Elective laparoscopy for herald symptoms of mesenteric/internal hernia after laparoscopic Roux-en-Y gastric bypass

BackgroundMesenteric internal hernia (MIH) is the most common cause of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass. Because MIH is a potentially life-threatening complication, we hypothesized that elective repair of MIH before developing acute SBO could decrease morbidity in this population.MethodsThe records of 702 consecutive patients undergoing primary laparoscopic Roux-en-Y gastric bypass from January 2002 and August 2007 were retrospectively reviewed to determine the incidence and etiology of SBO. During the last 9 months of the study, we offered elective laparoscopy to any patient who presented to us with symptoms of intermittent SBO.ResultsOf the 702 patients, 27 (3.8%) developed acute SBO. Of these 27 patients, 15 (55%) had obstruction related to an MIH. Nearly all patients had a typical history of intermittent abdominal pain, nausea, and bloating before developing acute SBO. Elective laparoscopy was offered to 11 patients with symptoms of intermittent SBO. Two patients who refused subsequently underwent operations for acute SBO. MIH was found at elective laparoscopic exploration in all cases. Of the 9 patients undergoing elective surgery, 3 (33%) had small bowel volvulus.ConclusionSBO due to MIH after laparoscopic Roux-en-Y gastric bypass is typically preceded by symptoms of intermittent obstruction. Patients who have these herald symptoms should promptly be offered elective laparoscopic exploration. Elective repair of MIH can be performed safely and expeditiously.     

Long-limb gastric bypass in the superobese. A prospective randomized study.

This study was designed to determine whether greater diversion of bile and pancreatic secretions away from the functional gastrointestinal tract would produce greater weight loss in superobese patients (greater than or equal to 200 pounds overweight) in comparison with conventional Roux-en-Y gastric bypass (RYGB). During the past 7 years, two modifications of RYGB were prospectively compared in 45 superobese patients: RYGB-1, in which the length of defunctionalized jejunum measured 75 cm, and RYGB-2, in which the defunctionalized jejunum measured 150 cm. Respective mean preoperative weight/body mass indexes were 393 pounds/63.4 for 22 RYGB-1 patients and 404 pounds/61.6 for 23 RYGB-2 patients. Two patients (5%) had nonfatal early complications. There were six late incisional hernias. There were no cases of protein deficiency, hepatic dysfunction, or diarrhea after operation. Mean follow-up was 43 +/- 17 months. Postoperative weight loss in pounds and daily calorie intake were compared at 6-month intervals. Weight loss stabilized by 24 months at a mean 50% excess weight lost in RYGB-1 patients and 64% excess weight lost in RYGB-2 patients. Nineteen of 23 RYGB-2 patients achieved at least 50% excess weight lost versus 11 of 22 RYGB-1 patients (p less than or equal to 0.03). Weight loss was significantly greater at 24 through 36 months in RYGB-2 versus RYGB-1 patients (p less than 0.02). There was no significant difference in either calorie intake or incidence of iron and vitamin B-12 deficiency between the two groups. These data show that gastric restriction and biliopancreatic diversion without intestinal exclusion resulted in significantly greater weight loss than conventional RYGB but did not cause additional metabolic sequelae or diarrhea. This long-limb modification of Roux-en-Y gastric bypass is a safe and effective procedure in patients who are 200 pounds or more overweight.     

Die Lipoide der weißen Hirnsubstanz während der Autolyse und bei der anämischen Erweichung

Zusammenfassung Während der sterilenAutolyse der weißen Hirnsubstanz bis zu 24 Tagen verändern sich die Lipoide nur geringfügig. Die erst vom 9. Tage an verstärkte Abnahme des Lipoid-P beruht auf der Spaltung von Lecithin und Plasmalogen und wird von einer entsprechenden Zunahme freier Fettsäuren (FFS), geringerer der Aldehyde begleitet. FFS sind in der frischen weißen Substanz nur in Spuren nachweisbar. Lysophosphatide treten—im Gegensatz zu anderen Organen—in papierchromatographisch nachweisbarer Menge nicht auf. Cholesterin und seine Ester bleiben unverändert. Kephaline, Inositphosphatide, Sphingomyelin, Cerebroside und Sulfatide verhalten sich chromatographisch weitgehend konstant. Die postmortale Autolyse hat bis mehrere Tage nach dem Tode keinen nennenswerten Einfluß auf die Lipoidzusammensetzung.Bei der Untersuchung von 20 verschiedenenErweichungsherden des Gehirns fand sich eine vom Alter der Herde nicht unbedingt abhängige Zunahme der FFS, Aldehyde, Triglyceride und Cholesterinester. Freie wie auch glycerid- und cholesteringebundene Fettsäuren und freie höhere Aldehyde stammen offensichtlich aus den strukturbildenden Lipoiden des Myelin. In verschiedenen Herden treten spurenweise Lysophosphatide auf.

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Summary Lipides change slightly during sterile autolysis of human white matter up to the 24 th day. From the 9 th day on, there is a decrease of lipid-phosphorus caused by a breakdown of lecithin and plasmalogen accompanied by a comparable increase of free fatty acids (FFA) and aldehydes. In fresh white matter there are only traces of FFA. In the autolysing brain, contrary to several other autolysing organs, there are no lysophosphatides detectable by means of paper chromatography. Free and esterified cholesterol, cephalins, phosphoinositides, sphingomyelin, cerebrosides and sulfatides remain chromatographically constant during sterile autolysis. According to the above findings it can be concluded that postmortem autolysis up to several days duration has only neglectable effects on the lipid-composition of the white matter.After analysis of 20 different foci of anaemic softening of human brain we found an increase of FFA, aldehydes, triglycerides and of esterified cholesterol which is independent on the age of the lesion. FFA as well as those fatty acids which are bound to glycerol and cholesterol and free higher aldehydes derive from the myelin lipides. Also in contrast to autolysis there were traces of lysophosphatides found in several foci.

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Herrn Prof. Dr.E. Letterer zum Geburtstag am 30. Juni 1966 gewidmet.

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Mit Unterstützung durch die Deutsche Forschungsgemeinschaft.     

Chemiluminescence microanalysis of substrates and enzymes.

Extracts from bioluminescent organisms are increasingly used for analysis of small amounts of substrates and enzymes. The light emission is in some organisms related to the conversion of substrates and cofactors of central metabolic importance. Extracts from such organisms are particularly valuable for analytical applications. This is quite obvious in the firefly where the energy, required for light production, is derived from ATP and in a couple of strains of luminescent bacteria where reduced pyridine nucleotides through reduction of flavine mononucleotide is utilized in the light reaction. It deserved to be noted that many biochemical reactions can be coupled more or less directly to the conversion of ATP, NAD(H), NADP(H) and FMN(H), thus providing the basis for a great variety of analyses. Special kinds of bioluminescent reactions are also of considerable interest, as for instance the relationship between "active sulphate" and PAP, which participate in the formation of light in the sea pansy (Renilla reniformis). High sensitivities are often reached in chemiluminescence analysis making the technique suitable for samples composed of a small number of cells. How bioluminescence has been employed in these kinds of microanalyses is examplified in studies of nucleotides, metabolites and enzymes with low activities.     

The Living Conditions of Children with Shared Residence – the Swedish Example

Among children with separated parents, shared residence – i.e., joint physical custody where the child is sharing his or her time equally between two custodial parents’ homes – is increasing in many Western countries and is particularly common in Sweden. The overall level of living among children in Sweden is high; however, the potential structural differences between children in various post-separation family arrangements have not been sufficiently studied. Potential risks for children with shared residence relate to the daily hassles and stress when having two homes. This study aims at investigating the living conditions of children with shared residence compared with children living with two custodial parents in the same household and those living with one custodial parent, respectively. Swedish national survey data collected from children aged 10–18 years (n ≈ 5000) and their parents were used. The outcomes were grouped into: Economic and material conditions, Social relations with parents and peers, Health and health behaviors, Working conditions and safety in school and in the neighborhood, and Culture and leisure time activities. Results from a series of linear probability models showed that most outcomes were similar for children with shared residence and those living with two custodial parents in the same household, while several outcomes were worse for children living with one parent. However, few differences due to living arrangements were found regarding school conditions. This study highlights the inequalities in the living conditions of Swedish children, with those living with one parent having fewer resources compared with other children.     

A Psychoneuroendocrino-immune approach in the nursing treatment of anorexia and bulimia nervosa

Recent clinical reports have shown an increasing number of patients afflicted by eating disorders in the western world. There are numerous causes and mechanisms leading to eating disorders that affect the psychoneuroendocrinoimmune system. In this study, we define a novel psychoneuroendocrinoimmune nursing approach for anorexic and bulimic patients’ treatment. According to the specific diagnostic items deriving from the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases, and clinical guidelines in eating disorders formulated by the National Institute for Clinical Excellence, we carried out a qualitative study on the nursing treatment chosen by 210 international centers considered as a sample. This study was based on a no structured interview via e-mail to better understand the nursing approach in anorexia and bulimia nervosa. Thanks to the selected centers’ answers, four different levels of nursing care were identified, that include:

1. the nursing role analyzing the spectrum of patients’ problems;

2. the nursing intervention in inpatient care;

3. the nursing intervention in outpatient care;

4. the day hospital treatment.

All four prove to be especially useful in the nursing practice.