Vertical gastroplasty for morbid obesity: clinical experience.

Our objective was to develop an operation for morbid obesity that would be simple, safe, and effective and yet have few long-term adverse physiologic effects. Vertical gastroplasty was chosen. A small proximal gastric pouch was fashioned by stapling vertically beginning 5 cm distal to the cardia along the lesser curvature of the stomach and ending just lateral to the esophagogastric junction along the greater curvature. A 1.1-cm channel through the staple line was left near the lesser curvature of the stomach. No gastric incisions, enterostomies, or anastomoses were necessary. Among 57 patients (with a mean +/- SEM preoperative weight of 136 +/- 4.5 kg) operated on since January 1981, no deaths occurred and no gastric reoperations were done. The hospital stay was short (mean, 9 days). In 32 patients who were followed up for 1 year or longer, the mean percentage of excess weight lost was 39% at 6 months, 43% at 12 months, and 34% at 24 months. Two patients had disruption of the staple line and regained weight by 24 months postoperatively. Channel stenosis occurred within 6 months after operation in seven patients, all of whom were managed successfully with endoscopic dilation. We conclude that vertical gastroplasty is a simple, safe operation for morbid obesity with few adverse sequelae, but the percentage of excess weight lost during a 1- to 4-year follow-up exceeded 50% in only 31% of our patients.

Postoperative gastroparesis and tachygastria--response to electric stimulation and erythromycin.

BACKGROUND: The purpose of this study was to correlate clinical course, gastric emptying, and gastric myoelectric activity in a patient after gastric operation and to determine the effect of electric stimulation and the administration of erythromycin on the patient's gastric rhythm. METHODS: Daily myoelectric recordings were obtained through implanted gastric electrodes after truncal vagotomy and gastroenterostomy for an obstructing duodenal ulcer. RESULTS: The patient had acute postoperative delayed gastric emptying, accompanied initially by stomal edema but subsequently associated with persistent tachygastria. The gastric rhythm was only transiently slowed by multiple attempts at electroversion but appeared to respond dramatically to intravenous erythromycin therapy. Although delayed gastric emptying persisted on radionuclide gastric emptying studies, the patient slowly improved clinically with continued erythromycin therapy. CONCLUSIONS: Disturbances in gastric rhythm may accompany postoperative gastroparesis, although in our patient the dysrhythmias appeared to occur secondary to gastric outlet obstruction. Although his stomach could be paced, pacing was not effective in restoring a normal gastric rhythm. In contrast, intravenous erythromycin therapy was associated with rapid restoration of a normal gastric rhythm and slow improvement in gastric function.

Myoelectric effects and histology after stapled occlusion of the small bowel.

Braun enteroenterostomy with stapled occlusion of the afferent limb has been advocated to treat bile gastritis and to avoid the motility effects of Roux-en-Y gastrojejunostomy. However, the motility effects of stapled occlusion are unknown. Myoelectric activity and histologic features were studied after stapled occlusion of the small bowel in a canine model. A 35 cm "recirculating loop" was created with a side-to-side anastomosis, beginning 25 cm from the ligament of Treitz. Serosal electrodes were placed at 5 cm intervals on the loop; at a second operation in one dog and simultaneously in three dogs, the bowel was occluded midway between two electrodes with 4.8 mm staples. Fasting recordings were obtained at weekly intervals to 6 months after surgery and were analyzed for slow wave frequency proximal and distal to the staple line and for propagation time of phase 3 of the migrating myoelectric complex across the staple line. The side-to-side anastomosis did not alter myoelectric activity. However, after stapled occlusion of the small bowel, the slow wave frequency dropped from a mean of 18.2 +/- 0.4 cpm proximally to 15.4 +/- 1.0 cpm distally (p less than 0.05). This correlated with loss of myogenic continuity in three of four animals. Propagation of phase 3 slowed across the staple line (115 +/- 27 seconds versus 47 +/- 9 seconds) (p less than 0.02). The bowel lumen recannulated in all animals. Stapling across the small bowel alters myoelectric activity, and occlusion of the bowel lumen may not be permanent.

Antiperistaltic and isoperistaltic intussusception associated with abnormal motility after Roux-en-Y gastric bypass: a case report.

Antiperistaltic and recurrent intussusceptions are extremely rare in the adult. We report a patient with both. The patient developed an antiperistaltic intussusception distal to her Roux enteroenterostomy years after a Roux-en-Y gastric bypass for morbid obesity. The diagnosis was made preoperatively with gastrointestinal contrast radiography and ultrasonography. At surgery, the intussusception was reduced, and 12 inches of nonviable bowel was resected, with a functional end-to-end anastomosis. An isoperistaltic intussusception occurred in the early postoperative period just distal to the anastomosis. Manometric evaluation of the Roux limb after the second operation showed altered gastrointestinal motility, consisting of orad-propagated and aboard-propagated migrating motor complexes, minimal phase 2 activity, and lack of conversion to the fed pattern with a liquid meal. Although manometry was not performed before the development of the intussusception, our findings are consistent with the hypothesis that altered intestinal motility may contribute to the development of intussusception.

Altered motility and bacterial flora after functional end-to-end anastomosis.

The functional end-to-end technique with a gastrointestinal stapler is commonly used for small-bowel anastomosis, but the effects of this anatomically side-to-side anastomosis on motility are unknown. Fasting small-bowel myoelectric activity and culture results were compared in six animals undergoing handsewn end-to-end and functional end-to-end anastomoses. Serosal electrodes were placed at 10 cm intervals, and the small bowel was divided 25 and 55 cm from the ligament of Treitz. The functional end-to-end and end-to-end techniques were performed in each animal in random order. Fasting myoelectric recordings were obtained at weekly intervals for up to 20 weeks after operation. New electrodes were placed, and additional recordings were obtained from 29 to 39 weeks, 51 to 63 weeks, and 108 to 112 weeks after operation. The recordings were visually inspected for passage of phase 3 of the migrating myoelectric complex (MMC). By 12 to 20 weeks after operation, 91% of MMCs crossed the end-to-end anastomoses versus 22% across the functional end-to-end anastomosis (p less than 0.001). Even 2 years after surgery only 56% of MMCs crossed the functional end-to-end anastomosis. Quantitative bacterial cultures suggested a trend toward bacterial overgrowth in the functional end-to-end anastomosis. These results demonstrate that the functional end-to-end anastomosis alters small-bowel motility to a greater degree than an end-to-end anastomosis and may predispose to bacterial overgrowth.

Role of alpha- and beta-calcitonin gene-related peptide in postoperative small bowel ileus.

Ablation of a-calcitonin gene-related polypeptide (CGRP) containing neurons with the afferent neurotoxin capsaicin improves postoperative foregut transit in a rodent model. Similarly, administration of a selective alpha-CGRP antibody or hCGRP((8-37)), a CGRP receptor antagonist, improves postoperative gastric emptying. Unlike the stomach, which contains only alpha-CGRP, the small bowel additionally contains beta-CGRP. The role of the latter in postoperative small bowel transit is unknown. The purpose of this study was to evaluate the effect of an alpha-CGRP antibody and hCGRP((8-37)) on postoperative small bowel transit. Male Sprague-Dawley rats underwent placement of duodenal catheters and were randomly assigned to 1 of 11 groups. Four groups were pretreated with 1% capsaicin. One week later, all animals underwent standardized laparotomy following administration of a control antibody or the alpha-CGRP mono-clonal antibody, or during infusion of hCGRP((8-37)) at varying doses. Small bowel transit was measured 25 minutes postoperatively. The alpha-CGRP antibody sped postoperative transit when given alone or in combination with capsaicin. In contrast, animals treated with hCGRP((8-37)) showed no significant improvement in postoperative transit, and the beneficial effect of capsaicin was blocked. Unlike their similar effects on postoperative gastric emptying, we found that hCGRP((8-37)) and the alpha-CGRP antibody had differing effects on postoperative small bowel transit. The reason for this is unknown but may be related to their differing specificities for alpha- and beta-CGRP.

Long-term response to subtotal colectomy in colonic inertia.

The purpose of this study was to determine the long-term outcome of patients who had previously undergone subtotal colectomy for severe idiopathic constipation at the University of Florida between 1983 and 1987. In addition, we aimed to determine whether preoperative motility abnormalities of the upper gastrointestinal tract are more common among those patients who have significant postoperative complications after subtotal colectomy. We evaluated 13 patients who underwent subtotal colectomy for refractory constipation between 1983 and 1987 at the University of Florida. Preoperatively, all patients exhibited a pattern consistent with colonic inertia as demonstrated by means of radiopaque markers. Each patient was asked to quantitate the pain intensity and frequency of their bowel movements before and after surgery. In seven patients an ileosigmoid anastomosis was performed, whereas in six patients an ileorectal anastomosis was used. Abdominal pain decreased after subtotal colectomy. Patients with abnormal upper gastrointestinal motility preoperatively experienced greater postoperative pain than those with normal motility regardless of the type of anastomosis. In addition, the number of postoperative surgeries was similar in those patients with abnormal upper motility compared to those with normal motility. Overall, the total number of bowel movements per week increased from 0.5 +/- 0.03 preoperatively to 15 +/- 4.5 (P < 0.007) postoperatively. The results of our study suggest that patients with isolated colonic inertia have a better long-term outcome from subtotal colectomy than patients with additional upper gastrointestinal motility abnormalities associated with their colonic inertia.

The effect of Roux-en-Y diversion on gastric and Roux-limb emptying in a rodent model.

BACKGROUND: The "Roux stasis syndrome" is characterized by symptoms of upper gut stasis following Roux-en-Y gastrojejunostomy (RG). Whether symptoms result from delayed gastric emptying, altered Roux-limb transit, or both has never been settled, partly because of the difficulty of measuring Roux-limb transit. The aim of this study was to develop a model to simultaneously quantitate Roux-limb transit and gastric emptying. METHODS: Rats underwent vagotomy and antrectomy with RG or Billroth II reconstruction (B-II). Gastrointestinal transit of a solid meal (Technetium-99m sulfur colloid-labelled egg white) was assessed 0.5, 1, and 1.5 hours postprandial (pp). Transit of a liquid marker (Na51-CrO4 injected through an efferent-limb catheter) was measured at 25 minutes pp. RESULTS: Solid gastric emptying was slower in RG than in B-II rats at 60 and 90 minutes pp. More of the solid meal and of the liquid marker was retained in the Roux limb than the efferent limb of the B-II at all time points (P < 0.05). CONCLUSIONS: In a rodent model, Roux-en-Y gastrojejunostomy is associated with delayed gastric emptying and slowed efferent-limb transit of solids and liquids.

Clinical and radionuclide evaluation of Roux-Y diversion for postgastrectomy dumping.

From 1973 to 1986, 22 patients underwent Roux-Y gastrojejunostomy for the early postgastrectomy dumping syndrome. In the early years, five patients underwent Roux-Y conversion with the addition of a 10 cm antiperistaltic jejunal segment interposed between the Roux-Y limb and the stomach. Within 4 years, all five patients had the jejunal segment removed due to severe symptoms of gastric retention. These patients underwent reconstruction to create Roux-Y limb only and joined the pool of 17 patients who underwent Roux-Y diversion only for the dumping syndrome. Overall, 19 of 22 patients (86 percent) had almost complete resolution of their dumping symptoms on long-term follow-up. Three patients showed no improvement, two with severe gastric retention and one with recurrent dumping symptoms. Overall, 5 of 22 patients (23 percent) had moderate to severe early and late postoperative gastric retention necessitating medical treatment in three and subsequent near-total gastrectomy in two. Although other procedures such as pyloric reconstruction or the addition of isoperistaltic or antiperistaltic jejunal interpositions have been reported to be equally successful in delaying gastric emptying and resolving dumping symptoms, we have preferred Roux-Y diversion for the treatment of combined alkaline reflux gastritis and dumping or the pure early vasomotor postgastrectomy dumping syndrome. As reported, we have abandoned the use of an antiperistaltic jejunal segment interposed between the stomach and the Roux-Y limb due to the high rate of postoperative gastric retention.

Does selective vagotomy prevent delayed gastric emptying and altered myoelectric activity following Roux-en-Y gastrojejunostomy?

Delayed gastric emptying occurs frequently following Roux-en-Y gastrojejunostomy. The role of vagal denervation in the etiology of this "Roux-stasis syndrome" is controversial. This study evaluates the effect of selective vagotomy on gastric emptying and motility following Roux-en-Y. Four dogs underwent control gastric emptying studies. The animals then underwent selective vagotomy, antrectomy, and Billroth II gastrojejunostomy, with placement of serosal electrodes. Gastric emptying was assessed with simultaneous myoelectric recordings, and the animals were converted to Roux-en-Y, followed by repeat studies. Gastric emptying was unchanged following selective vagotomy, antrectomy, and Billroth II gastrojejunostomy (T 1/2: 132 +/- 18 min [SEM] versus 118 +/- 14 min control) but was markedly delayed following Roux-en-Y diversion (T 1/2: 286 +/- 44 min; p less than 0.01). All animals went into the fed pattern following Billroth II gastrojejunostomy (migrating myoelectric complex [MMC] interval: 326 +/- 6 min postprandial versus 92 +/- 5 min fasting; p less than 0.01), but no fed pattern was recognized in three of four animals following Roux-en-Y diversion (MMC interval: 68 +/- 12 min postprandial versus 62 +/- 1.5 min fasting; p = NS). In a canine model, selective vagotomy does not prevent delayed gastric emptying or myoelectric alterations following Roux-en-Y.

Supradiaphragmatic fundoplication. Long-term follow-up and analysis of complications.

Supradiaphragmatic fundoplication has been useful in patients with an acquired short esophagus since the inception of the Nissen technique. Recent reports documenting a large number of life-threatening complications in relatively small groups of patients prompted us to review the records of all patients with supradiaphragmatic fundoplication. Forty-four supradiaphragmatic Nissen fundoplications were performed, with an average follow-up of 42 months. Operative mortality was 7 percent. Acceptable results were obtained in 82 percent (88 percent of patients not lost to follow-up). Poor results were obtained in 5 percent (one patient with scleroderma and one with diaphragmatic hernia). In another 5 percent, postoperative diaphragmatic hernia developed. In two patients, ulceration of the antrum developed that appeared unrelated to the operation. Sixteen patients have been followed for longer than 5 years, with no long-term complications. The wide variation in the incidence of these complications between our patients and those of others is probably related to varying details of operative technique. Supradiaphragmatic fundoplication provides uniformly effective protection against gastroesophageal reflux with an acceptable morbidity and low mortality.

Ketorolac prevents postoperative small intestinal ileus in rats.

The effect of ketorolac, a parenterally administered, nonsteroidal anti-inflammatory drug, was examined in a rat model of postoperative ileus. Small intestinal transit was measured by calculating the geometric center (GC) of distribution of 51CrO4. Laparotomy significantly delayed transit (GC: 2.2 +/- 0.2 after laparotomy versus 5.6 +/- 0.5 for unoperated controls, p < 0.01). The administration of ketorolac (1 mg/kg) improved the GC to 5.2 +/- 0.2 (p < 0.01), indicating normal intestinal transit after surgery in ketorolac-treated animals. Small intestinal myoelectric activity was recorded in rats with implanted electrodes. Animals treated with saline 2 hours postoperatively did not show return of the migrating myoelectric complex (MMC) in 183 +/- 25 minutes. In contrast, rats receiving ketorolac postoperatively had return of MMC activity in 59 +/- 18 minutes (p < 0.01). Preoperative ketorolac treatment reduced the duration of MMC inhibition after surgery from 197 +/- 55 minutes to 13 +/- 5 minutes (p < 0.05) when compared with saline. In summary, ketorolac hastens the return of MMC activity when given postoperatively. When ketorolac is administered preoperatively, it completely prevents the delay in intestinal transit and the inhibition of myoelectric activity seen in postoperative ileus. We concluded that ketorolac may be of benefit in the prevention and treatment of postoperative ileus.

Erythromycin enhances delayed gastric emptying in dogs after Roux-Y antrectomy.

Delayed gastric emptying occurs in up to 50% of patients after truncal vagotomy and Roux-Y antrectomy and is often resistant to nonsurgical therapy. This study evaluates the effect of erythromycin, metoclopramide, and motilin on delayed gastric emptying in four dogs after Roux-Y antrectomy. Solid food gastric emptying was measured using a radionuclide technique. Study groups were: (1) saline control; (2) erythromycin 1 mg/kg intravenously over 1 hour; (3) erythromycin 3 mg/kg by mouth 45 minutes prior to feeding; (4) metoclopramide 0.6 mg/kg intravenously over 1 hour; and (5) motilin 500 ng/kg intravenously over 1 hour. After Roux-Y antrectomy, saline control dogs had 73% +/- 5% (SEM) gastric retention at 2 hours. After intravenous and oral erythromycin, gastric emptying improved at 2 hours to 27% +/- 6% and 39% +/- 5% (p less than 0.01 compared with control). Erythromycin intravenously and by mouth improved gastric emptying compared with metoclopramide (64% +/- 8%, p less than 0.05). Motilin enhanced gastric emptying to a similar degree as erythromycin, with a 2-hour gastric retention of 37% +/- 4% (NS). Erythromycin improved gastric emptying in dogs with severe Roux-Y gastroparesis and may have clinical application.

Salsalate, morphine, and postoperative ileus.

BACKGROUND: Previously, we demonstrated that ketorolac, a nonsteroidal antiinflammatory drug (NSAID), prevented postoperative small bowel ileus in a rodent model. The aim of this study was to evaluate the effect of salsalate, an NSAID without antiplatelet effect, on postoperative ileus alone or in combination with morphine. METHODS: Forty-eight rats underwent placement of duodenal catheters and were then randomly assigned to one of eight groups (n = 6). Four groups had standardized laparotomy following drug administration, whereas 4 groups underwent the same treatment without laparotomy: control and morphine animals received 0.1 mL alcohol via the catheter, whereas salsalate and salsalate-plus-morphine animals received salsalate (15 mg/kg) dissolved in 0.1 mL alcohol. The animals also received 0.5 mg/kg morphine (morphine and salsalate plus morphine) or the same volume of saline (control and salsalate) subcutaneously. Transit was measured following the injection of a nonabsorbed marker via the duodenal catheter and is defined as the geometric center (GC) of distribution. An additional 20 rats had serosal electrodes placed on the jejunum, and were assigned to one of four treatment groups (control, salsalate, morphine, and salsalate plus morphine; n = 5 each group). Myoelectric activity was recorded until the reappearance of the migrating myoelectric complex (MMC) following laparotomy. RESULTS: Laparotomy and morphine independently reduced small bowel transit (P = 0.0006 and 0.006, respectively, by three-way analysis of variance [ANOVA]; GC 4.3 +/- 0.2 control versus 2.2 +/- 0.3 laparotomy versus 3.6 +/- 0.4 morphine), but morphine did not further worsen postoperative transit (GC 2.4 +/- 0.4; P = 0.42). Although salsalate did not alter baseline transit, pretreatment improved postoperative transit (P = 0.0002; GC 3.6 +/- 0.4). This effect was lost with the addition of morphine (GC 2.7 +/- 0.2; P = 0.21). The MMCs returned earlier after laparotomy in salsalate-pretreated rats (63 +/- 18 minutes salsalate versus 160 +/- 12 minutes laparotomy; P < 0.01, one-way ANOVA). However, this effect was also lost in animals receiving morphine (106 +/- 16 min; P > 0.05). CONCLUSION: Salsalate improves postoperative small bowel motility in a rodent model; however, this effect is masked by morphine.

Late hepatic histopathology after jejunoileal bypass for morbid obesity. Relation of abnormalities on biopsy and clinical course.

Late biopsy results in 53 patients after jejunoileal bypass were reviewed and compared with 1 year postoperative biopsies. Patients were divided into groups based on clinical course and liver function tests. Of 24 patients with normal liver function tests and no clinical symptoms of liver failure, 8 (33 percent) had new or progressive lesions on late biopsy, while 1 of these 8 patients had cirrhosis. Thirty percent (6 of 20) of patients with liver function abnormalities but no evidence of liver failure showed evidence of progression on biopsy; 4 of these 6 patients had cirrhosis. Of those with clinical evidence of liver failure in the first year after operation, 44 percent had evidence of progression, but none had cirrhosis. Clinical parameters and liver function tests did not correlate with liver biopsies. In this series of patients, new and progressive lesions were found in the late postoperative period. Long-term serial biopsies are advisable in all patients after jejunoileal bypass to determine whether progressive deterioration in liver histology had occurred.

Effect of antrectomy on the nervous phase of gastric secretion in the dog.

A method is described for complete isolation of the stomach in the dog with vagal innervation intact. This involves esophagostomy, double mucosal closure of the pylorus and a Maydl gastric fistula combined with gastrojejunostomy. The latter is occluded during periods of study. In this preparation the responses to sham feeding and to insulin-induced hypoglycemia were reduced approximately 10-fold, reiterating the significant synergistic effect of gastrin on vagal stimulation of the parietal cell mass. However, significant acid secretion could still be induced in this preparation by both sham feeding and insulin-induced hypoglycemia.

Pouch outlet obstruction following vertical ring gastroplasty for morbid obesity.

We have experienced a 14% (38 of 264 patients) incidence of pouch outlet obstruction following vertical ring gastroplasty. Initial management consisted of dilatation in 34 of 38 patients (94%). Ten of 34 patients (29%) were spared reoperation by 1 to 3 dilatations. Non-passage of an endoscope through the stoma immediately following dilatation predicted the need for surgery; 4 of 11 patients (36%) with passage underwent reoperation compared with 17 of 20 patients (85%) without passage (p less than 0.02). Surgical findings included "tipped bands" in 9 of 28 patients (32%); fibrous reaction to the band in 10 of 28 patients (36%); adhesions with angulation of the pouch in 2 of 28 patients (7%); and no identifiable cause of obstruction in 7 of 28 patients (25%). Surgical therapy consisted of removal of the band (2 patients), removal of the band and replacement with a similar length or larger band (20 patients), "tacking" the band in the horizontal position (4 patients), or conversion to a Roux-Y bypass (2 patients). The first three options were associated with an unacceptably high rate of weight regain and/or continued symptoms, whereas the last-named procedure met with good success.

Postgastrectomy syndromes.

The most common types of postgastrectomy disorders are the dumping syndromes (early postprandial and late or hypoglycemic) and alkaline reflux gastritis. Both are caused by destruction of the pyloric mechanism. A third problem, Roux-en-Y duodenal diversion, frequently results in delayed gastric emptying.

Preoperative and postoperative motility disorders of the stomach.

Improved technology has expanded the study and understanding of gastrointestinal motility. Although no clear cause and effect relation has been demonstrated, altered motility has been found in association with a variety of nonsurgical and postoperative settings. As this relation is better defined, perhaps patients who are at risk to develop complications of surgery can be better identified so that treatment can be tailored toward their specific defect. Technological advances can also be expected to provide new and more effective interventions in this expanding field.

Pharmacokinetics of ranitidine after partial gastrectomy in dogs.

The effect of gastric surgery on the pharmacokinetics of ranitidine was studied in six dogs, all serving as their own controls. Prior to and after surgery, each dog received a single oral dose (5 mg/kg of body weight) of a ranitidine solution. The surgery consisted of partial gastrectomy (antrectomy) and truncal vagotomy. Ranitidine plasma and urine concentrations were measured by reversed-phase ion-pair liquid chromatography with UV detection. Pharmacokinetic parameters were estimated by noncompartmental data analysis techniques. Gastric surgery tended to slow the absorption of ranitidine as reflected by a slight increase of the time necessary to reach the peak plasma concentration. The maximum observed plasma concentration was slightly lowered. The amount of drug absorbed remained unchanged as reflected by no change in the AUCs. Other parameters such as mean residence time, elimination half-life, apparent oral clearance, and fraction excreted unchanged in the urine remained unchanged. However, due to the small number of animals and the considerable intersubject variability, none of these trends reached statistical significance.