Bibbo, Christopher DO; Barbieri, Rocco A. MD; Deitch, Edwin A. MD, FACS, and; Brolin, Robert E. MD, FACS Author Information

Although iron, vltamm B12, and folate deficiency have been well documented after gastric bypass operations performed for morbid obesity, there is surprisingly little information on either the natural course or the treatment of these deficiencies in Roux-en-Y gastric bypass (RYGB) patients Durmg a l0-year period, a complete blood count and serum levels of iron, total iron-binding capacity, vltamin B12, and folate were obtained in 348 patients preoperatively and postoperatively at 6-month intervals for the first 2 years, then annually thereafter The principal objectives of this study were to determine how readily patients who developed metabolic deficiencies after Roux-en-Y gastric bypass responded to postoperative supplements of the deficient micronutrient and to learn whether the risk of developmg these deficiencies decreases over time Hemoglobin and hematocrit levels were slgnificantly decreased at all postoperative intervals in comparison to preoperative values Moreover, at each successive interval through 5 years, hemoglobin and hematocrit were decreased signifiantly compared to the preceding interval Folate levels were significantly increased compared to preoperative levels at all time intervals Iron and vltamin B12 levels were lower than preoperative measurements and remained relatively stable postoperatively Half of the low hemoglobin levels were not associated with iron deficiency Taking multivltamin supplements resulted in a lower incidence of folate deficiency but did not prevent iron or vitamin B12 deficiency Oral supplementation of iron and vitamin B12 corrected defiaencies in 43% and 81% of cases, respectively Folate deficiency was almost always corrected with multivitamins alone No patient had symptoms that could be attributed to either vitamin B12 or folate deficiency Conversely, many patients had symptoms of iron deficiency and anenua Lack of symptoms of vitamin B12 and folate deficiency suggests that these deficiencies are not clinically important after RYGB Conversely, iron deficiency and anemia are potentially serious problems after RYGB, particularly in younger women Hence we recommend prophylactic oral iron supplements to premenopausal women who undergo RYGB

Predicting the survivability of intestine that has been made ischemic by impairment of blood flow is a major unsolved problem in gastrointestinal surgery. Currently, the surgeon must rely on qualitative, often subjective assessments that are known to have marginal reliability. This review describes various approaches to quantitatively assess the survivability of intestine compromised by ischemic disease. Much of the review centers on work done in the authors' laboratory to evaluate various approaches to predicting long-term survival and to develop new assessment parameters. Towards that end the authors have designed and developed techniques based on intestinal contractility and myoelectric activity (the intestinal EMG). Their evaluations of these and other methods of viability assessment utilize a highly representative canine model of intestinal ischemia that closely follows the development and treatment of ischemic intestinal disease in humans. Results to date suggest that the myoelectric measurements are more reliable than parameters based on blood flow or visual evaluation in terms of predicting bowel survival. However, improvements in instrumentation and technique are needed before this approach is suitable for clinical use.

Human intestinal lymphocytes, particularly intraepithelial lymphocytes, proliferate minimally to some agents, like mitogens and stimuli of the CD3 pathway. This in vitro finding may be due, in part, to a loss of factors found in vivo. Three T-cell growth factors, IL-7, IL-9, and IL-12, were tested for their ability to stimulate the proliferation of intestinal lymphocytes. Both intraepithelial lymphocytes and lamina propria lymphocytes proliferated more vigorously to IL-7 than to IL-9 or IL-12, and only IL-7 increased stimulation through the CD3 pathway. The IL-7-induced response was IL-2-dependent: IL-2 receptors appeared on both intestinal lymphocyte types, and antibody to the IL-2 receptor blocked IL-7-induced proliferation. Both CD4+ and CD8+ T-cell subsets responded to this cytokine as shown by phenotype-depletion experiments and constancy in the CD4/CD8 ratios after culture with IL-7. In addition, the T-cell receptor alpha beta and gamma delta subsets responded equally well to IL-7. This newly described selective proliferative response of intestinal lymphocytes to IL-7, but not to IL-9 or IL-12, requires no preactivation and may enhance growth in vivo.

: Human intraepithelial and lamina propria lymphocytes are memory lymphocytes that migrate from the circulation to the intestinal mucosa. We studied the effect of the chemokine, GRO, on these lymphocytes. Intraepithelial and lamina propria lymphocytes were isolated from human jejunal mucosa of healthy individuals and cultured for three days in IL-2. Migration was assessed using the Boyden transwell assay. Increases in cytoplasmic free calcium concentration were measured by changes in fluorescence of Fura-2-loaded lymphocytes upon exposure to GRO. A large number of intraepithelial lymphocytes (IEL) but few lamina propria lymphocytes (LPL) migrated toward GROα, GROβ, and GROy. Checkerboard experiments showed that the response of intraepithelial lymphocytes was mainly by chemotaxis rather than chemokinesis. The action of GROa was independent of cytochalasin D, staurosporine, and pertussis toxin but was inhibited by sodium azide and cycloheximide. None of the GRO proteins triggered calcium mobilization by either lymphocyte type. This study shows that GRO is chemotactic for IEL but not LPL.

Malignant subungual melanoma is an infrequently encountered but often misdiagnosed clinical entity. The podiatric surgeon plays a major role in the early diagnosis and surgical management. An illustrative case report of its clinical presentation and a thorough review of current therapeutic modalities are presented.

Viability of ischemic bowel was assessed in 30 dogs after mesenteric arterial ligation in a 40-cm length of ileum. Viability was evaluated using two gross features, color and peristalsis, and four objective methods including bowel wall surface oximetry (pO2), Doppler ultrasound, quantitative fluorescein fluorimetry, and myoelectric activity measured by a strain gauge probe. Each parameter was measured at 2-cm intervals within the 40-cm ischemic segment before resection and anastomosis was performed. There were seven fatal anastomotic leaks, all due to further bowel necrosis. Survival did not correlate with bowel color, presence of peristalsis, bowel wall pO2 Doppler ultrasound, or the myoelectric parameters. However, fluorescein fluorimetry was predictive of long-term viability. These results suggest that quantitative fluorescein fluorimetry may be a useful adjunct in intraoperative bowel viability assessment.

Human intestinal intraepithelial lymphocytes (IEL) demonstrate target cell-restricted spontaneous cytotoxic (SC) activity that is due to CD2+CD3+CD8+CD16-CD56- effector cells; they kill epithelial cell (EC) tumours (such as DLD-1 colon cancer cells), but not natural killer (NK)-sensitive K-562 cells. The present study shows that the measured levels of SC activities by IEL correlated with those of autologous lamina propria lymphocytes (LPL), but not with those of peripheral blood lymphocytes (PBL). Also, the susceptibilities of DLD-1 cell clones to lysis by IEL and PBL effector cells did not correlate, suggesting different mechanisms of lysis. Antibody blocking experiments showed that the main surface molecules involved in lysis depended on the effector cell type: alpha E beta 7 (HML-1) on IEL and CD16 on PBL. No antibody-dependent cell-mediated cytotoxicity (ADCC) was demonstrated by IEL, even after stimulation with interferon-gamma (IFN-gamma). Few IEL expressed Fc receptors for IgG. This study describes further differences between the SC activities of IEL and PBL.

A strain gauge device called the electronic contractility meter (ECM) was designed to measure quantitatively intestinal ischemic damage by delivering electrical stimuli to the intestine. Threshold stimulus level (TSL) was the minimum stimulus in milliamps necessary to produce a smooth muscle contractile response. TSL scale ranged from zero to 100 milliamps. Resection and anastomosis in ischemic intestinal segments was carried out in 30 dogs to compare TSL, intestinal color, peristalsis, Doppler ultrasound and resection margin histology with survival. There were five fatal anastomotic leaks, all resulting from intestinal necrosis. Doppler pulse in the marginal artery (MA) was absent at four of the five anastomoses that leaked versus eight of the 25 that healed (p less than or equal to 0.01). Mean TSL at the resection site was 38 +/- 7 milliamps in surviving dogs versus 51 +/- 4 milliamps in nonsurvivors (p less than or equal to 0.001). Mean TSL of normal intestine was 22 +/- 2 milliamps. Both TSL and Doppler ultrasound also correlated with resection margin histology (p less than or equal to 0.02 and p less than or equal to 0.005, respectively). Presence of peristalsis did not correlate with histologic grade or survival rate. Intestinal color correlated with resection margin histology (p less than or equal to 0.001) but not survival. The ECM and Doppler ultrasound were both superior to gross visual assessment in predicting intestinal survival. The ECM quantitatively measures tissue damage, a potential advantage over Doppler ultrasound, which provides only an estimate of local arterial blood flow.

The diarrhea observed after infusing hypertonic enteral alimentation solutions may be due to the high osmolality. We compared Vivonex HN (810 mOsm) to Osmolite (300 mOsm) in two canine ileus models. After having bipolar electrodes implanted in the stomach, duodenum, jejunum, and colon, four dogs sequentially underwent operations to produce intestinal obstruction (SBO) or perforation/peritonitis (PER). The SBO was released and the perforation closed 24 hr later. GI myoelectric activity (MEA) was monitored during the first 4 postoperative days and again on the 10th day to determine steady-state MEA. Fasting MEA was recorded for 1 hr, followed by 1-hr recordings after intragastric cannula infusion of either Vivonex HN or Osmolite. There was no significant difference in MEA produced by Osmolite vs Vivonex at any recording site. The 24-hr postop gastric and small bowel MEA was significantly decreased (p less than 0.05) vs postoperative days 2 to 4 and 10 under both fasting and fed conditions. The ileus operations had no effect on colonic MEA. These data show that SBO and PER cause significant decreases in gastrointestinal MEA for 24 hr. There was no difference in MEA response of Osmolite vs Vivonex HN. These results suggest that infusion of hypertonic enteral alimentation solutions does not produce increases in GI myoelectric responsiveness vs isotonic solutions.

DRG #288 is composed of operative procedures performed for obesity, both gastric and plastic. A two-year cost analysis of 103 consecutive gastric reduction operations performed for morbid obesity was conducted at Robert Wood Johnson University Hospital. It showed a net loss to the hospital of $18,033 in 1984 and $24,126 in 1985. Although the mean length of stay was 1.43 days less in 1985 than in 1984, DRG #288 was still a money loser. A detailed cost breakdown of nine active cost-center categories showed large financial disincentives (losses) in surgical supplies, OR/recovery room time and X ray utilization during both years of the study. These losses were not offset by substantial profits in the room-and-board category, which is directly related to length of stay. It is intuitively obvious that plastic surgical procedures for obesity require less expensive surgical supplies, fewer X rays, and shorter OR/recovery room times than gastrointestinal operations performed for morbid obesity. We conclude that DRG #288 is improperly constructed because it contains a clinically incoherent, heterogeneous mixture of operations that cannot be expected to consume similar amounts of resources and incur similar costs. Hospitals in which the preponderance of operations performed for obesity are gastrointestinal as opposed to plastic are inherently penalized by the current aggregation of DRG #288.

From January 1973 through December 1977, 580 patients presented with 624 episodes of upper gastrointestinal hemorrhage at the University fo Pittsburgh Health Center Hospitals. Ninety-one patients (15%) underwent operation for uncontrollable hemorrhage. Operative mortality was 30 per cent for all patients and 21 per cent for patients with gastroduodenal bleeding (duodenal ulcer, gastric ulcer, erosive gastritis). In patients with gastroduodenal bleeding, seven of 15(47%) with preoperative hypotensive shock (systolic b.p. less than or equal to .02). Twenty-five patients had vagotomy and pyloroplasty with suture ligation of bleeding ulcers, while 34 patients underwent gastric resection. The operative mortality for resection was 21 per cent (7/34) compared with 16 percent (4/25) for vagotomy and pyloroplasty. The incidence of rebleeding was 15 per cent (5/34) for resection and 8 per cent (2/25 for vagotomy and pyloroplasty. Nine patients (26%) has suture-line leaks following resection, and none were found after vagotomy and pyloroplasty. Severe of nine patients (78%) who had leaks after resection had hypotensive shock prior to operation. Six of the seven patients who died following gastric resection had complication (either leak or rebleeding) directly related to the operative procedure, while the four deaths following vagotomy and pyloroplasty occurred in patients not having procedure-related complications. Procedure-related morbidity (leaks and rebleeding) with resection (41%) was significantly higher than with vagotomy and pyloroplasty (8%) (P less than or equal to .01). These data show vagotomy and pyloroplasty to be the safer operation for patients with uncontrollable gastroduodenal hemorrhage, particularly those with preoperative hypotension.