Biomedical subjects

R E Brolin

Publications and source records attributed to R E Brolin.

At least 19 recordsLinked to original sources

PubMed1998

Unsuspected cirrhosis discovered during elective obesity operations.

OBJECTIVE: To determine the incidence and outcome of cirrhosis encountered unexpectedly during gastric bariatric operations. DESIGN: A cohort study. SETTING: A tertiary care center. PATIENTS: One hundred twenty-five patients in whom cirrhosis was discovered during gastric bariatric operations. Cirrhosis may have been caused by severe obesity in 93 (74%) of the patients. INTERVENTIONS: A questionnaire survey of bariatric surgeons worldwide, including one of us (R.E.B.). RESULTS: One hundred twenty-six (52%) of the 243 surgeons responded to the survey. Planned bariatric operations were performed in 91 (73%) of the cases. Seventeen (14%) of the remaining cases were closed after the discovery of cirrhosis. There were no intraoperative deaths. However, the perioperative mortality rate was 4% and there were 7 late deaths, 6 due to complications of liver disease. Eleven other patients are described as alive with progressive hepatic dysfunction. The remaining 50 patients are "alive and well." The survey also included opinion questions. Regarding the appropriate operation to perform after discovering cirrhosis, 40% replied "perform liver biopsy only and close"; the remaining 60% would perform a bariatric procedure. Regarding bariatric operations that can be safely performed in patients with cirrhosis, 59% would perform banded gastroplasty, 39% would perform standard Roux-en-Y gastric bypass, 5% would perform biliopancreatic bypass, and 27% would perform none of the above. CONCLUSION: Although operative mortality is higher in cirrhotic vs other bariatric patients, most surveyed surgeons believe that gastric restrictive operations can be performed safely in this group of patients.

Adult↗

PubMed1998

Binge eating in bariatric surgery patients.

OBJECTIVE: Eating behavior, attitudes toward eating and body weight and shape, and depression were assessed in a sample of 64 morbidly obese gastric bypass surgery candidates. METHOD: The Beck Depression Inventory (BDI), the Three-Factor Eating Questionnaire (TFEQ), and the Eating Disorder Examination (EDE) were administered at the first preoperative visit. RESULTS: Twenty-five subjects (39%) reported at least one binge episode per week on average over the 3 months prior to seeking treatment. Binge eaters had significantly higher TFEQ Disinhibition and Hunger scores than nonbinge eaters. Binge eaters also differed from nonbinge eaters in terms of attitudes toward eating, shape, and weight. DISCUSSION: A significant number of gastric bypass surgery candidates report binge eating. The findings are consistent with other studies showing binge eaters to be a distinctive subgroup of the obese.

Adult↗

PubMed1997

Intestinal ischemia and reperfusion injury in transgenic mice overexpressing copper-zinc superoxide dismutase.

Superoxide dismutase (SOD) scavenges oxygen radicals that are implicated in the pathogenesis of intestinal ischemia-reperfusion injury. The effect of intestinal ischemia and reperfusion was investigated in transgenic mice overexpressing human Cu-Zn SOD. Ischemia was induced by occluding the superior mesenteric artery. Myeloperoxidase activity was determined as an index of neutrophil infiltration, and malondialdehyde levels were measured as an indicator of lipid peroxidation. Forty-five minutes of intestinal ischemia followed by 4 h of reperfusion caused an increase in intestinal levels of malondialdehyde in both nontransgenic and transgenic mice, but the concentration of malondialdehyde was significantly greater in nontransgenic mice. Intestinal ischemia-reperfusion also caused an increase in intestinal and pulmonary myeloperoxidase activity in nontransgenic and transgenic mice, but the transgenic mice had significantly lower levels of myeloperoxidase activity than nontransgenic mice. Transgenic mice had higher levels of intestinal SOD activity than nontransgenic mice. There were no significant differences in the catalase or glutathione peroxidase activities. In conclusion, our study demonstrates that the overexpression of SOD protects tissues from neutrophil infiltration and lipid peroxidation during intestinal ischemia-reperfusion.

Animals↗

PubMed1996

Prospective, randomized evaluation of midline fascial closure in gastric bariatric operations.

BACKGROUND: Severe obesity is cited as a major risk factor for fascial wound dehisence and late incisional hernia after major abdominal surgery. The purpose of this study was to prospectively compare two methods of closure of the linea alba after gastric restrictive operations performed for treatment of morbid obesity. METHODS: During a 6-year period 229 patients were randomized to have closure of the midline fascia using either a double-stranded #1 PDS suture placed in a continuous fashion or #1 Ethibond suture placed using an interrupted figure-eight technique. RESULTS: Two of 109 patients who had closure with Ethibond suffered an acute dehiscence of the midline fascia vs no cases of fascial dehiscence in the PDS group. There were no wound infections in either group. There were 20 late incisional hernias (18%) in the Ethibond group vs 11 late hernias (10%) in the PDS group (P < or = 0.04). Mean postoperative follow-up time for all patients was 29.4 months. The cost of suture material and the time required to completely close the linea alba were also calculated for each group. The mean closure time in the Ethibond group was 13.3 vs 9.1 minutes in the PDS group (P < 0.0001). Although the cost per suture pack of #1 PDS was $4.63 vs $1.76 per pack for #1 Ethibond, the mean cost of sutures per patient was $4.81 for PDS vs $11.09 for Ethibond. CONCLUSIONS: We conclude that #1 PDS placed in a continuous fashion provides a more secure and cost-effective closure of the midline fascia in morbidly obese patients than #1 Ethibond placed using an interrupted figure-eight technique.

Adult↗

PubMed1996

Update: NIH consensus conference. Gastrointestinal surgery for severe obesity.

The 1991 Consensus Development Panel was instrumental both in establishing criteria for selection of patients for surgical treatment and in recognition of operations that have been shown to be safe and reasonably effective in the long term. The Panel may have been premature in endorsement of any form of banded gastroplasty because the long-term weight loss results of these procedures are frequently disappointing. It seems likely that a consensus panel on the same subject would be worthwhile in the next decade to carefully evaluate such procedures as biliopancreatic bypass and the various laparoscopic techniques for gastric banding. In 1996 surgery remains the only effective treatment for patients with medically severe (morbid) obesity.

Adolescent↗

PubMed1995

Comparison of blood flow and myoelectric measurements in two chronic models of mesenteric ligation.

OBJECTIVE: To determine whether the predictive accuracy of intestinal motility and blood flow measurements is altered by the magnitude of ischemic damage. DESIGN: Inception cohort study (dogs). Motility was measured using a probe that quantifies both the electromyographic (EMG) measurements and the magnitude of evoked contractile response (ECR). Intestinal blood flow was assessed using Doppler ultrasonography in the marginal artery and perfusion fluorometry, which quantifies fluorescein in the bowel wall in dye fluorescence units. SETTING: Vivarium animal research facilities at a medical school. INTERVENTIONS: The blood supply of a 40-cm length of ileum was ligated in 102 dogs: 52 in which the marginal artery was ligated at two points 8 cm apart (severe model), and 50 in which the marginal artery was ligated only once (moderate model). Twenty-four hours after ligation, the motility and blood flow parameters were measured in normal bowel and at 2-cm intervals within the 40-cm ischemic segment. Resection and anastomosis of ischemic bowel was then performed using either EMG, ECR, or fluorometry to determine the site of resection. OUTCOME MEASURE: Anastomotic leak from progressive ischemia. RESULTS: There were 26 fatal anastomotic leaks, all due to necrosis at the anastomosis. Perfusion fluorometry and ECR measurements did not correlate with survival in either model. An audible Doppler pulse in the marginal artery correlated with survival in the moderate (P < or = .02) but not the severe model (P = .59). The EMG measurements were significantly greater in survivors vs nonsurvivors in both models. CONCLUSIONS: The EMG measurements may be useful in bowel viability assessment. Correlation of Doppler ultrasonographic findings with survival in the moderate model suggests that blood flow measurements may be more reliable in predicting viability in less ischemic bowel.

Anastomosis, Surgical↗

PubMed1995

Interleukin-7 activates intestinal lymphocytes.

Human intestinal lymphocytes, particularly intraepithelial lymphocytes, proliferate minimally to some agents, like mitogens and stimuli of the CD3 pathway. This in vitro finding may be due, in part, to a loss of factors found in vivo. Three T-cell growth factors, IL-7, IL-9, and IL-12, were tested for their ability to stimulate the proliferation of intestinal lymphocytes. Both intraepithelial lymphocytes and lamina propria lymphocytes proliferated more vigorously to IL-7 than to IL-9 or IL-12, and only IL-7 increased stimulation through the CD3 pathway. The IL-7-induced response was IL-2-dependent: IL-2 receptors appeared on both intestinal lymphocyte types, and antibody to the IL-2 receptor blocked IL-7-induced proliferation. Both CD4+ and CD8+ T-cell subsets responded to this cytokine as shown by phenotype-depletion experiments and constancy in the CD4/CD8 ratios after culture with IL-7. In addition, the T-cell receptor alpha beta and gamma delta subsets responded equally well to IL-7. This newly described selective proliferative response of intestinal lymphocytes to IL-7, but not to IL-9 or IL-12, requires no preactivation and may enhance growth in vivo.

Antibodies↗

PubMed1995

A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss.

BACKGROUND: Previous studies have documented a high incidence of gallstone formation following gastric-bypass (GBP)-induced rapid weight loss in morbidly obese patients. This study was designed to determine if a 6-month regimen of prophylactic ursodiol might prevent the development of gallstones. METHODS: A multicenter, randomized, double-blind, prospective trial evaluated 3 oral doses of ursodiol: 300, 600, and 1,200 mg versus placebo beginning within 10 days after surgery and continuing for 6 months or until gallstone development, for patients with a body mass index (BMI) > or = 40 kg/m2. All patients had normal intraoperative gallbladder sonography. Transabdominal sonography was obtained at 2, 4, and 6 months following surgery, or until gallstone formation. RESULTS: Of 233 patients with at least one postoperative sonogram, 56 were randomized to placebo, 53 to 300 mg ursodiol, 61 to 600 mg ursodiol, and 63 to 1,200 mg ursodiol. Preoperative age, sex, race, weight, BMI, and postoperative weight loss were not significantly different between groups. Gallstone formation occurred at 6 months in 32%, 13%, 2%, and 6% of the patients on the respective doses. Gallstones were significantly (P < 0.001) less frequent with ursodiol 600 and 1,200 mg than with placebo. CONCLUSION: A daily dose of 600 mg ursodiol is effective prophylaxis for gallstone formation following GBP-induced rapid weight loss.

Adolescent↗

PubMed1995

The antiobstruction stitch in stapled Roux-en-Y enteroenterostomy.

During the past 9 years, 393 Roux-en-Y gastric bypass operations for morbid obesity were performed by one surgeon at a university hospital. Twelve of the 393 patients subsequently developed mechanical small-bowel obstruction, and 7 of these 12 cases developed in the initial 38 patients in this series. There were 2 cases of small-bowel volvulus and 10 cases of postoperative adhesions. Three cases of adhesive obstruction occurred at the jejunojejunostomy. Two of the patients with anastomotic obstruction required operative treatment, whereas the remaining patient was successfully treated by nasogastric tube decompression. A simple technique is described that has successfully prevented this type of anastomotic obstruction in 355 subsequent Roux-en-Y gastric bypass operations. This technique should be useful in preventing anastomotic obstruction after any stapled end-to-side enteroenterostomy.

Humans↗

PubMed1995

A prospective, randomized trial of short versus long tubes in adhesive small-bowel obstruction.

BACKGROUND: Many cases of acute adhesive small-bowel obstruction (SBO) can be successfully treated with intestinal tube decompression. There is considerable controversy, however, regarding whether a short nasogastric tube (NGT) or a long nasointestinal tube (LT) is the best method of intestinal tube decompression. PATIENTS AND METHODS: A prospective, randomized trial was conducted to compare NGT and LT decompression with respect to the success of nonoperative treatment and morbidity of surgical intervention in 55 patients with acute adhesive SBO. RESULTS: Twenty-eight patients were managed with NGT and 27 with LT. There were 44 cases of partial SBO (23 NGT, 21 LT) and 11 cases of complete SBO (5 NGT, 6 LT). Twenty-one patients ultimately required operation, including 13 managed with NGT (46%) and 8 with LT (30%) (P = 0.16). The mean period between admission and operation was 60 hours in the NGT group versus 65 hours in the LT group. At operation, 3 patients in the NGT group had ischemic bowel that required resection. Postoperative complications occurred in 23% of patients treated with NGT versus 38% of patients treated with LT (P = 0.89). Postoperative ileus averaged 6.1 days for NGT patients versus 4.6 days for LT patients (P = 0.44). There were no deaths. CONCLUSIONS: Patients with adhesive SBO can safely be given a trial of tube decompression upon hospital admission. There was no advantage of one type of tube over the other in patients with adhesive SBO.

Female↗

PubMed1994

The effect of gastric bypass surgery on hypertension in morbidly obese patients.

BACKGROUND: Hypertension is the most common medical disorder associated with obesity. The relationship between dietary weight loss and the reduction of blood pressure is well established. However, the effect of gastric bypass surgery on blood pressure has not been well studied. METHODS: We evaluated the relationship between weight loss and blood pressure in patients with diastolic hypertension who had gastric bypass surgery for morbid obesity. Patients were defined as hypertensive if taking antihypertensive medication or if both the preoperative office and mean hospital diastolic blood pressures were greater than 90 mmHg. Two of the authors (J.L.C., M.E.R.), blinded to all postoperative weights, classified the follow-up hypertensive status into one of four categories: resolved, improved, no change, or worse. The relationship between postoperative changes in blood pressure status and mean weight loss, percent excess weight loss, and body mass index were examined using a one-way analysis of variance. The relationship between postoperative weight loss and blood pressure was assessed in the baseline normotensive population using linear regression analysis. RESULTS: There were 45 patients with diastolic hypertension; 91% were taking an antihypertensive medication. The mean follow-up was 39 months. The mean preoperative weight was 137 kg and the mean weight loss at 1, 12, and 24 months following surgery was 13, 21, and 45 kg, respectively. Twelve months after surgery, hypertension had resolved in 22 patients (54%) and had improved in six patients (15%). These findings persisted through 48 months postoperatively. There was a significant relationship between the percentage of excess weight lost and improvement of hypertension at the 6-month and 12-month follow-up visits. There was also a significant relationship between the body mass index and improvement of hypertension at the 1-month, 12-month, 24-month, and 48-month follow-up visits. In the baseline normotensive patients there was not a significant relationship between our weight loss measures and changes in blood pressure. CONCLUSIONS: We conclude that postoperative weight loss in patients undergoing gastric bypass surgery was associated with resolution or improvement of diastolic hypertension in approximately 70% of cases. Resolution or improvement of hypertension occurred more often in patients with a lower postoperative body mass index.

Adult↗

PubMed1994

Weight loss and dietary intake after vertical banded gastroplasty and Roux-en-Y gastric bypass.

OBJECTIVE: The purpose of this study was to learn whether preoperative eating habits can be used to predict outcome after vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RYGB). BACKGROUND SUMMARY: Several independent randomized and sequential studies have reported significantly greater weight loss after RYGB in comparison with VBG. Although the mechanism responsible for weight loss after both procedures is restriction of intake rather than malabsorption, the relationships between calorie intake, food preferences, and postoperative weight loss are not well defined. METHODS: During the past 5 years, 138 patients were prospectively selected for either VBG or RYGB, based on their preoperative eating habits. All patients were screened by a dietitian who determined total calorie intake and diet composition before recommending VBG or RYGB. Thirty patients were selected for VBG; the remaining 108 patients were classified as "sweets eaters" or "snackers" and had RYGB. Detailed recall diet histories also were performed at each postoperative visit. RESULTS: Early morbidity rate was zero after VBG versus 3% after RYGB. There were no deaths. Mean follow-up was 39 +/- 11 months after VBG and 38 +/- 14 months after RYGB. Mean weight loss peaked at 74 +/- 23 lb at 12 months after VBG and 99 +/- 24 lb at 16 months after RYGB (p < or = 0.001). Twelve of 30 VBG patients lost > or = 50% of their excess weight versus 100 of 108 RYGB patients (p < or = 0.0001). Milk/ice cream intake was significantly greater postoperatively in patients who underwent VBG versus patients who underwent RYGB after 6 months (p < or = 0.003), whereas solid sweets intake was significantly greater after VBG during the first 18 months postoperatively (p < or = 0.004). Revision of VBG was performed in 6 of 30 patients (20%) for complications or poor weight loss, whereas only 2 of 108 patients who underwent RYGB required surgical revisions (p < or = 0.001). CONCLUSIONS: These data show that VBG adversely alters postoperative eating behavior toward soft, high-calorie foods, resulting in problematic postoperative weight loss. Conversely, RYGB patients had significantly greater weight loss despite inferior preoperative eating habits. The high rate of surgical revision in conjunction with inconsistent postoperative weight loss has led us to no longer recommend VBG as treatment for morbid obesity.

Adult↗

PubMed1993

Determination of small bowel viability using quantitative myoelectric and color analysis.

Intraoperative assessment of viability in ischemic bowel remains a major unsolved problem in general surgery. Bowel viability was assessed in 31 dogs 24 hr after mesenteric arterial ligation in a 40-cm segment of ileum. The purpose of this study was to evaluate two new quantitative methods of viability assessment, electromyography (EMG) and reflection densitometry. These methods were compared with traditional methods of bowel viability assessment. EMG was measured using a specially designed probe which contains an electronic control unit for computer-assisted data acquisition. A computer algorithm quantified the EMG. Reflection densitometry quantified bowel color in the red and blue spectrum. Presence of visible peristalsis, Doppler ultrasound, and a visual color grading system were also used in viability assessment. Each parameter was measured at 2-cm intervals along the ischemic segment. Resection and anastomosis of ischemic bowel were then performed. There were nine deaths from anastomotic leak, all resulting from further bowel necrosis. EMG was the only viability assessment parameter that correlated with survival. EMG at the resection margin in survivors was 29 +/- 3% vs 23 +/- 4% at the resection site of nonsurvivors (P < or = 0.047 by unpaired Students t test). These results suggest that quantitative EMG measurements may be useful in assessment of viability in ischemic bowel.

Animals↗

PubMed1993

Operative tube versus percutaneous cholecystostomy for acute cholecystitis.

The records of 26 patients who underwent cholecystostomy procedures for presumed acute cholecystitis during a 6-year period were reviewed. Nine patients had operative tube cholecystostomy (OC), and 17 patients had radiologic percutaneous cholecystostomy (PC). A correct diagnosis of acute cholecystitis was made in 22 of 26 patients (84%), including 14 of 17 PC patients and 8 of 9 in the OC group. The rate of resolution of cholecystitis was the same in each group (75% OC versus 78% PC). APACHE II scores prior to treatment were significantly higher in OC patients (20.9 OC versus 12.4 PC, p < 0.01). There were 5 deaths, including 3 in the OC groups and 2 in the PC group. Nonfatal complications were more frequent in the PC group. Two of the 14 correctly diagnosed PC patients (14%) subsequently required emergency cholecystectomy for persistent biliary sepsis, and 6 patients (43%) required at least 1 tube exchange for occlusion or dislodgement. Overall, only 5 of the 14 patients (36%) in the PC group were successfully treated without complications compared with 5 of 8 patients (63%) in the OC group. Despite its theoretical advantages, PC was no more effective than OC in the treatment of acute cholecystitis. These data suggest that OC remains a viable treatment option in critically ill patients with acute cholecystitis.

Acute Disease↗

PubMed1993

Spontaneous cytotoxicity of intestinal intraepithelial lymphocytes: clues to the mechanism.

Human intestinal intraepithelial lymphocytes (IEL) demonstrate target cell-restricted spontaneous cytotoxic (SC) activity that is due to CD2+CD3+CD8+CD16-CD56- effector cells; they kill epithelial cell (EC) tumours (such as DLD-1 colon cancer cells), but not natural killer (NK)-sensitive K-562 cells. The present study shows that the measured levels of SC activities by IEL correlated with those of autologous lamina propria lymphocytes (LPL), but not with those of peripheral blood lymphocytes (PBL). Also, the susceptibilities of DLD-1 cell clones to lysis by IEL and PBL effector cells did not correlate, suggesting different mechanisms of lysis. Antibody blocking experiments showed that the main surface molecules involved in lysis depended on the effector cell type: alpha E beta 7 (HML-1) on IEL and CD16 on PBL. No antibody-dependent cell-mediated cytotoxicity (ADCC) was demonstrated by IEL, even after stimulation with interferon-gamma (IFN-gamma). Few IEL expressed Fc receptors for IgG. This study describes further differences between the SC activities of IEL and PBL.

Antibody-Dependent Cell Cytotoxicity↗

PubMed1993

Lipoprotein lipase regulation by insulin and glucocorticoid in subcutaneous and omental adipose tissues of obese women and men.

There are marked variations in the activity of lipoprotein lipase (LPL) among adipose depots, particularly in women. Consistent with data on LPL activity, the level of expression of LPL mRNA was lower in omental (OM) than subcutaneous (SQ) adipose tissue of women. To investigate the cellular basis of these differences, OM and SQ adipose tissues obtained at surgery from obese men and women were placed in organ culture for 7 d with varying concentrations of insulin and dexamethasone. Insulin increased levels of LPL mRNA and LPL activity in abdominal SQ but not OM adipose tissue. Dexamethasone also increased LPL mRNA and LPL activity, and these effects were more marked in the OM adipose tissue, particularly in men. When insulin and dexamethasone were added together, synergistic increases in LPL activity were seen in both depots, and this was in part explained at the level of LPL mRNA. The SQ depot was more sensitive to the effects of submaximal doses of dexamethasone in the presence of insulin. The maximum activity of LPL induced by insulin or insulin plus dexamethasone was higher in the SQ than in the OM depot of women, and this was associated with higher levels of LPL mRNA. Rates of LPL synthesis paralleled LPL mRNA levels. These data show that insulin and glucocorticoids influence human adipose tissue LPL activity at the level of LPL gene expression, as well as posttranslationally, and that responsiveness to these hormonal effects is dependent on adipose depot and gender.

Abdomen↗

PubMed1993

Elective one-stage abdominal operations after percutaneous catheter drainage of pyogenic liver abscess.

During the past 10 years, 15 patients have had percutaneous catheter drainage (PCD) of pyogenic liver abscesses (PLA) at a major teaching hospital. Five PLA were related to biliary tract disease, two were secondary to colonic diverticulitis, two developed after abdominal surgery, and the remaining were associated with hepatic trauma, gastric ulcer, Crohn's ileitis, and colon cancer. Two abscesses were cryptogenic. Mean diameter of PLA was 8 cm and ranged from 2-14 cm. Three patients had multiple PLA. All patients were initially treated by PCD without major complications. However, one patient required a second PCD after developing a recurrent abscess. Fever and leukocytosis defervesced at a mean 3.6 days and 7 days, respectively, after PCD. Seven of the 15 patients subsequently had one-stage elective abdominal operations for treatment of diseases underlying PLA including two cholecystectomies, two colon resections, one gastrectomy, one ileostomy closure, and one laparotomy for unresectable gall bladder cancer. There were no postoperative complications. These results demonstrate that PLA are best treated by using PCD as primary treatment with surgical drainage reserved for patients who do not respond clinically to PCD. The need for operative treatment in diseases underlying PLA should not deter use of PCD as primary treatment.

Abdomen↗

PubMed1993

Healing of the stapled stomach in bariatric operations.

Breakdown of the in-continuity gastric staple line after gastroplasty and gastric bypass is frequently associated with either complications or unsatisfactory weight loss. Although there is wide variation in the reported incidence of stale-line disruption after gastric bariatric operations, this complication is most frequently recognized by surgeons who routinely examine the integrity of the staple line at 12 months or more after operation. Upper gastrointestinal contrast studies are more sensitive than upper endoscopy in detecting small defects in the stapled gastric partition. The stomach should be routinely divided in patients who require reoperation for late staple-line disruption. This complication could be prevented by routine transection of the stomach at the initial gastric restrictive operation.

Animals↗