Community experience with small bowel bypass for morbid obesity

A comparison of small bowel bypass performed at university centers and by private practitioners in a large metropolitan area demonstrates definite stmilarities in terms of patient selection, mortality and morbidity, and weight loss results. The only aspect of small bowel bypass in the private sector that could be criticized would be the adequacy of follow-up. An operation with as many known and probably other unknown long-term complications as jejunoileal bypass necessitates prolonged careful patient follow-up. We belive the person most qualified to provide such follow-up is the surgeon who performed by bypass procedure.

Hepatocyte perfusion within a centrifuge

A centrifuge, as used in blood banks for washing erythrocytes, is shown to be a good perfusion chamber for hepatocyte suspensions being evaluated for potential extracorporeal liver support. The perfusate was cell-free oxygenated--pO2 300 millimeters of mercury--plasma, serum or tissue culture medium. A centrifuge that requires intermittent perfusion cannot deliver sufficient oxygen to maintain prolonged viability. A continuous flow unit can, at a flow of 800 milliliters per minute, support most functions of 100 grams of hepatocytes for six hours and some function for 12 hours. Metabolism of 2-14C tagged pyruvate to 14CO2 is the most useful sensitive measurement of liver function in this system. It is concluded that a centrifuge allowing a constant perfusion of oxygenated plasma into hepatocytes kept within the unit by centrifugal force is a suitable base for extracorporeal liver support.

Liver failure in the postoperative patient: the role of sepsis and immunologic deficiency

In a 4 year experience with 7- postoperative or postinjury patients in liver failure, we found that 27 (37 percent) had associated bacterial sepsis. The mortality rate in this group of patients was 48 percent, compared with an average of 80 percent among patients with liver failure from other causes. Laboratory evaluation of cellular immune response in 20 cirrhotic patients confirmed the clinical observation of a relative failure of cellular immunity. Mitogen response of lymphocytes to phytohemagglutinin was significantly decreased in cirrhotic patients as was the number of thymus-derived lymphocytes. The association and poor prognosis of pre-existing liver damage, injury, bacterial sepsis, and liver failure is discussed. It is concluded that a postoperative or postinjury patient, regardless of his general condition, who has any possibility of having undrained intraperitoneal sepsis, deserves re-exploration since the trade-off for benefit usually far outweighs the possibility of doing harm. The decision for reoperation in such critically ill patients is not easy, but such operative aggressiveness is warranted.

Cholecystectomy with and without surgical drainage

Thirty-seven patients who met specific criteria had cholecystectomy without drainage, and thirty-seven matched control patients had cholecystectomy with drainage. This study suggests that surgical drainage after every uncomplicated cholecystectomy is unnecessary and may be unwise. Such drainage may result in an increased incidence of postoperative morbidity and prolonged hospital stay.

Replacement of portal vein during pancreatectomy for carcinoma

Three patients are described in whom the portal vein, surrounded but not penetrated by pancreatic carcinoma, was resected and replaced by an expanded Teflon (Gore-Tex) tube. One patient, who has survived 32 months without recurrence of disease, had a radiographically patent graft at 2 and 17 months after operation. A second survivor has a patent graft at 8 months. The third patient died 10 days after operation with an open prosthesis. Excision of involved portal vein during pancreatoduodenectomy for carcinoma of the pancreas is justified in the absence of metastases. Vein grafting is the best means of portal vein reconstruction. Gore-Tex appears to be a suitable prosthesis when the portal vein must be sacrificed. Its clinical success in terms of patency substantiates previous experience in experimental animals.

A swine stress ulcer model

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