Experiences with antireflux valves in jejunoileal bypass surgery

Intussusception valves were created in the small intestine of jejunoileal bypass-operated dogs and patients with the intention to prevent reflux of chyme into the excluded intestinal loop and thereby increase weight loss. In the dogs the valves were shown to withstand a pressure of at least 100 cm of water. All patients with end-to-side bypass were at X-ray examination found to have sufficient valves whereas only four of fourteen with end-to-end bypass, where the defunctionalized loop was implanted into the cecum, had tight valves. During five years of observation no significant difference in weight loss was seen between the patients with valves and control groups without valves. It is concluded that reflux of chyme only plays a minor role for weight loss after jejunoileal bypass for obesity.     

Quadruple valve surgery in carcinoid heart disease

Abstract   We describe a 42-year-old male with primary carcinoid tumor of the ileum, secondary liver metastases, and subsequent severe carcinoid heart disease with quadruple valve involvement. The patient underwent tricuspid and pulmonic bioprosthetic valve replacement, mitral and aortic valve reconstruction. Transthoracic echocardiography at 25 months showed competent mitral and aortic valves with only mild regurgitation. Valve reconstruction is rarely performed in patients with carcinoid heart disease. However, in selected cases it is a valuable alternative technique with good mid-term outcome.     

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.     

A prospective comparison of gastric and jejunoileal bypass procedures for morbid obesity.

A randomized prospective evaluation of the gastric and jejunoileal bypass procedures for morbid obesity was performed. The gastric bypass was performed predominantly as a 90% gastric exclusion with a Roux-en-Y reconstitution. The jejunoileal bypass was an end-to-end anastomosis between 30 cm of jejunum and 25 cm of terminal ileum, the bypassed segment of small bowel being decompressed by an end-to-side ileocolostomy. There were 32 patients in the gastric group and 27 in the jejunoileal group. The two groups were comparable in age, preoperative weight and height. There were no postoperative deaths, but the gastric bypass operation was associated with a slightly higher early complication rate indicating it is a more technically demanding procedure. Late sequellae were more prominent in the jejunoileal bypass group and included significant diarrhea in 56% and need for medication in 74%. Kidney stones and cholelithiasis also complicated the jejunoileal group and were not seen after gastric bypass. All patients showed fatty metamorphosis on the original liver biopsy. This had worsened in 75% of the jejunoileal group at one year whereas it had improved or was stable in all of the patients in the gastric group.     

Mucin changes in ileoanal pouches monitored by metabolic labelling and histochemistry.

The pattern of mucin synthesis and secretion in mucosal biopsies from the proximal ileum, distal ileum, rectum and pouch before and after ileostomy closure was monitored in patients undergoing restorative proctocolectomy by metabolic labelling with [3H]glucosamine and [35S]sulphate and compared with the mucin histochemistry in each patient. Metabolic labelling clearly demonstrated a reduction in sulphation associated with the rectal mucosa in colitis. Significant differences in the turnover of isolated secreted mucin between proximal and distal ileum and rectum were also found, as was a metaplastic change towards a colonic-type mucosa in the pouch before and after ileostomy closure relative to the proximal and distal ileum, and rectum. This technique can be used to monitor colonic metaplasia in the pouch mucosa and is suitable for comparative studies where mucin changes are implicated.     

Concomitant aortic valve replacement and coronary bypass: the effect of valve type on the blood flow in bypass grafts.

OBJECTIVE: In cases of aortic valve replacement, the downstream flow profile and turbulence in the ascending aorta differ according to the prosthetic aortic valve implanted. The objective of this work is to study the influence of prosthetic valve type on the flow in the bypass grafts implanted to the ascending aorta in cases of concomitant aortic valve replacement and coronary artery bypass. METHODS: The study is conducted on 456 patients receiving concomitant aortic valve replacement and coronary bypass vein grafts anastomosed to the ascending aorta. The patients included in the study received a total number of 725 vein grafts, 249 biological aortic valves and 207 mechanical aortic valves. Intraoperative transit time flow measurement was done for all bypass grafts and a multiple regression model was calculated for the factors influencing the flow in the bypass grafts. RESULTS: The mean flow in vein grafts in patients receiving biological valves was 49.79+/-26.88 ml/min, while in patients receiving mechanical valves it was 46.54+/-26.68 ml/min. The multiple regression model revealed that receiving a mechanical valve is an independent risk factor for lower flow in the vein grafts. CONCLUSIONS: The type of the aortic valve implanted and consequently the downstream flow profile in the ascending aorta do affect the flow in the vein grafts in cases of concomitant aortic valve replacement and coronary bypass. Receiving a mechanical aortic valve is an independent risk factor for lower flow in the vein grafts.     

A randomized prospective study of valvulotome efficacy in in situ reconstructions.

OBJECTIVES: To compare the efficacy of valvulotomes during in situ bypass surgery. DESIGN: A randomized prospective blinded study. MATERIALS AND METHODS: Thirty PAD patients scheduled for infrainguinal greater saphenous vein bypass were randomized to use of adjustable or fixed valvulotomes for valve destruction. Valvulotomy was performed after construction of the proximal anastomosis. The efficacy of valve destruction was determined by angioscopy after completion of the distal anastomosis by a separate blinded examiner. RESULTS: A total of 123 valves were evaluated, 61 after use of an adjustable and 62 with a fixed valvulotome. There was no difference ( p = .88) in number of retained valves between the two groups ( n = 16, 17, respectively). The majority of incompletely destroyed valves were found in the proximal parts of the graft (46%, 13 out of 28). The primary patency at 30 days was 100 and 79%, respectively, p = .09). CONCLUSIONS: No significant difference in efficacy between valvulotomes was found. Both types tend to miss a large proportion of proximal valves.     

Jejunoileal bypass. A legacy of late complications

Since 1977, we have managed 56 patients (36 Payne and 20 Scott bypasses) with late (one to 18 years) complications resulting from a jejunoileal bypass. All patients underwent a one-stage conversion of the jejunoileal bypass to a gastric bypass. Patients were classified according to postbypass weight, the need for nutritional support, the type and severity of complication, and the time interval between jejunoileal bypass and the onset of the complication and correction of the complication. There were no operative deaths; one patient died 18 months after surgery of cirrhosis. The complication rate was 34%; however, most complications were minor. Our experience with this procedure has shown it to be highly effective in correcting complications other than polyarthritis. When coupled with nutritional support, it is safe even in malnourished patients.     

A Novel Technique to Relieve a Closed-Loop Obstruction Secondary to a Competent Ileocecal Valve and an Unresectable Mid-Colon Tumor

A competent ileocecal valve complicates the surgical treatment of an unresectable obstructing mid-colon tumor. Specifically, it may not be feasible to bypass with a colocolotomy, especially when the sigmoid colon has limited mobility or if the ascending colon is severely distended and edematous. A technique is described in which the closedloop obstruction is relieved at its proximal extent by an ileocecal valvuloplasty. A circular stapling device is fired across the ileocecal valve. Once the ileocecal valve is rendered competent, a loop ileostomy or a colocolotomy can be constructed, providing effective palliation for this difficult situation.     

Hemodynamic effects of venous valves in aorto-coronary bypass grafts.

Use of the saphenous vein in aorto-coronary bypass surgery for treatment of occlusive coronary artery disease is a well-established technique. Use of the mammary artery for the same purpose has also been favorably reported. This study was undertaken to determine whether a vein graft containing a valve would have an added advantage. A comparison of the effect of competent and incompetent valves in vein grafts on the hemodynamics of coronary circulation was made. In a group of 18 dogs, a 5 cm. portion of each dog's cephalic vein containing a valve was used in a single aorto-coronary bypass graft. Flow measurements were made between the valve and the anastomosis of the graft to the left anterior descending coronary artery (LAD). The valve was made temporarily incompetent by the insertion of a spring wire basket, 3.5 mm. in diameter, through the valve via a side branch. The flow of blood through the venous graft with the competent valve was 11.0 +/- 2.6 per cent higher than with the incompetent valve. An analysis of flow patterns showed that this increased flow could be attributed to a reduction of backflow during systole and an increase in forward diastolic flow. Results suggest that postoperative myocardial perfusion is enhanced by the presence of valves in aorto-coronary bypass vein grafts.     

心脏不停跳下行瓣膜置换及冠状动脉旁路移植术

目的 总结心脏不停跳下瓣膜置换及冠状动脉旁路移植术的体会,并评估其疗效.方法 对2005年1月至2007年8月12例同时合并冠状动脉粥样硬化性心脏病和心脏瓣膜病的病人进行手术.病人术前均存在心绞痛症状,心功能为Ⅱ～Ⅳ级,术前射血分数平均0.53±0.23.不停跳下进行冠状动脉旁路移植及瓣膜置换术,比较术前及术后相关心功能指标.结果 病人均痊愈出院.平均移植血管(3.4±1.5)支.复查时所有病人均无症状.心功能及射血分数均显著提高(P<0.001).结论 在心脏不停跳下行瓣膜置换及冠状动脉旁路移植术可行,并发症少.术后早期心功能、自主症状及生活质量均显著改善.远期疗效尚需观察.     

The continent ileostomy--indication and results

Proctocolectomy with conventional ileostomy cures patients with severe ulcerative colitis, however ileostomy appliances had to be worn for the rest of their lives. The continent ileostomy as devised by Kock provides the patient with an intraabdominal ileal reservoir and a valve constructed by invaginating the efferent ileal segment into the reservoir. The patient empties his reservoir 2 to 3 times a day by inserting a catheter through the valve. Our experience with 45 patients is reported. In most cases the continent ileostomy was constructed as a second procedure after proctocolectomy. The construction of a continent ileostomy as a secondary procedure can be recommended in patients with proctocolectomy. It offers patients a life situation differing only insignificantly from that of normal persons.     

Metabolic consequences from conversion of jejunoileal bypass to gastric bypass.

Conversion of jejunoileal bypass to gastric bypass was performed in 11 patients because of metabolic problems and physical discomforts, and in three patients because of insufficient weight loss. There was no mortality and little morbidity after operation. An additional mean weight loss of 6% occurred, and weight stabilized satisfactorily in most patients. Two patients regained significant weight. Serum cholesterol levels rose within a month in most patients, with a mean increase of 61%. However, levels remained within normal limits. Serum triglyceride levels did not change significantly, especially in patients whose weight remained stabilized. Plasma glucose levels remained normal in all patients, including four patients who had been clinically diabetic before jejunoileal bypass. These patients had become normoglycemic immediately after jejunoileal bypass, and remained normal after conversion to gastric bypass.     

Improvement in forward coronary blood flow by using a reversed saphenous vein with a competent valve.

Reversed segments of saphenous vein have been the grafts of choice for aortocoronary bypass (ACB). Internal mammary arteries and free radial autografts have recently been shown to have a higher ppatency rate, but flow is usually lower. Normally forward coronary blood flow ceases and retrograde flow occurs during cardiac systole. Prevention of retrograde flow with a rapidly acting valve proximal to the coronary artery anastomosis should improve forward coronary blood flow. Thirty-nine reversed saphenous veins containing a competent valve were implanted in 32 patients undergoing ACB. After accurate zero flow was determined and a resting state achieved, mean (22 veins) and pulsatile (17 veins) flows were measured distal to the valve with the valve competent and temporarily incompetent. A competent valve in 10 right coronary artery vein grafts increased mean flow by 29.7% (+41 ml/min; p less than 0.005) and pulsatile flow in 6 veins by 17.7% (p less than 0.001). A competent valve in 12 left coronary artery vein grafts increased mean flow by 31.3% (+34 ml/min; p less than 0.01) and pulsatile flow in 11 veins by 13.7% (p less than 0.001). This study suggests that a portion of reversed saphenous vein containing a competent valve provides greater coronary artery blood flow than veins without valves and may be the conduit of choice for coronary artery revascularization.     

Endoscopic vein preparation in peripheral bypass surgery

The autogenous saphenous venous bypass is accepted as an optimal procedure for distal arterial reconstruction. For the past ten years the "in situ" technique was developed, and excellent results have now been achieved. The achilles heel of the method is the complete and atraumatic disruption of the valves. We use an angiofiberscope (Olympus PF 22A) with an outer diameter of 2.2 mm, being introduced through the proximal exposed end of the saphenous vein. Through the distal end or a side branch a modified Mill's Valvulotome with a flushing channel is moved upwards to the angioscope. Every valve cusp is incised under direct vision in a retrograde direction. Simultaneously relevant tributaries are angioscopically located and ligated through small skin incisions.     

Bypass enteritis. A new complication of jejunoileal bypass for obesity.

Four patients who had jejunoileal bypass for morbid obesity had increased frequency of diarrhea, diffuse abdominal tenderness and distention, and fever to 104 degrees F. Roentgenographic studies disclosed multiple distended loops in the bypassed bowel with few air fluid levels. Two of these patients underwent operation for suspected peritonitis from abscess or obstruction. No abscess or mechanical obstruction was found. The bypassed bowel contained many subserosal gas-filled blebs. The remaining two patients were treated with antibiotics and showed prompt improvement. "Bypass enteritis" must be considered in the postoperative period in patients undergoing surgery for morbid obesity. It responds to antibiotics and appropriate electrolyte therapy. The presumed factor is overgrowth of enteric bacteria in the distal portion of the bypassed bowel. Accurate diagnosis will obviate the need for surgical exploration to exclude peritonitis.     

"Insitutom RC": a new instrument for valve incision in in-situ vein bypass

The "in situ" bypass technique was first used by Cartier in 1960. It has only slowly gained acceptance among vascular surgeons. In part this can be explained by the lack of an easy and reliable method to render vein valves incompetent. The instruments most widely used for this purpose have been developed by Hall, Gruss and Leather ("Valve Stripper", "Insitucut" and "Valve Cutter", respectively). Based on theoretical considerations and practical experience, we have developed a new instrument for the incision of vein valves: the Insitutom RC. Unlike other instruments, it allows rotation control of the cutting blade and thus enables the surgeon to incise the valve cusps more precisely and reliably.     

具有防移位设计的可压缩性肺动脉支架瓣膜动物置入手术及体内测试

目的 探讨具有防移位设计的可压缩性肺动脉支架瓣膜的防移位效果.方法 将带瓣牛颈静脉缝在3个"Z"字型镍钛合金支架上,制作成喇叭口型肺动脉支架瓣膜.非体外循环下用推送器将其经右心室置入羊肺动脉瓣位置(n=6),分别于术后早期、术后2个月采用右心导管、心脏彩超、血流动力学测定、大体病理等方法评价置入瓣膜的位置和功能.结果 6只羊支架瓣膜均在正确位置释放.超声、右心导管造影以及血流动力学检查显示,术后早期、术后2个月置入瓣膜支架固定好,无移位,1例瓣膜收缩期跨瓣压差24 mm Hg,1例瓣膜轻度关闭不全,其他瓣膜功能良好.结论 喇叭口型支架有助于防止瓣膜移位.     

Autogenous venous valve transplantation in the dog

Incompetence of femoral vein valves has been causally linked to venous insufficiency of the lower extremities. Attempts to transplant competent venous valves into the femoral region have historically been associated with a high rate of early thrombosis. Using modern vasclar surgical techniques, 10 mongrel male dogs had 20 competent valves from the external jugular veins transplanted to both femoral veins. Five dogs (Group I) received no perioperative pharmacological therapy, while 5 dogs (Group II) received low-dose aspirin (2 mg/kg) daily. The surgical technique involved gentle, no-touch dissection of the external jugular veins, systematic anticoagulation with a single bolus of heparin (5000 units), excision of a valve-containing segment of the femoral vein, and transplantation of a valve-containing segment of external jugular vein using interrupted 7-O monoflament sutures. Early patency was confirmed by venography at 2, 7, and 14 days postoperatively. Five animals were sacrificed at 43, 65, 69, 91, and 105 days. Valve competency was evaluated by retrograde flushing. Group I had 100% early and late graft patency and valve competency. Group II had two thrombosed grafts (80% patency) with irreversible valve destruction. Both graft failures were associated with wound hematomas. These results suggest that autotransplantation of competent venous valves into the femoral region can be accomplished using modern vascular surgical techniques. Adjunctive measures such as distal arteriovenous fistulae or anti-platelet therapy do not appear necessary to maintain graft patency or valve competence.     

Aortic valve replacement and aorta-coronary bypass surgery. Results with perfusion of proximal and distal coronary arteries.

The results in 80 patients undergoing simultaneous aortic valve replacement and aorta-coronary saphenous vein bypass grafting were analyzed to assess the effect of operative technique. The over-all operative mortality rate of 6.3% (five of 80) did not differ significantly from our results with aortic valve replacement alone. All patients who had isolated aortic valve replacement were operated upon with moderate hypothermia. The combined operation was performed in two ways. Thirty-one patients had aortic valve replacement prior to bypass grafting with intermittent coronary ostila perfusion. There were two deaths (6.5%), and five myocardial infarctions (16.1%) were diagnosed by standard electrocardiographic and enzyme criteria. More recently, 49 patients have undergone bypass grafting prior to aortic valve replacement. The proximal ends of the grafts were either anastomosed high on the aortic root or else individually cannulated to provide continuous distal perfusion during subsequent aortic valve replacement, with continuous coronary ostial perfusion. There were three operative deaths (6.1%) and one myocardial infarction (2.0%). The risk of combined aortic valve replacement and coronary bypass need be no greater than the risk of aortic valve replacement alone. Our experience suggests that myocardial perfusion distal to significant coronary artery stenoses reduces the risk of myocardial infarction in patients with coronary artery disease requiring aortic valve replacement.