A new biliodigestive anastomosis technique to prevent reflux and stasis

BACKGROUND: The Roux-en-Y procedure for biliodigestive drainage is most widely accepted, but 10% to 15% of patients postoperatively suffer from a blind-loop syndrome or cholangitis due to motility disorders. A new biliodigestive technique is evaluated in a rat model to prevent these complications. METHODS: This experimental study in Wistar rats compares the Roux-en-Y technique with a new biliodigestive anastomosis creating a jejunal loop with luminal occlusion. Clinical parameters, small bowel motility, bacteriologic growth, and liver histopathology were evaluated in native and postoperative animals within a study period of 180 days. RESULTS: Both operative procedures were well tolerated. After 6 months intense fibrosis of the liver and high-grade purulent cholangitis were observed in animals in the Roux-en-Y group. In these animals enterobacter and enterococci overgrowth was found. Myoelectric small bowel recordings revealed significant impairment of slow-wave frequency, aboral velocity, and action potentials (percentage of phase III) in Roux-en-Y animals. CONCLUSIONS: Motility disorders after conventional Roux-en-Y biliodigestive anastomosis are pivotal for histomorphological damage and infectious findings and can be prevented by using the new technique to create a jejunal loop with luminal occlusion.     

Off-pump coronary artery bypass attenuates transient hepatocellular damage after myocardial revascularization

OBJECTIVE: Cardiopulmonary bypass (CPB) affects hepatocellular integrity and occasionally results in liver dysfunction after cardiac surgery. Performing coronary artery bypass graft surgery without CPB may help to reduce the risk of this complication and better preserve perioperative liver function. This study compared perioperative hepatocellular damage in patients undergoing on-pump and off-pump bypass surgery. DESIGN: Prospective study. SETTING: University hospital. PARTICIPANTS: Patients scheduled for elective on-pump (n = 21) and off-pump (n = 17) coronary artery bypass surgery. MEASUREMENTS AND MAIN RESULTS: Liver function was assessed by serum levels of alcohol dehydrogenase (AD) and alpha-glutathione S-transferase (alpha-GST), which serve as more sensitive indices of hepatocellular injury than do conventional transaminases. Arterial blood was sampled at 6 stages: after induction of anesthesia (baseline); at the end of CPB in the on-pump group or on completion of the last distal anastomosis in the off-pump group; at the end of surgery; and 6 hours, 12 hours, and 24 hours after the end of anesthesia. The off-pump patients showed significantly lower increases in serum AD and alpha-GST levels than did the on-pump group. AD and alpha-GST values increased in the on-pump patients after the initiation of CPB and peaked at the end of surgery, with a return to baseline at 12 hours and 24 hours after the end of anesthesia. No clinically relevant liver dysfunction was observed in either group. CONCLUSIONS: CPB induced transient subclinical hepatocellular damage, whereas off-pump revascularization attenuated this damage.     

"Syndrome in syndrome": Wernicke syndrome due to afferent loop syndrome. Case report and review of the literature

Wernicke syndrome is a rare neurological pathology due to a deficit in vitamin B1. The syndrome is common among alcohol abusers, patients with malignant tumor or gastrointestinal diseases, those who undergo hemodialysis or long-term peritoneal dialysis, pregnant women with hyperemesis, women who breast-feed, patients with hyperthyroidism or anorexia nervosa or gastric or jejunal-ileal bypass surgery for obesity, patients submitted to gastric surgery or prolonged total parenteral nutrition or prolonged intravenous therapy. We report a case of Wernicke syndrome due to afferent loop syndrome characterized by incoercible vomiting.     

Do Arthralgias Occur after Bilio-intestinal Bypass for Morbid Obesity

Background: Intestinal bypass operations are used occasionally for treating morbid obesity if other methods are unsuitable. Jejuno-ileal bypass (JIB) operations are considered to be a cause of occasional joint pain related disorders. However, biliointestinal bypass (BIB) is intended to avoid the blind loop syndrome. This study compared joint pain disorders in an operated BIB group, an obese nonoperated control group, and a lean reference group. Methods: Using a questionnaire in a cross-sectional study, pain disorders were investigated in age-, sex- and weight-matched groups of operated, obese and lean subjects. The operated group had previously had a BIB and was matched using the preoperative BMI (body mass index, kg/m²). Results: Mean time since operation was 12.4 years (SD 3.4) and the BIB group had lost 15.2 kg/m² compared with the obese control group. These two groups had a high frequency of pain disorders of similar distribution, differing significantly from the lean reference group. No evidence of major differences in the type of pain disorders could be seen in the two groups. Conclusion: Pain disorder was an integral part of an obese syndrome, and was not affected significantly by weight reduction after BIB. The study appears to support the view that approximately 4% of patients develop arthritis vasculitis syndrome after BIB.     

Liver conditioning after cardiac arrest: the use of normothermic recirculation in an experimental animal model

The aim of this study was to compare the possible role of normothermic recirculation with the role of liver transplants from non-heart-beating donor pigs after 20 min of cardiac arrest. Three groups were studied, of which two were control groups: group 1, in which the liver was harvested from a heart-beating donor; group 2, in which the liver was harvested after a period of cardiac arrest followed by total body cooling; and group 3, in which the liver was procured as in group 2, but including a period of 30 min of cardiopulmonary bypass and tissue oxygenation at 37 °C before total body cooling. Survival at 5 days; endothelial (hyaluronic acid) and hepatocellular damage (AST, ALT, and α-GST); adenine nucleotides (energy charge), and histological changes were evaluated. Normothermic recirculation during 30 min showed a significant effect on survival (p = .03), endothelial damage (p < .05), and histological changes after reperfusion (p = .04). Cardiopulmonary bypass significantly increased the energy charge during the normothermic recirculation period (p = .001). Moreover, this study shows that a significant survival (100 %) can be achieved with a liver allograft after 20 min of cardiac arrest. Although the liver suffers a major insult in terms of endothelial damage and hepatocellular damage, lesions caused by the ischemic injury are reversible. Histological changes also indicate lesion reversibility, since they almost disappear after 5 days. Received: 10 November 1997 Received after revision: 24 April 1998 Accepted: 8 July 1998     

Bilio-pancreatic bypass for obesity: 1. An experimental study in dogs.

Bilio-pancreatic bypass is a new procedure that tries to obtain a maldigestion syndrome with selective malabsorption of the main high calorie foods. The operation consists of a gastric resection and division of the proximal jejunum just distal to the ligament of Treitz. A gastroentero-anastomosis is then constructed using the distal end of the transected jejunum, while the proximal jejunum is anastomosed to the side of the distal ileum. An experimental study carried out on 12 dogs confirmed that the operation causes a selective malabsorption with loss of weight and no complications. On the basis of this study it is suggested that this procedure has the following advantages over jejuno-ileal bypass: (a) normal absorption of bile salts, water and electrolytes; (b) slow recovery of absorption; (c) absence of a blind loop.     

Gastritis after gastric bypass surgery

To determine the preferable reconstruction of gastrointestinal continuity after gastric bypass, we studied by endoscopic, chemical, and histologic analyses 28 randomly selected patients with a loop gastroenterostomy, a loop gastroenterostomy plus enteroenterostomy between the afferent and efferent loops, and a Roux-en-Y anastomosis. Total bile acid levels for the three groups were: 5092 +/- 1673 mumol/L, 1638 +/- 581 mumol/L, and 404 +/- 384 mumol/L, respectively. The incidence of gastritis by endoscopy was 71% in the standard loop bypass, 45% in the enteroenterostomy group, and 13% in the Roux-en-Y group. Histologic abnormalities were present in 86% of the patients who underwent standard loop bypass, in 91% of those with an additional enteroenterostomy, and in 63% of the Roux-en-Y group. There was poor correlation of symptoms and objective findings. In our study Roux-en-Y reconstruction after gastric bypass, in comparison with loop gastroenterostomy or loop gastroenterostomy with an additional enteroenterostomy, is less likely to result in bile in the stomach, endoscopic changes, and histologic abnormalities.     

Liver Biopsies Following Ileogastrostomy

Patients who have had ileogastrostomy for the treatment of morbid obesity require close, long-term follow-up. One concern in patients undergoing any form of intestinal bypass surgery is that of possible liver damage. To assess for possible liver damage in morbidly obese patients undergoing ileogastrostomy, we undertook a prospective study of liver biopsies in 12 consecutive patients. Preoperative and 2-year postoperative biopsies of the liver were planned. There were six liver biopsies available for comparison both pre- and post-operatively. The biopsies showed changes of fatty infiltration both pre- and post-operatively. There were no differences in the degree of fatty infiltration, or of other histological parameters which we measured. There were no cases of cirrhosis of the liver recorded.     

保留半肝动脉血供肝血流安全阻断时限的研究

目的：探讨门静脉自然转流及非转流情况下保留半肝动脉血供肝血流阻断的安全时限。方法：将实验大鼠分为A、B、C组。A组保留肝左、肝中动脉血供及尾状叶动脉、门静脉血供（约占全肝5％）,夹闭肝左、肝中0tl＇]静脉,结扎肝右叶肝蒂,到预定阻断时相点,恢复肝脏灌流,切除肝右叶及尾状叶,24h后检测ALT、肝脏HE染色（细胞核）BSJI~面积的平均百分数及术后7d存活率。B组不保留尾状叶动脉、门静脉血供,其他与A组相同。C组完全阻断肝脏入肝血流,肝切除方式及检测指标与A组相同。结果：在A、B、C3组中,A组的阻断形式对肝脏的损害最轻,B组次之,C组最重。A/100、B／40与C／20损害程度相当。结论：大鼠门静脉转流下保留半肝动脉血供入肝曲流阻断的安全时限是100min,单纯保留半肝动脉血供入肝血流阻断组的安全时限是40min。     

Adult respiratory distress syndrome after cardiac surgery

Adult respiratory distress syndrome, characterized by high permeability pulmonary oedema caused by endothelial cell damage, resulting in refractory hypoxemia, has a very high mortality. Cardiopulmonary bypass is said to be responsible for the development of adult respiratory distress syndrome after cardiac surgery. The present study was performed in order to identify predicting and aetiological factors of adult respiratory distress syndrome and multiple organ failure after cardiac surgery. Between January 1984 and December 1993, 3848 patients underwent cardiac surgery with cardiopulmonary bypass in the authors' institution, and were analysed in a retrospective manner. The operations performed were 3444 coronary artery bypass grafts (CABG), 267 valve and 137 combined (CABG + valve) procedures. The incidence of adult respiratory distress syndrome was 1.0% (38 of 3848) with an overall mortality rate of 68.4% (26 patients); 24 of these died from multiple organ failure. Multivariate regression analysis identified hypertension, current smoking, emergency surgery, preoperative New York Heart Association (NYHA) class 3 and 4, low postoperative cardiac output and left ventricular ejection fraction < 40% as significant, independent predictors for adult respiratory distress syndrome. Combined cardiac surgery and diffuse coronary disease were also significant predictors; cardiopulmonary bypass time was not. Thirty-six of the 38 patients that later developed adult respiratory distress syndrome had low postoperative cardiac output, 12 requiring intra-aortic balloon pump support. The remaining two had severe hypotension caused by postoperative bleeding. Twenty-six adult respiratory distress syndrome patients (68%) had confirmed gastrointestinal complications (e.g. intestinal ischaemia). Adult repiratory distress syndrome is a rare complication after cardiac surgery but is associated with a very high mortality. Preoperative predictors were identified. Cardiopulmonary bypass alone was not found to be an important factor. Postoperative low cardiac output leading to splanchnic hypoperfusion may be the most important single factor in developing adult respiratory distress syndrome after cardiac surgery.     

Treatment of liver failure post one anastomosis gastric bypass by revising to normal anatomy: A case report

IntroductionObesity and the associated metabolic syndrome are global health problems. Significant weight loss after bariatric surgery can cause a substantial difference in those comorbidities in obese patients. In this case, we described a rare complication of a patient who developed acute liver failure after an uneventful one anastomosis gastric bypass treated conservatively and revision of the one anastomosis gastric bypass to normal anatomy.Case presentationWe present a 52-year-old female known to have hypothyroidism and morbid obesity with a BMI of 45. For that, she underwent uneventful one anastomosis gastric bypass. Later, she developed liver failure and hepatic encephalopathy, which was managed conservatively and revision surgery to normal anatomy.DiscussionBariatric surgery plays an integral role in treating obese patients for its associated impacts, like facilitating weight loss and related metabolic syndrome improvement. The effects of bariatric surgery on liver functioning are controversial. Some malabsorptive procedures are linked to postoperative hepatic complications. However, it is uncommon in a recent new technique in bariatric surgery. Liver transplant and revision of the bariatric surgery have been described as management. However, optimal nutrition support without a liver transplant along with revision surgery is possible in experienced hands.ConclusionEarly detection of liver impairment and early intervention by a revision to normal anatomy by an experienced surgeon is considered the safest and most effective procedure for such patients. However, late detection where liver failure occurs, liver transplantation is the only effective treatment for preventing fatal outcomes.     

Serum activity of ornithine carbamoyl transferase in patients operated with jejunoileal bypass for extreme obesity after pretreatment with aminoacids

Increased blood level of the liver specific enzyme ornithine carbamoyl transferase (OCT) is known to be a sensitive indicator of liver cell damage. The effect of preoperative aminoacid infusion to obese patients before jejunoileal bypass due to obesity was studied in 7 patients. They had a significantly lower rise on OCT than eight patients receiving only 5.5% glucose. The result seems to indicate that the liver in an obese patient undergoing abdominal surgery is protected against damage by an infusion of aminoacids.     

Adult Jejunojejunal Intussusception After Jejunoileal Bypass Bariatric Surgery

The jejunoileal bypass is one of the bariatric surgical options which have been abandoned for two reasons: first, it leads to severe malnutrition and liver failure and, second, the bypassed jejunum—being a blind loop—is susceptible to bacterial accumulation which might become a source of sepsis due to bacterial translocation. We hereby report a case of a 27-year-old lady who presented with jejunojejunal intussusception of the blind jejunal loop 2 years after jejunoileal bypass surgery. This complication could have led to serious consequences if it was not managed in the appropriate time.     

应用供者髂动脉行腹主动脉搭桥重建移植肝动脉的临床分析

目的探讨应用供者髂动脉行腹主动脉搭桥重建移植肝动脉对肝移植受者预后的影响。 方法回顾性分析中国医科大学附属第一医院2006年1月至2018年4月应用供者髂动脉行腹主动脉搭桥重建肝动脉的肝移植受者临床资料,观察其术后肝功能恢复情况及肝动脉血栓等并发症的发生情况,分析采用搭桥方式进行移植肝动脉重建的原因。 结果共纳入8例受者,其中1例存在脾动脉盗血综合征导致肝总动脉供血不足,3例肝总动脉纤细,4例肝总动脉壁薄弱或分层。重建后肝动脉平均血流为(315±178)mL/min。术后2例受者分别因肝脏流出道和胆管吻合口狭窄导致黄疸,其余受者移植肝功能恢复良好。1例受者术后2个月出现肝动脉血栓形成,继发肝脓肿,半年后因多脏器功能衰竭死亡。其余7例受者随访至2018年11月均存活,肝动脉均通畅,无狭窄或血栓形成。 结论当供、受者常规肝动脉端端吻合无法实施时,应用供者髂动脉行腹主动脉搭桥重建移植肝动脉是一种可行的肝动脉重建方法。     

Multiple malignant lymphoma within an ileal blind loop

A 55 year old woman presented to our hospital with abdominal fullness and edema of both legs. She had undergone a bypass operation by an ileotransversostomy for adhesive ileus following a drainage operation for acute appendicitis 35 years previously. We diagnosed the patient as having blind loop syndrome as a consequence of the side-to-side ileotransversostomy, and performed a right hemicolectomy and intestinal resection. The resected specimen of dilated ileal blind loop contained 15 crater-like lesions, proven histologically to be nodular proliferation of atypical lymphocytes. Lymph follicles had also proliferated in the mucosa of the blind loop and the histologically confirmed diagnosis of non-Hodgkins lymphoma of the diffuse medium-sized cell type was thus made. The etiology of such tumors is probably related to the alteration in intestinal environment caused by conditions such as fecal stasis, bacterial overgrowth, and bacterial toxins in the blind loop.     

Cavoatrial bypass in obstruction of the inferior vena cava in the hepatic portion through the posterior route of the hepatic caudate lobe

In a 32-year-old Japanese female who had a history of Sj?gren's syndrome, the obstruction of the inferior vena cava in the hepatic portion was found associated with Budd-Chiari syndrome. The obstruction of the inferior vena cava was about 6 cm in length by cavography. Cavoatrial bypass grafting was successfully performed with a 16 mm ring reinforced expanded polytetrafluoroethylene graft, which ran behind the caudate lobe of the liver and connected to the right atrium via right pleural cavity. This may be the first report of the posterior route of the hepatic caudate lobe in cavoatrial bypass grafting in Japanese and English literature.     

Multiple malignant lymphoma within an ileal blind loop--report of a case

A 55-year-old woman presented to our hospital with abdominal fullness and edema of both legs. She had undergone a bypass operation by an ileotransversostomy for adhesive ileus following a drainage operation for acute appendicitis 35 years previously. We diagnosed the patient as having blind loop syndrome as a consequence of the side-to-side ileotransversostomy, and performed a right hemicolectomy and intestinal resection. The resected specimen of dilated ileal blind loop contained 15 crater-like lesions, proven histologically to be nodular proliferation of atypical lymphocytes. Lymph follicles had also proliferated in the mucosa of the blind loop and the histologically confirmed diagnosis of non-Hodgkins lymphoma of the diffuse medium-sized cell type was thus made. The etiology of such tumors is probably related to the alteration in intestinal environment caused by conditions such as fecal stasis, bacterial overgrowth, and bacterial toxins in the blind loop.     

Cavoatrial bypass for occlusion of the inferior caval vein in a patient with Budd-Chiari syndrome

We report the case of a young man with Budd-Chiari syndrome and occlusion of the inferior caval vein. Peripheral edema was his predominant complaint. Symptoms of portal hypertension were lacking, indicating membranotomy and not portosystemic shunting as the treatment of choice. At operation, membranotomy was not feasible, and a cavoatrial bypass using a 22 mm Gore-Tex graft was placed instead. Shortly after the operation the peripheral edema vanished, diuretic treatment could be withdrawn, and liver function improved. Eighteen months later the bypass remains patent, edema is absent, and liver function is stable. We conclude that cavoatrial bypass is a therapeutic option in patients with occlusion of the inferior vena cava with no clinical symptoms of portal hypertension if transcardiac membranotomy is not feasible.     

Ileostomy of the distal end of the bypassed intestine in a patient with jejunoileal bypass for obesity

Ileostomy of the distal end of the bypassed segment of small intestine was done twenty-three months after a 28 to 20 cm (12 to 8 inch) end-to-end jejunoileal bypass for obesity (Scott operation) in a forty-eight year old white female, thus creating a Thiry fistula. Weight prior to jejunoileal bypass was 130 kg (287 pounds). Before ileostomy it had stabilized at 80.3 kg (177 pounds). Indications for ileostomy were three episodes of blind loop syndrome and three episodes of severe bleeding from the ileotransverse colostomy anastomotic site. Culture of the bypassed segment at laparotomy revealed bacteroides, clostridia, and other anaerobes as well as the usual aerobic large bowel flora. After ileostomy the bypassed segment contained no anaerobic bacteria. Daily fluid output from the ileostomy has decreased with time, averaging 436 ml per day for the first postileostomy month and 50 ml per day for the ninth month. Beneficial effects of the ileostomy include: (1) better sense of well being; (2) no further episodes of blind loop syndrome or intestinal bleeding; and (3) cessation of anal itching. Nine months after ileostomy, hyperoxaluria and acquired megacolon were present. Weight was 5.9 kg (13 pounds) greater than before ileostomy.     

Lung injury and acute respiratory distress syndrome after cardiopulmonary bypass.

Cardiopulmonary bypass is often followed by pulmonary dysfunction as assessed by measuring the alveolar-arterial oxygenation gradient, intrapulmonary shunt, degree of pulmonary edema, pulmonary compliance, and pulmonary vascular resistance. It is also regarded as a risk factor for development of acute respiratory distress syndrome. On the other hand, cardiopulmonary bypass is associated with a whole body inflammatory response, which involves activation of complement, leukocytes, and endothelial cells with secretion of cytokines, proteases, arachidonic acid metabolites, and oxygen free radicals. Leukocyte adhesion to microvascular endothelium, leukocyte extravasation, and tissue damage are the final steps. Although the inflammatory response to cardiopulmonary bypass often remains at subclinical levels, it can also lead to major organ dysfunction and multiple organ failure. This review article summarizes the recent literature on the molecular and cellular mechanisms involved in the phenomenon of pulmonary dysfunction after cardiopulmonary bypass. It also summarizes reports on the prevalence and mortality of acute respiratory distress syndrome after cardiac surgery.