroid function, lipid and glucose metabolism, and adipose tissue metabolism were not related to subsequent weight loss.

Protective colostomy in low anterior resection of the rectum using the EEA stapling instrument. A randomized study.

The need for protective transverse colostomy in low anterior resection using the EEA stapler was tested in a randomized series of 50 patients, half of whom received peroperative protective colostomy. Gastrografin enema on the tenth postoperative day showed a leakage frequency of 30 per cent in both groups. Clinical leakage was noted in 4 per cent (one patient) in the colostomy group and 12 per cent (three patients) in the noncolostomy group. Protective colostomy was followed by stenosis in nine instances, compared with only two in the noncolostomy group (2 alpha = 0.05). Routine protective colostomy should not be used in low anterior resection when the EEA stapling instrument is used. The occasional clinical leakage, which may appear in the postoperative period, can be revealed by close observation and successfully treated by an emergency colostomy. The majority of patients with anterior resection of the rectum, therefore, can be spared the inconvenience and cost of temporary colostomy.