Neutrophil functions in morbidly obese subjects.

The present study aimed to determine different peripheral blood neutrophil functions in 18 morbidly obese subjects with body mass index (BMI) ranging between 35 and 69 kg/m(2) in parallel with age- and gender-matched lean controls. Peripheral blood neutrophil functions of obese subjects and matched lean controls were determined. Neutrophils of obese subjects showed significant elevation of the release of basal superoxides (P < 0.0001), formyl-methionyl-leucyl-phenylalanine (fMLP)-stimulated superoxides (P < 0.0001) and opsonized zymosan (OZ)-stimulated superoxides (P < 0.045) compared with lean controls. Interestingly, there were no differences in phorbol myristate acetate (PMA)-stimulated superoxide production by neutrophils of the obese subjects and controls. There was also a significant elevation of chemotactic (P < 0.0003) and random (P < 0.0001) migration of neutrophils from obese subjects compared with lean controls. Phagocytosis, CD11b surface expression and adherence of neutrophils from obese subjects were not significantly different from those of the lean controls. The elevated superoxide production and chemotactic activity, together with the normal phagocytosis and adherence, suggest that neutrophils from obese subjects are primed and have the capability to combat infections. However, neutrophils in the priming state may participate in the pathogenesis of obesity-related diseases.

Nutritional status seven years after Roux-en-Y gastric bypass surgery.

BACKGROUND: Nutritional deficiencies in patients after Roux-en-Y gastric bypass operations have been mainly attributed to dietary restriction. However, most of these studies have been performed during the period of greatest caloric restriction. METHODS: Two hundred patients who were morbidly obese were followed for 6 to 8 years (mean, 6.7 years) after Roux-en-Y gastric bypass surgery. Each underwent a thorough physical examination and behavioral and nutritional assessments, including hemoglobin, red blood cell indices, serum iron content, iron binding capacity, and serum vitamin B12 and folic acid concentrations. RESULTS: Data obtained from blood tests disclosed a significant gradual decrease of the mean serum hemoglobin (p less than or equal to 0.0000), mean corpuscular volume (p less than 0.001), and iron saturation (p less than or equal to 0.0000). Mean vitamin B12 concentration improved during the last 3 years of follow-up. The mean values of iron saturation and vitamin B12 were not correlated with the patients' weight loss. Meat intolerance was observed in 51%, 60.3%, 59.5%, and 55.1% of the patients during the 0 to 12 months, 13 to 24 months, 25 to 72 months, and 73 to 96 months after surgery, respectively. A significant correlation was found between the eating habits and the laboratory values. The mean serum iron saturation, vitamin B12, and folic acid were significantly higher in patients who eat meat than in patients who do not eat meat (piron less than 0.0046, pB12 less than 0.0052, folate less than 0.01). In addition, oral vitamin and mineral supplements significantly improved the nutritional status of the patients. The patients had no caloric malnutrition or protein deficiency. CONCLUSIONS: Roux-en-Y gastric bypass induces long-term changes in eating habits, independent of caloric intake. Iron continuously declines 6 to 8 years after surgery, depending (significantly) on the eating behavior, but not on the caloric intake.

Acute cholangitis caused by ruptured hydatid cyst.

In four patients, acute cholangitis was found to result from a ruptured hydatid cyst. In three patients, the diagnosis was established before operation by ultrasonography, and the fourth case was diagnosed during operation. Once the diagnosis of cholangitis is reached, our working policy includes administration of antibiotics and fluids, accelerated diagnostic workup, and operation as soon as possible. Our suggested operative procedure is cholecystectomy, choledochotomy, choledochoduodenostomy, and removal of the echinococcal cyst. In all four cases treated by us, there were no deaths, and only one patient who did not undergo removal of the echinococcal cyst at the initial operation needed a second operation 2 months later.

[Retroperitoneal perforation after endoscopic sphincterotomy: the dilemma of management].

Retroperitoneal perforation is an occasional complication of endoscopic retrograde cholangiopancreatography, which is expected to increase in frequency. The outlook for patients with this complication is good. Conservative, nonsurgical management is suitable for most patients. The main goal is to achieve adequate drainage of the common bile duct which can be done endoscopically. Despite persistent obstruction an initial period of conservative management is usually appropriate. Surgical intervention should be withheld until the patient's condition is becoming worse, or until a complication such as localized retroperitoneal abscess is recognized.

[Parathyroid adenoma in a child].

Parathyroid adenoma presenting as primary hyperparathyroidism is rare in childhood. We report a case in a 9-year-old Bedouin girl. The diagnosis was based on hypercalcemia, which was found accidentally, and elevated serum parathyroid levels. Ultrasonography, scintigraphy, computerized tomography and magnetic resonance imaging failed to detect the lesion. The diagnosis was only established at exploratory operation, when an adenoma was removed from the right upper pole of the thyroid.

[Experience with biofragmentable anastomotic rings].

During 1991-92 we performed 50 bowel anastomoses using the biofragmentable anastomotic ring (BAR). The indications were malignancy (35 cases), Crohn's disease (3), dolichosigma (4), diverticulitis (2), gastric outlet obstruction (2), and 1 each for abdominal trauma, postoperative stricture, and stricture caused by ischemic colitis. The average age was 61; 28 were women and 22 men. The anastomoses were between colon and rectum (21 cases), ileum and colon (18), colon and colon (8), stomach and jejunum (2) and ileum and ileum (1). First stools were passed after an average of 4.7 +/- 2.5 (SD) days and a low-residue diet was well-tolerated after an average of 7 +/- 3.9 days. There were complications in 12 (24%). In 3 others leaks necessitated reoperation. Incomplete small bowel obstruction developed in 6, 4-18 days after operation and lasted 3-11 days. In 2 a perianastomotic inflammation appeared 1-3 weeks after operation and was treated successfully with IV antibiotics and bowel rest. In 1 case a stricture appeared 3 months after surgery and was treated successfully with balloon dilatation. No complications were seen after anastomosing bowel segments proximal to the ileocecal valve. The average time for expelling the BAR in 19 of the 45 patients was 2.5 +/- 0.6 weeks, assessed by weekly X-raying of the abdomen. Although the group of patients was small, our impression is that the method of anastomosis is easy to learn, easy to perform and relatively safe.

[Experience with laparoscopic appendectomy].

During April to August 1992, laparoscopies were performed in this department in 35 of 100 cases of appendicitis. The average patient age was 29 years; 18 of the 35 (51%) were women; 3 patients were operated on electively, and the rest as emergencies. Appendectomy was performed in 33 (94%), but not in 2 women with sepsis due to tubo-ovarian abscess; In 1 of these 2 we had to convert to laparotomy. Acute appendicitis was found in 20 (57%). In 7 women (20%) gynecologic disease was diagnosed. In 1 case (3%) a carcinoid tumor of the tip of the appendix was found and in another primary peritonitis. In the remaining 6 (17%) no lesions were found. In 33 (94%) a regular diet was resumed 25 hours postoperatively and 25 (71%) were discharged the day after operation. The only complication was an abdominal wall hematoma in a single case, which resolved spontaneously. It is our impression that laparoscopy is a useful diagnostic tool in acute appendicitis, that it is a safe route for appendectomy, and that recovery is quick with minimal complications.

[Laparoscopic-assisted colectomy].

After gaining experience in laparoscopic cholecystectomy, laparoscopic appendectomy and other laparoscopic procedures, we decided to perform laparoscopic-assisted colectomy. During July 1992 to February 1993 we performed 14 such procedures. Ages ranged from 46-83 years (mean, 68). In all cases the indication for surgery was neoplasm of the colon. 8 of the tumors were located in the right colon and 6 in the sigmoid. Procedures performed were laparoscopic-assisted right hemicolectomy with a biofragmentable anastomotic ring or laparoscopic-assisted sigmoidectomy with end-to-end anastomosis. In 1 operation we combined laparoscopic cholecystectomy with laparoscopic right hemicolectomy. Operation time varied from 90-130 min (mean, 100 min). In our opinion the procedure is as radical as standard laparotomy with the number of lymph nodes per specimen ranging from 4-10 (mean, 7); the surgical margins were free of tumor in all cases. There was less pain in the postoperative period than with the standard procedure and the average time from operation to discharge was 7 days (range, 5-9). Complications included 1 fatality due to postoperative myocardial infarction, and 1 case of duodenal perforation which was sutured during the operation. We conclude that laparoscopic-assisted right hemicolectomy and laparoscopic sigmoidectomy are feasible for carcinoma, and that recovery is quicker and with less pain. However, we need a larger series and long-term follow-up to conclude whether the laparoscopic assisted technic is an adequate operation in cases of cancer.

[Nutritional habits after Roux-en-Y gastric bypass for morbid obesity].

The nutrition of 200 patients after Roux-en-Y gastric bypass for morbid obesity was followed for 6.7 years. During the first 2 years their food intake was severely restricted, resulting in an excess weight loss of 69 +/- 14%. At an average of 3 years after surgery they began to regain weight significantly (p less than 0.04) due to nutritional adaptation. In the following years caloric consumption stabilized at an excess weight loss of 48-56%. However, they had continuing meat intolerance with 51.0, 60.3, 59.5 and 55.1% of them avoiding meat during 0-12 months, 13-24 months, 25-72 months and 73-96 months after surgery, respectively. We conclude that after Roux-en-Y gastric bypass there is nutritional adaptation lasting as long as 2 years, when a characteristic nutritional behavior is adopted which persists for years.

[Nutritional disturbances after Roux-en-Y gastric bypass].

200 patients after Roux-en-Y gastric bypass were nutritionally followed for an average of 6.7 years. They were randomly selected out of 450 patients operated on during 1980-1985. They had lost a mean of 56 +/- 22% of their excess weight and had remained stable in weight for the preceding 5 years with limited nutritional caloric restriction. Iron saturation, hemoglobin and mean corpuscular volume declined gradually and significantly (p less than 0.0001, p less than 0.0001 and p less than 0.001, respectively). However, mean serum concentration of vitamin B12, which also had decreased significantly during the preceding 5 years (p less than 0.0004), increased during recent years, but still was lower than before the bypass. Albumin and transferrin levels remained normal. There was no correlation between weight change and serum concentration of iron or vitamin B12. We conclude that 6.7 years after surgery, while there is no caloric or protein deficiency, there has been gradual development of iron deficiency, but not correlated with weight loss.

[Long-term weight changes after Roux-en-Y gastric bypass for morbid obesity].

100 patients were followed for 6-9 years after Roux-en-Y gastric bypass for morbid obesity. They were randomly selected from 600 patients operated on between 1980-85. Their initial weight averaged 118 +/- 16 kg, which was 196 +/- 25% of their ideal body weight. They reached their lowest weight during an average of 15.5 months after surgery, at which time 37% were at their ideal weight, 42% were 110-130% of their ideal weight and 21% were 131-192% of their ideal weight. 90% had lost more than 50% of their excess weight. 24% had lost all their excess weight or even more, which could jeopardize nutritional status. Longer follow-up of 6-9 years showed weight gain, with 24% having become morbidly obese again, 74% having lost more than 50% of their excess weight and only 7% having lost all their excess weight. We conclude that Roux-en-Y gastric bypass induces long term weight loss and largely prevents return of morbid obesity, as long as 6-9 years after surgery.

[Necrotizing soft tissue infection].

The dramatic course of necrotizing soft tissue infection represents a medical emergency, since it is limb- and life-threatening. Most necrotizing soft tissue infections are caused by mixed aerobic and anaerobic Gram-negative and Gram-positive organisms. Most case have been reported in immuno-compromised hosts after penetrating trauma or surgery. We describe a unique series of cases of necrotizing soft tissue infection. The mainstay of treatment is early and daily debridement of devitalized tissue and broad-spectrum antibiotics. Hyperbaric oxygen therapy should be considered.

Sigmoid perforation in patients with chronic constipation.

From 1976 to 1982, seven cases of free perforation of the sigmoid colon were treated at the Soroka University Hospital. None of the patients suffered any known underlying disease of the affected bowel such as malignancy, diverticulosis, stercoral ulcer, colitis, or trauma. The only feature common to all seven patients was a long history of chronic constipation. All patients were treated surgically with no mortality and with minimal morbidity. We believe that severe untreated chronic constipation may, on rare occasions, cause free perforation of the sigmoid colon.

A new approach to rectal anastomotic stricture.

A technique is presented that can serve as a solution for localized postoperative rectal stricture. This procedure was used after the failure of manual and instrumental dilatations. It consisted of cutting the prominent plication of the stricture, using the EEA stapler. Five patients successfully underwent this operation without morbidity or mortality, three after very low anterior resection and two after total colectomy, mucosal proctectomy, and ileoanal anastomosis.

Adrenal lipoma: a rare tumour of the adrenal gland.

We report a case of an adrenal lipoma, a very rare lesion first described in 1899 and of which a total of six cases have previously been reported (Lange 1966, Page, De Lellis & Hough 1986). Five of these cases were found incidentally at post mortem. In one case an acute hypertensive episode intra-operatively simulated the signs of phaeochromocytoma and contributed directly to the patient's death (Lange 1966). Intra-operative hypertension also occurred in our patient.

Gastroscopically Assisted Balloon Tamponade for Massive Bleeding after Silastic Ring Vertical Gastroplasty.

We report a case of massive upper gastrointestinal bleeding after silastic ring vertical gastroplasty. The bleeding originated from the staple-line at the insertion point of the silastic ring. A Sengstaken-Blakemore tube tamponaded the area of bleeding, by a new technique whereby the gastroscope was inserted through the gastrostomy orifice and used to guide the placement of the occluding balloon.

Influence of the cortical electrical activity level during general anaesthesia on the severity of immediate postoperative pain in the morbidly obese.

BACKGROUND: The objective of anaesthesia is to provide hypnosis, analgesia and adequate conditions during surgery. It is difficult to establish the appropriate dose of general anaesthetic drugs in the morbidly obese patient. Moreover, there are conflicting data concerning adequate anaesthesia levels and the severity of postoperative pain. The aim of this study was to investigate the relationship between the spectral edge frequency (SEF) during general anaesthesia and the severity of immediate postoperative pain following gastric banding surgery in morbidly obese patients. METHODS: Seventy-one ASA 2 morbidly obese patients (BMI > 35%) undergoing elective laparoscopic gastric banding procedure were recruited for this study. Anaesthesia consisted of midazolam, fentanyl and thiopental for induction, vecuronium for muscle relaxation, N2O and isoflurane with additional fentanyl administrations, according to the clinical judgement of the anaesthesiologist, for maintenance. Continuous SEF monitoring was added to the standard monitors (SpO2, ETCO2, ECG, NIBP, O2 and isoflurane concentration), but the EEG monitor screen was hidden from the anaesthesiologist's sight. SEF postoperative analysis divided the patients into two groups: group 1, SEF-recommended target range of 8-12 Hz, more than 80% of the surgical time; and group 2, SEF-recommended target range of 8-12 Hz, less than 80% of the surgery duration. Pain intensity was assessed in the post anaesthesia care unit using a standard visual analogue scale (VAS) of 10 cm, when patients were awake enough to correct a deliberately given wrong own telephone or ID number. Intravenous morphine was administered for postoperative analgesia in 2-mg increments, every 3-4 min, until the patient felt comfortable. A recovery room nurse unaware of the SEF range recorded during surgery registered pain severity and morphine requirements. RESULTS: The end-tidal isoflurane concentration was significantly higher in group 1 than in group 2 (0.83 vs. 0.7 P = 0.016). The intensity of pain at admission into the recovery room and at discharge was significantly lower in group 1 than in group 2 (VAS 6.1 vs. 6.9-P = 0.0049, and 3.9 vs. 4.2-P = 0.00478, respectively). CONCLUSIONS: Keeping the SEF range between 8 and 12 Hz during anaesthesia for laparoscopic gastric banding for morbid obesity, both the immediate post operative pain intensity and morphine requirement, are significantly reduced.

Topical modes in the preparation of human spleen specimens for routine scanning electron microscopy studies.

Various preparatory techniques were used to improve scanning electron microscopy images of the fine structure of vascular, cellular, and cordalreticular components of normal human spleens. The progressive method of fixation (GTGO) applied in the present study, allowed air drying of the tissues and rendered the specimens conductive even in newly fractured surfaces. Vascular perfusion proved necessary only in studies of the splenic blood vessels, while a simple immersion of tissue blocks in the washing solution resulted in better images of the white pulps. Interstitial (transsplenic) perfusion was found to be superior to vascular perfusion for routine preparation of spleen tissues, and freeze-cracking did not necessarily lead to improved images of the specimen's surfaces. Combined with proper washing and shaping protocols, the GTGO procedure is shown to be a superior mode of specimen preparation, abolishing most traditional artifacts and obtaining clear images of the complex splenic tissue.

Liver histology abnormalities in the morbidly obese.

A prospective study was undertaken in order to investigate the association between clinical and biochemical parameters and the histopathological findings in liver biopsies in the morbidly obese. Wedge liver biopsy specimens were taken at the beginning of the surgical procedure from 100 consecutive morbidly obese patients undergoing Roux-en-Y gastric bypass. Histological abnormalities were found in almost all of the examined material (98 of 100), which ranged from mild fatty infiltration through inflammatory change and alcoholic hepatitis-like change to fibrosis and cirrhosis. The patients with abnormalities were divided into two groups: those with a single abnormality (n = 56) and those with two or more histopathological findings (n = 42). Age, excess body weight, total cholesterol and triglyceride levels were significantly higher in the group with more than one histopathological finding. In a discriminant function analysis, it was found that the preoperatively available measures of age, sex and excess body weight, as well as ALT and triglyceride levels, could discriminate between the two patient groups. A model which uses these variables has been described which correctly assigns the patients to their histology groups in 73% of the cases. This model could provide a useful noninvasive clinical tool for the preoperative evaluation of possible hepatic damage in morbidly obese patients in whom there is no other known cause of possible liver disease.