Prospective hematologic evaluation of gastric exclusion surgery for morbid obesity.

To evaluate the long-term frequency and severity of anemia and selected vitamin and mineral deficiencies after gastric exclusion surgery for morbid obesity, the authors prospectively examined hematologic and nutritional parameters in 150 consecutive patients. These patients underwent a standardized gastric exclusion procedure during a six-year period (1976-1982) and were closely followed for up to seven years (mean, 33.2 months). Anemia developed in 36.8% of the population at a mean time from operation of 20 months. It was more frequent in women than in men (p less than 0.01), and it required transfusions in 3.5% of the population. A low serum iron concentration developed in 48.6%, iron deficiency in 47.2%, a low serum vitamin B12 concentration in 70.1%, vitamin B12 deficiency in 39.6%, and RBC folate deficiency in 18% of the population. Both iron and folate deficiencies responded to oral replacement. As a result of the high frequency and severity of anemia and nutritional deficiencies noted, all gastric exclusion patients should, as a minimum, be placed on oral multivitamin preparations containing iron, folate and vitamin B12. In addition, it is imperative that these patients be followed closely for the remainder of their lives with appropriate studies and replacement as necessary.

Prospective metabolic evaluation of 150 consecutive patients who underwent gastric exclusion.

The effect of weight loss produced by gastric exclusion on the metabolism of previously morbidly obese persons was examined. A standardized gastric exclusion procedure was performed in 150 morbidly obese patients during a 6 year period. These patients were followed for from 6 to 60 months (mean 27.8 months). The mean excess weight loss was 75 percent and was maintained from 2 to 5 years. A small but significant decrease was noted during the first 3 to 6 postoperative months in the parameters of protein metabolism examined. Although this may reflect mild depletion in protein stores, of greater importance was the demonstration that these parameters spontaneously corrected themselves by 12 months. Mild abnormalities in serum electrolyte concentrations were noted in the postoperative period. They appeared to be related to dehydration, were not clinically significant, and also resolved spontaneously. Clinically significant abnormalities in divalent ions were absent. Significant and sustained reductions in blood pressure, fasting glucose concentration, serum triglyceride values, and uric acid and hepatic enzyme concentrations were demonstrated in the entire population. A small and non-sustained decrease in cholesterol was seen. Hypertension was eliminated in 96 percent of the affected subpopulation, diabetes in 100 percent, gout in 100 percent, hyperlipidemia in 92 percent, and improved hepatic function was found in 95 percent. These changes should reduce the overall morbidity and mortality of the patient population in the future.

Complications and weight loss in 150 consecutive gastric exclusion patients. Critical review.

Results of extensive follow-up for weight loss and complications in 150 consecutive patients who underwent a standardized gastric exclusion procedure have been presented. A comparative review of the literature has also been presented. All patients were followed for up to 6 years (mean 27.8 months). Only one patient was lost to follow-up. Complications during this period occurred in 54.7 percent of our patients. These were mainly postsurgical biliary disease and ventral hernias. Our recent experience has suggested that the latter complications could have been prevented. The absence of pulmonary embolism, pneumonia, and stomal ulcer in our series, as well as the low incidence of perforations, thrombophlebitis, and stomal and pouch complications suggest that the occurrence of these complications can be minimized as well. Patients in this series lost an average of 75 percent of their excess weight, 38 percent of their original weight, and stabilized at 30 percent above their ideal body weight. Ninety percent of the weight loss occurred in the first 12 months. Eighty percent of the patients, however, continued to lose weight 18 months postoperatively and 40 percent lost weight up to 24 months postoperatively. Weight loss has been maintained from 2 to 5 years. In conclusion, analysis of available data has demonstrated that careful patient selection, attention to technical detail, and close follow-up are of paramount importance for providing successful results and minimizing complications in the morbidly obese population who undergo gastric exclusion surgery.

Osmolality of liquid and defined formula diets: the effect of hydrolysis by pancreatic enzymes.

The effect of hydrolysis was determined by a pancreatic enzyme preparation (Viokase) on a series of diets available for enteral nutrition. The increase in osmolality resulting from digestion by Viokase was measured. Small amounts produced very rapid increase in osmolality in almost all diets evaluated. Neither incubation at 37 degrees C nor the addition of larger amounts of the pancreatic enzyme preparation produced further substantial increases in osmolality. The importance of proper and adequate nutritional support of acutely and chronically ill patients is discussed, and a guideline for the choice of diets, route of delivery, and concentration of diets is suggested.

Hyperemic response for accurate diagnosis of arterial insufficiency.

Monitoring of calf (or ankle) blood pressure during reactive hyperemia after thigh arterial occlusion allows differentiation of normal from abnormal responses and of distal (femoropopliteal [FP] system) disease from proximal (aortoiliac [AI] disease. The hyperemic response of 106 lower extremities representing three disease states--FP (N = 19), AI (N = 15), and combined (AI plus FP)(N = 16)--were compared with each other and with 20 normal subjects and 36 asymptomatic diabetics. Not only were the three disease states readily distinguished from the very similar normal subjects and asymptomatic diabetics, but there was a highly significant difference between FP disease and AI disease up to 150 s. This is a simple, inexpensive, and reliable test that can be used at the bedside to determine levels of severe disease, especially in the claudicator, who may not have a critical stenosis under resting conditions.

A home program of long-term total parenteral nutrition in children.

Three children--ages 4 months, 5 months, and 14 years--have been on a program of total parenteral nutrition at home for ten, 23 and 44 months respectively, as of January, 1978. Using a specially designed silicone rubber catheter, placed in the right atrium, total nutritional needs of these children were delivered nightly by family members; the children carried out normal activity during the day with the catheter line maintained by a heparin lock. Normal skeletal development and weight gain have been achieved while allowing these children normal social and psychlogic development outside the hospital. During the course of the therapy the patients had multiple metabolic abnormalities which were successfully treated by replacement therapy. The duration of catheter patency ranged from three to 22 months. Catheter sepsis or mechanical failure occasionally required catheter removal and replacement.

Total blood washout and exchange. A valuable tool in acute hepatic coma and Reye's syndrome.

Total body washout (TBW) was accomplished thirteen times in twelve patients, with response in five and survival in three. TBW can be done without apparent harm to patients and is less laborious and more rapidly effective than repeated exchange transfusion. Early application of TBW in stage III to stage IV hepatic coma may increase survival and possibly prevent progression of metabolic derangements. Patients with stage III to IV Reye's syndrome probably should have TBW promptly, without time-consuming attempts at exchange transfusion. Based on our experience, further application of TBW is warranted in coma due to acute hepatic failure and stage III to IV Reye's syndrome.

Jejunoileal bypass for morbid obesity: early results and body composition changes in forty-five patients.

Forty-five patients who underwent a 14 by 4 inch jejunoileal bypass for morbid obesity were studied before the operation and at periodic intervals after operation to determine the complications and changes in body composition resulting from this procedure. Body composition studies were determined using 3H2O and 42K. Rapid weight loss occurred in the first 3 months, with a mean loss of 30 percent of excess weight. This weight loss was accompanied by a decrease in exchangeable potassium (Ke) and total body water (TBW) during this interval by 14 and 10 percent, respectively. Although most patients continued to lose excess weight Ke and TBW stabilized at the end of the first year and returned to preoperative values in six patients at the end of 24 months. Analysis of the ratios of body cell mass and total body water to weight shows an improvement of body composition 12 months after operation. Body composition studies permit a quantitative assessment of the nutritional status in patients undergoing jejunoileal bypass. In spite of significant complications (23 percent), surgery for morbid obesity appears to satisfy the objective of allowing desirable loss of fat with relative sparing of muscle and other supporting tissues.

Electrophoretic patterns of alkaline phosphatase isoenzymes in human sera with abnormally high activity, and an unusual band observed in sera of patients with pancreatic cancer.

Alkaline phosphatase isoenzymes in sera were resolved by electrophoresis on cellulose acetate membranes into seven different bands (L1, B, Pl, L2, l1, l2, and Pa, in decreasing order of electrophoretic mobility). The slowest moving band (Pa) was observed in the sera of 16 patients--15 with cancer of the pancreas and one with hemochromatosis. Sera of 50 other patients with malignant or benign diseases did not show the Pa band. The Pa band is more heat labile than is the liver isoenzyme (L1). Its behavior toward inhibitors (L-phenylalanine and L-homoarginine) is similar to that of L1. Sera containing the Pa band exhibit a diffuse band in the region where isoenzymes of intestinal origin migrate; however, its heat stability and sterospecific inhibition are different from those of intestinal isoenzymes in sera that show no Pa band.