Henry T. Randall

Complications and weight loss in 150 consecutive gastric exclusion patients

Results of extensive follow-up for weight loss and complications in 150 consecutive patients who underwent a standardized gastric exclusion procedure have been presented. A comparative review of the literature has also been presented. All patients were followed for up to 6 years (mean 27.8 months). Only one patient was lost to follow-up. Complications during this period occurred in 54.7 percent of our patients. These were mainly postsurgical biliary disease and ventral hernias. Our recent experience has suggested that the latter complications could have been prevented. The absence of pulmonary embolism, pneumonia, and stomal ulcer in our series, as well as the low incidence of perforations, thrombophlebitis, and stomal and pouch complications suggest that the occurrence of these complications can be minimized as well. Patients in this series lost an average of 75 percent of their excess weight, 38 percent of their original weight, and stabilized at 30 percent above their ideal body weight. Ninety percent of the weight loss occurred in the first 12 months. Eighty percent of the patients, however, continued to lose weight 18 months postoperatively and 40 percent lost weight up to 24 months postoperatively. Weight loss has been maintained from 2 to 5 years. In conclusion, analysis of available data has demonstrated that careful patient selection, attention to technical detail, and close follow-up are of paramount importance for providing successful results and minimizing complications in the morbidly obese population who undergo gastric exclusion surgery.

Use of the “space diet” in the management of a patient with extreme short bowel syndrome☆

Abstract 1. 1. Detailed studies of a patient surviving for one hundred and one days with 4 cm. of jejunum anastomosed to the midtransverse colon after thrombosis of the superior mesenteric artery are reported. 2. 2. The remaining gastrointestinal tract would not tolerate any type of normal food, including medium chain triglycerides. 3. 3. Elemental diets consisting of L-amino acids and simple sugars administered slowly through a gastrostomy tube showed evidence of significant absorption. 4. 4. A diet, modified from one constructed for use by the astronauts and containing L-amino acids, glucose and sucrose, macro- and microminerals, and vitamins, was evaluated. Up to 469 mOsm./L. and enough to provide 30 to 35 per cent of the total caloric requirement and virtually all the required nitrogen were tolerated. 5. 5. At postmorten examination gastric dilatation, duodenal dilatation and hypertrophy, and segmental colonic dilatation were present. There was no evidence of nutritional disturbances in sections of the liver and brain. The cause of death was acute bacterial endocarditis. 6. 6. Elemental diets requiring little or no digestion for absorption offer promise in the management of a variety of severe nutritional problems involving the gastrointestinal tract.

Prospective metabolic evaluation of 150 consecutive patients who underwent gastric exclusion

The effect of weight loss produced by gastric exclusion on the metabolism of previously morbidly obese persons was examined. A standardized gastric exclusion procedure was performed in 150 morbidly obese patients during a 6 year period. These patients were followed for from 6 to 60 months (mean 27.8 months). The mean excess weight loss was 75 percent and was maintained from 2 to 5 years. A small but significant decrease was noted during the first 3 to 6 postoperative months in the parameters of protein metabolism examined. Although this may reflect mild depletion in protein stores, of greater importance was the demonstration that these parameters spontaneously corrected themselves by 12 months. Mild abnormalities in serum electrolyte concentrations were noted in the postoperative period. They appeared to be related to dehydration, were not clinically significant, and also resolved spontaneously. Clinically significant abnormalities in divalent ions were absent. Significant and sustained reductions in blood pressure, fasting glucose concentration, serum triglyceride values, and uric acid and hepatic enzyme concentrations were demonstrated in the entire population. A small and non-sustained decrease in cholesterol was seen. Hypertension was eliminated in 96 percent of the affected subpopulation, diabetes in 100 percent, gout in 100 percent, hyperlipidemia in 92 percent, and improved hepatic function was found in 95 percent. These changes should reduce the overall morbidity and mortality of the patient population in the future.

Fluid, electrolyte, and acid-base balance.

A thorough understanding of the physiologic principles underlying fluid, electrolyte, and acid-base balance and of the compensatory mechanisms that come into play when disease, trauma, sepsis, or surgery distort normal patterns is essential for the surgeon.

Use of an elemental diet in the nutritional management of catabolic disease in infants

Abstract Elemental diets have proved useful in the nourishment of infants and children with gastrointestinal tract dysfunction. Newborn and premature infants, because of their immature gastrointestinal tracts and kidneys, are very sensitive to the elemental diet concentration and flow rates. They do not tolerate concentrations of elemental diets of greater than 10 per cent w v . This, however, provides 0.4 cal/ml and 2.40 mg protein nitrogen/100 ml. In children older than ten months, solutions up to 25 per cent w v are well tolerated if the diet is started slowly as a continuous 15 per cent w v feeding and then gradually advanced in speed and concentration over several days to a week or more to allow for gastrointestinal adaptation. Careful monitoring of weight, hematocrit, electrolytes, and urine sugar are important to guard against the development of hyperosmolar dehydration. Vitamin K must be given, since diets do not contain it, and patients will otherwise become hypoprothrombinemic. Elemental diets would appear to be useful in pediatric patients with massive small bowel resection, exocrine pancreatic insufficiency, fistulas of the gastrointestinal tract, malabsorption, food allergies, inflammatory bowel disease, and in conditions of markedly increased energy requirements such as burns, sepsis, and surgery.

Total blood washout and exchange. A valuable tool in acute hepatic coma and Reye's syndrome.

Total body washout (TBW) was accomplished thirteen times in twelve patients, with response in five and survival in three. TBW can be done without apparent harm to patients and is less laborious and more rapidly effective than repeated exchange transfusion. Early application of TBW in stage III to stage IV hepatic coma may increase survival and possibly prevent progression of metabolic derangements. Patients with stage III to IV Reyes syndrome probably should have TBW promptly, without time-consuming attempts at exchange transfusion. Based on our experience, further application of TBW is warranted in coma due to acute hepatic failure and stage III to IV Reyes syndrome.

A home program of long-term total parenteral nutrition in children†

Three children--ages 4 months, 5 months, and 14 years--have been on a program of total parenteral nutrition at home for ten, 23 and 44 months respectively, as of January, 1978. Using a specially designed silicone rubber catheter, placed in the right atrium, total nutritional needs of these children were delivered nightly by family members; the children carried out normal activity during the day with the catheter line maintained by a heparin lock. Normal skeletal development and weight gain have been achieved while allowing these children normal social and psychlogic development outside the hospital. During the course of the therapy the patients had multiple metabolic abnormalities which were successfully treated by replacement therapy. The duration of catheter patency ranged from three to 22 months. Catheter sepsis or mechanical failure occasionally required catheter removal and replacement.

Glove starch granulomatous peritonitis

Abstract A sharp increase in the number of reported cases of starch-induced granulomatous peritonitis indicates the rather frequent occurrence of this syndrome. The clinical features of five cases recently treated are outlined. After clean uncomplicated surgery and an asymptomatic period, the patients were rehospitalized because of fever and abdominal pain. Positive abdominal signs on physical examination included tenderness, frequently with rebound, and often a palpable mass. Leukocytosis and positive radiologic signs, particularly evidence of paralytic ileus, led to the usual preoperative diagnosis of intra-abdominal abscess. At operation characteristic findings of ascites, severe peritoneal inflammatory reaction, miliary nodules, and a greatly thickened omentum should lead to an early frozen section diagnosis and the avoidance of extensive surgery. A description of the granulomatous inflammation showing the typical birefringent Maltese cross configuration is presented. The finding of this diagnostic pathologic condition in all wound tissue available for study suggests that a small wound biopsy may be helpful in confirming the diagnosis. Methods of prevention and treatment are mentioned.

Role of electrolyte solutions in treatment of hemorrhagic shock

Abstract Hemorrhagic shock was induced in a standardized rat model and treated with replacement of shed blood and Ringers solution in a ratio of 3:1. Water content and sodium, potassium, chloride, and nitrogen concentrations in muscle and lung were determined after shock and treatment over a seven day period. Sodium and chloride were lost from muscle tissue during shock. This change was abated by infusion of lactated Ringers solution, but not by blood replacement. Sequestration of pulmonary fluid developed independently of the mode of therapy. Profound depletion of nitrogen occurred after shock and treatment. (Figure 9.) The data suggest that the preferred treatment for hemorrhagic shock includes the administration of an electrolyte solution in addition to replacement of blood volume loss.