Treatment of Vitamin B12 Deficiency after Gastric Surgery for Severe Obesity

Background: Vitamin B₁₂ deficiency after gastric surgery for obesity is due to a failure of separation of vitamin B₁₂ from protein foodstuffs and to a failure of absorption of crystalline vitamin B₁₂ in the presence of intrinsic factor. The purpose of this study was to determine which of four oral doses of crystalline vitamin B₁₂ was most effective in treating vitamin B₁₂ deficiency in 102 patients. Methods and Results: At time of entry into the study, the patients had a serum vitamin B₁₂ < 100 pmol L ⁻¹, were 29.9 ± 21.7 months post-op, were 37 ± 8 years old and had a body mass index of 30 ± 6 kg m⁻². Eight (8%) had had a vertical banded gastroplasty and 94 (92%) a gastric bypass. For the first 3 months all patients received 350 μg per day of crystalline vitamin B₁₂ and all increased their serum vitamin B₁₂ levels to over 100 pmol L⁻¹. The patients were then assigned to receive for a further 3 month period one of four oral doses of crystalline vitamin B₁₂-100 μg, 250 μg, 350 μg and 600 μg. Serum vitamin B₁₂ levels were greater than 150 pmol L⁻¹ after 6 months in 83.3% of patients who received 100 μg; 92.3% of patients who received 250 μg; 94.7% after 350 μg and 95.2% after 600 μg (p%0.525). Conclusion: At least 350 μg per day is the appropriate oral dose of crystalline vitamin B₁₂ after gastric surgery for obesity to correct low serum vitamin B₁₂ levels in 95% of patients.     

The Patient Factor

Long-term results of bariatric surgery are reviewed. The weight criteria for patient acceptance for bariatric surgery and their variation are presented graphically and discussed. Factors affecting patient selection in an attempt to improve outcome results in the small group of patients who currently achieve less weight loss than anticipated are defined. An attempt is made to define pre-operative criteria for selection of pure restrictive versus combined restrictive and malabsorptive procedures. Aspects of motivation, co-morbidity, age and pre-operative weight are discussed and the position statement of the ASBS in regard to laparoscopic bariatric surgery is defined.     

Back to the future for wound care?

The European Renaissance was a time of enormous change and rapid progress in the arts, sciences, and medicine. A glimpse of wound care in the last phase of the European Renaissance is provided by the analysis of work by Wilhelm Fabry, the "father of German surgery," as provided in his book De Combustionibus ("Burns") which details his range of treatments for the burn wound, as well as his approach to the later problems of scarring and contracture. We describe some of the historic events which may have stimulated Fabry's writings, in particular, the influences passed down from the medical school of Padua which thereby advanced the cause of wound care and surgery. Finally, we briefly explore the potential of such an approach to the works of our medical forefathers.     

Web creep: the role of infection and delayed healing

Summary Twenty-five digital webs from 21 patients, where web creep was noted after division of simple syndactyly were reviewed. In all cases web creep was related to delayed healing and the average time to its appearance was 8 months.     

The Rationale and Results of Gastroplasty/Distal Gastric Bypass

A recent review of the results of gastroplasties done at the University of Alberta Hospital showed that there was a high incidence of late weight loss failure. Therefore a new operation, gastroplasty/distal gastric bypass, has been performed on 263 patients. This operation results in a profound (mean greatest percentage excess weight loss of 87% at approximately 2 years) and lasting weight loss (mean final percentage excess weight loss of 78%) at 4 years, range 2-7.5 years post-operatively. Only 0.9% of patients failed to maintain at least a 40% excess weight loss. The operation achieves its effect through a moderate restriction that permits patients to eat normal table food from the time of discharge and with a mild malabsorption that is not ordinarily associated with diarrhea or notable deficiencies. Certain patients required debanding of the stoma and others developed staple-line eventration. Neither of these events after long-term follow-up resulted in weight loss failure nor in other serious side-effects. It is concluded that moderate failure of the gastroplasty stoma and staple line does not necessarily result in weight loss failure, because the malabsorptive portion of the operation remains intact. Low hemoglobin occurred in 16% of cases and deficiency of serum iron in 34%; a much smaller number of patients had chronic or intermittent deficiencies of these entities. Correction was easily achieved with oral replacement. Deficiencies in albumin, calcium, phosphorus and folate were rarely seen and minimal elevation of serum AST values occurred in just over 1% of patients. Chronic deficiencies or elevations were not seen in these patients. Stomal ulcer occurred in 6% of patients and bleeding associated with stomal ulcer in 1%. Half the patients with ulcer were managed with H₂ blockers, the other half with vagotomy. Both forms of treatment when individualized effectively prevent re-ulceration.     

A Medieval Medical View on Obesity

Medieval medical views on obesity are presented from Avicenna's Canon of Medicine. Health risks associated with obesity were appreciated, including respiratory and cardiovascular problems, infertility and even sudden death.     

Technical Points in Vertical Gastroplasty for Morbid Obesity

The success of vertical gastroplasty may be jeopardized by gastric leakage or ulceration due to failure of the technique. Reports of band erosion and staple-line leakage have led us to seek technical improvements to reduce technical failures. We describe a modification to the technique of band placement and a manoeuvre to aid the placement of staples when the TA90 staple gun is used.     

Observations on Nine Personal Cases Where Esophagitis Has Appeared as a Complication of a Functioning Vertical Gastroplasty

This paper is based on observations on a personal series of patients who presented with severe ulcerating esophagitis, unresponsive to medical treatment following a vertical stapled gastroplasty. With one exception this was a late complication in an effective weight loss procedure. The therapeutic modalities chosen to treat this problem depended on patient choice, as well as personal experience with treating earlier cases. Unfortunately, I could find little guidance in the literature or from my colleagues on how to treat this problem. Conversion to a Roux-Y gastric bypass seemed the most satisfactory solution to the problem, relieving the symptoms and maintaining the weight loss.     

Low-grade astrocytomas in children: evolving management strategies

Developments in imaging and in neurosurgical techniques over the past decade have substantially altered the management of children with low-grade astrocytoma. Indications for surgery have become more clearly defined, and a larger proportion of children undergo complete or subtotal resection than in the past. Fewer receive adjuvant therapy, even though the options in this regard are more numerous now and theoretically likely to result in less morbidity than conventional external beam radiotherapy.

This review will address in particular the correlations between location, imaging appearance, and behavior that need to be more widely appreciated, and present recommendations regarding the management of these tumors.     

Serial Transvaginal Ultrasonography Following McDonald Cerclage and Repeat Suture Insertion

Summary: The aim of this study was to explore the hypothesis that serial transvaginal ultrasonography identifies early evidence of suture failure and that repeat cerclage delays delivery. We undertook a review of our policy of transvaginal ultrasonographic cervical surveillance after McDonald cerclage and of repeat suture insertion if persistent cervical effacement developed. Data from 26 pregnancies in 26 women are analyzed. The women had had a total of 57 mid-trimester miscarriages with a median of 2 (1–6) mid-trimester losses per woman. Twelve (46%) of the 26 women developed cervical changes at scan and underwent repeat cerclage. All 14 women who had a single suture inserted progressed to live births but 1 of the 13 women who had repeat cerclage had a mid-trimester miscarriage (p>0.05). The median gestation at delivery for the women who had repeat cerclage was 35 (22–39) weeks compared with 38 (36–40) weeks for those who had a single suture (p>0.05). The median interval from the detection of cervical changes at scan to delivery was 13 (4–19) weeks. Serial transvaginal ultrasonography after cervical cerclage identifies a group of women who are more likely to deliver preterm, and provides an opportunity for intervention (repeat cerclage) which appears to delay delivery by an average of 7 weeks.