Charles A. Herbst

Complications of gastric bypass for morbid obesity

This report details the complications observed in 154 morbidly obese patients who has a gastric bypass performed in the period from April 1975 through March 1979. Thirteen intraoperative complications occurred. In the first 30 days after operation, one or more complications developed in 29 or 17.9 percent of the patients. One patient died from pulmonary embolism. The most serious complication unique to gastric bypass was a leak from the stomach or the anastomosis. The factors responsible are discussed and suggestions are made concerning the prevention of this complication. Sixteen late complications occurred in 13 patients. The 62 operative procedures performed incidental to gastric bypass and the 50 performed subsequently as a result of it are enumerated and discussed. The findings of this investigation document the serious complications that may occur with gastric bypass. The late complications of this operation are few and trivial compared with those that occur with jejunoileal bypass [1,2,4,5,9].

Cost effectiveness of postoperative carcinoembryonic antigen monitoring in colorectal cancer

Serial monitoring of carcinoembryonic antigen (CEA) has been thought to provide early indication of recurrent cancer in individuals who have undergone curative resection. The current study was designed to assess the costs associated with CEA monitoring. Costs included CEA determinations, other evaluative tests prompted by abnormal CEA values and hospital/surgical costs in patients undergoing “second‐look” procedures. The authors estimated that the cost per resectable tumor was

Perioperative complications of gastric restrictive operations

24,779; but, under optimal circumstances, it might be as low as

Intraoperative ultrasonography evaluation of the gallbladder in morbidly obese patients.

10,446. The most important factors were the percentage of recurrent tumors and the proportion of these that were resectable. It proved slightly more efficient to limit the preoperative workup rather than to decrease the frequency of CEA determinations. The true benefits of CEA initiated second‐look surgery in terms of prolonged survival remain unknown. More clinical experience is needed to better understand these benefits. Cancer 53:193‐198, 1984.

Computed tomography in recurrent or metastatic colon cancer: Relation to rising serum carcinoembryonic antigen

It has not been established which gastric restrictive operation produces the lowest postoperative morbidity. Of a total of 565 morbidly obese patients who underwent various operations, perioperative complications occurred in 70 patients who underwent gastric bypass with loop gastrojejunostomy, 192 patients who underwent Roux-Y gastrojejunostomy, 47 patients who had greater curvature gastroplasty, 226 who had gastrogastrostomy and 40 who had vertical banded gastroplasty performed on a total of 565 morbidly obese patients. Twenty (3.5 percent) of the patients had intraoperative complications that were not related to the specific procedure. The exception was splenic injury which should not occur with vertical banded gastroplasty. Twenty-five (4.4 percent) of the patients had general postoperative complications that were not related to differences in techniques of the five operations. Two postoperative deaths were caused by massive pulmonary embolism and one by cardiopulmonary arrest. When the complications specifically related to the five different operative techniques were compared, there was a 14.3 percent incidence with gastric bypass with loop gastrojejunostomy, a 14.5 percent incidence with Roux-Y gastrojejunostomy, a 23.4 percent incidence with greater curvature gastroplasty, a 10.2 percent incidence with gastrogastrostomy, and no incidence with vertical banded gastroplasty. The potentially most serious complication, leak from the stomach, was most common with the two types of gastric bypass operations but it also occurred with greater curvature gastroplasty and gastrogastrostomy. This study has indicated that vertical banded gastroplasty is the safest operation. Our 1 year follow-up findings indicate it is as effective as any of the other operations in helping patients lose weight.

Gallbladder function before and after fundoplication

Intraoperative ultrasound evaluation of the gallbladder was performed in 55 morbidly obese patients undergoing gastric bariatric surgery. Cholecystectomy was performed in the presence of any physical or ultrasonographic abnormality. Eighteen patients (33%) had cholecystectomy. Nine patients had palpable gallbladder disease confirmed by ultrasound. Nine patients had abnormalities detected by ultrasonography only. There was no false-negative ultrasonographic exam compared to physical exam. Pathologically, all specimens but one showed evidence of disease, thus there was a false-positive incidence of 1.8%. None of the 37 patients with normal physical and ultrasonographic examination have returned with gallbladder disease following the bariatric surgery. Intraoperative ultrasonography shows promise in detecting nonpalpable gallbladder disease and decreasing the incidence of delayed cholecystectomy.

Mallory-weiss syndrome in a 10-month-old infant requiring surgery

Twenty patients with Stage Duke B or C adenocarcinoma of the colon or rectum who have undergone radical surgical resection and demonstrated rising serum carcinoembryonic antigen (CEA) during follow-up are the subject of this study. In all cases, while there was a continuous and progressive elevation of serum CEA, CT examination of the abdomen and pelvis was performed. Abnormal CT findings were demonstrated in 19 patients and included pelvic mass, liver metastases, and periaortic or mesenteric lymphade-nopathy. There was one normal CT scan in a patient who subsequently developed metastases in the sacrum. Based on the observations in these patients, it is concluded that in routine follow-up after colorectal surgery, rising serum CEA should be considered a warning sign and warrants additional investigation by CT.

Augmentation mammoplasty, irradiation, and breast cancer. A case report.

No study has reported an association between gastroesophageal reflux disease (GERD) or its therapies and gallbladder function. We compared pre- and postoperative gallbladder function in patients undergoing fundoplication to determine the following: (1) whether patients with chronic GERD have preexisting gallbladder motor dysfunction; (2) whether medical or surgical therapy alters gallbladder function; and (3) whether division of the hepatic branch of the anterior vagus nerve is detrimental to gallbladder motility. Nineteen patients with documented GERD consented to a preoperative cholecystokinin-stimulated technetium hepatobiliary (CCK-HIDA) scan to quantify the gallbladder ejection fraction (GBEF). All patients underwent laparoscopic Nissen fundoplication. One month after fundoplication, 12 patients completed a repeat CCK-HIDA scan for determination of GBEF, with comparison to the preoperative GBEF. Among patients with preoperative GERD, 11 (58%) of 19 met the scintigraphic criteria for gallbladder dysfunction (GBEF <35%), which is a ratio comparable to that in patients undergoing a CCK-HIDA scan for presumed biliary dyskinesia during the same time period (31 [60%] of 53;P=NS, chi square test) and exceeds the rate of abnormal GBEF reported in healthy volunteers (3%). Six of seven patients with a low preoperative GBEF who underwent repeat evaluation postoperatively had normalization of the GBEF (P=0.05, paired t-test). In the 12 patients who underwent postoperative CCK-HIDA scanning, there was no association between preservation or division of the hepatic branch of the anterior vagus nerve and postoperative gallbladder dysfunction (P=NS, chi-square test). Unexpectedly, 58% of patients with GERD demonstrated gallbladder motor dysfunction prior to fundoplication, with improvement to normal occurring in most of those studied postoperatively. These data support controlled trials to determine the effect of chronic GERD and antisecretory therapy on gallbladder and global gastrointestinal smooth muscle function. Preservation of the hepatic branch of the anterior vagus nerve during fundoplication offered no clear benefit with regard to early postoperative gallbladder function.

Use of the flexible sigmoidoscope in women with previous pelvic irradiation.

Mallory-Weiss syndrome is infrequent in children. Intractable hemorrhage requiring surgery has been reported in only one 6-year-old child in the English literature. We present a case of intractable hemorrhage from a Mallory-Weiss lesion in a 10-month-old infant requiring surgery. The incidence, etiology, diagnosis, and treatment of Mallory-Weiss syndrome in children is discussed in relation to this case.

Continent feeding jejunostomy in children

A case report is presented of mammary adenocarcinoma in association with a Silastic prosthesis and earlier irradiation exposure. Causative relationships of these two variables are discussed. Recommendations for management of the breast cancer patient with a mammary prosthesis are suggested.