Arthur S. McFee

Radiologic evaluation before gastric bypass for morbid obesity

During a 4 year period, 69 patients received gastric bypass with stapling and Roux-Y gastrojejunostomy for morbid obesity. The results of 67 preoperative radiologic evaluations of the gastrointestinal tract were analyzed. Of these patients, 17.9 percent (12 of 67) had previous cholecystectomy for cholelithiasis; 14.6 percent (10 of 67) had cholelithiasis found on preoperative evaluation. This gave an overall incidence of gallbladder disease of 32.8 percent. The upper gastrointestinal examination revealed four patients with hiatal hernia, three with reflux, and one with evidence of reflux esophagitis. Two patients had one duodenal diverticulum each. Ten small bowel follow-through examinations were performed, six of which revealed no abnormalities and four of which were consistent with previous jejunoileal bypass. Results of air-contrast barium enema showed 1 patient with a cecal mass which was subsequently found to be a fatty iliocecal valve and 16 patients had diverticulosis without evidence of diverticulitis. The remainder of the findings of all studies were unremarkable. When all is considered, including radiation dose, difficulty in performing examinations, and cost, we conclude that because of the low incidence of significant abnormalities, routine preoperative evaluation of these patients should only include radiographic or sonographic evaluation of the gallbladder. Other examinations should be obtained if the patients have current symptoms or previous gastrointestinal disease or gastric surgery.

Modified system outcome score and outcome index : method of monitoring patient care in a special care area

A scoring system intended both to assess mortality risk and permit surveillance, evaluation, and comparison of medical care was developed in our surgical ICU. Five simple clinical indices of organ system failure were selected and weighted according to their statistically validated relationship to mortality, resulting in a daily System Outcome Score (SOS). Cluster analysis was used to divide the creation data set of 2,777 patients into suitable groupings of scores to predict mortality; the clustering was confirmed for reproducibility with a validation set of an additional 2,860 patients. Based on this validation of the scoring system, two computer-controlled patient care surveillance techniques were developed. The first involved the definition of three unfavorable SOS patterns evolving during the course of a patients admission. Detection of one or more of these patterns, described by the acronym SDL, permits review of the care administered to the specific patient generating the pattern. A global assessment of care is achieved with the Outcome Index (OI), which relates overall mortality risk in the ICU to the actual mortality rate over a given time period. Effectiveness of care can then be compared between different time periods within the one unit or between different units with similar patient mix. The overall system offers the potential for a surveillance-based quality assurance system with widespread applicability.

Pancreatic islet hormone response to oral glucose in morbidly obese patients.

Pancreatic islet peptides, as well as other gastrointestinal hormones, have been implicated in both the pathogenesis of obesity and the etiology of associated metabolic derangements. This study evaluated the pancreatic islet and gastrointestinal (GI) hormone response to oral glucose in 20 morbidly obese (151% above ideal body weight) patients. Glucose intolerance, hyperinsulinism, and exaggerated gastric inhibitory polypeptide (GIP) release occurred following glucose ingestion. Significant release of PP occurred in 14 patients, while only six patients had release of somatostatin. No significant changes in plasma concentrations of glucagon occurred. Since GIP is insulinotropic in the presence of hyperglycemia, the hyperinsulinism of morbid obesity may be secondary to the abnormally high glucose-stimulated GIP levels in these patients. Failure of glucagon suppression in response to oral glucose many contribute to the hyperglycemia noted. Somatostatin and pancreatic polypeptide may be responsible for some of the metabolic derangements of morbid obesity.

A simplified technique for loop colostomy closure

Stapling instruments have been used for gastrointestinal anastomoses and reconstruction with increasing regularity. A technique for loop colostomy closure employing a stapling device is described. This approach provides a secure closure while avoiding major contaimination.

Increased Sensitivity of in vivo Radioautographic Films

Several years ago an in vivo radioautographic technic for the diagnosis of gastric cancer was developed, using a radiosensitive balloon (1, 2). Patients were given 500 μc of radioactive phosphorus 32 (P32) before the test, and its increased concentration in the gastric cancer was detected by the radiosensitive balloon (Kodak Autoradiographic Elastic Film, Type 1). In some cases of gastric cancer where the overall tissue levels of P32 were relatively low, errors in diagnosis were made, in spite of the fact that the cancer/normal P32 ratios were 2 or higher. In vitro radioautographs of the resected specimens delineated the cancers, but demonstrated relatively low P32 levels in both the normal and the neoplastic areas. It is felt that a more sensitive in vivo radioautographic system could detect these cancers. To increase sensitivity, one can increase the P32 dose, the exposure time in the patient, or the radiosensitivity of the radioautographic balloon. As the phosphorus dose is already relatively high, and...