Intestinal bypass operation and pregnancy outcome

With the aid of the national Medical Birth Registries and Discharge Registries in Denmark and Sweden it was possible to identify and study delivery outcome in 77 women who, prior to pregnancy, had undergone an intestinal bypass operation for obesity. Analysis of birth weight and pregnancy length distribution showed that infants borne by these women had an increased rate of low birth weight, short gestation, and also growth retardation. There were no distinct differences between those infants that were conceived less than 24 months or more than 24 months after operation. Only two infants had congenital malformations, none died perinatally.

Intestinal kallikrein activity is reduced in a bypassed segment of the small intestine in the rat

The possible pancreatic origin of intestinal kallikrein was studied in a jejuno-ileal bypass model in the rat. The bypassed loops were made of variable lengths (2-72 cm) and samples were taken at 10 cm intervals to relate enzyme activities to adaptive changes caused by local and systemic stimulus. The kallikrein activity was dramatically reduced (mean 92.3%) in the bypassed loops while only moderately reduced (mean 35.8%) activities were found in the intestine remaining in continuity. Kallikrein was uniformly distributed throughout the functional small intestine in normal and bypass operated animals. The longitudinal distribution profiles obtained for brush border enzymes in normal animals were almost absent in the bypassed loops, but were apparent in the remaining intestine. The main adaptive growth was observed in the remaining small intestine, Both here and in the loop, the growth depended on the amount of bypassed tissue. Our observations are strongly in favour of a pancreatic origin of the glandular kallikrein activity found in the small intestine in the rat.

Intestinal calcium absorption in patients after jejuno-ileal bypass or small intestinal resection and the effect of vitamin D

A forearm counter and double-isotope technique were used to measure intestinal calcium absorption in 21 patients after jejuno-ileal bypass for obesity or small intestinal resection. In all but 2 patients calcium absorption was below the normal range for 10 male controls. 3 weeks treatment with 1-alpha-hydroxyvitamin D, 1 microgram b.d., or 1,25-dihydroxyvitamin D, 1 microgram b.d., was associated with significant increases in absorption whereas 3 weeks treatment with 24,25-dihydroxyvitamin D had no effect. This study demonstrates that oral 1,25-dihydroxyvitamin D or 1-alpha-hydroxyvitamin D are effective in increasing calcium absorption.

Whole-body nitrogen and tyrosine metabolism in surgical patients receiving branched-chain amino acid solutions

Fifteen patients undergoing gastric bypass surgery for morbid obesity received preoperatively a standard crystalline amino acid solution containing 15.6% branched-chain amino acids. During the first five postoperative days, the patients were randomized to receive one of three amino acid solutions (9.0 to 10.3 g of nitrogen per day) of different branched-chain amino acid content. The branched-chain amino acid concentrations of the mixtures were 15.6%, 50%, and 100% by weight with five patients in each group. Whole-body amino acid appearance and oxidation were estimated using a continuous intravenous infusion of L-(U-14C)-tyrosine preoperatively and on the third postoperative day. Daily postoperative nitrogen balance, fractional albumin renewal rate, and whole-body tyrosine appearance, oxidation, and incorporation into protein were not significantly different among the three groups. This study suggests that an adequate nitrogen intake of a balanced amino acid mixture, as well as a solution enriched with branched-chain amino acids, maintains protein homeostasis and supports protein synthesis similarly in well-nourished patients following major abdominal surgery. A diet containing only branched-chain amino acids in isomolar ratios was as effective at maintaining protein retention and whole-body protein synthesis and albumin renewal postoperatively when compared with a standard amino acid formula.

A unique late mechanical complication of jejunoileal bypass

The consequences of jejunoileal bypass include not just metabolic derangements, though the frequency and severity of these problems have led to the procedure being abandoned in the treatment of morbid obesity, but a variety of mechanical complications as well. In this report, a new mechanical complication is presented: Intussusception of the defunctionalized ileum into the sigmoid colon, an intussusception caused by malignant lymphoma of the ileum. Because the patient had pain but no evidence of obstruction, the ileal tumor was fortuitously discovered during flexible sigmoidoscopy.

Total parenteral nutrition in acute illness

Successful total parenteral nutrition in acute illness requires an appreciation of the pathophysiology of the illness and an understanding of the nutritional state of the patient, as well as a knowledge of the principles of total parenteral nutrition. Management of the acutely ill patient's general condition is essential prior to the introduction of nutritional support. A basic regimen which includes administration of 1-2g/kg/day of protein, and 8,400 kJ (2,000 kcal)/day of energy, part glucose and part lipid, together with all minerals, vitamins and zinc, in an appropriate amount of water, should be provided. Modifications to this regimen may be indicated to accommodate cardiac, respiratory, liver or renal failure. The questions of the optimum mix of carbohydrate and lipid, the ideal amount of protein and the correct mix of amino acids for a particular period in an individual patient's illness, are still debated. The fact that recent research supports many of the postulates of the Scandinavian pioneers of total parenteral nutrition suggests we may be returning to a correct approach.

[Morbid obesity: what is still justified in surgical therapy?]

The main surgical procedures in the treatment of obesity are described. Plastic surgery, e. g. apronectomy or breast reduction, may be discussed in patients after successful weight reduction, but not as a primary operative treatment of massive obesity. Different intestinal bypass procedures inducing malabsorption have been abandoned because of severe metabolic sequels. More physiologic conditions can be achieved with gastric partitioning creating a small upper gastric pouch in continuity with the remainder of the stomach. If strict rules of patient selection and operative technique are observed, satisfactory weight loss without significant late complications may be achieved.

[Pregnancy after treatment of obesity using jejuno-ileal anastomosis]

The authors report on 5 cases of pregnancy in women who had previously received a jejunoileal bypass for obesity. In two patients, menstruation had normalized after the operation. None of the patients changed her eating habits during the time of pregnancy and both their antenatal courses and births revealed no complications. All the babies were healthy and well developed. Conception occurred 6 to 18 months after the operation, which proved to be sufficient to avoid a fatal fatty metamorphosis of the liver. It can therefore be said that a weight reduction due to the jejunoileal bypass represents no contraindication for pregnancy; sometimes extremely obese women could even become pregnant after the operation. With a careful supervision of the electrolyte balance and the albumen and iron concentration, a jejunoileal bypass means no increased risk for mother and child, neither during delivery nor during the ante- or postnatal period.

[Intestinal adaptive response of the rat after bilio-pancreatic and food diversion from the duodenum]

The object of the research was to evalute, in the rat, the effects brought about on the intestinal trophism by the selective and combined exclusion of the bile, the pancreatic secretion and the food exsert, certainly, a trophic activity on the intestinal mucous membrane where they pass trough, as it has been observed by other authors; but the modifications, observed on last segments of the ileum, do not explain a direct action of these factors to modulate the adaptative intestinal reaction. In the following essay we propose the hypothesis that the privation of biliary and pancreatic secretions and the food from the duodenum may stimulate a hormonal and duodenal reaction which is able to produced observed phenomena.

A comprehensive psychological approach to obesity

Many different treatments for obesity have proven somewhat successful, with none emerging as clearly superior to the others. Surgical approaches, although usually successful at achieving and maintaining weight loss, are accompanied by varied and often harmful side effects. Unless new, safer procedures are developed, treatment may continue to be as hazardous as the obesity itself. Because medical treatment alone has not achieved beneficial, lasting results, research aimed at finding new procedures should be encouraged. Our five-year experience in working with obese patients has led us to the following conclusions: 1. The management of obesity must be a joint venture between psychiatry and medicine. Because of the complex nature of this illness, neither discipline alone can successfully and safely achieve significant initial weight loss coupled with successful long-term maintenance. The use of adjunctive psychological programs in a medical setting can be a successful alternative. 2. Fasting, weight loss, and realimentation must be accompanied by an effort at lifestyle change. Otherwise, patients will continue their self-destructive habits, which will ultimately lead to failure in yet another attempt at sustained weight reduction. The behavioral approach has provided a fairly effective treatment of obesity, sometimes with immediate results. Recent studies support the maintenance effect of behavioral treatments. However, longer studies with follow-ups are needed to better assess the overall effectiveness of these treatments. 3. Despite much false optimism that weight loss is a simple road to happiness, most patients experience some very real problems during the fasting part of the program. Crisis intervention can prove very helpful in terms of reducing stress and preventing dropouts. Group therapy, individual therapy, family therapy, and hypnosis have attained some very limited positive results when used alone; greater success has been reported from combining therapies. Patients generally became more socially effective, physically active, and mentally proficient when exposed to individual therapy together with group and family therapies. 4. Family environment appears to significantly affect compliance and completion. A conflict-laden family environment hampers the patient's ability to deal with the psychological changes encountered in weight loss programs. 5. Many obese patients lack a fundamental knowledge of nutrition, exercise, and health. In addition, most are poorly socialized and require assistance in learning assertiveness and other interpersonal skills. A behaviorally oriented component is very effective in providing these skills.(ABSTRACT TRUNCATED AT 400 WORDS)