Iain G M Cleator

Laparoscopic Ileogastrostomy for Morbid Obesity

This paper describes the technique of laparoscopic ileogastrostomy which we developed during the summer of 1993. The procedure is identical to that of our ‘open’ ileogastrostomy except that it is performed laparoscopically. The aim of the surgery is to increase ambulation of the patient, while reducing pain, morbidity, and the chance of apnea (due to impaired breathing in the first 24 h following conventional surgery), by carrying out surgery for the morbidly obese person through a laparoscope. This form of laparoscopic surgery may be completed within 4 h and, as our staff gains more experience with laparoscopic ileogastrostomy, we expect patient stays to be 2-3 days in length. Pulmonary function tests at 24 h show a great advantage in favor of the laparoscopic approach. Response of the medical team to this procedure was that it was more time-consuming and demanding than open surgery.

Long-Term Effect of Ileogastrostomy Surgery for Morbid Obesity on Diabetes Mellitus and Sleep Apnea

Background: The long-term effects of ileogastrostomy surgery for morbid obesity on diabetes mellitus and sleep apnea were investigated. Methods: All patients who had the ileogastrostomy for morbid obesity at the Bariatric Surgery Clinic of St. Pauls Hospital between 1997 and 2002 were registered in the International Bariatric Surgery Registry (IBSR). In 2005, IBSR follow-up was supplemented with a survey. Results: Of the 592 consecutive patients registered in the IBSR, 311 were available for follow-up. Of the 15 patients who had diabetes mellitus preoperatively, 12 (80%) had cure of their diabetes mellitus and 3 (20%) were improved. Remission or improvement of diabetes occurred early postoperatively. Of the 20 who had sleep apnea preoperatively, 11 (55%) were cured and 6 (30%) were improved. Conclusions: This is the first report of the long-term effect of the ileogastrostomy on diabetes mellitus and sleep apnea. The ileogastrostomy was associated with rapid improvement or normalization of diabetes mellitus, similar to the biliopancreatic diversion and the Roux-en-Y gastric bypass, but faster than other bariatric operations. Improvement in sleep apnea was slower and was related to weight loss, similar to other bariatric operations.

Liver Biopsies Following Ileogastrostomy

Patients who have had ileogastrostomy for the treatment of morbid obesity require close, long-term follow-up. One concern in patients undergoing any form of intestinal bypass surgery is that of possible liver damage. To assess for possible liver damage in morbidly obese patients undergoing ileogastrostomy, we undertook a prospective study of liver biopsies in 12 consecutive patients. Preoperative and 2-year postoperative biopsies of the liver were planned. There were six liver biopsies available for comparison both pre- and post-operatively. The biopsies showed changes of fatty infiltration both pre- and post-operatively. There were no differences in the degree of fatty infiltration, or of other histological parameters which we measured. There were no cases of cirrhosis of the liver recorded.

Mechanisms of Weight Loss following Intestinal Bypass Surgery.

Dramatic weight loss has been observed following intestinal bypass surgery. Initially, malabsorption was recognized as the major cause for weight loss. Only in recent years have investigators noted that the intestinal bypass could significantly reduce caloric intake, which largely or almost fully explains the weight loss following this procedure. The reduced energy intake as well as malabsorption are probably the major causes of weight loss after intestinal bypass surgery. Increased energy output has been proposed as a factor for weight loss, and more recently, it has been suggested that certain hormonal changes may play a role in regulating satiety and metabolic processes. This article examines these proposed factors that may impact on weight loss following intestinal bypass surgery.

Helicobacter pylori-induced diarrhea post-ileogastrostomy

A retrospective study of all ileogastrostomy procedures (n=26) performed in 1993 by one surgeon (IGMC) was carried out to investigate the hypothesis that Helicobacter pylori may be implicated in certain severe cases of postoperation nausea and diarrhea. Ten of 26 persons (38.5%) displayed nausea and notable diarrhea (greater than or equal to ten bowel movements per day), seven of which warranted upper GI investigation. One hundred per cent (seven of seven) of these persons were found to possess H. pylori upon C-14 breath test. In four of six cases eradication therapy (1 g amoxicillin b.i.d./20 mg omeprazole b.i.d. for 2 weeks) corresponded with a resolution of severe nausea and diarrhea (one additional case involved omeprazole use only), suggesting that H. pylori should be considered as a possible cause of these symptoms post-ileogastrostomy. Additionally, in four of seven cases persons were re-tested (C-14 breath analysis) at least 1 month post-therapy and in this group three persons were found to be free of the organism. All three cases of notable diarrhea and nausea resolved with treatment, providing the strongest evidence for a possible association between infection and these symptoms.

The Mechanism of Weight Loss after Ileo-gastrostomy for Morbid Obesity

Twelve patients (weight 107-178 kg and age range 19-43 years) were investigated following ileo-gastrostomy for morbid obesity. A number of variables were studied prospectively, pre- and postoperatively, to determine the cause of weight loss--previously attributed to malabsorption or decreased caloric intake. Weight loss of 10.9-36.5 kg, mean 22.9 kg, occurred. Three-day calorie counts demonstrated a postoperative decrease in daily caloric consumption of 320-3870, mean 1975 cal. Analysis of body compartment composition after derivation of lean body mass (from calculation of total body water with tritiated water) showed a mean decrease in adipose tissue of 17.7 kg. Postoperative weight loss, mainly fat, could not all be accounted for by decreased caloric consumption or steatorrhoea (72-h stool fat increased by a mean of 30 g). Pulmonary studies showed no significant change in respiratory quotient, but a large decrease in both postoperative utilization of oxygen and the production of carbon dioxide. This may indicate an alternate, anaerobic, energy cycle utilization. Other statistically significant variables included a large fall in cholesterol, LDH cholesterol and triglycerides, and smaller decrease in HDL cholesterol. Changes in gastro-intestinal (GI) hormones and cell counts in stomach and small intestine were also measured and will be reported later.