Resectional gastric bypass is a new alternative in morbid obesity.

BACKGROUND: Severe obesity is a common serious health problem in the United States. Medical therapy is often ineffective. A variety of surgical procedures have been employed for treatment of morbid obesity. Surgical therapy continues to evolve. METHODS: Eighty-five patients have undergone subtotal gastrectomy and retrocolic Roux-en-Y gastrojejunostomy for weight control at our institution. We refer to this procedure as resectional gastric bypass (RGB). Thirty-eight patients have undergone RGB as conversion from failed or problematic prior bariatric procedures. Forty-seven patients have had RGB as their primary bariatric procedure. RESULTS: Twenty-six patients undergoing RGB for conversion of an anatomically or functionally failed prior bariatric procedure have had mean additional weight loss of 37% excess body weight (EBWL) in 18 months follow-up. Twelve patients undergoing RGB for intractable side effects of prior bariatric procedures have all had clinical improvement. Forty-seven patients undergoing RGB as a primary procedure have had EBWL of 53%, in mean follow-up of 11 months. For the entire series, major complications were one anastomotic leak, one reexploration for suspected subphrenic abscess, and one major pulmonary embolus. These patients recovered. There was no mortality in the series. CONCLUSIONS: Resectional gastric bypass is a new alternative for salvage of a failed or problematic prior bariatric procedure. It is also effective as a primary weight control operation.

Necrotizing fasciitis after tumescent liposuction.

We report a case of necrotizing fasciitis after tumescent liposuction, a new and increasingly popular plastic surgery procedure. After radical surgical debridement and staged full-thickness skin grafting, the patient ultimately recovered. The significance and recognition of this serious complication is emphasized.

Atypical hyperplasia in the era of stereotactic core needle biopsy.

BACKGROUND AND OBJECTIVES: To characterize both atypical hyperplasia (AH) and the malignancies typically present at open surgical biopsy in women diagnosed with AH by stereotactic core needle biopsy (SCNB). METHODS: Patients with AH diagnosed by SCNB were advised to undergo surgical biopsy to rule out an associated malignancy. Mammography findings, pathology reports and follow-up data were analyzed. RESULTS: AH was identified by SCNB in 38 of 893 (4.3%) patients. Carcinoma was identified in 12 of 33 (36.4%) patients who went on to surgical biopsy. Ductal carcinoma in situ (DCIS) was present in 11 of the 12 patients with malignancy. There were no characteristic mammographic findings which would identify patients with carcinoma. CONCLUSIONS: When SCNB returns a diagnosis of AH there is a substantial risk of an associated malignancy in the breast. There appear to be no definitive criteria to distinguish which patients harbor a malignancy, and surgical biopsy should always serve as an adjunct diagnostic procedure.

Modified technique to recover microsporidian spores in sodium acetate-acetic acid-formalin-fixed fecal samples by light microscopy and correlation with transmission electron microscopy.

Microsporidia are an emerging cause of significant disease, particularly in the immunocompromised host. Until recently, the diagnosis of enteric infections has required invasive sampling, the use of expensive technology, and considerable technological expertise. The purpose of the present study was to examine three modifications to the processing of fecal specimens for light microscopy (LM) examination for microsporidian spores: the use of pretreatment with potassium hydroxide, modified centrifugation conditions, and a modified staining technique. A sodium acetate-acetic acid-formalin-fixed fecal sample containing numerous microsporidian spores confirmed to be positive by transmission electron microscopy (TEM) was used in all studies performed. A simulation of a heavy to lightly infected individual was used. The results of LM were correlated with those of TEM. Duplicate smears were stained with Weber's modified trichrome and Giemsa (GS) stains. The stained slides were randomized and examined blindly by LM at x 625 and x 1,250 magnifications. A portion of the dilutions after centrifugation were fixed for TEM. The Weber modified trichrome stain performance rating was higher than the Giemsa stain rating because of ease of interpretation, and material stained with Weber modified trichrome stain required less examination time at a lower magnification. The number of positive smears and the quantity of spores detected were significantly higher following pretreatment of the sample with KOH. TEM was positive only when numerous spores were present, but the quality of the photomicrographs was superior after pretreatment with KOH. Pretreatment of sodium acetate-acetic acid-formalin-fixed fecal samples with 10% KOH and then a 5-min centrifugation time and staining with Weber modified trichrome stain provide for the excellent recovery of microsporidia in the routine diagnostic parasitology laboratory.

Secondary hyperparathyroidism following biliopancreatic diversion.

OBJECTIVE: To investigate the cause of osteomalacia following biliopancreatic diversion(BPD) surgery for obesity. DESIGN: A retrospective, case-comparison study. SETTING: A tertiary care center. PATIENTS: A case group of 12 subjects (including 9 women; mean age +/- SEM, 48.5 +/- 3.0 years; mean preoperative body mass index +/- SEM, 43.7 +/- 2.3 kg/m2, and mean weight loss +/- SEM, 75 +/- 14 kg) who have undergone BPD (referred to as BPD group hereafter) and a comparison group of 10 subjects (including 9 women; mean age +/- SEM, 49.6 +/- 3.3 years; mean preoperative body mass index +/- SEM, 44.0 +/- 2.5 kg/m2; and mean weight loss +/- SEM, 55 +/- 15 kg) following vertical banded gastroplasty (VBG) (referred to as VBG group hereafter). MAIN OUTCOME MEASURES: Serum and urine markers for bone metabolism. RESULTS: Compared with the VBG group, the BPD group had significantly lower concentrations of the following components: serum calcium (2.14 +/- 0.05 mmol/L vs 2.37 +/- 0.05 mmol/L [8.6 +/- 0.2 mg/dL vs 9.5 +/- 0.2 mg/dL]), serum 25-hydroxyvitamin D (24 +/- 6 nmol/L vs 64 +/- 6 nmol/L), urine calcium excretion (1.7 +/- 0.7 mmol/d vs 4.5 +/- 0.7 mmol/d [68 +/- 28 mg/d vs 180 +/- 28 mg/d]), and serum carotene (0.40 +/- 0.15 mmol/L vs 1.29 +/- 0.16 mmol/L). The BPD group had significantly higher concentrations of the following components: serum parathyroid hormone (13.6 +/- 2.1 pmol/L vs 5.2 +/- 2.3 pmol/L), serum alkaline phosphatase (139 +/- 8 U/L vs 86 +/- 9 U/L), and urinary hydroxyproline/creatine (52 +/- 5 mumol/mmol vs 19 +/- 5 mumol/mmol). CONCLUSION: These data suggest that following BPD, secondary hyperparathyroidism attributed to hypocalcemia results from malabsorption of vitamin D. However, we cannot exclude the possibility of concurrent calcium malabsorption with vitamin D malabsorption.

Hepatic adenoma presenting as a right lower quadrant mass.

Most patients with hepatic cell adenomas present dramatically with an acute abdominal crisis associated with hemorrhage and an upper abdominal mass. We present an unusual case of hepatic cell adenoma presenting as a right lower quadrant mass and review the current literature concerning this tumor.

Routine cholecystectomy in the morbidly obese.

Proven disease is generally considered a sound indication for cholecystectomy. However, incidental removal of a gallbladder with unproven pathology is controversial. The morbidly obese, however, constitute a group at especially high risk for the development of gallbladder disease, with possible greater risk immediately after weight reduction procedures. In our series of 51 consecutive patients undergoing vertical banded gastroplasty (VBG), the gallbladder was routinely removed regardless of symptomatology or results of a preoperative workup. Two patients declined cholecystectomy. Twelve patients (24.4%) had undergone cholecystectomy for symptomatic stones prior to their VBG. Of the remaining 37 subjects, there was a 73% overall incidence of disease: 11 (29.7%) had cholelithiasis, 11 (29.7%) had cholesterolosis alone, three (8.1%) had chronic cholecystitis with cholesterolosis, and two (5.4%) had chronic cholecystitis alone; only 10 (27%) had normal findings. These results, when added to evidence demonstrating a high incidence of postoperative gallbladder disease in those not receiving cholecystectomy, suggest that routine cholecystectomy be considered in all morbidly obese patients undergoing VBG or similar procedures.

Liquid chromatographic determination of bendiocarb in technical materials and wettable powder formulations: collaborative study.

A liquid chromatographic method for determination of bendiocarb in technical materials and wettable powders was tested by 12 collaborators. Bendiocarb is dissolved in acetonitrile containing 0.1% propiophenone as internal standard. This solution is analyzed on a liquid chromatograph utilizing a reverse phase (C18) column. The compound is detected at 254 nm and peak area is used for quantitation. The 3 different materials studied contained 20, 80, and nominally 100% bendiocarb. Each was examined in duplicate to provide the necessary matched pairs. Collaborators approved of the ease and simplicity of the method and, in particular, the way the method can be applied to automatic injection assemblies. The statistical data show acceptable precision of the method: Reproducibility coefficients of variation were 20% material, 2.04%; 80% material, 1.02%; and nominal 100% material (technical product), 0.64%. The method has been adopted official first action.

Air gun injuries in children.

Air gun injuries occur frequently in children and are potentially lethal. Three cases of air gun injuries in children are described. Two children sustained air gun injuries to the neck that penetrated the platysma. Each had exploration of the wound. One had injury to the esophagus that was treated with external drainage; the other sustained no major injury to vital cervical structures. A third child received a penetrating injury to her right flank that did not appear to enter the peritoneal cavity. She was observed for 24 hours and released. After a six-month followup, all patients have remained free of complications. The emergency physician should be aware of the penetrating capabilities of these weapons, and they should be managed as would any other low-velocity gunshot wound.

The value of computed tomography in staging bronchogenic carcinoma: a changing role for mediastinoscopy.

Forty-one patients underwent operative staging for bronchogenic carcinoma following computed tomography of the mediastinum between August, 1982, and March, 1984. Twenty-seven patients were classified as Stage I preoperatively; in 2 of them, positive mediastinal nodes were found at thoracotomy. For the 14 patients in whom positive nodes had been identified by computed tomographic (CT) scanning, staging was unchanged as a result of the findings at mediastinoscopy or thoracotomy or both. In this series, computed tomography had a sensitivity of 89%, a specificity of 100%, and an overall accuracy rate of 95%. We conclude that mediastinoscopy is not needed in patients without evidence of mediastinal nodal enlargement by CT scan; when performed, it should be guided toward those nodes identified as positive.

Surface structures (peritrichous fibrils and tufts of fibrils) found on Streptococcus sanguis strains may be related to their ability to coaggregate with other oral genera.

We screened 36 strains of Streptococcus sanguis biotype I and 8 strains of S. sanguis biotype II for the presence of surface structures and for their ability to coaggregate with Actinomyces viscosus, Actinomyces naeslundii, and Fusobacterium nucleatum. Negative staining under an electron microscope revealed detectable surface structures on all S. sanguis strains. The majority of strains (38 of 44) carried peritrichous fibrils, which have an irregular profile and no distinct width. They usually appeared as a fringe with a constant width around the cell. Strains selected for measurement had a fringe with an average length of 72.4 +/- 8.5 nm on biotype I strains and 51.6 +/- 3.3 nm on biotype II strains. Some fibrillar biotype I strains carried an additional, longer (158.7 +/- 33.1 nm) type of fibril projecting through the shorter fibrils. Fibrillar density was characteristic for each strain, ranging from very dense on all cells in a population to very sparse on a few cells in a population. A small group of six strains carried tufts of fibrils in a lateral or polar position on the cell. Either one or two lengths of fibril were present in the tuft depending on the strain. One strain carried both peritrichous fibrils and fimbriae. Fimbriae are flexible structures with a constant width (4.5 to 5.0 nm) all along their length but very variable lengths (less than or equal to 0.7 micron) on each cell. S. sanguis I and II both included strains with peritrichous fibrils and tufts of fibrils, but the mixed morphotype strain was confined to biotype II. Fibrils were present on cells at all stages throughout the growth cycle for the strains tested. Freshly isolated fibrillar strains coaggregated consistently well with A. viscosus and A. naeslundii, although some fibrillar reference strains lacked the ability. In addition, all tufted strains could not coaggregate, but the strains with the mixed morphotype coaggregated well. Coaggregation with F. nucleatum was very strong for the fibrillar strains, but less strong for the tufted strains. We discuss the possible correlation between S. sanguis surface structure and ability to coaggregate.

Sepsis from sinusitis in nasotracheally intubated patients. A diagnostic dilemma.

The cause of sepsis in the intensive care unit patient can be a perplexing diagnostic problem. We have recently encountered seven patients who had sepsis associated with sinusitis of the paranasal sinuses. They represented 26 percent of all patients who had nasotracheal intubation for 5 days or more. Sinusitis as a complication of nasotracheal intubation has been previously reported, but its frequency has not been appreciated. Three case reports are presented to emphasize the importance of making this diagnosis. Standard x-ray studies will not adequately demonstrate all the paranasal sinuses. We have utilized computerized tomography to study these patients and found it to clearly demonstrate all the paranasal sinuses. We suggest a plan to help prevent sinusitis from nasotracheal intubation. Should this complication occur, however, the nasotracheal tube should be removed and the sinuses surgically drained or treated aggressively with topical agents.

Abnormal mammographic findings. A critical appraisal.

We performed a 1 year review of mammographic interpretations and breast biopsy experiences at Madigan Army Medical Center, correlating biopsy results with mammographic interpretations when possible. Fibrocystic mammary dysplasia was reported in two thirds of our patients, with interpretations heavily weighted toward findings of moderate or severe dysplasia. Sixteen percent of our patients had indeterminate or suspicious mammograms, and only 11 percent of the mammograms were read as normal. Of 19 patients who underwent needle-directed biopsy for nonpalpable lesions and suspicious or indeterminate mammograms, two had invasive cancer and one lobular carcinoma in situ. Our data suggest that many patients who have indeterminate mammograms are followed in preference to early biopsy if there is no palpable lesion and no high yield radiologic criteria of malignancy.

Streptococcus salivarius strains carry either fibrils or fimbriae on the cell surface.

Strains of Streptococcus salivarius were screened by negative staining for the presence of surface structures. Two structural subgroups were found, carrying either fibrils or fimbriae, projecting from the cell surface. Eight strains carried a very dense peritrichous array of fibrils of two distinct lengths. Long fibrils had an average length of 175 nm, and short fibrils had an average length of 95 nm. Two strains carried only long fibrils, one strain carried only short fibrils, and another strain carried a lateral tuft of very prominent fibrils of two lengths, with a fibrillar fuzz covering the remainder of the cell surface. In all the strains in which they were present, the long fibrils were unaffected by protease or trypsin treatment. In contrast, the short fibrils were completely digested by protease and partially removed by trypsin. Neither long nor short fibrils were affected structurally by mild pepsin digestion or by lipase. The Lancefield extraction procedure removed both long and short fibrils. These twelve fibrillar strains were therefore divisible into four structural subgroups. Extracts of all the fibrillar strains reacted with group K antiserum. The second main structural subgroup consisted of nine strains of S. salivarius, all of which carried morphologically identical, flexible fimbriae arranged peritrichously over the cell surface. The fimbriae were structurally distinct from fibrils and measured 0.5 to 1.0 micron long and 3 to 4 nm wide, with an irregular outline and no obvious substructure. There was no obvious reduction in the number of fimbriae after protease or trypsin treatment. Extracts of the fimbriated strains did not react with the group K antiserum. The two serological and structural subgroups could also be distinguished by colony morphology.

Fluorescent assay of total serum cholesterol, with use of gas-liquid chromatography to study saponification efficiency.

We describe a fluorescent determination of total cholesterol in serum for which the accuracy and precision are comparable to that for the method of Abell-Kendall, a method of generally accepted accuracy. By the use of quality reagents and the rigorous exclusion of water, the strong fluorophor that develops on reacting concentrated sulfuric acid with cholesterol can be used to quantitatively determine the total cholesterol in serum. We used gas-liquid chromatography to monitor the extent of saponification of the cholesterol esters, because we found them to have fluorescent efficiencies that differed from that of free cholesterol. Sodium methoxide in methanol/methylene chloride (1/3 by vol) was shown by gas-liquid chromatography to very effectively saponify the cholesterol esters in serum.

New microtechnique for the leptospiral microscopic agglutination test.

A new microtechnique has been developed for the detection of leptospiral antibodies in serum by the microscopic agglutination test. The test was set up in a microtiter transfer plate held in a transfer plate holder, resting on a transfer plate cover. Live leptospiral antigen was added and a second transfer plate cover was placed over the transfer plate during 2 h of incubation at 32 C. After incubation the bottom cover was removed and the complete unit was placed in a specially designed base plate containing microscope slides (50 by 75 mm). The serum/antigen mixture was ejected on to the microscope slides by means of a sharp tap. The agglutination was then read using a 10 X objective, 10 X eyepieces, and a dry, dark field condenser.