Evaluation of postinjury hepatocyte function by central amino acid clearance.

It has been demonstrated by other investigators that central plasma clearance of amino acids accurately predicts hepatocyte function in patients with liver disease and correlates with clinical outcome. This methodology has not heretofore been studied in the trauma patient. It is our hypothesis that central amino acid clearance in trauma patients is more reflective of hepatocyte function than traditional liver function tests. We examined the plasma amino acid clearance rates using L-[1-13C]phenylalanine. Clearance rates were compared to standard liver function tests (LFTs) and the sensitivity and predictability of the technique were determined. The study was conducted on uninjured control subjects and in seriously injured patients, both with and without significant liver injuries. Compared to baseline values in the control group, initial phenylalanine breath scores were reduced in the injured, but exceeded control levels at 7 days postinjury. These changes were statistically significant. There was no difference between those with and without liver trauma. LFTs showed inconsistent and conflicting results. Thus, central amino acid clearance measured by L-[1-13C]phenylalanine oxidation is depressed immediately following injury but reaches supranormal levels at 7 days postinjury. Compared to LFTs, amino acid clearance suggests initial hepatocyte suppression followed by hyperactivity and is a more accurate determinant of hepatocyte function.

Hormonal changes after Roux-en Y gastric bypass for morbid obesity and the control of type-II diabetes mellitus.

Morbid obesity (MO) is associated with diabetes mellitus-type II (DM-II). Roux-en Y gastric bypass (RNY) has been shown to normalize glucose intolerance in these patients through an incompletely understood mechanism. Gastrointestinal hormonal changes have been suggested as an explanation for resolution of DM II. Preoperatively, 20 MO patients with DM-II were evaluated for demographics and fasting levels of the following: glucose, insulin, C-peptide, glucagon, cortisol, gastric inhibitory polypeptide (GIP), and glucagon-like peptide-1 (GLP-1). Each patient underwent RNY with a 15-cc gastric pouch and 150-cm Roux limb. Postoperatively, each of the variables was measured at 2 weeks, 6 weeks, and 12 weeks and compared with the preoperative result using Student t test with significance, P = 0.05. Results are expressed as mean +/- SD. Twenty patients (5 male and 15 female), age 40.3 +/- 7.9 years, weight 146.3 +/- 34.0 kg, height 158.7 +/- 18.7 cm, and BMI 52.7 +/- 8.8, were enrolled in this IRB-approved protocol. Weight and BMI decreased progressively (117.5 +/- 26.9 kg and 47.0 +/- 7.4, P = 0.01, respectively) during the study but reached significance only at 12 weeks. Fasting plasma glucose decreased significantly within 2 weeks after RNY. Insulin and cortisol both approached, but never achieved, significant changes over 12 weeks. GLP-1 increased initially, but not significantly. GIP and C-peptide both decreased significantly. Glucagon remained essentially unchanged over 12 weeks. RNY rapidly normalizes fasting plasma glucose in morbidly obese patients with DM-II. GIP, a gactor in the enteroinsulin axis, decreases and may play a role in the correction of DM-II after gastric bypass.

Gastrointestinal symptomatic outcome after laparoscopic Roux-en-Y gastric bypass.

Laparoscopic Roux-en-Y (RY) gastric bypass is an effective treatment for morbid obesity. However, little information is available regarding the gastrointestinal symptomatic outcome after laparoscopic RY gastric bypass for morbid obesity. The purpose of this study is to identify changes occurring in gastrointestinal symptoms after laparoscopic RY gastric bypass. A previously validated, 19-point gastrointestinal symptom questionnaire was administered prospectively to each patient seen for surgical consultation to treat morbid obesity. Patients rated the degree to which each symptom affected their lives on a 0 to 100 mm Liekert scale with 0 indicating absence of a symptom, 33 indicating the symptom was present occasionally, 67 indicating the symptom occurred frequently, and 100 indicating the symptom was continuous. The same survey was readministered 6 months postoperatively. The mean of each symptom (preoperative vs. postoperative value) was compared using Student's t test with significance at P<0.05. Forty-three preoperative patients (age 37.3+/-8.6 years; body mass index 47.8+/-4.9) and thirty-five, 6 months' postoperative patients (81% follow-up; body mass index 31.6+/-5.3) completed the questionnaire. The result for each symptom is expressed as mean+/-standard deviation of preoperative vs. postoperative scores. Significantly different symptoms include the following: abdominal pain 23.3+/-26.4 vs. 8.6+/-13.5, P=0.003; heartburn 34.0+/-26.6 vs. 8.0+/-14.0, P=0.0001; acid regurgitation 28.1+/-24.0 vs. 10.7+/-21.0, P=0.001; gnawing in epigastrium 19.3+/-22.7 vs. 7.5+/-16.0, P=0.01; abdominal distention 38.2+/-31.5 vs. 11.1+/-19.2, P=0.0001; eructation 27.7+/-24.4 vs. 15.5+/-16.9, P=0.01; increased flatus 40.2+/-25.7 vs. 25.2+/-25.3, P=0.005; decreased stools 5.4+/-16.8 vs. 17.4+/-20.0, P=0.0005; increased stools 23.9+/-26.7 vs. 6.5+/-11.7, P=0.0005; loose stools 29.7+/-26.5 vs. 17.5+/-20.0, P=0.03; urgent defecation 34.3+/-26.5 vs. 14.3+/-19.3, P=0.0009; difficulty falling asleep 44.1+/-38.4 vs. 27.5+/-32.9, P=0.05; insomnia 42.4+/-36.2 vs. 21.6+/-30.5, P=0.008; and rested on awakening 65.1+/-33.8 vs. 30.5+/-28.8, P=0.0001. Symptoms that did not significantly change included the following: nausea/vomiting 17.2+/-22.7 vs. 22.1+/-19.9, P=0.33; borborygmus 28.8+/-25.2 vs. 26.8+/-29.7, P=0.75; hard stools 10.3+/-22.9 vs. 7.1+/-18.6, P=0.56; incomplete evacuation of stool 17.2+/-22.8 vs. 13.4+/-21.7, P=0.45; and dysphagia 10.9+/-15.6 vs. 17.7+/-28.4, P=0.18. Laparoscopic RY gastric bypass significantly improves many gastrointestinal symptoms experienced by morbidly obese patients without adversely affecting any of the measured parameters. This information is useful in preoperative counseling to assure patients of overall symptomatic improvement after this operation in addition to significant weight loss and improvement of comorbid conditions.

Gastrointestinal symptoms are more intense in morbidly obese patients and are improved with laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Currently there are few reports comparing gastrointestinal (GI) symptoms in the morbidly obese versus control subjects or the effect of laparoscopic Roux-en-Y gastric bypass (LRYGBP) on such symptoms. METHODS: A previously validated, 19-point GI symptom questionnaire was administered prospectively to each patient undergoing LRYGBP, and the questionnaire was re-administered 6 months postoperatively. Six symptom clusters (abdominal pain, irritable bowel [IBS], reflux, gastroesophageal reflux disease [GERD], sleep disturbances, and dysphagia) were compared in the following manner using Students t-test: 1) Control vs. Preop, 2) Control vs Postop, and 3) Preop vs Postop. Results are expressed as mean +/- standard deviation, significance P=0.05. RESULTS: 43 patients (40 female and 3 male, age 37.3 +/- 8.6, BMI 47.8 +/- 4.9) completed the questionnaire preoperatively, and 36 patients (34 female, 2 male, BMI 31.6 +/- 5.3) completed the questionnaire 6 months postoperatively, for a response-rate of 84%. Abdominal pain, IBS, reflux, GERD and sleep disturbance symptoms were significantly worse in preop versus controls. Dysphagia was not different. Postop vs preop scores revealed abdominal pain, IBS, GERD, reflux, and sleep disturbance symptoms to be improved significantly. Dysphagia was not significantly different. Only dysphagia was worse when comparing postoperative to controls. No other symptom cluster was significantly different in controls vs postoperative. CONCLUSIONS: Morbidly obese patients experience more intense GI symptoms than control subjects, and many of these symptoms return to control levels 6 months after LRYGBP. Dysphagia is equivalent to control subjects preoperatively but increases significantly after LRYGBP. This data suggests another quality-of-life improvement (relief of GI symptoms) for morbidly obese patients. Further follow-up is needed to document the long-term reduction of GI symptoms.

The Future of Laparoscopic General Surgery.

Video controlled laparoscopy has dramatically changed general surgery. Further striking alteration is sure to occur in the immediate future. Not only are the surgeons who are concentrating on this area making great strides, but innovative equipment and technological innovation are certain to make more complex procedures feasible. Thus the future of laparoscopic surgery is very bright.