Iatrogenic ocular complications in patients after jejunoileal bypass surgery

We conducted complete eye examinations and retinal function tests on nine patients who had undergone jejunoileal bypass (JIB) surgery and subsequently had low serum vitamin A levels. All patients had manifested clinically demonstrable keratoconjunctival xerosis; in addition, two had abnormally high dark-adaptation final thresholds, and two had concomitant implicit prolongation in the electroretinogram. The age-matched control groups that consisted of 14 patients with various gastrointestinal disorders and four asymptomatic volunteers showed fewer or no ocular abnormalities. Our findings suggest that, even though patients who underwent JIB surgery may manifest keratoconjunctival xerosis and have low serum vitamin A levels for several months to years, retinal function will remain normal until the tissue stores of vitamin A are depleted. A long-term ophthalmologic follow-up of JIB patients, therefore, is recommended.

Differentiation status of rat enterocytes after intestinal adaptation to jejunoileal bypass

The differentiation status of epithelial cells in intestinal adaptation remains unclear. To determine whether enterocytes reach optimum maturity following adaptation after 85% shortening of the rat gut by jejunoileal bypass surgery, activities of two brush border enzymatic markers of differentiation, alkaline phosphatase and sucrase, were examined in subpopulations of epithelial cells isolated sequentially from the villus/crypt axis of normal (sham operated) and hyperplastic mucosa. In jejunal villi, adaptational hyperplasia was associated with an increase in total epithelial alkaline phosphatase, but not total sucrase, activity; alkaline phosphatase activity increased most obviously in cells at the 11-50% position (from the tip) on villi. In hyperplastic ileal villi, total alkaline phosphatase activity fell, although sucrase activity did not change significantly. Specific activity (per mg protein) of sucrase on jejunal villus epithelium was reduced by the adaptational changes to bypass; alkaline phosphatase specific activity remained unchanged. In the ileum, despite adaptational changes to bypass, there was no increase in the normally low specific activities of sucrase and alkaline phosphatase. Bypass surgery did not change the major site of expression of either enzyme on jejunal or ileal villi. In conclusion, enzymatic markers of functional differentiation are not all equally affected by adaptational hyperplasia. Hypertrophy of villi and increased cell proliferation seen in jejunum remaining exposed to luminal contents resulted in an increase in the alkaline phosphatase but not the sucrase content. This is not, therefore, the result of a simple immaturity of villus cells. Morphological adaptation in the ileum, however, is not accompanied by adaptation of brush border enzyme markers of differentiation, confirming a functional immaturity of these cells. Strategies for increasing the expression of these markers may have clinical value.

Normal plasminogen activator inhibitor levels at long-term follow-up after jejuno-ileal bypass surgery in morbidly obese individuals

Forty-five patients who had been subjected to jejuno-ileal bypass (JIB) surgery for morbid obesity and 10 obese nonsurgery subjects were studied. The former group was examined 14 to 20 years after surgery, and was found to have lower mean plasminogen activator inhibitor type 1 (PAI-1) activity (8.4 v 32 U/mL, P < .001), tissue plasminogen activator (tPA) antigen concentrations (7.2 v 12 micrograms/L, P < .01), body mass index (BMI), and fasting plasma insulin, triglyceride, and cholesterol levels. The PAI-1 levels were correlated with BMI, waist to hip ratio, and insulin, triglyceride, and cholesterol levels. Thus, previously obese subjects have normal PAI levels 14 to 20 years after treatment with JIB surgery, in contrast to the high PAI-1 levels in nonsurgery obese subjects.

Intestinal secretion after jejunal bypass in the ground squirrel

The preceding paper [H. V. Carey, Am. J. Physiol. 263 (Regulatory Integrative Comp. Physiol. 32): R1202-R1208, 1992] demonstrated that a 3-day fast or the extended fast of hibernation enhanced the chloride secretory responses to a variety of agonists in the ground squirrel jejunum. Here we examined the effect of jejunal bypass on intestinal secretory capacity in squirrels that either remained active and continued to feed (ACT), or were induced to hibernate (HIB). Mucosal wet weights were reduced in jejunal segments that had little or no exposure to the luminal stream (all segments from HIB and bypassed segments from ACT) compared with segments in contact with luminal contents (sham and in continuity segments of ACT). Tissue conductances were greater in those segments not exposed to luminal contents. Short-circuit current (Isc) responses to electrical stimulation of submucosal neurons, or to serosal carbachol, were greater in segments not exposed to luminal contents when responses were normalized to serosal surface area. Normalization of secretory responses to crypt area produced a similar pattern. Isc responses to mucosal alanine, which reflect electrogenic Na+ absorption, were greatest in segments with little or no exposure to luminal contents. Tissue wet weights, conductances and secretory responses of bypassed segments of HIB and ACT squirrels were always similar. These results suggest that luminal contents directly influence jejunal secretory capacity.

[The dynamic electrocardiogram in the late period after the surgical treatment of obesity patients]

An analysis is presented of ECG of 68 patients with obesity (grade III-IV) before the operation of jejunoileal shunting and 1-2, 3-5 and 6-10 years after surgery. It was found that the main changes in the cardiovascular system occur during the first 2 years, i.e. during the period of body mass reduction. The importance of ECG in the diagnosis of hypertrophy of different compartments of the heart in obesity of grade III-IV.

Women in the POSCH trial. Effects of aggressive cholesterol modification in women with coronary heart disease. The POSCH Group. Program on the Surgical Control of the Hyperlipidemias

The Program on the Surgical Control of the Hyperlipidemias (POSCH) provided the clearest and the most convincing evidence supporting the beneficial effects of cholesterol lowering in hypercholesterolemic survivors of a myocardial infarction. In POSCH, 78 of the 838 patients (9.3%) were women, with 32 randomized to the diet-control group and 46 to the diet plus partial ileal bypass surgery-intervention group. At 5 years, the mean per cent change from baseline was -23.9% for total plasma cholesterol (p < 0.0001), -36.1% for low-density lipoprotein cholesterol (p < 0.0001), and +8.5% for high-density lipoprotein cholesterol (p = not significant). Because of the small number of women, no statistically significant changes in clinical event rates were observed between the control and the surgery groups. A comparison of 162 coronary arteriography film pairs in the POSCH women, between baseline and 3, 5, 7, and 10 years, consistently showed less disease progression in the surgery group (p = 0.013 for combined assessments of the baseline to the longest follow-up film). Because the lipid and coronary arteriography findings in the POSCH women paralleled these findings in the total POSCH population and in the POSCH men, and because the arteriography changes in POSCH have previously been demonstrated to be statistically significant surrogate end points for certain clinical events and predictors of overall and atherosclerotic coronary heart disease mortality rates, we conclude that the lipid modification achieved in the POSCH women by partial ileal bypass reduced their atherosclerosis progression. The POSCH findings in women support the aggressive treatment of hyperlipidemia in the general management of atherosclerosis in women.

Decrease of lactase activity in the small intestine of jejunum-bypassed rats

The effect of jejunum-bypass operation on lactase in rat small intestine was examined. Three groups of four or five rats were designated as jejunum-bypassed, sham-operated and normal rats. All animals including normal rats received by pair-feeding 5% glucose/1% NaCl for 5 days following the operation; thereafter they were fed ad libitum the laboratory chow diet. Three weeks after the jejunal bypass operation, the proximal ileum exhibited a hyperplasia as evidenced by a concomitant increase in mucosal contents of both total proteins and DNA. The specific activity of lactase in this segment was significantly lower in the operated rats than sham-operated controls, whereas the specific activity of sucrase in this segment was significantly elevated. The reduction of lactase activity was also evident in the proximal jejunal segment as well as in the distal jejunum which was deprived of luminal nutrition, suggesting that some hormonal factor(s) might be involved in the decrease of lactase activity in jejunum-bypassed animals. Electroimmunoassay revealed that the amount of immunoreactive lactase also declined in the operated rats relative to the sham-operated controls. Our results thus suggest that lactase activity in residual ileum is not only unable to compensate for the loss of digestive-absorptive surface of jejunum, but lactase activity even decreases following jejunum-bypass operation.

Body composition and surgical treatment of obesity. Effects of weight loss on fluid distribution

Obesity is associated with absolute and relative expansion of the extracellular water compartment (ECW). The effects of substantial and prolonged weight reduction on body water distribution are unknown, however. The authors studied total body water (TBW) by tritiated water dilution, ECW by 35SO4 dilution, exchangeable sodium (Na(e)) by 24Na, and total body potassium (TBK) by 40K whole-body counting in 25 severely obese women (body mass index [BMI] = 48 +/- 7 kg.m-2, mean +/- standard deviation) aged 36 +/- 8 years before and at intervals after gastric restrictive (GR; n = 12) and malabsorptive (MA; n = 13) operations for obesity. Results are compared with a control group of 26 healthy normal-weight women (BMI = 21 +/- 2). Before operation, the obese patients had absolute elevations of all water compartments compared with controls, with significantly higher ratios of Na(e) to TBK (1.17 +/- 0.13 versus 0.91 +/- 0.10; p less than 0.05) and ECW to intracellular water (ICW) (E/I = 0.82 +/- 0.17 versus 0.63 +/- 0.06; p less than 0.05). After weight loss of 52 +/- 20 kg in MA and 47 +/- 19 kg in GR patients (nonsignificant between groups) to a stable level 22 +/- 8 months after operation, there were statistically significant reductions in TBW, ICW, TBK, and Na(e) in both groups, but a significant reduction in ECW only after GR. Adjusting for preoperative weight, duration of follow-up, and rate of weight loss, E/I was greater after MA than GR (1.09 +/- 0.25 versus 0.82 +/- 0.14; p less than 0.05). The elevated preoperative E/I ratio did not normalize with weight loss after surgery, and the response was related to the type of operation. The finding remains to be explained although the increased E/I after MA may reflect mild protein-calorie malnutrition not detectable in the blood. The persistence of elevated E/I with significant weight loss after GR might imply an intrinsic or irreversible imbalance of fluid distribution in obese patients.

Joint manifestations in gastrointestinal diseases. 2. Whipple's disease, enteric infections, intestinal bypass operations, gluten-sensitive enteropathy, pseudomembranous colitis and collagenous colitis

This review addresses the clinical picture of rheumatic diseases seen in Whipple's disease, gluten-sensitive enteropathy, pseudomembranous colitis, collagenous colitis and that developing after enteric infections and intestinal bypass operations for morbid obesity. These disorders exemplify the interplay between antigen entrance through the gastrointestinal canal, specific bacterial properties and genetic host factors such as HLA B27. In most cases such as interplay results in formation of circulating immune complexes causing the development of peripheral joint disease.

[Regression of coronary atherosclerosis: possible--and clinically relevant?]

Several recent clinical trials have shown that in male patients with stable coronary heart disease, progression of atherosclerosis can be delayed even in short time. The interventions to bring about less progression and even a regression of coronary artery lesions mainly consisted in lowering high lipid levels, either with drugs, partial ileal bypass surgery or comprehensive lifestyle changes. The results of trials using calcium antagonists were less consistent and failed to show clear-cut slowing or prevention of progression. Some questions, however, arise and are discussed: i.e. the shortcomings of quantitative angiography to assess the extent of atherosclerotic lesions and the clinical importance of the observed changes in luminal diameter, which tended to be small. Despite these intriguing issues, the reported studies provided the additional information that the angiographically demonstrated benefits were paralleled by a reduction of clinical vascular events and an improvement of the short-term clinical outcome.

Effect of alcohol-feeding on IgA-producing immunocytes in the small intestine of rats with and without jejunoileal bypass

Alcohol-feeding to rats subjected to jejunoileal bypass operation has been shown to lead to marked liver injury (fatty liver, necrosis and inflammation). This study investigated the influence of alcohol-feeding over a period of 3 months on the number of IgA-producing immunocytes and the villus surface area in various sections of the small intestine of rats subjected to a jejunoileal bypass or a sham operation. A jejunoileal bypass in animals receiving the control diet led to a decrease in the number of IgA-producing immunocytes in the duodenum and ileum, but not in the bypassed (blind) loop of the jejunum. In animals subjected to a jejunoileal bypass, alcohol-feeding led to an increase in the number of IgA-producing immunocytes in the duodenum and the bypassed jejunal loop as compared with animals with a jejunoileal bypass receiving the control diet. Among the animals with a jejunoileal bypass fed the control diet, the villus surface area within the duodenum and ileum increased as compared with the groups of sham-operated rats. The feeding of alcohol prevented this increase in the villus surface area in animals with a jejunoileal bypass. The increase in the number of IgA-producing immunocytes induced by alcohol in the animals with a jejunoileal bypass, in the duodenum and bypassed jejunum, supports the assumption of a change in antigen uptake in these parts of the small intestine, brought about by alcohol.

Influence of ileal resection, type of diet and ursodeoxycholic acid on biliary secretion in rats

We studied the effects of the type of dietary fat and of ursodeoxycholic acid, an exogenous bile acid added to the diet, on bile physiology in rats with 50% resection of the distal small intestine. The amount of fat was the same (4%) in all diets assayed, which differed only in the type of fat, (olive oil in diet A, and 1/3 medium-chain triglycerides, 1/3 sunflower oil and 1/3 olive oil in diet B). The removal of 50% of the distal small intestine raised the de novo hepatic synthesis of bile acids with respect to controls, regardless of whether diet A or diet B was given. The addition to diet B of ursodeoxycholic acid decreased bile flow and osmotic activity of bile acid in resected rats and raised bile acid-independent bile flow in comparison to resected rats given diet B without ursodeoxycholic acid.

Program on the Surgical Control of the Hyperlipidemias (POSCH): patient entry characteristics. The POSCH Group

The entry characteristics of patients in the Program on the Surgical Control of the Hyperlipidemias (POSCH), a randomized, controlled, clinical trial, are described in this article. The primary objective addressed by POSCH was whether lowering total plasma cholesterol by partial ileal bypass surgery results in a reduction in mortality and morbidity in post-myocardial infarction patients. Between 1975 and 1983, 838 patients between the ages of 30 and 64 years were randomized into POSCH. The mean age at entry was 51 years, and 91% of the patients were men. The mean time between myocardial infarction and entry was 2.2 years. The mean baseline total plasma cholesterol was 251 mg/dl, with a mean LDL-cholesterol of 179 mg/dl and a mean HDL-cholesterol of 40 mg/dl. Significant disease (greater than or equal to 50% occlusion) of one or more major coronary arteries was found in 91% of the patients. In addition to a description of the POSCH patient population at entry, comparisons of the POSCH patient population to populations of participants in other lipid-lowering trials are presented to provide a perspective on how POSCH relates to these trials.

Reduction of LDL production rate in ileal bypassed rabbits treated with lovastatin

The effect of lovastatin on the low density lipoprotein metabolism in bypassed rabbits was investigated. Partial ileal bypass effectively reduced total and low density lipoprotein (LDL) cholesterol by 44 and 48% respectively. The LDL drop was due to an increased fractional catabolic rate (FCR) of apolipoprotein B (apo B) from 0.74 to 1.27 pools per day with no effect on the apo B absolute catabolic rate and an increased expression of liver LDL receptors (+71%). Association of lovastatin with PIB resulted in a further decrease of total and LDL cholesterol (56 and 75% respectively) as compared to bypassed animals, without effects on the LDL FCR (1.27 +/- 0.11 versus 1.42 +/- 0.13 pools/day) or the expression of LDL receptors by the liver. The reduction of LDL was due to a decrease of the apolipoprotein B absolute synthetic rate (8.5 +/- 1.7 versus 13.6 +/- 1.7 mg/day). From these data we conclude that in bypassed rabbits lovastatin lowers total and LDL cholesterol mainly by reducing apolipoprotein B production rate.

The ambiguity of interstitial bone thickness: a new approach to the mechanism of trabecular thinning

The assumption that a change in interstitial bone thickness reflects a converse change in resorption depth was recently found to be incorrect. Accordingly, we re-examined previously published data concerning trabecular thickness and wall thickness in 15 patients with nonosteomalacic osteopenia following intestinal bypass surgery for obesity. The average number of remodeling cycles completed since the operation was calculated according to two assumptions: First, that the measured activation frequency had been present since the operation; second, that activation frequency had increased in the first two years after operation because of secondary hyperparathyroidism. In comparison with mean wall thickness in 40 normal subjects (38.6 microns), resorption depth calculated in accordance with the first assumption was significantly increased (54.1 microns; p less than 0.001), but calculated in accordance with the second assumption was unchanged (42.1 microns; NS). Reasons are given for believing that the second assumption is more likely to be correct than the first. Mean trabecular thickness and mean wall thickness were significantly correlated (r = 0.68; p less than 0.005). We conclude: 1) Mean resorption depth cannot be inferred from interstitial bone thickness, but can be calculated if the number of remodeling cycles corresponding to the observed structural changes is known. 2) Even though interstitial bone thickness is reduced, trabecular thinning following intestinal bypass surgery is mainly due to decreased wall thickness, as the result of defects in the recruitment and/or function of osteoblasts. The same probably applies to cancellous osteopenia in various other gastrointestinal and hepatobiliary disorders. 3) The study of intestinal bone disease may shed light on the pathogenesis of other, more common, forms of osteoporosis.

Effect of fecal loading with/without peritonitis on the healing of a colonic anastomosis: an experimental study

An experimental randomized prospective study was carried out in 64 dogs to evaluate the effect of intraluminal fecal matter at the anastomosis with/without peritonitis on the healing of a colonic anastomosis. The animals, none of whom had bowel preparation, were randomized in four groups: group I sigmoid resection and anastomosis, group II sigmoid resection and intraluminal fecal diversion from the anastomosis, group III induced fecal peritonitis, sigmoid resection and anastomosis and group IV induced fecal peritonitis, sigmoid resection and intraluminal fecal diversion from the anastomosis. Forty-eight hours before sacrifice at 5, 10 and 15 days, 10 microCi/kg C14 proline was given intravenously. Specimens were analyzed for hydroxyproline content, tissue counts and specific activity. The tissue counts and specific activity were analyzed by three-way analysis of variance. Overall, regardless of the groups, there was a statistically significant decrease in specific activity and tissue count from day 5 to day 15 and day 10 to day 15 at the anastomosis (p less than 0.05). When comparing groups II and IV to groups I and III, there was a significant increase in specific activity and tissue count at the anastomosis of group II and IV (p less than 0.05). This experimental study demonstrates that early anastomotic healing can occur even in presence of treated peritonitis as long as the fecal matter is diverted and prevented from coming in contact with the anastomotic site without disrupting the bowel continuity or function.