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.

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.

Late outcome of isolated gastric bypass.

OBJECTIVE: To complete a long-term (>5 years) follow-up of patients undergoing isolated gastric bypass for severe obesity. SUMMARY BACKGROUND DATA: Previous experience as well as randomized trials suggested that the ideal operation for obesity should rely on manipulation of satiety rather than the production of malabsorption. Such an operation should incorporate a small gastric pouch of less than 30 mL placed in a dependent position on the lesser curvature of the stomach, not dependent on staples, and separated from the remaining stomach with a retrocolic, retrogastric Roux-en-Y gastrojejunostomy without external support. METHODS: The authors established an obesity clinic where patients were seen six times during the first year and semiannually thereafter. Emphasis was placed on defining success in terms of approximation to normal body-mass index. RESULTS: Of 274 patients, 243 (89%) were followed up for 5.5 +/- 1.5 years. Before surgery, the patients were obese (n = 13), morbidly obese (n = 134), or super-obese (n = 96). The obese and morbidly obese group achieved an excellent result, and the super-obese a good result. Individual results showed considerable variation from the mean. CONCLUSIONS: This study of isolated gastric bypass with a 5.5-year follow-up rate of 88.6% revealed a success rate of 93% in obese or morbidly obese patients and 57% in super-obese patients. Isolated gastric bypass compares favorably with biliopancreatic diversion in terms of weight loss, maximum weight loss, weight regain, current body-mass index, and percentage of patients with a body-mass index less than 35 kg/m2.

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.

Exercise capacity and energy expenditure of morbidly obese and previously obese subjects.

OBJECTIVE: To determine whether morbidly obese and previously obese women fail to lose weight after gastric bypass surgery because of reduced energy expenditure, and whether a large, surgically induced, rapid weight loss improves exercise capacity on a treadmill. DESIGN: Cross-sectional study. PARTICIPANTS: Four groups of 5 subjects: 1) patients still obese 12 months after surgery (failure); 2) patients who achieved normal weight after surgery (success); 3) obese patients who had not yet undergone surgery (preoperative); and 4) nonobese (control) subjects. Four subjects in the preoperative group were studied again at 6 months postsurgery. MAIN OUTCOME MEASURES: Total daily energy expenditure (TDEE), and exercise capacity and peak oxygen consumption (VO2) during treadmill exercise. RESULTS: TDEE or energy expenditure (EE) above basal metabolic rate (when normalized for body size) was similar for all groups, but the absolute energy consumption was higher in the preoperative and failure groups. Treadmill endurance time was greater in the success than the failure and preoperative groups, and the endurance times of these 3 groups were less than those of the nonobese subjects. Peak VO2 body weight was similar in the success, failure and preoperative groups, which meant that the peak VO2 was lower in the success group than in the preoperative and failure groups. Six months after surgery, peak VO2 had not decreased in the preoperative group. CONCLUSION: Failure to lose weight after isolated gastric bypass surgery was not because of a lower level of activity. Aerobic capacity was impaired 1 year, but not 6 months, after a large weight loss. Exercise training may be appropriate to maintain absolute peak oxygen consumption.

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.

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.

The delayed hypersensitivity response and host resistance in surgical patients. 20 years later.

OBJECTIVE: A 20-year follow-up was conducted on research into the implications of a lack of a delayed-type hypersensitivity (DTH) skin test response among surgical patients. SUMMARY BACKGROUND DATA: The authors' original report showed that a failed DTH response was associated with increased hospital mortality, but the role of specific and nonspecific host defense elements, comorbid factors, nutritional supplementation, and the mechanism for anergy in this adverse outcome was unknown. METHODS: A data base of 4292 patients was analyzed and reported on individual studies designed to answer some of the above questions. RESULTS: Prospective studies showed a strong association between the DTH response and mortality: reactive patients, 2.9% (75/2576); anergic patients, 20.9% (239/1142, chi square = 265, p < 0.0000001). Antibody response to protein antigens was reduced in anergic patients. Antibody response to polysaccharide antigens was normal in all patients. The hallmark of anergy is a lack of T cells in the skin, as measured by mRNA signal (CD3) for T cells. The nonspecific component of host defense, as measured by circulating and exudate polymorphonuclear cell function, showed no statistically significant difference between elective reactive and elective anergic patients. Notwithstanding some mild malnutrition in anergic patients, parental nutrition failed to correct the DTH response or many of the cellular immune functions measured. CONCLUSIONS: Over the last 5 years, because of a reduction in overall patient mortality, the contribution of a reduced DTH response to septic related mortality has lost statistical significance in elective surgical patients. A reduced DTH response maintains its strong association to sepsis-related mortality in intensive care/trauma patients, and this is the group on which future research efforts should be concentrated.

Health care delivery and the training of surgeons.

Most countries have mastered the art of cost containment by global budgeting for public expenditure. It is not as yet clear whether the other option, managed care, or managed competition will accomplish cost control in America. Robert Evans, a Canadian health care expert, remains skeptical. He says, "HMO's are the future, always have been and always will be." With few exceptions, the amount spent on health care is not a function of the system but of the gross domestic product per person. Great Britain is below the line expected for expenditure, which may be due to truly impressive waiting lists. The United States is above the line, which is probably related to the overhead costs to administer the system and the strong demand by patients for prompt and highly sophisticated diagnostic measures and treatments. Canada is on the line, but no other country has subscribed to the Canadian veto on private insurance. Reform or changes are occurring in all countries and will continue to do so. For example, we are as terrified of managed care in Canada as you are of our brand of socialized insurance. We distrust practice by protocol just as you abhor waiting lists. From my perspective as a surgeon, I envision an ideal system that would cover all citizens, would maintain choice of surgeon by patients, would provide mechanisms for cost containment that would have the active and continuous participation of the medical profession, and would provide for research and development. Any alteration in health care delivery in the United States that compromises biomedical research and development will be a retrogressive, expensive step that could adversely affect the health of nations everywhere. Finally, a continuing priority of our training programs must be to ensure that the surgeon participating in this system continues to treat each patient as an individual with concern for his or her own needs.

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.

Regional differences in triacylglycerol synthesis in adipose tissue and in cultured preadipocytes.

The initial suspicion that obesity increases coronary risk has been much sharpened with the demonstration that risk is more tightly linked to abdominal than to peripheral obesity, and tighter yet again when the mass of omental adipose tissue is taken into account. These data suggest that important metabolic differences might exist between adipocytes from different regions, and indeed, it has long been appreciated that triacylglycerol hydrolysis can be stimulated to a greater extent in omental than in subcutaneous adipocytes. The present study focuses on triacylglycerol synthesis in human subcutaneous and omental adipocytes, a process which, by contrast, has received relatively little attention. Experiments were done on adipose tissue removed at laparotomy and on cultured preadipocytes. With the former, triacylglycerol synthesis was measured in the presence and absence of oleate added to the medium using radiolabeled glucose and oleate as tracers. The results demonstrate that under all conditions examined triacylglycerol synthesis in subcutaneous adipose tissue exceeded that in deep omental adipose tissue. To study the cells in more detail, preadipocytes were cultured and triacylglycerol synthesis was examined again under basal conditions and with stimulation with insulin and acylation stimulating protein (ASP). Under basal conditions, particularly when oleate was added to the medium, clear differences were present such that triacylglycerol synthesis was substantially greater in subcutaneous preadipocytes than in omentally derived preadipocytes. These differences were more pronounced when the cells were stimulated with either insulin or acylation stimulating protein. Overall, triacylglycerol synthetic capacity in subcutaneous tissue exceeded that in omental tissue. As a consequence, omental tissue as compared to subcutaneous adipose tissue would have a limited capacity to prevent fatty acids from reaching the liver and stimulating hepatic lipoprotein synthesis.

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).

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.

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.

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.

Delayed type hypersensitivity testing in surgical patients.

DTH skin reactions can identify a population of surgical patients at increased risk for sepsis and related mortality. The usefulness of the technique is increased by repeating the test during the hospital course and by calculating a DTH score, which is the sum of the diameter of induration of all five or six tests expressed in millimeters. Regression analysis of factors that could possibly indicate development of sepsis and death after surgical treatment reveals that the most powerful predictors are serum albumin, DTH score and age of the patient. The population of patients who are anergic are more frequently malnourished than reactive patients, but the DTH response cannot be used to determine the malnourished state in individual patients. The lack of a DTH reaction (anergy) identifies an immune defect characterized by a failure of release of lymphokines in vivo. Lymphokines from normal individuals can restore to normal the absent response of anergic patients to specific antigens. In experimental animals made anergic by a heat injury, the mortality rate from bacterial peritonitis can be significantly lowered by lymphokines. Immunomodulation of demonstrated defects in host resistance is an exciting prospect for the future of surgical patients.