Intravenous nutrition during a twin pregnancy

A case is reported of a woman in the third trimester of a twin pregnancy who required intravenous nutrition because of inadequate absorption of nutrients due to a jejunoileal bypass. Weight gain was poor, and there was evidence of intrauterine growth retardation before commencement of intravenous feeding. She received overnight intravenous nutrition for 6 weeks and gained weight with ultrasound evidence of fetal growth. During the 33rd week of gestation, she was delivered of healthy twin males who were at appropriate birth weights and development for their age of gestation. The considerations in intravenous nutrition for a twin pregnancy after jejunoileal bypass are discussed.

Multiple nutritional deficiencies and metabolic complications 20 years after jejunoileal bypass surgery

We have reported a patient with multiple nutritional and metabolic abnormalities following JI bypass. Most of her biochemical abnormalities were corrected with cautious but vigorous supplementation, and her nutritional status improved, as documented by several positive nitrogen balances and normalization of most of her vitamin and trace element serum concentrations. This case clearly demonstrates many of the metabolic complications that can result from the JI bypass procedure and the meticulous followup that is needed during nutritional rehabilitation.

Effects of gastrointestinal surgery on ingestive behavior in animals

Surgical manipulations of the gastrointestinal system can have a major impact on the ingestive behavior of animals. Particularly well-documented are the feeding and drinking effects of JIB and vagotomy. These two surgical procedures are similar in that they reduce the food intake and body weight of obese animals more than that of lean animals, and of hypothalamic obese rats more than that of genetically obese rats. Intermediate effects are obtained with other obesity models. Given the multiple etiologies of human obesity, it is not surprising that gastrointestinal surgery has variable effects in obese humans. The effects of gastric surgery on the ingestive behavior of animals have received relatively little attention. This is unfortunate because gastric bypass is now one of the most widely used methods for surgical treatment of human obesity. In light of recent developments in gastric surgical techniques and new findings concerning the gastric modulation of food intake, the effects of gastric surgery on the feeding behavior of animals should be further investigated. Much remains to be learned about the physiologic and behavioral mechanisms by which gastrointestinal surgery influences ingestive behavior and body weight. Surgical manipulations of the gastrointestinal system may affect ingestive behavior by directly altering the neural and hormonal feedback signals to the brain from the stomach, intestines, and other organs (liver, pancreas), or they may indirectly alter these feedback signals by modifying the preabsorptive and/or postabsorptive flow of nutrients. Seen from a functional perspective, the gut sends to the brain different types of messages that modulate ingestive behavior. Most attention has focused on gut satiety signals, but the gut can also be the source of painful sensations that suppress ingestive behavior. The distinction between satiety and discomfort is not always clear-cut. For example, gut distention may be satiating when it is moderate, but painful when it is extreme. Nevertheless, the distinction is an important one, and the nature of the feeding-inhibitory effects obtained in animal studies must be carefully evaluated. Ideally, obesity surgery should produce minimal aversive consequences, although whether it is possible to reduce food intake and body weight without producing any discomfort remains to be established. In addition to being a source of feeding-inhibitory cues, the gastrointestinal system may also provide excitatory cues that stimulate feeding and modify food preferences. For example, intestinal infusions of carbohydrates increase subsequent food intake under certain conditions.(ABSTRACT TRUNCATED AT 400 WORDS)

Small bowel bypass prevents the trophic action of cholecystokinin on the rat pancreas

The effect of a chronic administration of cholecystokinin (CCK) on the rat pancreas has been studied in rats subjected to a 90% jejunoileal bypass or an intestinal transection (controls). Jejunoileal bypass, when compared to transection, did not modify the size of the pancreas but decreased its enzyme content, especially for amylase, and reduced the number of zymogen granules. These structural and biochemical changes were maintained when bypassed animals were treated three times daily and for six days with cholecystokinin (20 Ivy Dog Units (IDU)/kg). In contrast, CCK treatment in transected animals induced growth of the pancreas due to cellular hypertrophy and hyperplasia; pancreatic enzyme content, especially for chymotrypsin, and the population of zymogen granules in acinar cells were also enhanced. It is concluded that jejunoileal bypass prevents the trophic action of chronic CCK on the pancreas.

Lipoprotein modification achieved by partial ileal bypass: five-year results of The Program on the Surgical Control of the Hyperlipidemias

The Program on the Surgical Control of Hyperlipidemias (POSCH) is a multicentered, randomized, secondary intervention trial assessing the effect of lipoprotein modification achieved by partial ileal bypass (PIB) on overall mortality rates and the course of coronary heart disease. Of the 838 participants, 396 (196 control and 200 surgical patients) have complete 5-year lipoprotein results and are the basis of this report. After PIB, total cholesterol level decreased 24 +/- 1.2% (mean +/- SEM) and low-density lipoprotein cholesterol level fell 38 +/- 1.5% in comparison with control subjects. High-density lipoprotein (HDL) cholesterol level was not changed by PIB; however, a significant decrease in HDL occurred over 5 years in the control group (41.7 +/- 0.7 mg/dl versus 39.5 +/- 0.6 mg/dl, p less than 0.05). This led to consistently higher HDL levels in the surgical group in comparison with control subjects after PIB. Very low-density lipoprotein cholesterol and triglyceride levels were higher in the surgery group than in control subjects (24 +/- 7.6% and 21 +/- 5.4% at 5 years). Apolipoprotein B-100 was significantly lower, and apolipoprotein A-I and HDL-2 were significantly higher in the surgery group. These lipoprotein changes are greater than have been reported from any previous trial of dietary or pharmacologic intervention, including the Lipid Research Clinics-Coronary Primary Prevention Trial, which used cholestyramine. Based on available epidemiologic data, these changes predict a marked reduction in morbidity and mortality rates associated with coronary heart disease after PIB.

[The surgical treatment of exogenous morbid obesity]

19 patients underwent a subtotal gastric bypass following Griffen as the treatment of their morbid obesity. All patients had a complete follow-up ranging from 18 to 36 months. All patients had a weight reduction, into the proposed norms, f.i. below 20 to 30% above the ideal body weight. The sequelae of the obesity disappeared progressively with the weight reduction. Two patients however developed an anastomotic ulcer more than one year after the intervention (11.2%-2/19 patients). 21 patients died of a leakage after Mason-plasty (1/40 patients-2.5%). A minimal morbidity and mortality can only be obtained by using a meticulous operative technique and a team approach of the patient by medical, nursing, dietary and physiotherapist staffs.

Radiology of obesity surgery

Modern imaging modalities are the key to prompt evaluation of the efficacy and complications of obesity surgery. These are divided into the early and late complications of gastric restrictive surgery and intestinal bypass surgery.

Overview of surgical techniques for the treatment of morbid obesity

A brief review of current and antecedent surgical techniques is presented with advantages and disadvantages of the most common operations.

Malabsorptive procedures in surgical treatment of morbid obesity

There is no ideal operation for morbid obesity and there probably never will be one. The disease is multifaceted, with unknown polyfactorial etiology. The multitude of surgical methods attests to the frustrations in trying to palliate the morbidly obese. Gastric restriction on its own is proving inadequate for the heaviest patients ("super obese"), for patients with preferences for "sweets," and for patients who have had failure of previous surgery, whether it be jejunoileal bypass or gastroplasty. The current trend toward performing malabsorptive procedures is symptomatic. Experimentation with varying sizes and configurations of gastric remnants in combination with varying lengths of small intestine in continuity is reminiscent of the early experience with jejunoileal bypass. That era has been called by some respected and influential surgeons the "dark ages of surgery." Very few of the tens of thousands of patients would agree with this assessment. Nevertheless, Payne was convinced that the "malignant abuse of all of these operations. . . could result in the abandonment of the only practical method. . . for the treatment of the morbidly obese patient." Jejunoileal bypass operations can be "salvaged" by vigorous medical management. When that fails, there are several surgical options for dealing with the blind loop, short of reanastomosing the bowel. New malabsorptive operations have been developed and are being rigorously scrutinized by relatively few dedicated surgeon-scientists. The most important lesson learned from the many severe late complications of jejunoileal bypass is that operations for morbid obesity need to be studied intensely and for a sufficiently long period of time before they can be considered ready for routine use.

Elevated plasma enteroglucagon alone fails to alter distal colonic carcinogenesis in rats

The effect of physiologic increases of plasma enteroglucagon, induced by massive bypass or resection of small bowel, on large bowel cell turnover and carcinogenesis was studied in rats in which the distal colon was isolated as a mucous fistula. After injections of azoxymethane, either 85% end-to-side jejunoileal bypass, 85% jejunoileal resection, or sham bypass was performed. Controls underwent colonic transection and resuture, azoxymethane treatment, and then sham bypass. Thirty weeks later the plasma enteroglucagon level had almost trebled after jejunoileal bypass (p less than 0.001) and almost doubled after jejunoileal resection (p less than 0.002) when compared with sham bypass; sham values did not differ from controls. The median number of tumors per rat in the distal (defunctioned) colon fell from 2 to 0 (p less than 0.05). Segmental weight fell by 45% (p less than 0.001) and crypt cell production rate by 75% (p less than 0.001). Neither tumor yield nor adaptation was affected by jejunoileal bypass or jejunoileal resection. Plasma enteroglucagon has no effect on colonic cell turnover or carcinogenesis in the absence of luminal content.

Postoperative alterations in interorgan glutamine exchange in enterectomized dogs

The effect of enterectomy on postoperative visceral organ glutamine exchange was studied in order to gain further understanding of the role of the intestinal tract in the altered glutamine metabolism that occurs following catabolic illness. In addition to studying glutamine, which transports 1/3 of whole blood amino acid nitrogen, we determined the fluxes of glutamate and alanine across the gastrointestinal tract, liver, and kidneys in 18 postoperative dogs. Arterial glutamine and glutamate were significantly higher in enterectomized animals than in controls. With enterectomy the gut became an organ of glutamine balance while in control dogs the GI tract consumed glutamine (0.11 +/- 0.04 vs 1.67 +/- 0.14 mumole/kg X min, P less than 0.001). The gut switched from an organ of glutamate release to one of net glutamate uptake following enterectomy and intestinal alanine release simultaneously fell by 50%. Simultaneously, the liver reduced its uptake of alanine and became an organ of glutamine release. Renal glutamine consumption was also diminished in enterectomy animals. The interorgan exchange of glutamine and other amino acids is altered by enterectomy. The increase in circulating glutamine levels in enterectomized animals suggests that the accelerated intestinal glutamine consumption that characterizes catabolic illnesses contributes to the low glutamine levels in these stress states. In addition, it becomes apparent that the gut is an important supplier of alanine to the liver, which supports gluconeogenesis. Metabolic adaptation and cooperation between organs is essential during organ absence or dysfunction if the organism is to survive critical illness.

Effects of partial ileal bypass on the progression of atherosclerotic lesions in WHHL rabbits

At age of 40 weeks, 9 WHHL rabbits were necropsied as a baseline control group for evaluating aortic and coronary atherosclerosis. An additional 18 WHHL rabbits of the same age underwent either a partial ileal bypass (PIB) or a sham operation. Serum cholesterol concentrations were significantly lower in PIB rabbits than in sham-operated rabbits, mean postsurgical values being 7.9 +/- 2.3 mmol/l and 13.2 +/- 2.4 mmol/l, respectively. This effect was mainly due to a lower LDL-cholesterol concentration. Serum triglycerides remained unaffected. Thirty weeks after surgery the PIB and sham rabbits were necropsied and atherosclerosis was evaluated. Progression of atherosclerotic plaque size in the sham group was most prominent in the aortic arch. PIB largely prevented this progression. The frequency of plaque complications in the aortic arch also increased in the sham groups. Here, no significant improvement was found in the PIB group. Extensive examination of the heart showed some affected coronary arteries in every 40-week-old WHHL rabbit. Progression of coronary atherosclerosis during the postsurgical period was small in both sham and PIB groups. However, while PIB did not affect the plaque size, it significantly reduced the number of coronary arteries affected.

High density lipoprotein, apoproteins A-I and A-II and postheparin plasma lipolytic enzymes after ileal bypass

Apoproteins A-I and A-II, and the activities of lipoprotein lipase (LPL) and hepatic lipase (HL), were studied in 16 patients 3-12 years after ileal bypass operation and in 13 controls, all heterozygous for familial hypercholesterolemia, to investigate why the operated subjects had a higher HDL cholesterol level than the unoperated controls. HDL- and HDL2-cholesterol and apoprotein A-I were higher, HDL3-cholesterol was similar and apoprotein A-II tended to be lower in the operated than the control subjects. The activities of LPL and HL were similar in the 2 groups. HL was negatively correlated with HDL2-cholesterol, whereas LPL was not associated with any of the HDL components. The controls had gained in weight during the follow-up, but the HDL components were not correlated with relative body weight. It is concluded that in familial hypercholesterolemia ileal bypass results in higher HDL- and HDL2-cholesterol and apoprotein A-I level than conservative treatment and that postheparin plasma lipolytic enzymes do not explain the higher level of these HDL components in the operated subjects.

Effect of ileal exclusion on plant sterol metabolism in familial hypercholesterolemia

Factors regulating the metabolism of plant sterols (sitosterol and campesterol) and their serum levels were studied in sixteen patients with heterozygous familial hypercholesterolemia. Eight patients had undergone an ileal bypass operation, resulting in slight fat and severe bile acid malabsorption and in lowered serum cholesterol concentration, but normal fractional cholesterol absorption. Serum plant sterol concentrations (mg/dl) were similar in the two groups, but expressed per milligram of cholesterol were higher in the operated patients. Fecal excretion (equal with intake) and biliary secretion (reflecting absorption) of the plant sterols were similar in the two groups and were significantly correlated with the serum plant sterol content, which also correlated positively with the fractional cholesterol absorption in the control but not in the operated group. The estimated fractional absorption of the plant sterols was similar in the two groups, but that of sitosterol (3.5%) was lower than that of campesterol (9.1%). Our study shows that serum plant sterols are associated with fractional cholesterol absorption even in patients with familial hypercholesterolemia. However, after ileal exclusion dietary intake of the plant sterols is the main regulator of their serum levels.

Jejunal bypass stimulation of pancreatic growth and cholecystokinin secretion in rats: importance of luminal nutrients

The effect of jejunal bypass on pancreatic growth and plasma cholecystokinin (CCK) was investigated in rats. Rats underwent bypass of jejunum or sham operation. Rats with jejunal bypass were further divided into three groups; one group received a continuous infusion of a partially hydrolysed liquid diet (Vital) into the bypassed jejunum; a second group received the nutrient solution mixed with trypsin and infused into the bypassed jejunum; the third bypass group did not receive infusion of nutrient or trypsin into the jejunum. Jejunal bypass alone did not significantly stimulate pancreatic growth or DNA content at one or two weeks postoperative. Infusion of nutrient solution into the bypassed jejunum stimulated pancreatic growth and DNA content, with maximal increases of 185% and 181% for pancreatic weight and DNA content, respectively, at two weeks. This coincided with significant increases in postabsorptive plasma CCK concentrations. Infusion of pancreatic proteases into the bypassed jejunum partially reversed the effects of nutrient infusion. These results suggest that exclusion of bile-pancreatic juice or pancreatic proteases from the jejunum does not lead to maximal release of CCK unless the jejunum receives luminal nutrients. It is proposed that CCK release from rat jejunum occurs spontaneously in the absence of pancreatic proteases, and that luminal nutrients in bypassed jejunum increase plasma CCK and stimulate pancreatic growth by maintaining synthesis of CCK.

The effect of jejunoileal bypass (JIB) in the obese Zucker rat on a sub-group of enteroendocrine cells

The effect of jejunoileal bypass in lean and obese Zucker rats on a number of enteroendocrine cell types was investigated 5 weeks following surgery to remove 80 percent of the small bowel from continuity. The endocrine cells containing somatostatin, cholecystokinin, gastric inhibitory polypeptide, enteroglucagon and neurotensin were investigated. In control rats enteroglucagon cell number was decreased in obese compared to lean animals (5 +/- 1 vs 11 +/- 1 cells/mm). Following jejunoileal bypass the enteroglucagon cell population increased two-fold in both the functional and bypassed bowel in obese rats but was not elevated in lean animals. A significant increase in the number of cholecystokinin cells in the bypassed loop of the jejunum in both lean and obese bypassed rats was observed. The cholecystokinin cell population was also markedly elevated in the functional jejunum of obese but not lean bypassed rats. Only small changes were noted in cell numbers of gastric inhibitory polypeptide, somatostatin and neurotensin containing cells, suggesting that individual cell types have specific stimuli for proliferation. Epithelial height, a measure of intestinal adaptation, was similar in lean and obese rats in both the control and bypassed states, but weight loss in obese bypassed animals was significantly greater than that of lean bypassed rats. The hyperinsulinemia of obese rats was only partially normalized by jejunoileal bypass. These data indicate that jejunoileal bypass has effects on specific enteroendocrine cells which differ between lean and obese Zucker rats, and between individual cell types.(ABSTRACT TRUNCATED AT 250 WORDS)

Fasting and meal-stimulated plasma levels of neurotensin in obese patients after jejunoileal bypass with 3:1 or 1:3 jejunoileal ratio

The functional role of the jejunum and ileum with regard to peripheral plasma levels of intact neurotensin and NH2-terminal immunoreactivity of neurotensin was studied by using jejunoileal bypass as a model. Plasma levels were measured by radioimmunoassay before and after jejunoileal bypass randomized to different jejunoileal ratios. Seven patients were studied before bypass surgery and 28 were examined after end-to-side jejunoileal bypass with 50 cm intestine in continuity and a 3:1 or 1:3 ratio between the length of the jejunal and ileal segments. Fasting levels of intact neurotensin were unchanged by surgery, whereas levels of NH2-terminal immunoreactivity were higher in bypass patients with a long ileal segment (37.5 cm) than in unoperated patients and in those with a short ileal segment (12.5 cm). Meal-stimulated levels of intact neurotensin were higher after 1:3 than 3:1 jejunoileal bypass. The levels of NH2-terminal immunoreactivity in patients with a short ileal segment and in controls were lower than in patients with a long ileal segment. The results show that postprandial levels of both intact neurotensin and NH2-terminal immunoreactivity are related to the length of the functioning ileum and that even a difference in length of 25 cm is reflected in the circulating levels of neurotensin.

Effects of intestinal adaptation on insulin binding to villus cell membranes

Insulin affects the expression of brush border enzymes by villus cells in vitro and in vivo. Physiological (lactation) and surgical (jejunoileal bypass) models of hyper- and hypoplasia were established so that insulin receptor characteristics could be related to villus histology, expression of sucrase and alkaline phosphatase, and plasma insulin concentrations. In lactating rats, villus height increased up to 55% (p less than 0.005), and fasting plasma insulin increased 71% (p = 0.005), compared with controls. Insulin binding to villus cell membranes, and sucrase and alkaline phosphatase activities were, however, unchanged. In ileum of bypass operated rats, villus height increased 134% (p less than 0.005) while insulin binding fell 68% (p = 0.025). Scatchard analysis revealed that this was largely because of reduction in binding by high affinity receptors. Sucrase and alkaline phosphatase specific activities fell 57% (p = 0.03) and 49% (p = 0.02) respectively, suggesting that ileal villus cells were hypomature. The slightly hypoplastic tissue of selfemptying loops showed normal insulin binding compared to jejunum of sham operated controls. Bypass and sham operated rats had similar fasting plasma insulin concentrations. Reduced insulin binding in markedly hyperplastic gut of bypass operated rats might reflect hypomaturity of villus cells. The reduction in insulin binding, however, might significantly modulate the effect of insulin on small intestinal mucosa and account for the fall in enzyme activity which occurs despite villus hyperplasia.

[Pyridoxine can normalize oxaluria in idiopathic renal lithiasis]

Pyridoxine (vitamin B6), given to patients with primary hyperoxaluria of type I, generally leads to a decrease in urinary excretion of oxalate owing to stimulation of conversion of glyoxylate to glycine instead of oxalate. It is not known, however, whether pyridoxine would equally influence hyperoxalurias of other origins, e.g. idiopathic or enteric. Two groups of patients were therefore given pyridoxine orally for 2 months (300 mg/d). Group 1 consisted of 10 idiopathic stone formers with mild hyperoxaluria of unknown origin. Group 2 consisted of 4 patients with enteric hyperoxaluria after intestinal bypass surgery. As a mean, enteric hyperoxaluria was not influenced by vitamin B6, which suggests that this disorder is the consequence of intestinal hyperabsorption of oxalate rather than of glyoxylate. In contrast, idiopathic hyperoxaluria was influenced by vitamin B6: urinary excretion of oxalate decreased in 8 patients out of 10 and became normal in 7. However, two patients did not respond to pyridoxine; both had concomitant severe hyperuricosuria (greater than 1 g/24 h), an observation suggesting that in these cases hyperoxaluria was of dietary origin. Four of the patients whose urinary excretion of oxalate became normal while on pyridoxine were followed up for 8 to 36 months after treatment: in all of them oxaluria remained normal. One whose oxaluria had returned to the upper normal limit was retreated after 2 years and again displayed a fall in urinary oxalate. It is concluded that pyridoxine given to idiopathic hyperoxalurics may correct the disorder, as in primary hyperoxaluria of type I; this is not the case in enteric hyperoxaluria. The mechanisms governing this sensitivity to vitamin B6 remain to be clarified.