Cobalamin absorption and hematologic status after two types of gastric surgery for obesity.

A series of morbidly obese patients was treated surgically with a gastric bypass, and a subsequent series received a vertical banded gastroplasty. To compare some of the nutritional effects of these two procedures we measured serum vitamin B12 levels, absorption of food vitamin B12, frequency of microcytosis of erythrocytes, and frequency of anemia at one or more years after surgery. Patients with a gastric bypass showed greater weight loss, a greater frequency of microcytosis and anemia, more frequent subnormal serum levels of vitamin B12, and impressive failure to absorb food vitamin B12. Boiling the food containing vitamin B12 led to increased absorption.

The relative lethality of intestinal bacteria for gnotobiotic rats with experimental intestinal strangulation.

In eight experiments utilizing 28 animals each, germfree rats with and without ischemically or hemorrhagically strangulated closed loop intestinal segments were contaminated with either one of four common intestinal anaerobic bacteria, or a combination of two or three bacteria previously found to be innocuous in pure culture. The results showed that: a) in pure culture, Bacteroides fragilis, Bacteroides melaninogenicus, and Peptostreptococcus anaerobius were innocuous; b) Fusobacterium necrophorum alone was a very lethal organism that produced intense, confluent, intraperitoneal, fibrous adhesions after four to six days; and c) mixed inoculum of Klebsiella pneumoniae, Bacteroides fragilis, and/or Streptococcus faecalis was found to be lethal for gnotobiotic rats with intestinal strangulation. It is concluded that Fusobacterium necrophorum is so patent that it should be specifically treated with antibiotics when suspected or known to be present in clinical specimens. This gnotobiotic animal model will be useful to delineate the lethality of known combinations of intestinal bacteria.

The natural course of Clostridium perfringens--induced pneumatosis cystoides intestinalis.

Primary pneumatosis cystoides intestinalis (PCI) is an uncommon, usually benign condition whose natural course is poorly understood and which can sometimes produce significant changes in a patient's cecum and sigmoid colon. In this study, PCI was produced by monocontaminating the peritoneal cavities of adult germfree rats with Clostridium perfringens. These animals were then observed for up to 26 weeks. PCI took up to two weeks to develop, lasted at least ten weeks in most animals, and presumably disappeared from 42% of 26 animals killed during the final 16 weeks. PCI was usually benign, but in some animals produced extensive and persistent subserosal and submucosal air cysts of the cecum and sigmoid colon without evidence of intra-abdominal sepsis. These profound segmental colonic lesions suggest a possible etiology for other segmental inflammatory bowel diseases.

Weight control after vertical banded gastroplasty for morbid obesity.

Vertical banded gastroplasty is a common method of treating morbid obesity. Several physical, behavioral, economic, and psychologic factors are believed to affect its efficacy. In this study, 100 consecutive patients received a 4.5-cm circumference band, while a second 100 consecutive patients were given a 5.0-cm circumference band. One year after surgery, with a follow-up of 97.5%, neither the patient's stoma size nor their preoperative occupation, economic status, or mental health significantly affected the patient's weight loss, which averaged 27% of their original weight. Postoperative eating behavior, however, dramatically affected weight loss. Among the patients who lost less than 20% of their original weight, 25% drank large volumes of caloried liquids, while 75% ate large amounts of soft foods. Patients with banded gastroplasties must "use" their operation to lose weight.

Conversion surgery for morbid obesity: complications and long-term weight control.

Some operations for morbid obesity fail--for a variety of reasons. To better understand the risk and efficacy of converting, during a single operation, a failed procedure to a second type of operation for morbid obesity, a review was made of all 120 patients who underwent this type of conversion surgery at one university hospital during a 10-year period. The initial operations of 62 patients were converted to a gastric bypass with a Roux-en-Y gastrojejunostomy, 11 to an unbanded gastrogastrostomy, and 47 to a vertical banded gastroplasty. Four patients are dead (three of unrelated causes), 11 have undergone a third operation for morbid obesity, and five (4.2%) are lost to follow-up. For 69 of 86 patients, 3- to 5-year follow-up data are available. Serious early complications occurred in 5.8% of the patients. Almost 80% of the patients who received an unbanded gastrogastroplasty did not control their weight, whereas most of those who received a Roux-en-Y gastrojejunostomy or a vertical banded gastroplasty had satisfactory long-term weight control 3 to 5 years later, maintaining an average weight loss of 30% of their original weight or 55% of their excess weight. Conversion surgery is safe and effective.

Gastric surgery for morbid obesity. Complications and long-term weight control.

The efficacy of gastric surgery for morbid obesity has often been questioned because of incomplete long-term patient follow-up. Between 1977 and 1984, 537 consecutive patients received either a gastric bypass with a Roux-en-Y gastrojejunostomy, an unbanded gastrogastrostomy, or a vertical banded gastroplasty. The follow-up period was 5 years for all patients who underwent Roux-en-Y gastrojejunostomy and unbanded gastrogastrostomy and 3 years for all patients who underwent vertical banded gastroplasty. Only 5.8% of all patients were unavailable for this late follow-up. The unbanded gastrogastrostomy was not an effective weight-control operation. Both the Roux-en-Y gastrojejunostomy and vertical banded gastroplasty provided effective long-term weight control. Although the Roux-en-Y gastrojejunostomy gave slightly better weight control than the vertical banded gastroplasty, the more simple, safe, and physiological vertical banded gastroplasty is the procedure of choice for most patients with morbid obesity.

Surgery for morbid obesity. Selecting the patient and procedure.

Every physician strives for a treatment that is 100% effective. Although operations for morbid obesity are not perfect, their 80% success rate in helping patients maintain a loss of at least 20% of their original weight is far better than the less-than-10% success rate of nonsurgical treatments. Of the procedures available, intestinal bypass should be avoided, as side effects are numerous. Roux-en-Y gastric bypass is generally successful, as is banded gastroplasty. Surgical candidates need to be selected carefully, and patients must be educated to stay involved in treatment, that is, "use" their operation to ensure a successful outcome.

Balloon dilation for the treatment of stomal stenosis complicating gastric surgery for morbid obesity.

In a retrospective analysis, we evaluated our results with endoscopic dilation of enterostomy stenoses that complicated gastric procedures performed for the treatment of morbid obesity. Of 541 patients who underwent a gastric procedure for treatment of morbid obesity, we found 19 patients in whom endoscopic dilations of stenoses had been attempted. We also include three patients who had surgery elsewhere but who underwent dilations at our institution. Fourteen had stenoses complicating gastric bypass with Roux-en-Y anastomoses, and eight had stenoses complicating a gastroplasty (gastrogastrostomy). Two different types of dilation were attempted during the interval reviewed--Fogarty balloon dilations and Grüntzig balloon dilations. None of the eight patients with gastroplasties benefited from the attempted dilation, but 10 of the 14 patients with stenoses complicating gastric bypasses have done well. We found no significant difference between Fogarty and Grüntzig balloon dilations. We conclude that balloon dilation is an effective means of treating stenosis that complicates gastric bypass performed with Roux-en-Y anastomoses in cases of morbid obesity.

Control of bleeding esophageal varices by transabdominal esophageal transection, gastric devascularization, and splenectomy.

Between November 1980 and October 1982, 11 patients underwent modified Sugiura procedures (esophageal transection, gastric devascularization, and splenectomy) for bleeding esophageal varices, with an operative mortality of 36%. One patient rebled at 2 months and was successfully managed by sclerotherapy. Intraoperative portal pressure fell approximately 25% after splenectomy. We contend that esophageal transection and gastric devascularization provide good short-term control of bleeding varices, and that the decrease in portal pressure provided by splenectomy allows scars to form during a period of reduced portal pressure, providing long-term arrest of variceal hemorrhage.

Shunts for portal hypertension.

Eighty-nine patients underwent 95 portasystemic shunts for portal hypertension at our institutions between June 1963 and March 1981. Ninety-three shunts were performed for bleeding varices. Procedures that were performed included 11 Warren shunts, 29 Linton shunts, 28 interposition mesocaval shunts, 26 classic portacaval shunts, and one umbilical to saphenous vein shunt. Thirty-six shunts were performed in Child class A patients (5.5% operative mortality), 37 in Child class B (16.2% operative mortality), and 22 in Child class c patients (36.3% operative mortality). Five-year survival for Child A patients was 74 per cent, 17.4 per cent for Child B patients and 26.3 per cent for Child C patients. Twelve of 14 patients (15.7%) who had recurrent postoperative upper gastrointestinal bleeding were found to have occluded shunts (two Warren, six Linton, one mesocaval, and three portacaval). Of 21 patients who became encephalopathic postoperatively, 17 had alcoholic liver disease. In 15 of these alcoholic patients who survived the immediate postoperative period, encephalopathy correlated directly with continued alcohol consumption. Several conclusions can be drawn from our data: portasystemic shunts can be performed with acceptable morbidity and mortality; rebleeding generally indicates shunt occlusion; encephalopathy can be correlated with continued alcohol consumption after shunting; there appears to be little difference in survival and rebleeding in the various shunt procedures; the poor survival figures for Child B and C patients must make one seriously consider alternative procedures in these poor-risk candidates.

Intestinal strangulation in germfree and monocontaminated dogs.

Earlier studies in the germfree rat demonstrated that the common intestinal bacteria vary greatly in their ability to cause death after intestinal strangulation. Some of these experiments were repeated in adult, germfree and monocontaminated beagles. Neither short closed-loop hemorrhagic nor long closed-loop ischemic strangulation killed the germfree dog. Either procedure rapidly killed the dog with a conventional bacterial flora or a dog monocontaminated with Clostridium perfringens. The dogs monocontaminated with Bacteroides fragilis died after several days, whereas Escherichia coli killed only one of three animals. These experiments demonstrate the usefulness of the germfree dog as a unique research subject, confirm our earlier studies on intestinal strangulation in germfree rats, and further emphasize the differing lethal potentials of the intestinal bacteria in intestinal strangulation.

Marital changes after intestinal bypass surgery.

A retrospective interview study was undertaken of 14 spousal pairs in which one member had undergone the intestinal bypass procedure for massive obesity. Much unanticipated marital discord occurred. Sexual problems were particularly troublesome and affected both members in the spousal pairs. The results point to the role of massive obesity as a selective and stabilizing factor in the marriages of this subset of overweight persons.

An autoclavable electronic interface for germfree isolators.

An electronic interface was designed and fabricated for use with germfree isolators. It allows a variety of sensors or electrical instruments inside an isolator to be readily connected to monitoring or activating devices on the outside of an isolator. It was built into a 25 cm diameter cylinder whose open ends were loosely covered by an inner and outer connector panel. These two panels were wired together through an airtight dividing wall placed transversely across the middle of the cylinder. The interface was mounted in an entry port of a stainless steel isolator and steam sterilized with the isolator. It has proven to be a useful, contamination-free, durable device.

Bacterial association in the gastrointestinal tract of beagle dogs.

Nine male beagle dogs, housed in either a conventional or locked environment for 2.5 years, were killed, and the bacterial flora present in various regions of each gastrointestinal tract was assessed by culture techniques, light microscopy, and scanning electron microscopy. All dogs possessed a complex microflora in their colons; in almost every dog anaerobes predominated. The highest number of bacteria cultured was 10(10)/g (dry weight) of tissue and contents; highest counts obtained with a Petroff-Hauser counting chamber were 10(10)/ml (wet weight). Although there was a consistency in the detectable genera, there were also noticeable differences in the flora of dogs housed under different environmental conditions. These differences included qualitative and quantitative changes in the flora as well as alterations in the distribution and localization of microorganisms along the gastrointestinal tract and in the crypts of Lieberkuhn. No bacterial layers were detected on the surfaces of stomach or proximal bowel in any of the dogs. Dogs housed in a conventional, open, environment had bacteria that occurred in layers on their ceca and colons and in their crypts of Lieberkuhn; however, dogs housed under "locked" environmental conditions did not possess them or had them less frequently. Dogs removed from the locked environment and kept (30 days) in conventional housing conditions were the only ones with detectable segmented filamentous microbes in their ilea. This study shows that the microbial flora does not simplify when dogs are housed in a locked environment. Indeed, it may increase in complexity and cause alterations in the bacterial flora that is associated closely with gastrointestinal epithelial cells and crypts of Lieberkuhn.

Nose, throat, and fecal flora of beagle dogs housed in "locked" or "open" environments.

The microbial flora of the nose, throat, and feces of male beagle dogs housed in a "locked environment" (i.e. confined to germfree-style isolators and supplied with sterile food, air, and water) or an open environment were assessed between 26 and 30 months into the study. Forty-five genera and 170 different species or types of microorganisms were cultured from the nose, throat, and feces of the beagles. Clostridia, eubacteria, corynebacteria, bacteroides, lactobacilli, and anaerobic, gram-positive cocci accounted for most of the microbial diversity in the flora. Some of the facultative anaerobes, especially streptococci and lactobacilli (in feces), occurred in numbers that were comparable to the most numerous anaerobic species. Confinement to the locked environment resulted in an increased diversity of microorganisms in the flora, but the total microbial counts did not increase to any great extent. Even with the increased diversity of bacteria in the flora of confined dogs, some bacteria seemed to favor certain areas of the gastrointestinal tract over others. The increased diversity of bacteria observed in these confined dogs may pose some infectious disease problems for other mammals (including humans) that may be confined to a locked, ultra-clean environment for a prolonged period of time.

Effect of age, sex, and intestinal flora on the induction of colon tumors in rats.

Germfree and conventional Sprague-Dawley rats were assessed for their susceptibility to intrarectally injected N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) or N-methyl-N-nitrosourea (MNU). Adenocarcinoma of the colon was induced in germfree and conventional rats by both MNNG and MNU. The colons of germfree rats were more susceptible to the direct-acting carcinogens, as manifested by earlier morbidity and development of colon tumors (50% tumors within 30-35 wk), than were those of conventional rats (50% colon tumors within 48-50 wk). Germfree and conventional male rats were more susceptible to the carconogens than were their female germfree and conventional counterparts. Young (30 days old at the start of the experiment) germfree rats developed colon tumors more quickly (15-20 wk) than did older (60 days) germfree rats after intrarectal injections of MNNG. No colon tumors were observed in germfree and conventional rats after 75 weekly intrarectal injections with a buffer. Transplantation of an adenocarcinoma induced with MNU in a female rat to germfree and conventional rats showed that it was easily transplantable, required no immunosuppression, and had essentially the same morphologic characteristics as did the primary tumor.

An autoclavable isolator for operating on the adult gnotobiotic dog.

An isolator, in which complex operations can be performed on a large gnotobiotic dog, was designed and fabricated of lightweight stainless steel. This "T" shaped chamber is 20-40 inches wide, 96 inches long, and 38-58 inches high. It has two 18-inch diameter entry ports and a pair of gloves mounted beneath each of four plate glass windows. The isolator rests on a 12-inch high stainless steel pallet and is moved about the laboratory by a portable hydraulic platform lift. It is readily sterilized in an autoclave at temperatures up to 285 degrees F (140 degrees C) and can be cleaned and resterilized in less than 8 hours. Although the isolator is more expensive than one made of flexible plastic film, it has the advantages of not being readily punctured and it requires less labor to clean and sterilize between uses. Thus, it is more secure and, in the long run, more economical.