History of surgery for obesity.
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Female↗
Biomedical subjects
E R Woodward
Publications and source records attributed to E R Woodward.
Marginal ulcer following gastric bypass for morbid obesity.
Four hundred twelve patients underwent gastric bypass for treatment of morbid obesity between 1981 and 1985 at the University of Florida Affiliated Hospitals. Thirty-four patients (8.2%) developed marginal ulcers, considerably higher than the 0-3 per cent ulcer occurrence commonly reported in the literature. Factors predisposing to ulcer formation include: (1) a large gastric pouch; (2) a vertically oriented pouch; and (3) staple-line dehiscence. Twenty-two of 34 patients (65%) with symptomatic marginal ulcers were noted to have staple-line disruption. Twenty-one of these patients (95%) eventually required operative therapy for their ulcers compared with four of 12 patients (33%) with an intact gastric staple line. Surgical therapy consisted of takedown of the Roux-en-Y limb with resection of the ulcer and gastrogastrostomy. Staple-line dehiscence is a significant etiologic factor in the development of marginal ulcer following gastric bypass and when present constitutes an indication for reoperation.
Adolescent↗
Pouch outlet obstruction following vertical ring gastroplasty for morbid obesity.
We have experienced a 14% (38 of 264 patients) incidence of pouch outlet obstruction following vertical ring gastroplasty. Initial management consisted of dilatation in 34 of 38 patients (94%). Ten of 34 patients (29%) were spared reoperation by 1 to 3 dilatations. Non-passage of an endoscope through the stoma immediately following dilatation predicted the need for surgery; 4 of 11 patients (36%) with passage underwent reoperation compared with 17 of 20 patients (85%) without passage (p less than 0.02). Surgical findings included "tipped bands" in 9 of 28 patients (32%); fibrous reaction to the band in 10 of 28 patients (36%); adhesions with angulation of the pouch in 2 of 28 patients (7%); and no identifiable cause of obstruction in 7 of 28 patients (25%). Surgical therapy consisted of removal of the band (2 patients), removal of the band and replacement with a similar length or larger band (20 patients), "tacking" the band in the horizontal position (4 patients), or conversion to a Roux-Y bypass (2 patients). The first three options were associated with an unacceptably high rate of weight regain and/or continued symptoms, whereas the last-named procedure met with good success.
Anastomosis, Roux-en-Y↗
Analgesia and postoperative hypoxaemia after gastric partition with and without bupivacaine wound infiltration.
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Anesthesia, Local↗
The surgical treatment of chronic gastric atony following Roux-Y diversion for alkaline reflux gastritis.
Symptoms of severe nausea, vomiting, abdominal pain, and frequent bezoars, as well as objective gastric retention, can occur following Roux-Y biliary diversion for alkaline reflux gastritis. Medical therapy and prokinetic drugs have proven ineffective. This review evaluates 37 patients who underwent further gastric resection from 1979 to 1987 to improve gastric emptying and resolve symptoms. Fifteen patients underwent perioperative radionuclide solid-food gastric emptying studies. Seventy-three per cent (27 of 37 patients) of the patients who underwent further gastric resection (70% to 95%) had a satisfactory postoperative response. Twenty patients were graded Visick 1 or 2 and 7 Visick-3 patients, although much improved, still had some symptoms of gastroparesis. Twenty-seven per cent (10 of 37 patients) failed to improve and underwent completion total gastrectomy. Overall, 70% of this group had almost complete resolution of their symptoms. Three of 10 patients were considered "failures" due to postprandial pain in 1 and early vasomotor dumping in 2. Of the 10 patients who failed initial revisional surgery, 7 underwent a 70% to 80% subtotal gastric resection (STG) and 3 patients underwent 85% to 95% extensive resection (EXT.G.). Of the 15 patients who underwent perioperative radionuclide evaluation, a mean two-hour gastric retention of 61.4% +/- 4% (SEM) decreased to 25% +/- 4% following further gastric resection. Eight patients were in the STG group and seven patients were in the EXT.G group. Following STG, mean two-hour gastric retention of 58.2% +/- 3.5% decreased to 38% +/- 3% (p less than 0.05). In seven patients who underwent EXT.G, mean two-hour retention of 65% +/- 4% decreased to 10% +/- 2.5% (p less than 0.005). EXT.G resulted in normal gastric emptying and few late failures. In post-Roux-Y patients with symptoms of gastroparesis and documented gastric retention, EXT.G normalizes gastric emptying and restores a better quality of life. Total gastrectomy should be reserved for those patients who are failed by more extensive resection.
Adult↗
Human intestinal brush border angiotensin-converting enzyme activity and its inhibition by antihypertensive Ramipril.
Angiotensin-converting enzyme (ACE) has been identified as a prominent brush border membrane-bound enzyme of human jejunum. In this study, we purified brush border membrane vesicles enriched in ACE, and characterized the ACE with regard to (a) its stability in the membrane, (b) substrate hydrolysis kinetics compared with pulmonary endothelial ACE, and (c) pharmacologic interaction with Ramipril. These investigations resulted in the following findings. The uninhibited enzyme is stable in native membranes in vitro, with a half-life of 195 +/- 7 h. Kinetic analysis of ACE hydrolysis activity revealed the presence of a single enzyme species, which yielded a high Vmax and displayed a Km similar to purified ACE from lung endothelium. Brush border ACE was inhibited by Ramipril, one of the most specific and potent orally administered ACE inhibitors indicated for hypertension. We determined the brush border ACE value of IC50 = 3 X 10(-9) M Ramipril-diacid, which is the same value for serum and lung ACE. Brush border ACE remains 100% inhibited by 10 microM Ramipril during at least 8 days in vitro. The data indicate that ACE is a prominent jejunal brush border enzyme that behaves pharmacologically and kinetically like its peripheral circulation counterpart. This study suggests that high doses of orally administered ACE inhibitors may affect intestinal epithelial function.
Angiotensin-Converting Enzyme Inhibitors↗
Clinical and radionuclide evaluation of Roux-Y diversion for postgastrectomy dumping.
From 1973 to 1986, 22 patients underwent Roux-Y gastrojejunostomy for the early postgastrectomy dumping syndrome. In the early years, five patients underwent Roux-Y conversion with the addition of a 10 cm antiperistaltic jejunal segment interposed between the Roux-Y limb and the stomach. Within 4 years, all five patients had the jejunal segment removed due to severe symptoms of gastric retention. These patients underwent reconstruction to create Roux-Y limb only and joined the pool of 17 patients who underwent Roux-Y diversion only for the dumping syndrome. Overall, 19 of 22 patients (86 percent) had almost complete resolution of their dumping symptoms on long-term follow-up. Three patients showed no improvement, two with severe gastric retention and one with recurrent dumping symptoms. Overall, 5 of 22 patients (23 percent) had moderate to severe early and late postoperative gastric retention necessitating medical treatment in three and subsequent near-total gastrectomy in two. Although other procedures such as pyloric reconstruction or the addition of isoperistaltic or antiperistaltic jejunal interpositions have been reported to be equally successful in delaying gastric emptying and resolving dumping symptoms, we have preferred Roux-Y diversion for the treatment of combined alkaline reflux gastritis and dumping or the pure early vasomotor postgastrectomy dumping syndrome. As reported, we have abandoned the use of an antiperistaltic jejunal segment interposed between the stomach and the Roux-Y limb due to the high rate of postoperative gastric retention.
Anastomosis, Roux-en-Y↗
The case for prophylactic cholecystectomy concomitant with gastric restriction for morbid obesity.
The pre and postoperative incidence of cholelithiasis were investigated in patients undergoing bariatric surgery at the University of Florida. The first part of the study was retrospective and revealed a pre and 24-month postoperative incidence of cholelithiasis of 30 and 40 percent respectively. Age and postoperative interval were not predictive of cholelithiasis. Patients with cholelithiasis had a significantly greater weight loss (130 +/- 61.0 lbs) than those without stones (109 +/- 59.9 lbs) P = 0.04. Men had a significantly greater weight loss than women (160 +/- 15 lbs SEM versus 99 +/- 7 lbs SEM) as well as a higher incidence of cholelithiasis (53 and 24%, respectively). In the second, prospective part of the study, cholecystectomy was performed in 73 consecutive patients concomitant with their bariatric procedure. Ninety six per cent of removed gallbladders had gross or histologic abnormalities including cholelithiasis in 27 per cent and cholesterolosis/cholecystitis in 69 per cent. The incidence of cholelithiasis was higher than that found in the retrospective series by preoperative ultrasound. The bariatric surgical patient is clearly at risk for the development of postoperative cholelithiasis and cholecystitis. The risk appears to be related to the amount of weight loss. In addition, some gallstones may remain undetected at the time of surgery. We therefore recommend prophylactic cholecystectomy at the time of bariatric surgery.
Adult↗
The history of vagotomy.
The anatomic characteristics of the vagus nerve were described by Galen in the second century AD, and its physiology was studied by Pavlov almost a century ago. Therapeutic possibilities of vagal denervation of the stomach was explored by several surgeons in the first quarter of this century. The most auspicious effort was that of Latarjet. The rebirth of vagotomy in 1943 by Dragstedt was based on cumulative new data supporting the concept that vagal denervation should favorably influence the clinical course of duodenal ulcer. This now proved concept renders vagotomy in some form a basic part of all operations for duodenal ulcer. The Dragstedt operation, vagotomy and pyloroplasty, is particularly useful in cases of acute bleeding and obstruction. Vagotomy and antrectomy has the lowest ulcer recurrence rate. Parietal cell vagotomy has the lowest mortality and morbidity rates and is the procedure of choice in patients with uncomplicated, intractable duodenal ulcer.
Animals↗
Collagen content, histology, and tensile strength: determinants of wound repair in various gastric stapling devices in a canine gastric partition model.
Various stapling devices have been applied to create the small gastric pouch necessary for effective weight loss in morbid obesity, but it is unclear as to which staple line arrangement provides the most reliable gastric wound healing. Five variants of staple lines (Groups I-V) were used to create a gastric partition in 47 adult mongrel dogs (20-30 kg). Staple-line arrangements were as follows: Group I (n = 10)--two superimposed double rows (TA-90), Group II (n = 10)--prototype staple line of four rows 2.03 mm apart, Group III (n = 12)--two double rows of staples 6.5 mm apart, Group IV (n = 10)--prototype staple line of two double rows of staples 0.64 mm apart, and Group V (n = 5)--a single double-row staple line (TA-90). Staple lines were examined at 2, 4, 8, and 13-16 weeks for evidence of healing, histology, tensile strength, and collagen (hydroxyproline) content. Significant differences in staple-line disruption rates were found between all groups (chi 2, P less than 0.01). The prototype four-row staple line (Group II) had the most significant parameters of wound repair determined by biochemical evidence of wound healing and enhanced tensile strength. Staple-line arrangement appears to be an important determinant of gastric wound healing and may influence the rate of postoperative gastric partition disruption.
Animals↗
Postgastrectomy syndromes.
The most common types of postgastrectomy disorders are the dumping syndromes (early postprandial and late or hypoglycemic) and alkaline reflux gastritis. Both are caused by destruction of the pyloric mechanism. A third problem, Roux-en-Y duodenal diversion, frequently results in delayed gastric emptying.
Dumping Syndrome↗
Localization and resection of gastrinomas in Zollinger-Ellison syndrome.
From 1971-1986, 24 patients were diagnosed as having Zollinger-Ellison syndrome (ZES) and 22 patients had laparotomy. Of this group, gross tumor was identified in 15 of 22 patients. Ten of 15 patients had resection of their gastrinomas with the specific aim of curing the disease. This group had responded favorably to either cimetidine or ranitidine before operation. Preoperative transhepatic portal venous sampling (PVS) with gastrin determinations was performed in six patients; three patients had this procedure twice. The tumor was correctly localized by PVS in five of six patients. In four of six patients, the tumor was easily found at surgery. In two of six patients (33%) PVS was vital to intraoperative decisions. Criteria for biochemical cure are normal periodic fasting gastrin and secretin infusion tests. Of the 10 patients who had resection for potential cure, two patients failed within 48 hours of surgery on the basis of an elevated fasting serum gastrin level in one patient and a positive secretin infusion test in the other patient. Eight patients were considered cured with follow-up from 6 months through 15 years. Of the eight cured patients, the tumors were located as follows: four were extraintestinal and extrapancreatic, four were in the duodenal wall, one patient had a tumor located in the uncinate process of the pancreas, and one tumor was located in a lymph node along the lesser curve of the stomach. Two patients had mobilization of the pancreas and duodenum for a "blind" pancreatoduodenectomy based on preoperative PVS (2 procedures each patient). In one patient a 3-mm gastrinoma was enucleated from the posterior uncinate process. The second patient had pancreatoduodenectomy with findings of two duodenal wall gastrinomas. Both patients remained cured of ZES beyond 2 years. It is concluded that PVS does indeed locate some tumors before operation, even those not easily found at surgery. ZES can be cured by an aggressive approach combining preoperative tumor localization and tumor resection. Of the eight patients biochemically and perhaps biologically cured, follow-up was greater than four years in five patients, greater than two years in two patients, and beyond six months in one patient.
Duodenal Neoplasms↗
Gastric partition after reversal of jejunoileal bypass.
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Body Weight↗
The treatment of complicated reflux esophagitis.
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Esophagitis, Peptic↗
Surgical management of the failed jejunoileal bypass.
The jejunoileal bypass is an efficient surgical treatment for morbid obesity, but it has a high complication rate that necessitates reversal in about 25 percent of patients. Conversion to Roux-Y gastric bypass was associated with acceptable morbidity and provided excellent control of weight. On the other hand, conversion to gastric partition resulted in weight gain almost equal to that seen with simple reversal alone. Conversion to Roux-Y gastric bypass is an acceptable procedure in the surgical treatment of the unsuccessful jejunoileal bypass.
Adult↗
Reoperations for esophagitis following failed antireflux procedures.
During the last 20 years, several procedures have been introduced that effectively control gastroesophageal reflux. Nevertheless, little has been written regarding surgical management of patients with recurrent esophagitis following a failed antireflux procedure. The purpose of this study was to review the results of all operations for recurrent esophagitis. Fifty-five patients had undergone a total of 61 previous operations for reflux (initial operation: Hill, nine; Nissen, 30; Allison, eight; Thal, patch three; Belsey, 10; other, one). Eleven patients underwent a Hill procedure (indications: intractable "gas-bloat" syndrome, 4 patients, esophagitis, 7 patients). Two developed recurrent esophagitis (18%). Seventy-eight per cent had satisfactory results (mean follow-up 24 months), and there were no deaths. Three individuals had a transabdominal fundoplication. One patient was lost to follow-up while the other two had satisfactory results (follow-up, 1 and 6 years). Twenty-nine patients were subjected to a transthoracic fundoplication, with two deaths (seven per cent). One patient (four per cent) was lost to follow-up at 9 months; mean follow-up was 44 months). Eighty-six per cent had satisfactory results. The sole poor result occurred in a scleroderma patient who ultimately required colon interposition. Twelve patients underwent a Thal-Nissen procedure. One patient was lost to follow-up (eight per cent), while another with scleroderma had an unsatisfactory result (eight per cent); 83% had satisfactory results. The mean follow-up was 70 months. There were no deaths. Overall, 80% of patients subjected to reoperation had satisfactory results. Mortality was four per cent. Reoperations for gastroesophageal reflux constitute an effective means of controlling recurrent esophagitis and compare favorably with primary operations in both mortality and success rate.
Esophagitis, Peptic↗
Gastric partition after reversal of jejunoileal bypass for morbid obesity: three-year follow-up.
The jejunoileal bypass (JIB) has met with increasing disfavor as a result of its unacceptably high complication rate. JIB reversal was done in 54 patients at the University of Florida, with a gastric partition done concomitantly to avoid regaining weight. Weight control was generally adequate up to six months after conversion to gastric partition. However, mean weight gain progressed steadily afterward to a mean increase of 40% at three years. Six months after conversion to gastric partition, 55% of the patients (15/27) had gained weight, contrasted with 3% of 100 patients who had a gastric partition as a primary procedure. The percentage of patients gaining weight progressed until at three-year follow-up 30 of the 38 patients (79%) in this subpopulation showed a failure to control weight. It is apparent from these data that jejunoileal bypass has created a nutritional life-style that predisposes patients to hyperphagia. Conversion to a gastric partition has a much higher incidence of failure than gastric partition done de novo.
Adult↗
Endoscopic balloon dilation of outlet stenosis after gastric bypass.
Eighteen of 22 patients with stenotic gastrojejunostomies following gastric bypass surgery were successfully corrected by endoscopically placing a guidewire through the narrowed outlet and then passing a dilating balloon catheter over the wire. No complications occurred. All procedures were done without general anesthesia, and 64 per cent were done without hospitalization. This procedure can spare patients prolonged hospitalization for nasogastric decompression or reoperation, the two standard approaches to this problem. Successful use of this technique to dilate obstructed gastric partitions and distal esophageal strictures suggests that it may be considered for any gastrointestinal stenosis within reach of the endoscope.
Catheterization↗