Surgical treatment of obesity and its effect on diabetes: 10-y follow-up

Since 1980 we have performed the identical Greenville gastric bypass (GGB) procedure on 479 morbidly obese patients with an acceptable morbidity and a mortality rate of 1.2%. The weight loss in the series was well maintained over the follow-up period of 10 y. The GGB can control non-insulin-dependent diabetes mellitus (NIDDM) in most patients. The group of 479 patients included 101 (21%) with NIDDM and another 62 (13%) who were glucose impaired. Of these 163 individuals, 141 reverted to normal and only 22 (5%) remained with inadequate control of their carbohydrate metabolism. Those patients who were older or whose diabetes was of longer duration were less likely to revert to normal values. The gastric bypass operation is an effective approach for the treatment of morbid obesity. Along with its control of weight, the operation also controls the hyperglycemia, hyperinsulinemia, and insulin resistance of the majority of patients with either glucose impairment or frank NIDDM.

Adipose tissue glucose transporters in NIDDM. Decreased levels of muscle/fat isoform

We investigated the mechanism of peripheral insulin resistance in the adipose tissue of obese and non-insulin-dependent diabetes mellitus (NIDDM) patients at the level of the glucose-transport effector system. Freshly isolated adipocytes from obese nondiabetic and obese NIDDM subjects had decreased insulin sensitivity and responsiveness for glucose-transport stimulation compared with control subjects, with more pronounced changes associated with obese NIDDM patients. The relative abundance of muscle/fat glucose-transporter isoform in the three groups of subjects was determined by Western-blot analysis of detergent-soluble adipose tissue extracts with monoclonal antibody 1F8. Obesity per se had no effect on adipose tissue muscle/fat glucose-transporter isoform (3150 +/- 660 vs. 4495 +/- 410 counts/min [cpm]/mg protein). Furthermore, decreased levels of muscle/fat isoform in adipose tissue of NIDDM patients were also reflected in isolated adipocytes. Our results demonstrate that insulin resistance in isolated adipocytes of NIDDM patients could at least partly be due to a significant depletion of adipose tissue muscle/fat glucose-transporter isoform.

Decreased expression of glucose transporter in muscle from insulin-resistant patients

We have observed that in vitro incubated human muscle fiber strips from obese patients with or without non-insulin-dependent diabetes mellitus (NIDDM) have reduced insulin-stimulated glucose transport rates compared with nonobese control patients. To investigate if the decrease in glucose transport is associated with a depletion of glucose transport protein, we performed Western blot analysis of muscle samples from nonobese control, obese nondiabetic, and obese NIDDM patients to measure the levels of the muscle-adipose tissue glucose transporter (GLUT-4) protein. Glucose transporter protein was depressed by 23% in the obese nondiabetic and 18% in the obese NIDDM group. The results were essentially the same in the rectus abdominus and vastus lateralis muscles. These data suggest that the decreased glucose transport rate observed in muscle of these obese patients with or without NIDDM may be due, at least in part, to a decreased expression of the "insulin-sensitive" (GLUT-4) glucose transporter. This alteration may play a role in the insulin resistance seen in obesity and diabetes.

Long-term studies of mental health after the Greenville gastric bypass operation for morbid obesity

From February 1, 1980, to May 1, 1989, 462 patients underwent the Greenville gastric bypass at the East Carolina University School of Medicine. The operation effectively maintained satisfactory weight loss after 9 years (mean weight preoperatively, 293 lbs; at 24 months, 179 lbs; at 96 months, 194 lbs). The gastric bypass favorably affected non-insulin-dependent diabetes, hypertension, and physical and role functioning. In the most recent 157 patients, our studies were extended to study the effects of the gastric bypass on mental health. The significant improvements in mental health indices that were observed 6 and 12 months after surgery eroded by the end of 2 years. This return of the mental health indices to the preoperative status, plus the late occurrence of 3 suicides and 2 deaths from alcohol abuse among the total 462 patients, suggest that long-term follow-up and continued emotional support are essential ingredients for successful bariatric surgery.

Liver pathology in morbidly obese patients with and without diabetes

The contribution of obesity and/or diabetes to liver pathology in the morbidly obese patient is controversial. We studied the liver biopsies of 100 consecutive patients undergoing gastric bypass surgery for morbid obesity. Multiple morphologic parameters were analyzed and graded independently, without knowledge of the clinical history, liver function tests, and oral glucose tolerance results of the patients. Six percent of the entire group demonstrated no fat, 42% mild fat, 20% moderate fat, and 24% severe fatty metamorphosis of the liver. Twenty-three percent of the patients had central vein fibrosis, 23% sinusoidal fibrosis, 19% bridging fibrosis, and 4% cirrhosis. Thirty-six percent of the patients had some degree of steatohepatitis, 66% possessed so-called glycogen nuclei of hepatocytes, 6% had PAS-positive thickening of blood vessels in the portal tracts, and 1% had lipogranulomas. The degree of fatty metamorphosis and fibrosis was analyzed in three separate groups, categorized by the glycemic status of the patient: 46 patients with normal glucose tolerance (NGT), 23 patients with impaired glucose tolerance (IGT), and 31 patients with non-insulin-dependent diabetes mellitus (NIDDM). Increasing severity of fatty metamorphosis from the normoglycemic obese to the diabetic obese patients was found, which was statistically significant by chi 2 analysis. Four of the six patients showing no fatty metamorphosis were normoglycemic. Glycogen nuclei and PAS-positive blood vessels were significantly more prevalent in the diabetic obese than in the normal obese. In conclusion, the distribution of significant liver histopathology in the morbidly obese patient correlates in severity with the degree of impaired glycemic status.

Fine needle aspiration cytology of pancreatoblastoma with immunocytochemical and ultrastructural studies

The cytologic features of a pancreatoblastoma (infantile adenocarcinoma), a rare pancreatic neoplasm of childhood, are described. Fine needle aspiration (FNA) under ultrasound guidance produced a hypercellular specimen consisting of numerous oval-to-cuboidal cells that had a moderate amount of granular cytoplasm. Spindle-shaped, elongated and triangular-shaped epithelial cells were also seen, along with smaller cells that had a higher nuclear/cytoplasmic ratio and a denser cytoplasm. In addition, there were abundant fragments of stroma present, including some surrounded by epithelial cells. Immunoperoxidase studies performed on the aspirated material revealed positive staining of the epithelial cells for cytokeratin (AE1/3), including high and low molecular weight cytokeratin, carcinoembryonic antigen, neuron-specific enolase and alpha-1-antitrypsin. Ultrastructural examination demonstrated epithelial cells containing either large electron-dense zymogen granules in the range of 400 nm to 600 nm or small dense neuroendocrine granules measuring from 100 nm to 200 nm. This finding, in concert with the immunocytochemical studies, supported a "blastemal" cell origin with bidirectional differentiation for this unusual pancreatic neoplasm and enabled a specific preoperative diagnosis of pancreatoblastoma to be made. The differential diagnosis of pancreatoblastoma from other pediatric neoplasms involving the pancreas, including neuroendocrine tumors and neoplasms of acinar cell derivation, is presented. We believe that the FNA cytologic findings can lead to a correct diagnosis of pancreatoblastoma, especially when coupled with immunocytochemical and ultrastructural studies performed on the aspirated material.

IGF-I--stimulated glucose transport in human skeletal muscle and IGF-I resistance in obesity and NIDDM

Based on the observation that insulinlike growth factor I (IGF-I) can stimulate glucose utilization in nondiabetic subjects and that the action of the IGF-I receptor is normal in the skeletal muscle of patients with non-insulin-dependent diabetes mellitus (NIDDM), it seems possible that IGF-I might provide an effective acute treatment for the hyperglycemia of NIDDM. Using our recently developed in vitro human muscle preparation, we investigated the hypothesis that IGF-I might be an effective alternative to insulin in stimulating glucose transport in diabetic muscle. Abdominal muscle samples from nonobese nondiabetic, obese nondiabetic, and obese NIDDM patients were obtained during elective abdominal surgery. Plasma levels of IGF-I in diabetic patients were lower than those in either of the nondiabetic groups. Binding studies with wheat-germ-agglutinin-chromatography-purified receptors demonstrated the presence of IGF-I receptors in human muscle, with IGF-I binding being approximately 24% that of insulin. There was no change in IGF-I binding in muscle from obese or diabetic subjects, and the structural characteristics of the IGF-I receptor were not altered, as determined by electrophoretic mobility. IGF-I stimulated glucose transport approximately twofold in incubated muscle from control subjects, but there was no IGF-I stimulation of transport in muscle from obese subjects with or without NIDDM. These results confirm a previous report that human muscle contains receptors for IGF-I and demonstrate for the first time that IGF-I can stimulate glucose transport in human muscle. However, muscle from obese subjects with or without NIDDM is resistant to the action of IGF-I.

Comparison between two methods of hydrostatic weighing without head submersion in morbidly obese females

This study compared two methods of hydrostatic weighing without head submersion to conventional hydrostatic weighting in morbidly obese females. We concluded that hydrostatic weighing without head submersion is a valid alternative to conventional hydrostatic weighing especially when subjects are apprehensive in the water. The use of anthropometric head measures (HWNS-A) did not significantly improve the accuracy of the body composition assessment; therefore, elimination of these time consuming measurements in favor of the direct correction of head above Db is recommended.

Sensitivity and specificity of current methods for classifying morbid obesity

This study examined the sensitivity and specificity of current methods for classifying morbid obesity in females. Results suggest that current methods for classifying morbid obesity (greater than or equal to 45.5 kg over ideal weight or BMI greater than or equal to 45) do not provide acceptable specificity and sensitivity, respectively. We suggest that additional measurements such as total body fatness determined by hydrodensitometry be used to classify morbid obesity and determine eligibility for aggressive therapeutic interventions for weight loss.

Mechanism of IGF-I-stimulated glucose transport in human adipocytes. Demonstration of specific IGF-I receptors not involved in stimulation of glucose transport

We demonstrate the presence of specific insulinlike growth factor I (IGF-I) receptors in human adipocytes. Competition studies with 125I-labeled IGF-I and unlabeled IGF-I, IGF-II, and insulin showed the specificity of 125I-IGF-I binding to the IGF-I receptors in adipocytes, membranes, and partially purified detergent-solubilized extracts. The monoclonal antibody to the IGF-I receptor (alpha-IR3) inhibits 125I-IGF-I binding and immunoprecipitates the IGF-I receptor. In addition, the alpha-subunit of IGF-I receptor is approximately 10,000 Mr larger than the alpha-subunit of insulin receptor, and IGF-I stimulates phosphorylation of the beta-subunit of the IGF-I receptor. IGF-I stimulates basal glucose transport in human adipocytes, but the concentrations of IGF-I required for half-maximal and maximal stimulation of glucose transport are 800- and 1000-fold greater than that of insulin. The possibility of IGF-I stimulating glucose transport by interacting predominantly with insulin receptors is suggested by data showing that 1) IGF-I competes with insulin-binding sites, 2) there is a lack of an additive effect with IGF-I and insulin in stimulating glucose transport, 3) alpha-IR3, which specifically inhibits IGF-I binding, does not inhibit IGF-I or insulin-stimulated glucose transport, 4) insulin-receptor antibody MA-10 inhibits IGF-I and insulin-stimulated glucose transport, and 5) IGF-I stimulates insulin-receptor autophosphorylation, although its effect is markedly decreased compared with insulin. In summary, human adipocytes possess specific IGF-I receptors. However, IGF-I stimulates glucose transport predominantly by interacting with the insulin receptor.

Laryngotracheoesophageal cleft: endoscopic diagnosis and surgical repair

The laryngotracheoesophageal cleft results from congenital nonfusion of the upper tracheoesophageal septum and cricoid primordium. The diagnosis remains an endoscopic one and often is difficult to make in the neonate. This article describes a method for determining the diagnosis, as well as details of a successful surgical repair.

Trace element status of some commercial smokeless tobaccos

Baseline conditions for sample handling, processing, chemical extraction, and chemical analysis of chewing tobacco were established. The chemical solubility patterns for cadmium, copper, nickel, selenium, and zinc in several commercial brands of chewing tobacco were determined. Five extractants were used: water with pH value of 3.0, pH value of 5.4, and pH value of 6.5; amylase (0.1%); and methanol (99.9%). The bulk of the total cadmium, copper, nickel, and zinc in the tobacco samples was in a tightly bound form not extracted to any appreciable degree by the solvents used. Selenium was below detectable limits for each of the extractants. It has been reported that copper and zinc may counter the carcinogenic effects of cadmium and nickel. The extractants solubilized a greater amount of copper and zinc than cadmium and nickel from the total metal present in the chewing tobacco.

Screening for selected trace elements in single cell populations by energy dispersive X-ray fluorescence spectrometry

An adaptation of the thin film approach to energy dispersive X-ray fluorescence spectrometry (EDXRF) is described, which provides for a screening analysis for Fe, Ni, Cu, Zn, Se, and Cd in K-562 leukemic cells incubated in various metal-enhanced cultures. Valuable quantitative and semiquantitative data can be obtained on as few as 400,000 cells.

Thoracic neuroblastoma presenting as a cystic hygroma

A case of thoracic neuroblastoma with extension into the supraclavicular fossa is described. By physical examination and ultrasound the patient was thought to have a cystic hygroma with mediastinal extension. A 'cystic' neck mass may be the initial presentation of a mediastinal neuroblastoma.

An in vitro human muscle preparation suitable for metabolic studies. Decreased insulin stimulation of glucose transport in muscle from morbidly obese and diabetic subjects

We have developed an in vitro muscle preparation suitable for metabolic studies with human muscle tissue and have investigated the effects of obesity and non-insulin-dependent diabetes mellitus (NIDDM) on glucose transport. Transport of 3-O-methylglucose and 2-deoxyglucose was stimulated approximately twofold by insulin in muscle from normal nonobese subjects and stimulation occurred in the normal physiological range of insulin concentrations. In contrast to insulin stimulation of 3-O-methylglucose and 2-deoxyglucose transport in muscle from normal, nonobese subjects, tissue from morbidly obese subjects, with or without NIDDM, were not responsive to insulin. Maximal 3-O-methylglucose transport was lower in muscle of obese than nonobese subjects. Morbidly obese patients, with or without NIDDM, have a severe state of insulin resistance in glucose transport. The novel in vitro human skeletal muscle preparation herein described should be useful in investigating the mechanism of this insulin resistance.

Bromine levels in human serum, urine, hair. Short communication

Much is known about the essentiality of the halogens fluorine (F), chlorine (Cl), and iodine (I), but very little has been discussed with respect to bromine (Br). As a member of the halogen family its chemical properties are comparable to those of other halogens, but its presence has been masked by the presence of I and Cl in chemical analyses. By virtue of new technology and a special computerized machine called the Kevex Model 0600 Energy Dispersive X-Ray Induced X-Ray Fluorescence Spectrometer (EDXRF), we can specifically identify bromine in different compartments and verify its concentration accurately. In order to establish standard values of Br concentrations and evaluate the nature of its presence in humans, samples of serum, urine, and hair were collected from ten healthy adult males and analyzed for bromine content. Our samples had normal distributions, with serum bromine levels ranging from 3.2 to 5.6 micrograms/mL, urine levels between 0.3 to 7.0 micrograms/mL, and hair levels determined from 1.1 to 49.0 micrograms/mL. These levels, especially those of serum bromine, have been encountered by other examiners whose samples also had normal distributions. These findings suggest to us that bromine may well be an essential trace element, as are its other halogen family members.

Insulin-like growth factor I binding in hepatocytes from human liver, human hepatoma, and normal, regenerating, and fetal rat liver

Insulin-like growth factor-I (IGF-I) in human hepatoma cells (HEP-G2) has, in addition to its effect on cell growth, short-term metabolic effects acting through its own receptor. We have demonstrated that normal human hepatocytes, compared with HEP-G2 cells, have virtually no IGF-I binding sites. Because the rate of growth is the major difference between the hepatoma and the normal liver, we asked if normal liver might express IGF-I binding sites under physiologic growth conditions. Indeed, whereas adult rat hepatocytes have low IGF-I binding sites similar to those in human liver, hepatocytes from regenerating liver after 3 d subtotal hepatectomy have an approximately sixfold increase (P less than 0.005) and those from fetal rat liver a approximately 12-fold increase (P less than 0.005), to levels comparable to those in the HEP-G2 cells. The specificity of 125I IGF-I binding to its receptor was demonstrated by competition studies with monoclonal antibodies directed toward the IGF-I and the insulin receptors, with unlabeled IGF-I and insulin and by affinity labeling experiments. Thus, if IGF-I has any short-term metabolic functions in the adult human liver, it is not through interaction with its own receptor. Autocrine regulation by IGF-I of liver growth appears possible since IGF-I binding sites are expressed under pathological and physiological conditions of growth. The mechanism that couples these two phenomena remains to be elucidated.

Long-term effect of insulin on glucose transport and insulin binding in cultured adipocytes from normal and obese humans with and without non-insulin-dependent diabetes

We have tested the hypothesis that in vitro exposure of insulin-resistant adipocytes with insulin results in improved insulin action. A primary culture system of adipocytes from obese subjects with or without non-insulin-dependent diabetes mellitus (NIDDM) and nonobese control subjects has been developed. The adipocytes when cultured in serum-free medium do not lose their original characteristics in regard to insulin binding and glucose transport. The adipocytes from three groups were incubated with insulin (0, 10(-10) M, and 10(-7) M) for 24 h at 37 degrees C, receptor-bound insulin was dissociated, and basal and insulin (1 X 10(-11)-10(-7) M)-stimulated glucose transport and 125I-insulin binding were determined. The 24-h insulin exposure of adipocytes from control subjects decreased basal and insulin-stimulated glucose transport. The effects of 1 X 10(-7) M insulin were more pronounced than 1 X 10(-10) M insulin. Similarly, insulin exposure decreased insulin sensitivity and responsiveness of cultured adipocytes from obese and NIDDM patients. The insulin-induced reduction in insulin sensitivity and responsiveness for glucose transport in three groups were due to alterations at insulin binding and postbinding levels. In conclusion, insulin induces insulin resistance in control adipocytes and further worsens the insulin resistance of adipocytes from obese and NIDDM subjects. For insulin to improve the insulin resistance of adipocytes from NIDDM patients, either more prolonged in vitro insulin exposure and/or other hormonal factors might be required.

The control of diabetes mellitus (NIDDM) in the morbidly obese with the Greenville Gastric Bypass

Since February 1, 1980, the identical standardized Greenville Gastric Bypass has been performed in 397 morbidly obese patients with an operative mortality rate of 0.8%. The operation effectively controlled weight and maintained satisfactory weight loss even after 6 years (mean weights and ranges: Preoperative: 290 lbs (196-535); 18 months: 175 lbs (110-300); 72 months: 205 lbs (140-320). The gastric bypass favorably affected non-insulin-dependent diabetes (NIDDM), hypertension, physical and role functioning, and several measures of mental health. Rigorous follow-up (97.5% over 6 years) revealed that health problems were common in postoperative patients; there were nine late deaths. Abnormal glucose metabolism was present in 141 (36%) of 397 patients before surgery: NIDDM was present in 88 patients (22%) and 53 patients (14%) were glucose impaired. Of these, all but two became euglycemic within 4 months after surgery without any diabetic medication or special diets. The most recent 42 morbidly obese patients with NIDDM were studied intensively. In that cohort, fasting blood glucose, fasting insulin, and glycosylated hemoglobin returned to normal after surgery; insulin release, insulin resistance, and utilization of glucose improved sharply. The normalization of glucose metabolism after gastric bypass may not be related solely to weight loss and restriction of caloric intake, but may also be due to the bypass of the antrum and duodenum.

Insulin receptor kinase in human skeletal muscle from obese subjects with and without noninsulin dependent diabetes

We have studied the structure and function of the insulin receptors in obese patients with and without noninsulin dependent diabetes mellitus (NIDDM) and in nonobese controls using partially purified receptors from muscle biopsies. Insulin binding was decreased in obesity due to reduced number of binding sites but no differences were observed in insulin binding between obese subjects with or without NIDDM. The structural characteristics of the receptors, as determined by affinity labeling methods and electrophoretic mobility of the beta-subunit, were not altered in obese or NIDDM compared to normal weight subjects. Furthermore, the ability of insulin to stimulate the autophosphorylation of the beta-subunit and the phosphoamino acid composition of the phosphorylated receptor were the same in all groups. However, insulin receptor kinase activity was decreased in obesity using Glu4:Tyr1 as exogenous phosphoacceptor without any appreciable additional defect when obesity was associated with NIDDM. Thus, our data are supportive of the hypothesis that in muscle of obese humans, insulin resistance is partially due to decreased insulin receptors and insulin receptor kinase activity. In NIDDM the defect(s) in muscle is probably distal to the insulin receptor kinase.

Insulin-receptor kinase activity of adipose tissue from morbidly obese humans with and without NIDDM

We have determined glucose transport, insulin binding, and insulin-receptor kinase activity in adipose tissue from morbidly obese patients with and without non-insulin-dependent diabetes mellitus (NIDDM). The insulin sensitivity and responsiveness of glucose transport in freshly isolated adipocytes were significantly reduced in NIDDM subjects compared with nondiabetics. This was due in part to decreased insulin binding in adipocytes. Reduced specific 125I-labeled insulin binding was also observed in crude detergent extracts and partially purified insulin receptors from adipose tissue. In addition, the basal and insulin-stimulated tyrosine-specific protein kinase activity per milligram of protein was significantly decreased in NIDDM patients compared with nondiabetics. The differences between maximally insulin-stimulated and basal kinase activities expressed by insulin-binding activity were also significantly reduced in NIDDM subjects. We conclude that insulin resistance in morbidly obese patients with NIDDM is due to both insulin-binding and postbinding defects. One of the postbinding defects in NIDDM appears to be impaired insulin-receptor kinase activity of fat tissue.

Localized primary (AL) amyloid tumor of the breast. Cytologic, histologic, immunocytochemical and ultrastructural observations

Two examples of localized primary amyloid tumor of the breast are presented, including one patient with metachronous bilateral lesions. Our findings and review of the literature indicate that this rare lesion occurs predominantly in elderly females and can be mammographically and clinically confused with carcinoma. Fine-needle aspiration biopsy can be a useful procedure to make a preliminary diagnosis. Congo red staining with prior potassium permanganate incubation confirmed the AL type of amyloid in our two cases; this might be the predominant type in the localized form involving the breast. Immunofluorescence studies demonstrated IgA, with kappa and lambda light-chain deposition within the amyloid foci in one case, and intracytoplasmic IgG with both light chains within plasma cells and amyloid deposits of the second case. Ultrastructural examination of one of the cases showed characteristic findings of straight, nonbranching fibrils of 4-9 nm, diagnostic of amyloid. From our findings and a review of the literature, we conclude that amyloid tumors of the breast can occur in three separate settings: secondary amyloidosis, systemic or multiple myeloma associated amyloidosis, and as a localized primary type having a benign course.

Changes in zinc metabolism following exercise in human subjects

Changes in zinc (Zn) availability in muscle tissue that influence muscle performance in vitro have been observed. The effect of exercise of plasma Zn levels and urinary excretion of Zn was observed in sever untrained volunteers following brief intensive exercise and in seven trained volunteers after more prolonged road-running exercise. With brief exercise, plasma Zn decreased predominantly in the more loosely bound albumin fraction. Prolonged exercise resulted in a greater plasma Zn decrease of 30%. Urinary Zn excretion increased transiently with minimal effect on daily losses. However, weight loss by sweating was significant, and sweat Zn losses were greater than those in the urine. Exercise resulted in changes in Zn metabolism that may influence performance.

Studies on the mechanism of insulin resistance in the liver from humans with noninsulin-dependent diabetes. Insulin action and binding in isolated hepatocytes, insulin receptor structure, and kinase activity

We have developed a method to isolate insulin-responsive human hepatocytes from an intraoperative liver biopsy to study insulin action and resistance in man. Hepatocytes from obese patients with noninsulin-dependent diabetes were resistant to maximal insulin concentration, and those from obese controls to submaximal insulin concentration in comparison to nonobese controls. Insulin binding per cell number was similar in all groups. However, insulin binding per surface area was decreased in the two obese groups because their hepatocytes were larger. In addition, the pool of detergent-extractable receptor was further decreased in diabetics. Insulin receptors in all groups were unaltered as determined by affinity-labeling methods. However, insulin-stimulated insulin receptor kinase activity was decreased in diabetics. Thus, in obesity, decreased surface binding could explain resistance to submaximal insulin concentrations. In diabetes, diminished insulin-stimulated protein kinase activity and decreased intracellular pool of receptors could provide an explanation for postinsulin-binding defect(s) of insulin action in human liver.

Cost-effectiveness of fine needle biopsy of the breast

Although fine needle aspiration (FNA) biopsy of the breast has been shown to be a safe and accurate technique, many surgeons question whether it is reliable enough to replace excisional biopsy. If FNA biopsy is followed by excisional biopsy for confirmation, it would seem that the cost of diagnostic work-up would be increased. In this study, however, the authors show that the major economic benefit of FNA biopsy is not that it replaces excisional biopsy, but that it allows the surgeon to triage which patients should have a 1-stage inpatient procedure with frozen section and which patients should have an excisional biopsy as an outpatient under local anesthesia. Over the past 2 years, the average cost at the East Carolina University School of Medicine of excisional outpatient biopsy (negative) was +702 +/- 348; inpatient biopsy (negative) was +1410 +/- 262; inpatient 1-stage procedure (positive) was +4135 +/- 361; and outpatient biopsy (positive) followed by inpatient procedure was +4822 +/- 586. The authors' last 100 FNA biopsies were read as 23 positive, three suspicious, 65 negative, and nine insufficient. There were no false-positives and four false-negatives, for a sensitivity of 87%, specificity of 100%, and accuracy of 96%. Using the above figures, it is possible to calculate the cost per case if all 100 cases had been biopsied by the 1-stage inpatient technique (+2227), by the 2-stage outpatient method (+1938), or guided by the FNA biopsy where positive and suspicious readings are followed by an inpatient 1-stage procedure and negative and insufficient readings followed by an outpatient 2-stage procedure (+1759). Since the FNA biopsy costs +75, it resulted in a savings per case of +393 over routine inpatient biopsy and +104 per case over routine outpatient biopsy. Computer analysis revealed that the FNA biopsy would still be economically favorable if the sensitivity of the test fell as low as 37%, the specificity as low as 80%, or if the percentage of cases of cancer in the population biopsied fell as low as 13%. Since FNA biopsy is cost effective even when followed by an excisional or frozen section biopsy for confirmation, it would be safe and reasonable to expand its use to smaller hospitals where the personnel may be initially less experienced with the technique.

The bypassed stomach

Retrograde duodenogastroscopy solves the problem of postoperative evaluation of the gastric bypass patient. The stomach may be bypassed to treat morbid obesity, but it no longer need be inaccessible. Endoscopic gastritis is rare in the proximal gastric pouch but common in the distal gastric segment and may be related to the presence of bile. Although the gastric mucosa is histologically normal in half of the gastric bypass patients, acute and chronic gastritis, regenerative changes, and intestinal metaplasia may develop in either or both segments. The causes and implications of these endoscopic and histologic findings are unknown.

The Greenville gastric bypass. Progress report at 3 years

Two hundred and ten morbidly obese patients underwent a standardized gastric bypass procedure between February 1980 and November 1983. We conclude, based on 100% follow-up, that the operation is safe (operative mortality--1%, significant complications--10%) and effective (reoperation rate--4%). Only one patient failed to lose more than 25% of preoperative weight. The operation produced a mean weight loss in the group from 289 pounds (202-505) before surgery to 176 pounds (118-308) at 18 months after surgery. Stated as "per cent of ideal weight," patients lost from a preoperative mean of 214% (153-350) to 130% (88-189) at 18 months. Maximum weight loss was reached by 18 months after the procedure and was maintained during 36 months of observation in over 95% of patients. When patients were divided into four groups according to preoperative weight, weight loss occurred at a roughly similar rate, but heavier patients, although they lost more weight, plateaued at a higher weight than patients originally less obese. Striking and objective benefits were seen in patients with diabetes, hypertension, heart disease, and pulmonary insufficiency.

The effectiveness of gastric bypass over gastric partition in morbid obesity: consequence of distal gastric and duodenal exclusion

Eighty-seven morbidly obese patients were prospectively randomized to two operations: gastric bypass was performed on 42 and gastric partition on 45. Gastric bypass proved to be more effective; gastric bypass patients lost 15% more of their original weight at 12 months and 21% more at 18 months. There were no failures in the gastric bypass group; 28 of the 45 operations failed in the gastric partition group. An additional 60 patients underwent gastric bypass since the completion of the study. In the total series of 147 patients who underwent gastric bypass or gastric partition, there was no mortality, and the surgical complication rate was 12%. Because the gastric pouches and the anastomoses were similar in the two operations, the superiority of the gastric bypass may well be due to a heretofore unexplained effect of distal gastric and duodenal exclusion.

Zinc as an integral component of the metabolic response to trauma

Following injury, there is a major redistribution of zinc, as demonstrated by 65Zn tracer studies in rats receiving 20 per cent burns. This injury resulted in a rapid uptake of 65Zn into spleen, lung, wound, kidney and, particularly, liver, while the uptake of 65Zn was decreased in the brain, some muscle groups and, particularly, in bone. Simultaneously, plasma 65Zn occurred predominantly as the albumin bound fraction decreased. The total amount of tracer appearing in the wound was considerably less than that in the liver, where the induction of zinc binding protein was demonstrated in the cytosol. The synthesis of this protein may have an important regulatory role in zinc homeostasis following injury. These widespread changes in 65Zn distribution are consistent with the essential role of zinc in numerous metabolic processes and the increased metabolic activity of such tissues as the liver and the wound that follows injury. It is apparent that the liver has a central role in the early postinjury changes in zinc metabolism and that bone as well as muscle provides an available source of zinc in these circumstances.

Prophylactic cefazolin in gastric bypass surgery

Because surgery in obese patients is associated with a high risk of infection, gastric bypass procedures offer an excellent opportunity to test the efficacy of prophylactic antibiotics. Accordingly, a double-blind prospective trial of prophylactic cefazolin was carried out in 53 consecutive patients who underwent gastric bypass surgery for morbid obesity. The patients were randomized to two treatment arms: (1) cefazolin intravenously, 1 gm 2 hours prior to surgery, at induction of anesthesia, and then 0.5 gm every 6 hours for 48 hours, or (2) an indistinguishable placebo of 5% dextrose at identical intervals. Serial cultures were taken at operation and in the postoperative period. Antibiotic levels of fat were measured by tissue extraction and B. subtilis assay. After surgery, patients were monitored for infection by clinicians unaware of their random assignment group. The study was terminated and the code broken when it was evident that wound infections were increased to a statistically significant difference in one arm of the study. The brief perioperative administration of cefazolin reduced the incidence of wound infection from 21% to 4% (P less than 0.05) and the incidence of urinary tract and pulmonary infections from 17% to 0% (P less than 0.05). Tissue levels of antibiotics confirmed adequate dosages in the test subjects. The advantages of prophylactic administration of cefazolin for gastric bypass procedures are clearly demonstrated in this study. This confirms other reports which have shown prophylactic antibiotics to be useful in a variety of procedures. These studies suggest the need to reconsider the traditional opposition to prophylactic antibiotics and to determine whether perioperative antibiotics should be used routinely in all major operations.

Failure of Doppler ultrasound in the early assessment of blood flow in polytetrafluoroethylene grafts

PTFE is widely used as an arterial and venous graft. The assessment of patency and flow through vascular grafts has been facilitated by the use of Doppler blood flow measurement instruments. However PTFE grafts do not predictably transmit the ultrasound beam used in these instruments in the operative and early postoperative period. Consequently Doppler flow measurements over PTFE grafts are unreliable and may confuse the early assessment of operative results.

Trace element profiles in cancer patients

It has become evident over the last two decades that there is an intimate relationship between the trace elements and cancer. Some trace elements have been shown to be carcinogens, others appear to provide protection against cancer. Profound changes in trace element concentrations and distribution occur in patients with cancer, but most changes remain undefined.A review of a number of studies of trace element changes in patients with cancer demonstrates that simple correlations of trace element levels in disease are of only limited use. Such reports underscore the need for large-scale studies that consider the many variables of malignancies and of trace element chemistry. The variables that must be considered for cancer include tissue of origin; histologic, pathologic and clinical staging; nutritional status as reflected by serum levels of calcium, iron, magnesium, phosphorus, the electrolytes, pH, albumen, and globulin; endocrine balance, effects of previous and concurrent therapies such as surgery, chemotherapy, hormonal manipulation, immunotherapy, and radiotherapy; history of exposure to toxic agents; and the presence of other disease.Similarly, trace element studies entail variables that must be considered and controlled prospectively, including timing and techniques of sampling, storage, and analysis, and simultaneous measurement of at least the majority of possibly interrelated elements rather than studying one element at a time.The various national cooperative oncology groups such as ECOG, SWOG, and SEOG now offer unusually well-studied groups of cancer patients who are managed according to carefully and prospectively defined protocols in participating institutions. With present knowledge, it is now time to approach these groups with a proposal to incorporate trace element studies in their protocols. A potential protocol will be discussed.

Mineral metabolism of the healing arterial wall

The mineral metabolism of healing arterial walls was studied by measuring the accumulation of several radioisotopes at the site of vascular repair in rats. Each rat was subjected to a 1-cm full-thickness aortotomy and then immediately injected by tail vein with c 5 muCi of one of the following radioisotopes: chromic chloride Cr 51 or sodium chromate Cr 51; ferrous chloride Fe 59 or ferric chloride Fe 59; manganous chloride Mn 54; selenious acid Se 75; strontium chloride Sr 85; or zinc chloride Zn 65. At intervals of 1, 2, 4, 6, and 10 days after operation and injection, groups of four rats for each radioisotope were killed, aortas dissected, and the specific radioactivity of healing vascular tissue compared with that of adjacent normal artery. There were sharp and statistically significant differences in the preferential accumulation of the radioisotopes in healing compared with normal aorta. Zinc appeared to be the element most involved in vascular repair, followed by selenium and chromium.

Stewart-Treves syndrome. A lethal complication of postmastectomy lymphedema and regional immune deficiency

Lymphangiosarcoma is a fatal complication of postmastectomy lymphedema. The pathogenesis of lymphangiosarcoma in chronic lymphedema is a combination of two factors. First, the edematous region responds in a manner similar to "immunologically privileged sites." Second, because of its anatomic and physiologic properties, it is a favorable site for the development of mutant cell populations for reasons that are not fully understood. As a result, these mutant cells, with their genetically nonidentical antigens, escape recognition by the host's impaired immune surveillance mechanism. The failure to promote a sufficient immune response allows unrestricted tumor growth to take place, resulting in the ultimate death of the patient. Available therapeutic measures are equally unsatisfactory. Emphasis is placed on periodic examination of the lymphedematous extremity, aggressive treatment of established lymphedema and infections, and surgical preservation of lymphatic channels during breast cancer surgery.

[Mammary carcinoma (author's transl)]

The new discoveries concerning mammary carcinoma promise hope and offer surgeons a demanding challenge. Many more opportunities can now be offered to patients suffering from this dreaded disease, including new diagnostic methods, a wide range of operations, various adjuvant applications of radiotherapy and chemotherapy, a wholly new armamentarium of hormonal and chemical approaches to advanced disease, cosmetic reconstruction, and gentle terminal care. Some of the new findings are true breakthroughs, others remain mirages. Especially in the choice of the type of mastectomy, surgeons must be cautious: The new is not necessarily the best.

Incidental cholecystectomy during major abdominal surgery in the elderly

Forty-four elderly patients with an average age of seventy-eight years were found to have cholelithiasis during unrelated major abdominal surgery. Thirty-nine of them underwent incidental cholecystectomy, one had cholecystostomy, and four had no surgical treatment of their gallbladder disease. Of the thirty-nine patients with an incidental cholecystectomy, none died and only sixteen had nonfatal complications. Of these complications, only one was clearly related to the cholecystectomy and resolved spontaneously. The results compare favorably with other reports of similar procedures in elderly patients. Incidental cholecystectomy does not seem to significantly alter the mortality and morbidity of elderly patients undergoing major abdominal surgery. We advocate incidental cholecystectomy for cholelithiasis in elderly patients as long as the gallbladder is easily accessible and the condition of the patient warrants the additional procedure.

Implications of the inhibition of animal tumors by dietary zinc deficiency

Because zinc is an essential nutrient for tissue growth, cellular division, protein synthesis, and DNA and RNA replication, it also ought to play a critical role in the growth of tumors. To test this thesis, a series of experiments were performed to test the effect of zinc deficiency on the lethality of a variety of solid and ascites tumors in mice and rats. Specifically, the following models were tested: Walker 256 carcinosarcomas, solid and ascites forms in rats; three mouse leukemias (L5178yf, L1210, and P388) in CDF, male mice; and Lewis lung carcinoma in C57BI/6 male mice. Rats receiving a zinc-deficient diet showed marked reduction of tumor growth, both of solid or ascites models, and this was accompanied by striking increase in survival. Survival of mice with transplanted leukemia was also significantly prolonged by zinc deficiency. In addition, growth of the Lewis lung carcinoma was inhibited, but the survival through increased, was probably limited by the adverse effects of zinc deficiency. The results suggest that tumor inhibition is a general effect of zinc deficiency, irrespective of cell type, cell growth rate, species, or site of growth. There are numerous potential applications of zinc metabolism to the diagnosis, therapy, and understanding of cancer.

Extra-anatomic bypasses for aortoiliac disease in high-risk patients

A series of 75 patients, with an average age of 65 years, underwent the following extra-anatomic bypasses involving the crossover femorofemoral principle: femorofemoral (F-F), 54 patients; aortofemorofemoral (A-F-F), 12 patients; common iliac-femorofemoral (CI-F-F), six patients; and axillofemorofemoral (Ax-F-F), three patients. Fifty eight of the 75 patients (77 percent) initially presented with rest pain or gangrene. The operative mortality rate in this high-risk group of patients was 4 percent. Analysis by the life-table method showed the graft patency rate to be 91.1 percent at one year and 87.4 percent at 18 months. There have been no graft failures or deaths in the series of 20 patients followed longer than 18 months. Two amputations followed graft failures and nine of the remaining 11 amputations were done in patients with patent grafts during the same period of hospitalization, reflecting the severity of their gangrene upon admission. High-risk patients who are not suitable for crossover F-F grafts without an inflow procedure may be suitable for a CI-F-F or A-F-F bypass before being considered for an Ax-F-F bypass.

External diversion for palliative treatment of malignant tracheoesophageal or bronchoesophageal fistulas

The creation of cervical esophagostomy, distal esophageal ligation, and a feeding gastrostomy in combination with an external bypass device for the treatment of malignant tracheoesophageal and bronchoesophageal fistulas offers a simple and rational approach for a critical situation in which more extensive surgical procedures are neither warranted nor more effective.