[Nutritional support in surgical treatment of patients with post-gastroresection and post-gastrectomy syndromes].

The aim of the research determine the character and peculiarities of nutritional support in surgical treatment of patients with gastroresection--and total gastrectomy syndromes. Analyzed are the results of the evaluation nourishing status of 68 patients who have had a resection intervention on the stomach. It was noted that the 26.5% of patients with clinical manifestations of diseases of operated stomach arise sub- and decompensated forms of disorders metabolism and nutrition, entailing numerous violations of homeostasis and requiring compliance with reconstructive surgical interventions. We studied the results of the implementation of the reconstructive operations with the formation of functionally active (see text for symbol) in 18 patients, suffering from the disease of stomach operated on. It is proved, that the rational nutritional support in the perioperative period allows to avoid gross violations of metabolism and provides a reasonably good compensation digestive function, significantly improving the quality of life of this category of patients.

Use of pulmonary hydrogen (H 2 ) measurements to quantitate carbohydrate absorption. Study of partially gastrectomized patients.

A technique was developed to quantitate the absorption of ingested carbohydrate by means of continuous measurements of pulmonary H(2) excretion. This technique is based on the observation that H(2) is produced in the colon when carbohydrate is fermented by colonic bacteria, and this H(2) is then excreted by the lungs. The quantitative relationship of pulmonary H(2) excretion to unabsorbed carbohydrate was studied in nine subjects. After ingestion of 6.5, 13, and 26 g of lactulose (a nonabsorbable disaccharide), H(2) excretion increased linearly, averaging (+/-1 SEM) 13+/-3.5, 23+/-7.2, and 49+/-7 ml per 2 hr. Because of consistent individual differences in H(2) excretion per gram of lactulose, the variability of this linear response was less in a given subject, with the H(2) excretion after 6.5 g and 26 g lactulose dosages averaging 55+/-4.2% and 214+/-16% of that observed after the 13 g dose. It was further demonstrated with fecal homogenates, as well as in rats after direct intracecal instillation of carbohydrate, that there was no significant difference in the rate of H(2) formation from lactulose as compared with the normally ingested sugars. Thus, a subject's H(2) excretion after a 13 g dose of lactulose can be used as a standard to convert H(2) excretion after ingestion of other carbohydrates into grams of carbohydrate not absorbed. Application of this technique to seven partially gastrectomized patients indicated all subjects malabsorbed a portion of a 100 g dose of glucose whereas six of seven completely absorbed a 25 g dose. Malabsorption of physiologic quantities of various carbohydrates was clearly demonstrated in one subject. This technique appears to provide quantitative information on carbohydrate malabsorption not readily obtained by presently available techniques.

Bsm1 vitamin D receptor polymorphism and calcium homeostasis following bariatric surgery.

PURPOSE/AIM: To evaluate the association between the Bsm1 vitamin D receptor polymorphism and the calcium-vitamin D-parathormone axis following bariatric surgery. MATERIALS AND METHODS: This cross-sectional study included 86 morbidly obese patients, who underwent either gastric bypass or sleeve gastrectomy, with a mean follow-up of four years. Calcium metabolism indices and bone turnover markers were assessed according to the presence of secondary hyperparathyroidism and the Bsm1 vitamin D receptor genotypes. RESULTS: Secondary hyperparathyroidism (42.2% of sample) was associated with lower levels of 25hydroxyvitamin D and elevated markers of bone turnover. In subjects without secondary hyperparathyroidism, presence of the unfavorable B allele resulted in higher levels of parathormone (Bb and BB vs. bb genotype: 50.3 ± 8.2 pg/dl vs. 44.4 ± 10.7 pg/dl, p = .011, adjusted for weight loss, baseline body mass index, 25hydroxyvitamin D, surgical procedure, and duration after surgery). In the whole sample, patients bearing the unfavorable B allele exhibited lower weight loss, a parameter that was negatively associated with markers of bone resorption. CONCLUSIONS: Secondary hyperparathyroidism is highly prevalent after bariatric surgery. Bsm1 vitamin D receptor polymorphism may have an effect in early stages of calcium metabolism imbalance, while no association is detected in patients who have already developed secondary hyperparathyroidism. Moreover, vitamin D receptor polymorphism is associated with post-surgery weight loss, a process related to bone turnover.

Bioavailability of digoxin tablets in patients with gastrointestinal dysfunction.

In 47 patients with disorders of the gastrointestinal tract, the bioavailability of digoxin tablets was assessed by measuring the area under the serum concentration-time curve (AUC) after the oral administration of single 0.5 mg doses. In 13 or 14 patients who had undergone a previous ileal resection, in 10 of 10 patients with sprue and in 14 of 14 patients with a variety of disorders of the gastrointestinal tract, digoxin absorption was normal despite marked steatorrhea in many. A patient with extensive jejunal and ileal resection, and inflammation of the remaining small bowel,was the sole exception. Impaired digoxin bioavailability was found in five of nine patients who had undergone jejunoileal bypass procedures (bypass patients. A strong correlation was noted between the length of jejunum remaining in continuity and the AUC (r = 0.86, p less than 0.01). Two of three bypass patients also showed decreased absorption of more rapidly dissolving tablets or an elixir. Digoxin bioavailability correlated significantly with and 2 hour serum xylose levels but not with urinary xylose excretion, fecal fat or the Schilling test result. The findings are consistent with the role of the upper small bowel as the predominant site of digoxin absorption as well as the reserve function of the ileum in the event of jejunal dysfunction or bypass.

Participation of Hageman factor dependent pathways in human disease states.

Abnormalities of Hageman factor dependent pathways have been described in a wide variety of human disease states. Congenital deficiencies of factor XII (Hageman trait) prekallikrein (Fletcher trait) and high molecular weight kininogen (Williams, Fitzgerald and Flaujeac traits) although resulting in profound in vitro changes, do not cause in vivo difficulties. In contrast, deficiency of C1 esterase inhibitor (hereditary angioedema) results in significant morbidity and mortality. Acquired diseases may exhibit decreased synthesis of these three proteins in cirrhosis and dengue fever. In vivo activation of factor XII initiated pathways occur in septic shock, disseminated or localized intravascular coagulation, typhoid fever, polycythemia vera, hyperbetalipoproteinemia, coronary artery disease, nephrotic syndrome, transfusion reactions, hemodialysis and extracorporeal bypass. Activation of both the intrinsic system and tissue mediators contribute to the vasomotor phenomena in carcinoid syndrome and postgastrectomy dumping. Roles for factor XII, prekallikrein and kininogen have been suggested in gouty arthritis, allergic disorders and cystic fibrosis but the evidence is not yet convincing in these disorders.

Measurement of intestinal absorption of 57-Co vitamin B-12 by serum counting.

The results of the measurement of vitamin B(12) absorption by counting the radioactivity of 5 ml. serum obtained eight to 10 hours after the ingestion of an oral dose of 0.5 mug. vitamin B(12) labelled with 0.5 muc. (57)Co are compared with those obtained with the urinary excretion (Schilling) test. Inadequate urine collection and impaired renal function were responsible for low results in the Schilling test in four of the 12 control subjects, and an incomplete urine collection in four patients with pernicious anaemia could have led to doubt about the validity of the low result. The measurement of serum radioactivity for 1,000 seconds gave conclusive results, the range in the patients with malabsorption of vitamin B(12) being between 0 and 24 counts per minute, and in the control subjects and other patients with megaloblastic anaemia between 28 and 64 counts per minute. The highest serum radioactivity level in a patient with pernicious anaemia was 19 counts per minute. Serum counting is simpler than the Schilling test and may be done alone when the patient's renal function is known to be poor, when urine collection is expected to be unreliable, or when the flushing dose of vitamin B(12) should be avoided. Otherwise there is an advantage in doing both tests together for confirmation.

Determination of vitamin B 12 absorption by a simple whole body counter.

This paper reports the results of estimating vitamin B(12) absorption by whole body counting in patients without known gastrointestinal disorder, and in patients with pernicious anaemia, idiopathic achlorhydria, achlorhydria following gastric operations, and various forms of small intestinal disease. Patients with pernicious anaemia absorbed less than 30% of the test dose; they could be distinguished from patients without gastrointestinal abnormality and from most achlorhydric patients who secreted more than 300 mg units of intrinsic factor in the post-histamine hour. Nevertheless, the wide range of normal absorption and the variable absorption from the normal gastrointestinal tract is emphasized and discussed. There is no relation between histamine-stimulated intrinsic factor production and vitamin B(12) absorption in patients with small intestinal disease.

Studies on the 57Co vitamin B12 plasma level absorption test.

Results of the (57)Co vitamin B(12) plasma level absorption test are described in 163 patients. The use of intramuscular carbachol with the test and the presence or absence of current vitamin B(12) therapy did not affect the test results. Injection of 1,000 mug of unlabelled vitamin B(12) during the test augmented plasma levels in patients with normal absorption but tests without this injection gave satisfactory differentiation between the normal and malabsorption ranges. Results from patients having had a gastrectomy, ileal resection, or a past history of adult coeliac disease are also described. Amongst patients with presumed Addisonian pernicious anaemia, two with unresolved equivocal results and three with falsely normal results were found. The significance of these is discussed.

An assessment of serum 57Co cyanocobalamin as an index of vitamin B12 absorption.

A technique has been developed for accurately assaying serum and urine (57)Co cyanocobalamin during the conventional Schilling test. Serum and urine radioactivity in a large number of patients has been correlated and the precise normal limits have been determined by statistical analysis. The implications of this for investigating conditions other than pernicious anaemia and the malabsorption syndromes are stressed.

Vitamin B12 absorption in some neurological and neuroendocrine disorders.

An assessment of vitamin B(12) absorption in neurological patients has been made by both serum and urine counting of (57)Co cyanocobalamin during the conventional Schilling test. Although patients with pernicious anaemia, some with subacute combined degeneration of the cord, have been studied, emphasis in the discussion is placed on the significantly increased excretion of the radioactive vitamin in a group of patients with pituitary insufficiency. Results are also given for epileptic patients who have developed folate deficiency (as assessed by serum folate levels) coincidental with anticonvulsant therapy, as well as for some patients who have had neurological symptoms or signs following partial gastrectomy operations.

The value of sham-feeding tests in patients with postgastrectomy syndromes.

OBJECTIVE: The value of gastric secretory testing in surgical practice has been questioned. Sham feeding (SF) is a test of gastric secretion that determines the status of gastric vagal innervation or incomplete vagotomy. Our purpose was to show that the results of SF tests affect operative strategy and/or clinical management. DESIGN: The medical records of 30 consecutive patients studied with SF in our laboratory were reviewed to determine if patient management was affected by the results of SF. PATIENTS: All 30 patients had prior vagotomies. Sham feeding was performed in patients (1) before planned reoperation for postgastrectomy syndromes (n = 17), (2) with peptic ulcerations/pain of unclear etiology (n = 8), or (3) postoperatively in those who were at high risk for recurrent ulcer (n = 5). RESULTS: Sham feeding indicated complete vagotomy in 16 patients and incomplete vagotomy in 14 patients. In 17 patients studied before planned reoperation, operative strategy was affected by results of SF in 15 cases; five patients had revagotomies performed at reoperation, 11 did not, and one patient had her operation canceled. In patients with atypical postoperative ulcers/pain, management was changed in only two of eight patients. In the high-risk patients studied postoperatively, management was affected in four of five patients. CONCLUSIONS: (1) We believe that our results justify the performance of SF before any reoperation on the stomach, since an operative plan was nearly always affected. (2) In patients with atypical peptic complaints after gastric surgery, SF usually (80%) confirmed acid hypersecretion, thereby affecting management less often. (3) Although unproved, we believe SF results can guide the use of "prophylactic" H2-blockers in treating selected high-risk postgastrectomy patients.

Correlation between lowered PgE2 levels and alkaline reflux gastritis in patients subjected to Billroth II. Pylorogastrectomy: possible improvement with sulglycotide.

In patients subjected to pylorogastrectomy with anterior gastroenterostomy (Billroth's operation II) the remaining gastric mucosa is exposed to the damaging action of bile with consequent reduction of locally generated prostaglandins. The purpose of the present study was to explore the correlation between PgE2 levels in such postgastrectomy patients before and after treatment with sulglycotide. Twelve patients with clinical, endoscopic and histological evidence of alkaline reflux gastritis were treated with sulglycotide in daily doses of 1600 mg for 30 days. At termination there was a definite clinical, endoscopic and histological improvement with significant (p less than 0.001) increase of PgE2 levels.

[Metabolic disorders in the gastrectomized patient]. / Estudio de los trastornos metabólicos en el enfermo gastrectomizado.

The present study attempts on one hand to study the metabolic disorders which may present themselves in the gastrectomized patient, such as the malabsorption of fat, vitamin B12, folic acid and iron as well as the possible correlation between steatorrhea and the presence of exocrine pancreatic insufficiency. For this purpose a group of 71 patients have been studied who have undergone a subtotal gastrectomy (70.42%) or total (29.58%) in the General Surgery Services of Elche. The results obtained show the presence of ferropenic or megaloblastic anemia in 61.97% of the group, serious steatorrhea in only 3 patients (4.22%) and calciumphosphorous metabolism alterations appeared in 21.13%. With this we conclude that anemia is the most frequent ferropenic alteration in the gastrectomy patient; steatorrhea does not seem to be produced exclusively by the presence of exocrine pancreatic insufficiency and bone alterations in the gastrectomized patient appear in an insidious manner, being more a question of biochemical alterations than actual clinical lesions.

[The late complications and nutritional follow-up in 96 patients who underwent a total gastrectomy]. / Complicanze tardive e follow-up nutrizionale in 96 pazienti sottoposti a gastrectomia totale.

Clinical and nutritional follow-up was performed in 96 patients who had undergone total gastrectomy. We studied the incidence of clinical complications and alterations of nutritional parameters in those patients who had undergone curative resection and were alive and free of neoplastic disease 1 year (36 patients) and 2 years (26 patients) after operation. We observed a very low incidence of late complications, and nutritional parameters, 1 year and 2 years after operation, were normal in almost all the patients. We obtained these results because we performed a Roux en Y esophagojejunostomy using an at least 60 cm-loop; we also adopted a strict and rigorous follow-up, able to guarantee an adequate daily calorie intake. In fact, a close relationship between calorie intake and the variations of nutritional parameters was observed.

Gastrointestinal disease: nutritional implications.

The management of patients with gastrointestinal disease must include attention to nutritional status. It has been documented that morbidity and mortality previously considered common in these patients can be reduced significantly. Perhaps the largest contribution that advances in nutritional support have made is the reduction in the frequency of surgical intervention. Remission of inflammatory bowel disease, closure of fistulas, intestinal adaptation, and prevention of malnutrition in complicated pancreatitis with the use of nutritional therapies help to avoid the complications of operative procedures.

[Study of postgastrectomy fatty liver].

Fatty liver was often found concomitantly by the ultrasound during the follow up study of the gastric cancer operation. By ultrasound, development of postgastrectomy fatty liver was seen in 29 out of 176 patients (16.5%) with several gastrectomies. The number of the patients with postgastrectomy fatty liver was 12 out of 104 patients (11.5%) with distal partial gastrectomy with B-I reconstruction, while that was 17 of 72 patients (23.6%) with total gastrectomy with several reconstructions. The incidence of postoperative fatty liver change was significantly higher in the patients under 59 years old compared to the elders. Seventy-five g oral glucose test induced oxyhyperglycemia and hyperinsulinemia in patients with gastrectomy, especially with total gastrectomy. Integrated plasma insulin and triglyceride responses during first one hour in postgastrectomy patients were significantly higher than preoperative values. Moreover, plasma insulin and blood sugar in response to oral glucose test were significantly higher in patients with postgastrectomy fatty liver, compared to those in patients without fatty liver. These results suggested that the postgastrectomy fatty liver was resulted from the abnormality of the glucose metabolism.

[Bone disorder after gastrectomy--clinical & experimental studies].

To study the pathophysiology of bone disorder after gastrectomy, 320 patients and 40 Wistar male rats were used. Clinically, patients who had received gastrectomy 1-15 years previously, were examined for skeletal symptoms, serum biochemistry, microdensitometry of second metacarpal bone, and 20 of them were then studied in a calcium infusion test. Using microdensitometry, abnormality of bone metabolism was observed in 38% of the patients. In severe cases, a significant decrease of serum Ca. and increase of alkaline phosphatase were observed (p less than 0.05), 65% complained of joint pain. In the calcium infusion test, severe cases showed a low urinary excretion of Ca, like osteomalacia, and unlike osteoporosis. Experimentally, body weight & amount of food intake decreased and fatty diarrhea was observed in rats after total gastrectomy. Skeletal changes including thinning of the cortex, loss of medullary trabeculation & decrease of bone ash and biochemical changes such as low serum Ca. 25(OH)D3, 24, 25(OH)2D3 and high iPTH levels were observed. Also the bone formation rate was lower than control as detected by tetracycline double labelling method. As low food intake & fatty diarrhea after gastrectomy which result in Ca. & vit. D insufficiency may be the major etiology of bone disorder.

[Desferal test study of the iron reserves of the body in chronic digestive organ diseases]. / Izuchenie zapasov zheleza v organizme bol'nykh khronicheskimi zabolevaniiami organov pishchevareniia s pomoshch'iu desferalovogo testa.

In 73 patients suffering from diverse chronic affections of digestive organs the possibility of using desferal--a new complexion--for determining iron reserves in the organism was studied. The obtained data bear proof to the existence of a direct relationship between the renal excretion of iron following introduction of desferol, localization of the pathological process and the severity of the disease. The profoundest changes in the iron metabolism were noted in the organism of patients with an extensive resection of the small intestine in their past and in those with chronic enterocolities of the III degree of severity. Thus, desferal test may be recommended for studying iron reserves in the organism of patients with chronic affections of the digestive organs.

[The enterochromaffin-serotonin system and Helicobacter infection in the mechanisms of the staged development of peptic ulcer]. / Enterokhromafinno-serotoninova systema i khelikobaktriina infektsiia v mekhanizmakh stadiinoho rozvytku vyrazkovoï khvoroby.

Submitted in this article are scientific propositions and problems concerning the way ulcer disease (UD) of the gastroduodenal system (GDS) develops through its particular stages, and pathosanogenous role which the enterochromaffin-serotonin system (ECSS), a part of the diffusive neuroendocrine APUD-system of the organism, has in it, along with etiopathogenetic role Helicobacter infection plays in the gastroduodenal mucosa (M). Experience gained by the authors with prospective comprehensive evaluation and treatment of 310 patients with chronic gastroduodenitis (CGD), 198 UD GDS patients and 350 of those surgical patients who had undergone resection of the stomach for complicated UD GDS, indicates that all above pathological states share common etiopathogenetic, clinical, histomorphological and microbiological (Helicobacter infection) features, which facts suggest a common pathomorphogenesis of CGD, erosive GD, UD GDS and postgastroresectional UD, and a staged character of erosive-ulcerous transformation in the GDS M, with the hypercoagulative sings being present at the level of hemomicrocirculation. Progressing structural and functional changes in ECSS parallel to stages of development and severity of the UD GDS course suggest their interrelationship to pathosanogenesis during all stages of erosive-ulcerous transformation. At the molecular level, this may reflect directly the course of staged ulceration and a point of activation of processes of physiological defence, this being of diagnostic as well as prognostic value. The enterochromaffin-serotonin conception of pathosanogenesis of staged erosive-ulcerous transformation in GDS M supplements, rather than contradicts to a current infectious Helicobacter hypothesis of ulcerogenesis. Thus, evaluation of ECSS structural and functional status in UD GDS is to be part of a diagnostic algorithm testing severity of the course as well as of a monitoring of treatment and prognostication.