Vitamin B-12 deficiency after gastric surgery for obesity.

Low serum vitamin B-12 concentrations after gastric bypass (GB) surgery for obesity were observed in 11 of 28 patients without detectable impairment of crystalline vitamin B-12 absorption. This was observed in 2 of 19 patients with vertical banded gastroplasty (VBG). In contrast, protein-bound vitamin B-12 absorption was markedly impaired, as demonstrated in eight of these patients after GB (n = 7) and VBG (n = 1). Correction of this impaired absorption occurred when protein-bound vitamin B-12 was incubated with an enzyme mixture before consumption. Simultaneous ingestion of the enzyme mixture with protein-bound vitamin B-12 did not improve absorption of the vitamin. In a separate experiment, 10 patients with a normal result from the Schilling test failed to correct low serum vitamin B-12 concentrations with a quantity of oral crystalline vitamin B-12 equal to the recommended dietary allowance of 2 micrograms, taken twice daily for 3 mo. Serum total homocysteine values declined during this interval. An oral daily dose of 350 micrograms crystalline vitamin B-12 raised the average serum vitamin B-12 concentration to an amount greater than the lower reference limit. A dose > 350 micrograms/d was required to raise all patients' vitamin B-12 concentrations above this concentration rather than just above the population mean. We conclude that because concentrations of oral crystalline vitamin B-12 were required to normalize serum vitamin B-12 concentrations, that a mechanism other than formation of a vitamin B-12 intrinsic factor complex is responsible for crystalline vitamin B-12 absorption after GB for obesity.

Iron absorption and therapy after gastric bypass.

BACKGROUND: Iron deficiency anemia is a common complication of gastric bypass. The authors assessed the value of taking vitamin C with oral iron in correcting deficiencies in iron stores and anemia postoperatively. MATERIALS AND METHODS: Iron absorption tests were performed on 55 patients 3.2+/-2.0 years after isolated gastric bypass to identify those at higher risk for the late development of anemia. Twenty-nine of this group agreed to a therapeutic trial of iron alone or with vitamin C over a 2-month period. All 55 patients were followed up for 27.1+/-1.0 months following the study. RESULTS: The iron absorption test identified patients with low iron stores, as indicated by low serum ferritin, and those with sufficient absorption surface to benefit from oral iron. The addition of vitamin C appears to enhance the therapeutic effect of iron by correcting ferritin deficits (P < 0.01) and anemia (P < 0.05). Differences in intestine length bypassed by the operation (10 vs. 100 cm) did not affect late ferritin and hemoglobin values. CONCLUSION: This study suggests but does not prove that the addition of vitamin C to iron therapy after gastric bypass is more effective in restoring ferritin and hemoglobin than iron alone. These results are in contrast with the outcome 22.8 months later, when approximately 50% of study patients were again anemic. Closer follow-up of patients is urgently needed.

The delayed hypersensitivity response: application in clinical surgery.

Delayed hypersensitivity skin testing was performed on 520 surgical patients. Significantly higher incidences of sepsis and mortality (p less than 0.001) were found in the abnormal patients as compared to normal responders in the preoperative (322 patients), postoperative and post-trauma (115 patients), and nonoperative (83 patients) groups. Sequential testing in individual patients was of even greater prognostic value. Of the 177 patients who either remained normal or whose responses became normal, the sepsis rate was 10.1%, and the mortality rate was 8.4%. However, a sepsis rate of 57.6% and a 78% mortality rate were found in those patients who developed abnormal responses or whose responses did not improve. Cancer and increased age (older than 80 years) did not account for the incidence of anergy and relative anergy. The mortality rate was higher in the cancer group. Anergy and relative anergy were found to be associated with malnutrition, sepsis, shock, and trauma. In the clinical setting, effective treatment of these associated conditions, especially the maintenance of body cell mass by the use of total parenteral nutrition, was associated with reversal of the anergic state and an improved prognosis.

Late results of vertical banded gastroplasty for morbid and super obesity.

Two hundred one patients who underwent vertical banded gastroplasty have been followed up for a minimum of 2 years to more than 5 years. Staple line perforations occurred in 48% of patients, and 36% underwent reoperation. The instability of the operation becomes apparent only with careful follow-up. More than 50% of patients who maintained a small orifice of less than or equal to 11 mm in diameter and an intact staple line over 3 to 5 years achieved an excellent result (0% to 25% excess weight), which equals the best results in the literature for any gastric-limiting operation, whether bypass or gastroplasty. The results of this operation for super obesity (a body mass index greater than or equal to 50 kg/m2) are disappointing. Only 8% of these patients achieve an excellent result. Failure of vertical banded gastroplasty in the morbidly obese (body mass index of 40 to 50 kg/m2) is frequently technical, and a method that eliminates dependence on integrity of staples should be evaluated. Results should be reported so that unsatisfactory results are apparent. Mean weight loss and mean percent excess weight loss are both highly satisfactory in this study, whereas unsatisfactory results ranged from 10% to 21% for each of the 5 years of follow-up.

A gastroplasty that avoids stapling in continuity.

BACKGROUND: Staple line perforations have been the principal cause of failure after vertical-banded gastroplasty in patients followed at least 4 years at our institution. In the present study an operation was devised that created a vertical-banded gastroplasty not dependent on staple lines to avoid this complication. METHODS: One hundred two patients with a body mass index (BMI) greater than 35 kg/m2 underwent vertical-banded gastroplasty from Jan. 1 to Dec. 30, 1986, with an orifice size of 45 to 47 mm external circumference and division between the vertical staple lines to prevent gastric pouch to gastric fundus fistula. RESULTS: Ninety-eight of the patients have been followed up for a minimum of 4 years. Sixty-two percent of patients obtained an excellent or good final result after 4.5 +/- 0.1 years. This was a BMI of less than 35 kg/m2 or less than 50% excess weight. This acceptable long-term result was achieved 90% of the time if the patient was obese (BMI, 35 to 40 kg/m2) before surgery and in 75% of patients who were morbidly obese (BMI, 40 to 50 kg/m2) but in only 30% of patients who were superobese (BMI > 50 kg/m2) before surgery. Staple line disruption was markedly reduced; however, stenosis or failure to lose weight or late weight gain required reoperation in 36% of the patients. CONCLUSIONS: Gastric bypass was superior to reversal or revision of the gastroplasty as a remedial operation. This study again questions the value of vertical-banded gastroplasty in the treatment of obesity even when staple line disruption is markedly diminished.

Antibiotic prophylaxis for surgery in morbidly obese patients.

The rate of wound infections in morbidly obese patients who underwent gastroplasty surgery at our institution was 16.5% compared with a rate of 2.5% in normal-weight patients who underwent clean-contaminated surgery. Both groups received 1 gm of cefazolin intramuscularly before surgery was performed. We hypothesized that this regimen of prophylaxis did not provide adequate tissue levels in the morbidly obese. Morbidly obese patients who were undergoing gastroplasty were randomly selected to receive 1 gm cefazolin in the buttock fat, buttock muscle, or by intravenous injection. A fourth group of morbidly obese patients received 2 gm of cefazolin intravenously. Normal-weight patients who were undergoing upper abdominal surgery received 1 gm of cefazolin intravenously. At incision and closure, both blood and tissue levels of cefazolin were significantly (p less than 0.001) lower for all morbidly obese patients who received 1 gm cefazolin when compared with the blood and tissue levels of the drug found in normal-weight patients. The cefazolin levels obtained were below the minimal inhibitory concentrations of greater than 2 micrograms/ml for gram-positive cocci and of greater than 4 micrograms/ml for gram-negative rods. Only when the morbidly obese patient received 2 gm cefazolin were both the serum and adipose tissue levels adequate. For a 4-month period, all morbidly obese patients received 2 gm cefazolin prophylaxis, and the wound infection rate dropped to 5.6% compared with the previous rate of 16.5% (p less than 0.03). We conclude that antibiotic prophylaxis must be specially tailored to the needs of these obese patients.

Assessment of cardiac function in patients who were morbidly obese.

Cardiac function of 30 patients who were morbidly obese was studied before bariatric surgery. Twelve patients were studied 13 +/- 4 months after surgery. These patients had a mean age of 37.1 +/- 2.9 years and a body mass index of 50.0 +/- 1.4 kg/m2. Cardiac function was measured by echocardiography, radionuclide angiography scanning, and right heart catheterization. To determine the degree of cardiac dysfunction, the patients were studied with exercise and intravenous fluid challenges. Ultrasonography produced evidence of myocardial thickening with an increased interventricular septum in eight patients (32%) and increased left ventricular mass in 17 patients (53%). The radionuclide scan suggested that morbid obesity was associated with a significantly (p less than 0.05) increased end-diastolic volume and decreased left ventricular ejection fraction as compared with patients who were of normal weight. With exercise the patient who was of normal weight had an increase in the end-diastolic volume, stroke volume, and heart rate, but the patient who was morbidly obese only increased heart rate to produce the necessary increase in cardiac output. Right heart catheterization indicated that the relationship of the pulmonary wedge pressure and the left ventricular stroke work index was abnormal in 14 of 29 patients (48.3%) and depressed in six of 29 patients (20.7%) with exercise. One liter of fluid caused an abnormal relationship of the pulmonary wedge pressure and the left ventricular stroke work index in 12 of 30 patients (40%) and a depressed response in 10 of 30 patients (33.3%). Cardiac studies were repeated in 12 patients after a 54.8 +/- 1.9 kg weight loss. Echocardiography indicated a decrease in dilatation (27.3% to 9.1%) and a significant (p less than 0.05) decrease in hypertrophy (45.5% to 0%). After the weight loss, radionuclide and right heart catheterization studies indicated improved cardiac function with reduced filling pressures and increased left ventricular work during fluid and exercise challenges. These results support the presence of obesity-related cardiomyopathy with ventricular dysfunction, which appears to be caused by a noncompliant ventricle. Significant weight loss achieved with gastroplasty results in increased ventricular compliance and improved cardiac function.

Protein malnutrition following intestinal bypass for morbid obesity.

Intestinal bypass surgery, performed for weight reduction in the morbidly obese patient, is frequently complicated by the development and hepatic complications. In 44 morbidly obese individuals, 55 inches of proximal jejunum were anastomosed, end to side, to 5 inches of distal ileum. All the patients were followed with body composition measurements, performed by multiple isotope dilution, prior to and at regular time intervals following bypass surgery. In 33 patients a decrease in body fat accounted for the entire postbypass weight loss, while the lean body mass remained normal in both size and composition. In these patients, at 1 year, body weights had decreased by 24.4 +/- 2.1%, while the body cell masses had decreased by 2.1 +/- 7.1%. In the remaining 11 patients, the postbypass weight loss resulted from a loss of both body fat and body cell mass. Their body weights at 1 year had decreased by 27.0 +/- 3.0%, while the body fat and body cell mass. Their body weights at 1 year had decreased by 27.0 +/- 3.0%, while the body cell masses decreased by 22.0 +/- 6.1%. Furthermore, their body compositions were characteristic of protein malnutrition with a contracted body cell mass and an expanded extracellular mass. Six of these 11 patients have required admission to hospital on 10 occasions because of malaise, anorexia, debilitating weakness, hypokalemia, and abnormal liver function. They were treated for 14.5 +/- 1.9 days with an intravenous infusion of amino acids without additional nonprotein calories. The body composition, initially characteristic of malnutrition, became normal. Their symptoms disappeared and hepatic function returned to normal. Subsequently a high-protein diet was required to prevent a recurrence of symptoms and to maintain a normal body composition. The data indicate that protein malnutrition developed in 11 of 44 patients undergoing jejunoileal bypass for weight reduction.

Protein and fat utilization in shock.

A previous study demonstrated that in the dog, shock, regardless of its etiology, resulted in increased oxidative utilization of substrates which form lactate and pyruvate as intermediary metabolites. The study implied a concomitant decrease in free fatty acid oxidation, as the oxidative pathway of the latter does not involve the lactate-pyruvate step. To test this hypothesis, free fatty acid metabolism was investigated by infusing carbon-14 labelled fatty acid in 12 normal dogs, in nine animals in shock due to controlled cardiac tamponade, and in six animals with endotoxin shock. The shock state was characterized by significant (p less than 0.05) decrease both in arterial fatty acid concentration and in free fatty acid turnover. In addition, both the rate of free fatty acid oxidation and the percentage of the total CO2 derived from free fatty acid oxidation were significantly (p less than 0.05) diminished. In contrast, urea production rates were higher in shock, and the calculated maximum contribution of protein oxidation to total CO2 production rose from 23% in the control animals to 50% in the test groups.

Alterations in body composition following intestinal bypass for morbid obesity.

The efficacy of the jejunolieal bypass operation, performed as a weight-reducing procedure in the morbidly obese patient, was assessed by measurements of body composition. In 20 patients measurements were performed by multiple isotope dilution, before and following jejunoileal bypass. Prior to bypass the excess body weight was due primarily to an increase in body fat (BF), which accounted for 52 percent of body weight. The nonfatty component of body composition, the lean body mass, although slightly increased in size, was essentially normal. Two distinct patterns were observed following bypass. In 12 patients followed for 8.4 +/- 1.5 months, there was a 21 percent decrease in body weight, resulting entirely from a loss of BF. The total exchangeable potassium and intracellular water volume, both measures of the body cell mass (BCM), were unchanged. In the second group of eight patients followed for 13.9 +/- 2.1 months, the mean body weight decreased by 27 percent or 38.8 Kg., due to a 26.6 Kg. reduction in BF and a 13.0 Kg. decrease in the BDM. This was accompanied by a relative expansion of the extracellular mass. As a result, the mean Nae/Ke ratio increased significantly (p less than 0.05) from a normal prebypass value of 0.95 +/- 0.7 to 1.46 +/- 0.11 following bypass. Thus in eight of the 20 patients following jejunoileal bypass, there was an undesirable loss of BCM with a relative expansion of extracellular supporting component of body composition, a pattern characteristic of malnutrition.

Massive spontaneous portal-systemic shunting without varices.

Using umbilical vein portal phlebography, a group of patients, often with previously unsuspected liver disease or portal hypertension, have been identified with massive spontaneous portal-systemic shunts. In all cases, the collateral circulation was a single large vessel. The splenoadrenorenal, umbilical vein, or inferior mesenteric vein routes were the common pathways. These natural shunts were functional and effective in the alleviation of portal hypertension without evidence of esophageal varices or other collaterals. Portal flow was usually retrograde, perhaps contributing to the small atrophic liver seen in all patients. Six such patients were seen in the last 40 studied. This phenomenon may be more common than suspected in the cirrhotic population and account in part for differences in natural history, complications, and results of surgical therapy.

Reliability of skin testing as a measure of nutritional state.

The reliability of skin testing to assess the nutritional state was evaluated in 257 patients who received total parenteral nutrition (TPN). The nutritional state was assessed by determining body composition, by multiple-isotope dilution. Immunocompetence was simultaneously evaluated by skin testing with five recall antigens. These measurements were carried out before and at two-week intervals during TPN. A statistically significant relationship existed between the response to skin testing and the nutritional state. A body composition consistent with malnutrition was present in the anergic patients, while body composition was normal in the patients who reacted normally to skin testing. However, a considerable overlap existed as 43% of the reactive patients were malnourished, and 21% of the anergic patients were normally nourished. Thirty-seven (43%) of the 86 anergic patients converted and became reactive during TPN, and their body composition improved significantly. The remaining 49 anergic patients (57%) did not convert, and their body composition did not change despite similar nutritional support. The principal difference between the two groups of anergic patients was the nature of the therapy administered. In the anergic patients who converted, therapy was aggressive and appropriate, and clinical improvement occurred in 23 (62.2%) of the patients, with a mortality of 5.4%. In the 49 patients who remained anergic, therapy was often inappropriate or unsuccessful, with clinical improvement in only three (6.1%) of the patients and a mortality of 42.8%. The data demonstrated a significant relationship between the response to skin testing and the nutritional state. However, because of the wide overlap, skin testing does not accurately assess a person's nutritional state. The persistence of the anergic state is indicative of a lack of response to therapy.

Norman Bethune and Edward Archibald: sung and unsung heroes.

Edward Archibald was a pioneer, master thoracic surgeon. He laid the foundation for surgical research in Canada and made fundamental contributions to the training and certification of surgeons. He did it all without raising his voice and within the confines of organized medicine. He became an unsung hero. Norman Bethune, with a flair for publicity, used extraordinary measures and delivered them heroically with talent and total dedication, ignoring conventional approaches. He became a truly sung hero.

Stomal ulcer after gastric bypass.

BACKGROUND: Stomal ulcer is a serious complication of gastrogastric fistula following Roux-en-Y gastric bypass for obesity. STUDY DESIGN: A 1-8 year continuous followup of 499 patients with gastric bypass in continuity (GB) and isolated gastric bypass (IGB) documented the incidence of fistula formation, development of stomal ulcer, stimulation of acid production within the gastric pouch, and response to treatment. RESULTS: In 123 GB patients, staple line disruption occurred in 36 (29%) and stomal ulcer occurred in 20 (16%). Gastrogastric fistula with stomal ulcer was significantly lower in 376 patients who underwent IGB, (ie, 11 patients [3%]). Significantly larger amounts of acid, a lower pH, and a greater time with a pH less than 2 were found in the gastric pouches of patients who developed stomal ulcer after Roux-en-Y gastric bypass. All patients had a perforated staple line. Successful closure of the staple line significantly decreased acid production and pH in the gastric pouch when tested before and after remedial operation with healing of stomal ulcers. CONCLUSIONS: Stomal ulcer after gastric bypass is the result of acid production in the bypassed stomach in the presence of a gastrogastric fistula. Separation of the gastric pouch from the main stomach decreases the incidence of fistula formation and stomal ulcer but does not eliminate it. Interposition of a well vascularized organ, the jejunum between the pouch and main stomach, is an attractive solution for patients who require remedial operations on the stomach and possibly for primary operations as well.

Abnormalities in the cellular phase of blood fibrinolytic activity in systemic lupus erythematosus and in venous thromboembolism.

Fibrinolytic activities of whole blood and plasma were determined by 125I-fibrin radiometric assay in 16 normal subjects, and in 11 patients with systemic lupus erythematosus (SLE), 14 with progressive systemic sclerosis (PSS), 23 with venous thromboembolic disease, and 20 patients awaiting elective surgery. Mean whole blood and plasma activities for patients with PSS, and for those awaiting elective surgery, were similar to normal values, as was the mean plasma activity in patients with SLE. However, mean whole blood activity in SLE was significantly decreased compared with normals (p less than 0.05), with mean plasma activity accounting for 44% of mean whole blood activity (compared with 17% in normal subjects), representing a 67% decrease in mean calculated cellular phase activity in SLE, when compared with normals. Since the numbers of cells (neutrophils, monocytes) possibly involved in cellular activity were not decreased, the findings suggest a functional defect in fibrinolytic activity of one or more blood cell types in SLE. An additional finding was the participation of the cellular phase as well as the well-known plasma phase of blood in the fibrinolytic response to thromboembolism.

Long- or short-limb gastric bypass?

The aim of this study was to determine whether longer limb length improved results of gastric bypass in patients who were morbidly obese (body mass index <50 kg/m(2)) or superobese (body mass index >50 kg/m(2). A total of 242 patients were followed for a mean of 5.5 years. The standard operation was a Roux-en-Y gastric bypass with a 40 cm Roux limb and a 10 cm afferent limb. The long-limb operation had a 100 cm Roux limb and a 100 cm afferent limb. Morbidly obese patients did not benefit from a long-limb bypass. The final body mass index was 28.6 +/- 4.7 kg/m(2) in the short-limb group and 28.5 +/- 3.8 kg/m(2) in the long-limb group. The superobese patients did benefit from a long-limb bypass. Final body mass index was 35.8 +/- 6.7 kg/m(2) in the short-limb patients and 32.7 +/- 5.1 in the long-limb patients (P = 0.049). A subgroup of 20 patients, all of whom had a body mass index greater than 60 kg/m(2), benefited the most from long-limb bypass. No macronutritional side effects unique to the long-limb bypass were encountered.

Results of the surgical treatment of obesity.

A prospective, randomized trial comparing vertical banded gastroplasty (VBG) and vertical gastric bypass (GB) for obesity was completed in 106 patients who did not differ in baseline body mass index (BMI = kg/m2) or length of follow-up. The goal of this surgery was to return patients to within 50% of their ideal weight, i.e., a body mass index less than 35 kg/m2, and to accomplish this while maintaining a low risk for malnutrition as well as other morbidity and mortality. Success was defined as a BMI less than 35 kg/m2 because the mortality risk increases rapidly above this degree of obesity. Surgical failures were encountered in 43% of the 54 patients in the VBG group, all of whom had division between the vertical staple lines. The main causes of failure were stenosis and enlargement of the gastroplasty orifice. Surgery failed in 23% of the GB-treated patients, due to perforation of the vertical staple line. An isolated gastric bypass (IGB) not dependent on staples was performed as the remedial operation for the failures of both VBG and GB. IGB was significantly better than VBG or GB, with a success rate of 83% compared with 39% for VBG and 58% for GB. Subsequent experience since completion of this randomized trial in 54 consecutive patients supports IGB for primary, as well as remedial, operations for the morbidly obese (BMI = 40 to 50 kg/m2), as well as for patients who are super obese (BMI greater than 50 kg/m2).

Comparison of effect of narcotic and epidural analgesia on postoperative respiratory function.

A prospective, randomized comparison was made of the value of meperidine versus epidural analgesia when used for the relief of pain after cholecystectomy in twenty patients without cardiopulmonary disease. Respiratory function was assessed the day before surgery and at 3 to 4 hours and 24 hours after operation by the bedside measurement of expiratory peak flow, vital capacity, and arterial blood gases. The two groups of patients were comparable as to age, height, weight, smoking habits, preoperative peak flow, vital capacity, and duration of operation. The arterial oxygen tension and oxygen saturation were significantly greater and carbon dioxide tension lower in the epidural analgesia group 24 hours after operation. At this time peak flow rates and vital capacity were not different. However, at 3 to 4 hours postoperatively, vital capacity was significantly greater in the epidural anesthesia group. This might account for the differences in arterial blood gases the following day. These findings suggest that epidural analgesia is valuable in the early postoperative period after upper abdominal surgery.