Michel M. Murr

Malabsorptive procedures for severe obesity: comparison of pancreaticobiliary bypass and very very long limb Roux-en-Y gastric bypass

The aim of this study was to determine the efficacy and safety of two malabsorptive procedures for severe obesity. Prospectively collected data from eight men and three women who underwent partial biliopancreatic bypass (PBB) and 19 men and seven women who underwent very very long limb Roux-en-Y gastric bypass (WLGB) for superobesity (preoperative weight >225% above ideal body weight) were evaluated. Age (42 ±3 years and 40 ±2 years), body mass index (64 ±4 kg/m2 and 67 ±3 kg/m2), and percentage of excess body weight (183% ±17% and 203% ±12%) were similar (mean ± standard.error of the mean). Median follow-up was 96 months (range 72 to 108 months) and 24 months (range 18 to 60 months) for the PBB and WLGB groups, respectively. Weight loss expressed as percentage of excess body weight was 68% ±4% 2 years and 71% ±5% 4 years after PBB, and 53% ±7% 2 years and 57% ±5% 4 years after VVLGB. Current body mass indexes are 37 ±2 kg/m2 and 42 ±2 kg/m2 in the PBB and WLGB groups, respectively. Hospital mortality was zero. Morbidity occurred in five patients after WLGB (wound infection in four, wound seroma in one, and pulmonary embolus in one) and in two patients after PBB (abscess in two, anastomotic leak in one, and gastrointestinal bleeding in one). After PBB, one woman died of refractory liver failure 18 months postoperatively and two other patients developed metabolic bone disease. No such known complications have occurred to date after VVLGB. We conclude that VVLGB is safe and effective for clinically significant obesity, results in sustained weight loss, and improves quality of life.

Gastroesophageal reflux after intact vertical banded gastroplasty: Correction by conversion to Roux-en-Y gastric bypass

Symptomatic gastroesophageal reflux disease is common in our experience after vertical banded gastroplasty. Our aim was to determine the safety and efficacy of Roux-en-Y gastric bypass in the treatment of symptomatic gastroesophageal reflux disease complicating vertical banded gastroplasty. We evaluated prospectively collected data on 25 patients who underwent revisional bariatric surgery because of severe gastroesophageal reflux disease after vertical banded gastroplasty. Only 4 of 25 patients had gastroesophageal reflux disease symptoms prior to vertical banded gastroplasty. Endoscopic findings in 24 patients included esophagitis (SS%), Barrett’s esophagus (28%), pouchitis (29%), and gastritis (2 1%); 7 (28%) of 25 patients had evidence of stenosis at the pouch outlet. Mean follow-up (complete in all 2 5) after Roux-en-Y gastric bypass was 3 7 ±7 months (range 3 to 102 months). There were no deaths. Post-operative complications occurred in six patients: pneumonia in two, wound infection in two, prolonged drainage of the defunctionalized stomach via gastrostomy in one, and fever in one. Median hospitalization was 7 days (range 5 to 43 days). At follow-up (3 7 ±7 months), 24 (96%) of 25 are completely or almost completely symptom free. Body mass index was 33 ±2 kg/m2 before and 28 ±2 kg/m2 after Roux-en-Y gastric bypass (P = 0.001). Symptoms of gastroesophageal reflux disease are common after vertical banded gastroplasty. Conversion to Roux-en-Y gastric bypass is safe, relieves gastroesophageal reflux disease, and promotes further weight loss. Moreover, maladaptive eating (vomiting, and so forth) induced by vertical banded gastroplasty is relieved.

Results of Bariatric Surgery for Morbid Obesity in Patients Older than 50 Years

Background: Surgery is increasingly used for weight loss in morbidly obese patients. The authors evaluated the safety and efficacy of bariatric surgery in patients older than 50 years. Methods: Prospective data on 62 consecutive patients (Male = 13, Female = 49) undergoing bariatric procedures between 1985-1994 were reviewed. Mean followup was 30 ± 2 months (3-48 months). All data are mean ± sem. Results: Age was 57 ± 1 year (range 50-71 years). Patients had a mean preoperative weight of 125 ± 4 kg (275 ± 9 lb) and 119 ± 6% excess body weight. A total of 68 procedures were performed: vertical banded gastroplasty (VBG = 23), Roux-en-Y gastric bypass (RYGB = 43), and biliopancreatic diversion (BPD = 2). Six patients were converted to RYGB (5) and BPD (1) after failed VBG. Hospital mortality was nil. Complications were wound infection (5), pulmonary (4), gastric leak (2), abscess (1) and others (4). Mean weight loss at 3 years was 55 ± 7 and 33 ± 6% of percent excess body weight for RYGB and VBG, respectively. Postoperative use of medications for arthritis, diabetes mellitus and asthma was reduced by 23%, 62% and 100%, respectively. Satisfaction with the outcome of treatment and weight loss was reported by 81% of patients. Six patients that were converted from jejunoileal bypass (metabolic complications) to VBG gained weight. Conclusions: Bariatric surgery is safe and well tolerated in morbidly obese patients older than 50 years. Weight loss parallels that of younger populations and is greater in patients treated with RYGB in this subgroup. Age should not be a contraindication to bariatric surgery provided the patient has obesity-related medical morbidity. Control of obesity-related co-morbid conditions is improved by weight loss.

Near-total completion gastrectomy for severe postvagotomy gastric stasis: Analysis of early and long-term results in 62 patients

The aim of this study was to evaluate results of completion gastrectomy for severe postgastrectomy gastric stasis. A total of 51 women and 11 men underwent completion gastrectomy for gastric stasis between 1985 and 1996; follow-up was complete in 98% at 5.4 ±-5 years. All patients had modified Visick scores preoperatively of grade III (37%) or IV (63%). Presentation included combinations of nausea, vomiting, postprandial pain, chronic abdominal pain, and chronic narcotic use. All had undergone prior vagotomy and had a median of four previous gastric operations. Hospital mortality was zero. Complications occurred in 25 patients (40%) and included the following: narcotic withdrawal syndrome (18%), ileus (10%), wound infection (5%), intestinal obstruction (2%), and anastomotic leak (5%). All or most symptoms were relieved in 43% (Visick grade I or H), but 57% of the patients remained in Visick grade HI or TV. Nausea, vomiting, and postprandial pain were reduced from 93% to 50%, 79% to 30%, and 58% to 30%, respectively (P <0.05), but chronic pain, diarrhea, and dumping syndrome were not significantly affected. Univariate analysis revealed no preoperative characteristic to be predictive of good outcome. Logistic regression analysis suggested that the combination of nausea, need for total parenteral nutrition, and retained food in the stomach predicted a poor outcome (P <0.05). Completion gastrectomy is successful in 43% of patients. The combination of nausea, need for total parenteral nutrition, and retained food at endoscopy are negative prognostic factors.

Contractile properties of enteric smooth muscle after small bowel transplantation in rats

BACKGROUND The effects of small bowel transplantation (SBTx) on the function of enteric smooth muscle are not understood. PURPOSE To study the contractile properties of enteric smooth muscle after SBTx in rats. METHODS Five groups of inbred Lewis rats (n > or = 8 each group) were studied: unoperated, naive controls; operated controls 1 week (OC1) and 8 weeks after intestinal transection/reanastomosis of the proximal jejunum and distal ileum; and 1 week (TX1) and 8 weeks (TX8) after syngeneic orthotopic SBTx. Contractile activity of circular muscle strips of jejunum was evaluated in tissue chambers. Spontaneous contractile activity (force per wet weight tissue) increased in TX1, TX8, and OC1 rats (P < or = 0.01). Frequency of contractions doubled in OC1 rats (P < or = 0.001) but was unchanged in the other groups. In the presence of nonadrenergic noncholinergic (NANC) blockade, spontaneous contractile activity increased in TX1 and OC1 (P < or = 0.005) without a change in frequency of contractions. Inhibition of neural activity with tetrodotoxoin increased amplitude and frequency in all groups. Bethanechol (3 x 10(-6) to 3 x 10(-4) mol/L) increased, and norepinephrine (1 x 10(-6) to 1 x 10(-4) mol/L) dose-dependently decreased the amplitude and frequency of contractions in all groups; equi-effective concentrations, however, did not differ among groups. CONCLUSIONS The increase in contractile activity after intestinal transection/reanastomosis is secondary to an increase in frequency of contractions and not amplitude. SBTx increases contractile amplitude of circular muscle due, in part, to downregulation of NANC nerves but not via muscarinic or adrenergic hypersensitivity. These alterations in enteric physiology of intestinal contractile activity may have important implications in clinical SBTx.

Contractile activity of circular smooth muscle in rats one year after small bowel transplantation: differing adaptive response of the jejunum and ileum to denervation

The aim of the present study was to determine the long-term effects of isogeneic small bowel transplantation (SBT) on jejunal and ileal circular smooth muscle contractile activity in the rat. Transmural strips of circular muscle were prepared from proximal jejunum and distal ileum of 1-year-old control rats and rats 1 year after SBT (SBT-1Y) to measure isometric force. Spontaneous contractile activity and the doseresponses to bethanechol and norepinephrine were studied Electrical field stimulation (EFS) at varying frequencies (1 to 20 Hz) was evaluated under adrenergic and chohnergic blockade to investigate inhibitory nerves Spontaneous activity both in the jejunum and ileum in SBT-1Y rats was not different compared to control rats Sensitivity to bethanechol did not differ between control and SBT-1Y rats in the jejunum or ileum Sensitivity to norepinephrine, however, was significantly mcreased after SBT in the ileum but not in the jejunum During EFS, inhibition was seen at low frequencies, and contractions were induced at high frequencies in all groups The degree of inhibition did not differ between control and SBT-1Y rats in the jejunum, however, it tended to be mcreased in the ileum after SBT The long-term adaptive response of smooth muscle to the extrinsic denervation accompanying SBT differs between the jejunum and the ileum

An end-to-end pancreaticojejunostomy using a mechanical purse-string device

Pancreatic-jejunal anastomosis leaks are a major cause of morbidity and mortality after pancreaticoduodenectomy. We have used a mechanical purse-string device to secure the jejunum to the intussuscepted pancreatic stump in 17 patients. A major leak developed in 1 patient and minor leaks developed in 2 patients, all of which were managed nonoperatively. This technique is expeditious and safe.

Small bowel transplantation: effects on function of nonadrenergic, noncholinergic nerves☆

Previous work from our laboratory showed that spontaneous contractile activity of jejunal smooth muscle increases after small bowel transplantation. Our aim was to determine whether small bowel transplantation alters the function of nonadrenergic, noncholinergic (NANC) nerves. Seven groups of rats, (n ≥7 in each group) were studied as follows: 1 week after sham celiotomy and 1 week and 8 weeks after 45 minutes of ischemia/ reperfusion (IR1 and IR8), jejunal and ileal transection and reanastomosis (TR1 and TR8), or orthotopic small bowel transplantation (TX1 and TX8). Contractility of jejunal circular muscle strips was studied in vitro. Spontaneous contractile activity increased in the IR1, TR1, and TX1 and TX1 and TX8 groups (P<0.01). Under NANC conditions, spontaneous activity increased in TR1 and in both TX1 and TX8 (P<0.01) despite the lack of an increase in the frequency of contraction in TX1. Electrical field stimulation inhibited contractile activity at low frequencies, but under NANC conditions this inhibition persisted at higher frequencies. The calculated equieffective frequency (F100) that produced a response equal to baseline contractile activity was similar in all groups, but under NANC conditions was greater in TX1 (P<0.025). Functional alterations of NANC nerves are partly responsible for the increase in spontaneous activity in rat jejunal circular muscle strips after a limited ischemia/reperfusion injury, after selective disruption of enteric neural continuity (transection/reanastomosis), and after small bowel transplantation. These findings may provide important insight into graft dysfunction after small bowel transplantation in humans.

Small Bowel Transplantation: the New Frontier in Organ Transplantation

The last ten years have witnessed the emergence of small bowel transplantation (SBT) as a viable treatment modality for selected patients with intestinal failure. The introduction of effective immunosuppressive medications was the most important factor in allowing transplantation of this “forbidden organ”. The technical aspects of harvesting and transplanting the intestine were studied early in the century by Alexis Carrel and later refined by Lillehei and colleagues [1] at the University of Minnesota in 1955. Monchick and Russell [2] established a rat model for SBT which opened the door for investigators to explore unidirectional immune phenomena as well as physiologic function of the transplanted gut. All seven attempts at SBT in humans that were made prior to the introduction of cyclosporine failed because grafts were lost to early rejection or sepsis. Experience with SBT under cyclosporine immunosuppression was encouraging, but ultimately proved to be unsatisfactory as graft loss to rejection continued to be inevitable. Success in human SBT hinged on the advent of FK506 (tacrolimus), which has shown to be of great promise in liver and experimental SBT.