Surgical palliation of massive and severe obesity

Experience with planned small intestinal bypass for palliation in either massive or severe obesity in 123 patients is reported. The patients underwent careful preoperative evaluation which attempted to select those patients who were likely to have a marked improvement in their prognosis and who could be restored to a productive socioeconomic status. All patients had had multiple attempts at conservative therapy without effective control of the obesity. In addition, a number of patients had had other surgical conditions of the abdomen or disabling orthopedic or medical problems whose treatment, in the absence of obesity, would have been successful. A few had had life-threatening cardiorespiratory disorders, and control of obesity by aggressive surgical treatment was successfully applied.Jejunoileostomy with the end to side technic described by Payne was performed in all but two patients. The Salmon procedure was used successfully in two patients. Panniculectomy was a concomitant procedure in eighty patients.There were two deaths during the early postoperative period and one death from hepatic failure occurred six months postoperatively. Pulmonary embolism was the most serious postoperative complication but subcutaneous wound infection was a slightly more frequent postoperative complication in our series.Diarrhea occurred for varying periods postoperatively in almost all patients, but the electrolyte depletion did not cause any significant morbidity. Only four patients required supplemental therapy for hypokalemia.Results measured by an acceptable degree of weight loss in a twelve to eighteen month postoperative period were excellent in over 90 per cent of the patients followed up for one year or longer. Two patients underwent reversal of the bypass because of secondary problems. To date, it has not been necessary to reverse the procedure because of excessive weight loss in any patient in this series.Our studies and observations thus far suggest only a small risk of acute hepatic failure as a serious late complication. Almost all patients adapted well to the severe malabsorption and do not have evidence of a significant deficiency state. Vitamin B₁₂ absorption was markedly impaired postoperatively and parenteral vitamin B₁₂ must be given indefinitely.Weight loss ceased about twelve to fifteen months postoperatively in all patients and usually stabilized thereafter at a level somewhat above the ideal weight.Serum carotene determinations have proved to be a reliable test to assess the effectiveness of the intestinal bypass and have correlated quite well with the level of weight eventually attained.Secondary operations to increase malabsorption were performed in seven patients who had an inadequate response to initial jejunoileostomy. These reoperations produced less satisfactory weight reductions than did a properly performed primary procedure but appeared to be worthwhile in all but one patient. No late sequelae occurred in those patients who had additional shortening or revision of the bypass.Proper selection of patients for operation and frequent and thorough postoperative care are essential to obtain a good palliation.     

Metal allergy and the surgical patient

Allergy to metal implants is under study at the Dartmouth-Hitchcock Medical Center using in vitro examination of white blood cell migration. Retrospective data from 121 patients confirm that allergic responses do occur. Prospective data are being gathered to investigate the incidence, prevalence and relation to morbidity.     

Cervical pharyngostomy: A safe alternative for gastrointestinal decompression

Cervical pharyngostomy provides an alternative means of gastrointestinal decompression. It appears to have some advantages over nasogastric intubation for long-term use in seriously ill patients. The technic deserves a wider clinical trial.     

Thermal influence on the lymphocytic response of cancer patients.

A variation was noted between normal subjects and cancer patients in the response of their lymphocytes to different antigens. Raising the temperature from 37 degrees C to 40 degrees C aided in improving lymphocytic activity to the antigenic stimulation. The heat response was more noticeable in normal subjects than in cancer patients, which suggests that immunotherapy should be initiated early in patients with malignant disease before there is systemic involvement from an increasing tumor burden.     

Spontaneous regression of malignant melanoma. Pathologic and immunologic study in a ten year survivor

A gradual decrease in lymphocyte blastogenesis to autologous tumor cells was observed in a patient with an eight year history of metastatic cutaneous malignant melanomas. The appearance of visceral metastases was associated with a complete loss of lymphocyte reactivity in the mixed leukocyte-tumor cell assay. Simultaneously the marked infiltration of lymphocytes and plasma cells disappeared from the tumor nodules. This change in host response to autologous tumor was not associated with a generalized deterioration of the patient's immune responsiveness. These findings suggested the gradual emergence of a new cell line which was less antigenic than that of the original tumor. A serum factor that augmented lymphocytotoxicity disappeared after the emergence of visceral metastases.     

Arteriovenous malformations of the bowel: An obscure cause of bleeding

Of twenty-two patients with intestinal bleeding of obscure origin, four were found by mesenteric angiography to have arteriovenous malformations of the ascending colon after often repeated failure of intubation, endoscopy, barium contrast radiography, and even laparotomy to disclose the cause. The two male and two female patients, fifty-nine to seventy-four years of age, presented clinical pictures of chronic iron deficiency anemia; three had episodic gross hemorrhage. They underwent a total of at least twenty barium contrast radiographs, seven endoscopies, two laparotomies, and sixteen transfusions before the correct diagnosis was established. The arteriovenous malformations were discrete, consisting of a tortuous feeding artery, dilated draining veins, and an intervening tangle of vessels. Extravasation of dye was observed as a consequence of active bleeding in one case. The lesions were not visible on gross inspection of the bowel wall, but their location could at times be inferred by the associated vascular mesenteric dilatation and accurately localized by injection of the feeding vessel. The microscopic appearance was that of dilated vascular channels both with and without elastic tissue intertwined in the bowel wall and, in two of three patients undergoing resection, was associated with fibrofatty tissue suggesting hamartoma. It is concluded that a significant number of cases of otherwise occult intestinal bleeding will be found to be caused by such arteriovenous malformations, readily diagnosed and cured by appropriate arteriography and surgery.     

A simple technic for predicting daily maintenance dose of warfarin.

Warfarin anticoagulation data from forty-seven patients studied retrospectively was used to develop an algorithm for predicting daily maintenance dose of warfarin. A plot of prothrombin time versus cumulative warfarin loading dose was made for each of the forty-seven patients and the aera under the curve (AREA) measured from the baseline prothrombin time to a prothrombin time of 20 seconds. A linear correlation between the established daily maintenance dose of warfarin and AREA was derived regression analysis: Daily maintenance dose (mg/day) = 0.0465 x (AREA) + 1.5. The correlation was then used to predict daily maintenance dose in twenty-four patients studied prospectively. The mean prothrombin time for a seven day stabilization period after loading for all patients in the prospective study was 21.5 +/- 2.2 seconds and the seven day mean prothrombin time for each patient fell between 19 and 24 seconds. The results of the prospective study indicate that this technic is useful in the early, accurate prediction of a daily maintenance dose of warfarin.     

Early colonic dysplasia: comparison of differential mucin staining and tritiated thymidine labeling

Controversy has arisen regarding the interpretation and significance of histochemical changes in the mucin produced by the globlet cells in colonic mucosa. The shift from sulfomucin to sialomucin, which is readily identified utilizing high iron diamine-alcian blue staining techniques, has been alternately interpreted as a specific, early dysplastic and premalignant change or a nonspecific generalized response to trauma and inflammation, among others. An attempt to clarify this issue was made by comparing mucin changes identified by high iron diamine-alcian blue staining techniques with increases in DNA synthetic activity identified utilizing autoradiographic analysis of tritiated thymidine uptake. Male Holtzman rats were treated with 15 weekly subcutaneous injections of dimethylhydrazine (30 mg/kg per week) (10 rats) or placebo (10 rats). The colons were prepared and fixed, sequential sections were stained with hematoxylin-eosin or high iron diamine-alcian blue, autoradiography was performed. Analyses of labeling index showed no difference in normal background crypts between the control and treatment groups nor in crypts adjacent to those displaying abnormal mucin staining. Crypts with abnormal mucin production (sialomucin dominant) had significantly higher labeling indexes when compared with those of control animals (p less than 0.005). These findings indicate that the shifts in mucin production identified with high iron diamine-alcian blue staining represent crypts with increased and abnormally distributed mitotic activity that is an early dysplastic response to the carcinogenic stimulus.     

Differential mucin staining in colorectal neoplasms: Potential clinical application

Screening techniques that can identify histochemically different mucin production by colonic mucosa have been claimed to be able to identify early dysplastic changes in the colon and rectum. Controversy has arisen regarding interpretation of these changes, and this study has attempted to address this issue. Utilizing a high iron diamine-alcian blue staining technique, several benign and malignant pathologic conditions of the colon were evaluated. Significantly abnormal staining patterns were identified at the resection margins of all patients in whom either anastomotic recurrence or metachronous carcinomas developed compared with patients who were without recurrence for more than 5 years. It is postulated that this technique may be useful in prospectively identifying this group of patients at high risk for the development of recurrence.     

Soft-tissue reconstruction of below-knee defects

The stable closure of an indolent wound below the knee may require the placement of well vascularized flap tissue. Recent advancements in axial and microvascular flap transfer have nearly obviated the use of the cumbersome traditional cross-leg flap. Thirty-two flaps in 25 below-knee defects illustrate a variety of surgical options. Closed stable wounds were achieved in 24 of the 25 defects, and bony union was accomplished in 11 of 12 unhealed fractures.     

Simple mechanical method for decreasing the incidence of thromboembolism

Increasing awareness of the dangers of low dose heparin therapy has stimulated interest in mechanical methods for decreasing the incidence of thromboembolism. Plantar flexion and dorsiflexion of the feet while the patient is on the operating table by the use of a mechanical device (the Pedi-Pulsor) significantly decreases the incidence of deep vein thrombosis (45 percent in control patients versus 18 percent with the Pedi-Pulsor [p = 0.05]). In addition, use of this machine during the postoperative period should further aid in decreasing the incidence of thromboembolism.     

Use of physician's assistants in a general surgical practice.

A study has been made of three PAS employed in a rural, small town, general surgical practice during a four year period. Their work was equally divided among three areas: minor trauma, obtaining and recording data for history and physical examinations, and assisting at routine surgical procedures and endoscopies. This resulted in a significant saving of time for each surgeon who was thus freed for more time in the care of the more critically ill or injured patients.     

Nonhuman primate animals for research in gastrointestinal problems

Problems of husbandry, anesthesia, tranquilization, physical restraint while awake, prevention of disease transmission, fluid and electrolyte balance, and postoperative care have now been overcome enabling one to make a choice of primate animal subject based on the scientific merit of the species available.The Laboratory for Experimental Medicine and Surgery in Primates (LEMSIP) was planned to fill the need for nonhuman primate animals and appropriate related facilities in a large biomedical research community (Greater New York). Innovative methods of husbandry, caging, cost accounting, and space utilization have reduced dramatically the cost of experimentation with primates, making them competitive with other animals. A program of simultaneous and sequential utilization of animals by more than one investigator has resulted in an average utilization of each animal for 6.5 programs per year. The Laboratory now functions as a truly interinstitutional program providing a unique resource and a possible prototype for shared facilities elsewhere.     

Nonoperative management of adult splenic injury due to blunt trauma: a warning

An analysis of 11 patients with splenic injury initially receiving nonoperative treatment revealed that 73 percent subsequently required surgery for delayed hemorrhage. The influence of age and the anatomic differences between the adult's spleen and child's spleen may account for the increased incidence of delayed bleeding seen in this series. Which patients might avoid surgical intervention cannot be predicted with certainty from the mechanism of injury or the lack of early physical signs and symptoms. The corresponding medical problems that often exist with the older patient may make nonoperative management, with the inherent risk of hypotension and large transfusion requirements, inappropriate. Although not advocating immediate splenectomy, we encourage early operative intervention with splenorrhaphy. Although improved diagnostic techniques will uncover a greater incidence of splenic injury, the inability to identify the nonoperative patient remains a clinical dilemma. The true role of nonoperative management of splenic injuries in the adult and the criteria for selection need to be further defined with larger prospective series. Although this approach may be useful for some patients, its application cannot be universal, and one must be willing to accept the consequences of delayed hemorrhage.     

Renal circulation during hypotension

The partial pressures of canine aortic and renal parenchymal oxygen and carbon dioxide were measured spectrometrically in vivo. Renal parenchymal hypoxia and hypercapnia, disproportionate to aortic controls, were found to occur in systemic hypotension and to persist after a return of normotension. This argues for the existence of a vasoconstrictive mechanism in renal vasculature.