Measurement of Functional Pouch Volume following the Gastric Bypass Procedure

Background: The cottage cheese test was developed in an attempt to find a simple way to measure functional pouch volume and to better understand the fate of the tiny proximal pouch following the gastric bypass procedure. Methods: Our patients were asked to eat cottage cheese in a structured fashion before their return visits from 3 months to 2 years postoperatively. Results: We found there was a step-wise progression of increase in functional pouch volume with statistical significance between each time interval. Also, we compared the patients' excess weight loss at 1, 2, and 3 years postoperatively to their pouch size at 1 year postoperatively. Although there is a wide range (2.5-9.0 oz) of pouch sizes at 1 year, there is no significant difference in excess weight loss between the smaller and larger pouches. Conclusions: The pouches enlarge by the orderly process of hyperplasia. Within the 2.5-9 oz volume variation, the pouch volume alone is not a predictor of weight loss. Rather, how the patient uses the pouch/tool, in addition to the other behavior modifications, determines the degree of weight loss. This data strongly suggests that the surgeon's understanding of and teaching of the optimal use of the pouch/tool may be more important than previously thought.     

Drug Distribution in Obesity and following Bariatric Surgery: A Literature Review

Background: The pharmacokinetic variables of drug clearance and volume of distribution are usually corrected for body weight or surface area. Only recently have the relationships which exist between body size, physiologic function and pharmacokinetic variables been evaluated in the obese population. These effects are not widely known, and data on this and the effects of bariatric surgical procedures are scantily documented in the surgical literature. Methods: Literature review. Results: Drugs with a low or moderate affinity for adipose tissue have a moderate increase in the volume of distribution (Vd), and this correlates with the increase in lean body mass (LBM). Highly lipophilic drugs, with some exceptions, show the expected increase in Vd and prolongation of elimination half-life, indicating a marked distribution into adipose tissue. Drug absorption, in general, is slowed by delayed gastric emptying and is normal when gastric emptying is normal or increased. Most drug absorption occurs in the small intestine where duration of drug/mucosal contact is the most important factor. Conclusions: Drugs whose distribution is restricted to LBM should utilize a loading dose based on ideal body weight (IBW). For those drugs which distribute freely into adipose tissue, the loading dose should be based on total body weight (TBW). Adjustment of the maintenance dose depends on clearance rates. In a few cases dosage adjustment depends on pharmacodynamic data, since drug clearance does not conform to these recommendations, for reasons which remain to be defined. Following bariatric surgery, in the absence of delayed gastric emptying or uncontrolled diarrhea, drug absorption rates are usually comparable to the non-operated patient.     

Acceptance of Surgery for Obesity by Academic Surgeons in North America

BACKGROUND: Have surgeons in North America accepted operations for the treatment of severe obesity? This question was posed by organizers of the Ninth International Symposium on Obesity Surgery that met in Stockholm in September, 1995. Study design: In order to obtain opinions which might help to answer the question posed, a 1-page questionnaire was sent to 151 chairmen of academic departments of surgery in North America in December 1994 asking about the acceptance and use of surgical operations for the treatment of severe obesity. RESULTS: Answers, received from 112 or 74%, indicated that operative treatment should be used (74%), was effective (77%) and safe (71 %). However, only 65% of departments provided such operations. Operative treatment for obesity was available outside the department in 53%. The operations most frequently used were Roux-en-Y gastric bypass (RGB) and vertical banded gastroplasty (VBG). A single operation was offered by 44 departments and a choice of two or more operations in 30 departments. RGB and VBG were equally in use. Gastric banding was used as an alternative to VBG in six departments. Other operations were in use in six departments either alone (three) or as alternatives to RGB and VBG (three). CONCLUSIONS: It appears that surgical treatment of obesity is accepted and available in the majority of academic departments of surgery.     

The Gastric Bypass for Failed Bariatric Surgical Procedures

Background: Revision of failed bariatric surgical procedures is a significant challenge for every bariatric surgeon. Methods: Evaluated are surgical difficulties, management problems and weight loss in patients with distal gastric bypass as a revisionary procedure. Eighty patients were followed up to 3 years; four were lost to follow-up. Mean age was 43; mean prebariatric surgery weight 134 kg; height 1.65 meters; body mass index 40.1; ideal body weight 62.7 kg; excess weight 70.5 kg; per cent excess weight 214%. A 250 cm stomach-to-ileocecal valve segment of small bowel was used, and the biopancreatic secretions were brought into the terminal ileum 100 cm from the ileocecal valve. Mean pouch size was 63 cc; length of hospital stay 5 days; operative blood loss 616 cc; operative time 130 min. Results: Intraoperative complications included three splenic injuries (without splenectomy). Early complications included one deep vein thrombosis, two marginal ulcers, one GI hemorrhage, one wound dehiscence, one pouch outlet obstruction and one pancreatitis. Late complications included: one death from protein malnutrition/ARDS; 21 hypoproteinemia; six protein malnutrition, and of these, three had hyperalimentation; three cholecystitis; 27 anemia; 22 incisional hernia; two staple-line disruption (reoperated); 26 low serum iron; 11 prolonged (> 6 months) diarrhea; three prolonged frequent vomiting; and two unrelated deaths (chronic myelogenous leukemia and amyotrophic lateral sclerosis). Mean excess weight loss was 83% at 12 months; 89% at 24 months; and 94% at 36 months. Conclusion: The distal gastric bypass is fraught with the operative and immediate post-operative complications experienced in any revisionary bariatric surgery. Distal gastric bypass is very effective in producing long-term weight loss. Nutritional problems are common but usually easily corrected. The most serious nutritional complication is protein malnutrition, which must be identified and corrected early. Success of this procedure is dependent upon patient compliance with proper nutrition and supplements, and regular office follow-up with monitoring of laboratory data. Patients who are noncompliant are at significant risk for complications.     

Effect of the phosphodiesterase inhibitor 4-(3-cyclopentyloxy-4-methoxyphenyl)-2-pyrrolidone (ZK 62711) on gastric secretion and gastric mucosal cyclic AMP

Summary The effect of the phosphodiesterase inhibitor 4-(3-cyclopentyloxy-4-methoxyphenyl)-2-pyrrolidone (ZK 62711) on gastric secretion and the cyclic AMP system of the gastric mucosa was studied in rats and guinea pigs. In rats, 0.03–0.3 moles/kg ZK 62711 i.v. stimulated acid and pepsin secretion in a dose-dependent manner and 0.03 moles/kg i.v. enhanced the effect of histamine. In guinea pigs no reproducible stimulation was found after intravenous injections of ZK 62711. The stimulation of gastric secretion in the rat by 0.3 moles/kg ZK 62711 i.v. was not affected by vagotomy but was totally inhibited by 10 moles/kg cimetidine i.v. The structurally related phosphodiesterase inhibitor, 4-(3-butoxy-4-methoxybenzyl)-2-imidazolidine (Ro 20-1724), at the dose of 3.3 moles/kg i.v. stimulated gastric secretion in anaesthetised rats to a similar extent as 0.3 moles/kg ZK 62711 i.v. The content of cyclic AMP in the rat gastric mucosa in vivo was slightly increased by 10 moles/kg ZK 62711 i.v, whereas lower doses did not change it. Accumulation of cyclic AMP in the rat gastric mucosa by 50 moles/kg histamine i.v. was enhanced by simultaneous injections of 3.3 moles/kg ZK 62711 i.v. In rat gastric tissue slices in vitro 1–50 M ZK 62711 increased the level of cyclic AMP but 100 M histamine had no effect in the absence or presence of ZK 62711. In gastric mucosal slices of the guinea pig 10 and 50 M ZK 62711 increased the cyclic AMP content which effect was inhibited by 100 M cimetidine and enhanced the stimulatory effect of 100 M histamine on cyclic AMP. The activity of soluble cyclic AMP phosphodiesterase was inhibited by ZK 62711 in the rat (IC₅₀=18 M) and guinea pig gastric mucosa (IC₅₀=1.5 M). Adenylate cyclase was not affected in the homogenate of the guinea pig gastric mucosa. The results indicate that the phosphodiesterase inhibitor ZK 62711 which increases cyclic AMP levels in the gastric mucosa in vivo and in vitro, is a potent stimulator of gastric acid secretion.     

Unaltered insulin sensitivity during calcium channel blockade with amlodipine

Summary The sensitivity of peripheral tissues to insulin is of pathophysiological, therapeutic and possibly also of prognostic relevance. Calcium channel blockers are widely used in the treatment of cardiovascular disorders that are commonly associated with decreased insulin sensitivity (S_I). To evaluate the effects of calcium channel blokkade on S_I, glucose homoeostasis and lipid profiles, studies were made of S_I (determined by the Minimal Model Method of Bergman), basal glucose and insulin levels, serum total triglyceride (Tg) and lipoprotein cholesterol (C) fractions and certain other variables in 38 healthy young men (24 y) during placebo and after 3 weeks of calcium channel blockade with amlodipine 5 mg once daily. Measurements were made after 3 days on a standard diet (2200 kcal · day^–1, 45% carbohydrates, 40% fat and 15% proteins) and after an overnight fast. Compared to placebo, amlodipine decreased supine systolic blood pressure (P<0.01). Heart rate, body weight and 24 h urinary sodium excretion were unaltered, and so were fasting plasma glucose (placebo vs amlodipine: 4.86 vs 4.83 mmol·1^–1, respectively) and insulin levels (7.7 vs 7.9 U·ml^–1), S_I (10.5 vs 9.6·10^–4 × min^–1 pro U·ml^–1), serum total Tg, C and lipoprotein C fractions.The findings demonstrate unchanged insulin sensitivity and secretion, as well as lipoprotein regulation, during maintenance administration of 5 mg amlodipine daily to healthy young men.This work was supported in part by the Swiss National Science Foundation     

Cytological immunodetection of yeast glycoprotein secretion

Expression of antigenic epitopes shared by secreted yeast glycoproteins was studied using specific immunological probes. Application of cytological and ultrastructural methods of immunodetection, employing monoclonal antibodies, permitted us to localize these glycoproteins in the cytoplasm, through the cell wall and at the yeast cell surface. Importance of glycosylation-secretion relationships were evaluated in the secretion process of these molecules. The cell wall crossing and the cell surface distribution of antigenic glycoproteins was described in immunoelectron microscopy and immunofluorescence. Some preferential secretion ways were suspected through the yeast cell wall leading to an heterogenous distribution of cell surface glycoproteins destined to be excreted into the medium.Antigenic variability of cell wall glycoproteins expression was discussed in relation with the glycloprotein secretion.     

Assessment of thyroidal "C" cell secretion in osteoporotic girls with Turner''s syndrome. Basal and calcium-stimulated levels of total calcitonin, extractable calcitonin and katakalcin

Osteoporosis is a common finding in Turner's syndrome. To test the hypothesis that calcitonin deficiency may contribute to bone mineral loss in Turner's syndrome, we studied basal and calcium-stimulated (2 mg/kg body weight in 5 min) levels of total calcitonin, extractable calcitonin and katacalcin in 15 girls with Turner's syndrome and osteoporosis. Fifteen age-matched healthy girls were studied as controls. Both basal calcitonin (total and extractable) and katacalcin values were not significantly different in patients with Turner's syndrome in comparison with those of the controls. The calcium stimulation test showed a similar "C" cell secretory reserve in both groups. The calculation of delta CT/delta iCa of total and extractable calcitonin and delta KC/delta iCa, which accounts for individual variations in serum ionized calcium increases, did not show any significant difference between girls with Turner's syndrome and controls. We conclude that calcitonin deficiency is not a causative factor of osteoporosis in girls with Turner's syndrome and that in this syndrome long-life estrogen deficiency does not impair "C" cell secretory activity.     

Revisional Surgery for Severe Obesity with Fascia Banded Stoma Roux-en-Y Gastric Bypass

The fascia banded stoma Roux-en-Y gastric bypass (RYGBP) has been effective both as a primary and revision operation for severe obesity or failure of another operation. Since May 1984, 361 primary and 100 revisional fascia banded RYGBP operations have been reported. Weight loss achieved a mean body mass index of 30 for primary and 31 for revision patients at most recent follow-up of 3-6 years (mean 4.3 years) postoperatively. Mean overweight was 28% for primary, and 34% for revision patients. Eighty percent of primary and 79% of revision patients were within 50% of ideal weight. Revision rates for these patients were 0 for primary and 1% for revision patients. Operative mortality was 0 for primary and 1% for revision patients. Since morbidity and mortality, although low, are higher for revision than primary surgery, it is important to use an effective primary operation.     

The Effect of Gastric Bypass on Cholesterol,HDL, and the Risk of Coronary Heart Disease

A review of 150 charts revealed that 36 patients had pre-operative serum cholesterol greater than 200 mg% prior to Roux-Y gastric bypass. The average pre-operative weight was 266 lb (121 kg) and at 1 year post-operative 166 lb (75 kg), or 100 lb (45 kg) lost (77% excess weight loss). We compared the following pre- and post- operative data and found that: (1) cholesterol was decreased by 24% and triglycerides decreased by 40%; (2) post-operative cholesterol/HDL-C ratio of 3.31 put our patients in the half of average risk category for a clinical pathological coronary event according to the SmithKline Beecham Laboratories risk ratio chart. We conclude that Roux-Y gastric bypass and its ability to produce a significant weight loss and markedly affect cholesterol and triglyceride metabolism will also reduce a patient's risk of myocardial infarction.