Joseph F. Amaral

Gallbladder disease in the morbidly obese.

During a 7 year period, 200 consecutive morbidly obese patients underwent a standardized gastric exclusion procedure. Group A was composed of the first 120 patients and Group B of the last 80 patients. In Group A, 22 patients had undergone a previous cholecystectomy and 12 patients had a cholecystectomy at the time of gastric exclusion because of positive diagnostic studies or palpation of stones. Of the remaining 87 patients in this initial group who were at risk for the development of gallbladder disease, 24 (27.6 percent) required a cholecystectomy in the first 3 postoperative years (mean 15.6 months). Twelve patients had acute cholecystitis, 3 patients had choledocholithiasis, and 1 patient had acute gallstone pancreatitis. In Group B, 18 patients had a previous cholecystectomy, 15 had positive diagnostic studies (ultrasonography and oral cholecystography) preoperatively, and 47 had negative studies. Cholecystectomy was routinely performed at the time of gastric exclusion surgery in the 62 patients with gallbladders in Group B. Of the 47 patients who had normal preoperative diagnostic studies, 40 (85.1 percent) had abnormal histologic findings in the gallbladder. Only seven patients in Group B had a normal gallbladder (14.7 percent). We conclude that gallbladder disease is considerably more frequent in the morbidly obese population (91.3 percent) than has previously been recognized, that diagnostic studies are frequently inaccurate, and that postoperative gallbladder disease is common (28.7 percent). On the basis of these results, routine cholecystectomy at the time of gastric exclusion surgery is recommended.

Prospective Hematologic Evaluation of Gastric Exclusion Surgery for Morbid Obesity

To evaluate the long-term frequency and severity of anemia and selected vitamin and mineral deficiencies after gastric exclusion surgery for morbid obesity, the authors prospectively examined hematologic and nutritional parameters in 150 consecutive patients. These patients underwent a standardized gastric exclusion procedure during a six-year period (1976-1982) and were closely followed for up to seven years (mean, 33.2 months). Anemia developed in 36.8% of the population at a mean time from operation of 20 months. It was more frequent in women than in men (p less than 0.01), and it required transfusions in 3.5% of the population. A low serum iron concentration developed in 48.6%, iron deficiency in 47.2%, a low serum vitamin B12 concentration in 70.1%, vitamin B12 deficiency in 39.6%, and RBC folate deficiency in 18% of the population. Both iron and folate deficiencies responded to oral replacement. As a result of the high frequency and severity of anemia and nutritional deficiencies noted, all gastric exclusion patients should, as a minimum, be placed on oral multivitamin preparations containing iron, folate and vitamin B12. In addition, it is imperative that these patients be followed closely for the remainder of their lives with appropriate studies and replacement as necessary.

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.

Improvement in survival from typhoid ileal perforation. Results of 221 operative cases.

Typhoid ileal perforation remains a frequently fatal illness in the developing world. The purpose of a retrospective review of 195 cases was to ascertain prognostic indices and therapeutic options influencing outcome. The overall mortality rate of 31% was worsened by extremes of age (p < 0.025), generalized peritonitis (p < 0.025), lower white blood cell count (p < 0.05), increased number of perforations (p < 0.005), and postoperative enterocutaneous fistula (p < 0.005). Double-layer closure of the perforation lowered the mortality rate compared with singlelayer closure (p < 0.01). Broader-spectrum antibiotics, in the form of chloramphenicol with gentamycin, metronidazole, or both, reduced the mortality rate compared with chloramphenicol alone (p < 0.05). Based on these findings, a prospective series was initiated in which all patients were treated with two-layer closure and chloramphenicol, gentamycin, and metronidazole. The mortality rate of 8% for the 26 patients treated in this manner confirmed the improved survival with these treatment modalities. Improved survival from typhoid perforation is possible with simple, low-cost measures.

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.

The temporal characteristics of the metabolic and endocrine response to injury.

The neuroendocrine and substrate responses immediately after injury have been extensively investigated in man and animals. The purpose of the present study was to examine simultaneously, the temporal, metabolic and endocrine consequences of a single uniform injury induced by the injection of lambda-carrageenan into the hindlimbs of male Sprague-Dawley rats and to compare this response to that observed in semistarved pair-fed control animals. Immediately after injury there was a decrease in the plasma hematocrit, increase in tissue water and peripheral vasoconstriction that suggested hypovolemia. This was followed by a restoration of the blood volume by 1 day as reflected in hemodilution. Alterations in insulin, glucagon, ACTH, corticosterone, epinephrine, norepinephrine, and dopamine in wounded animals occurred during the first 5 days. However, similar changes were observed in pair-fed control animals from days 1 to 5. These findings implied that the early endocrine response observed from 0 to 24 hours after injury arises, primarily as a result of hypovolemia, whereas the response observed from 1 to 5 days appeared to be the result of semistarvation. In contrast to the endocrine alterations observed, alterations in the plasma concentrations of lactate, acetoacetate and beta-hydroxybutyrate persisted for up to 15 days. The presence of these substrate alterations in the absence of hormonal stimuli suggest that nonendocrine mechanisms exist to induce these alterations. The possibility is raised that these substrate alterations may be, at least in part, the result of the inflammatory infiltrate.