Tuberculosis after jejunoileal bypass for obesity

One hundred patients who underwent jejunoileal bypass for obesity were followed for a mean period of 2 1/2 years. Four patients developed a clinical illness that resembled a systemic form of tuberculosis during the first postoperative year. This incidence exceeds that found in the general population by sixtyfold. Any patient with jejunoileal bypass who develops an illness with accelerated weight loss, enlarged lymph nodes, and unexplained fever with chills should be suspected of having tuberculosis. Aggressive diagnostic measures are required. Treatment with isoniazid and ethambutol at usual doses can be successful, but blood levels should be measured to confirm adequacy until additional information becomes available.     

Lipid composition of bile in morbid obesity before and after jejunoileal bypass surgery

Bile cholesterol, phospholipids, total bile acids, individual bile acids, and fatty acid compositions of bile neutral lipids and phospholipids were analyzed before, at one month and at six months following jejunoileal bypass surgery in a series of morbidly obese patients. Preoperative mole percentages of cholesterol and lithogenic indices were high, indicating that biles were supersaturated with cholesterol and outside the micellar solubility zone when plotted on triangular coordinates. At the one month post-operative period percentages of cholesterol and lithogenic indices were significantly increased as compared to the pre-operative state. At six months post-operatively these values had decreased to approximately the pre-operative levels. No changes were observed in percentages of lithocholic acid, but deoxycholic acid decreased to markedly low levels at one month and remained low at the six month post-operative interval. Relative proportions of cholic acid increased, and the ratio of cholic to chenodeoxycholic acid was significantly increased at both post-operative intervals. No significant changes were noted in bile neutral lipid or phospholipid fatty acid composition, indicating that no depletion of essential fatty acids had occurred.     

Long-term morbidity of jejunoileal bypass

A total of 169 patients who had jejunoileal bypass for morbid obesity were available for study more than 24 months after operation. Continuing high morbidity, especially "the bloats" and the regaining of weight, are arguments against the use of jejunoileal bypass unless clear medical indications exist.     

An approach to the treatment of recurring polyarthralgia after jejunoileal bypass

Polyarthralgia after jejunoileal bypass (JI) is a well-documented complication. In the past, this was treated by antibiotic therapy, but definitive therapy uncommonly necessitated surgical reversal of the JI bypass. This case report discusses the etiology of arthralgias and presents a technique for its treatment without bypass reversal.     

Gastrointestinal complications after aortocoronary bypass

Under analysis are gastrointestinal complications (hemorrhage, perforation of the duodenum, acute pancreatitis) which were observed in 10 of 177 patients after aortocoronary bypass. Risk factors of these complications, their specific diagnosis, treatment and prophylactics are discussed.     

Long-term outcome when major complications follow coronary artery bypass graft surgery. Recovery after complicated coronary artery bypass graft surgery

OBJECTIVE: To determine whether information available 1 week after surgery correlates with long-term function in patients who suffer major complications after coronary artery bypass graft (CABG) surgery. DESIGN: An inception cohort study. SETTING: A 526-bed community teaching hospital. PATIENTS: All 67 patients who required at least 7 days of CT-ICU care following 2,751 consecutive CABG operations. MAIN OUTCOMES: Hospital survival, long-term survival, and functional ability at long-term follow-up. RESULTS: Forty-three patients survived hospitalization (64%), while 24 died 37 +/- 45 days (range, 7 to 190 days) after surgery. When 42 patients were surveyed 22 +/- 9 months after surgery, 21 of the survivors enjoyed excellent, independent function, 7 were moderately impaired but living at home, 6 were institutionalized with severe limitations, and 8 had died. Patients with very severe cardiac or neurologic dysfunction 1 week after surgery had an extremely poor outcome. When mechanical ventilation was required for causes other than primary failure of the respiratory system, long-term function and hospital survival were poor. Twelve of 14 patients with pulmonary complications survived hospitalization, and all 12 were alive at long-term follow-up. CONCLUSION: More than half of patients requiring 7 days or more of ICU treatment after CABG surgery survive, and many enjoy excellent long-term function. However, those with very severe cardiac or neurologic dysfunction 1 week after surgery have little chance for independent recovery.     

Reversibility of hepatic failure following jejunoileal bypass

Jejunoileal bypass was performed in 50 morbidly obeses patients. The morbidity encountered compared favorably with that of other series. All patients manifesting hepatic failure demonstrated hyperbilirubinemia within the first three months postoperatively. Hyperbilirubinemia, if uncorrected, resulted in a mortality of 75%. Augmentation jejunal interposition was performed in three patients who demonstrated hepatic decompensation or severe electrolyte imbalance or both. This resulted in rapid correction of electrolyte disturbances, liver function measurements, and patient symptoms without significant postoperative weight gain. Persistent hyperbilirubinemia or recalcitrant electrolyte problems or both are indications for augmentation jejunal interposition.     

Local complications after arterial bypass grafting

We have documented prospectively the problems occurring after 496 arterial bypass grafts (149 aortoiliac, 238 femorodistal, 65 extra-anatomic, and 44 others) implanted during the period 1987 to 1991 in a district general hospital. Postoperative bleeding occurred early in 14 (2.8%), and later (because of infection) in 3 (0.6%). Early graft occlusion (< 30 days) was seen in 2.9% aortofemoral, 10.4% femoropopliteal, and 25.3% femorotibial grafts, and amputation was required after 6.9% grafts. Wound problems were most common after femorotibial bypass--weeping of fluid in 3% and dehiscence or infection in 13.9%. Lymphatic collections occurred after 1.2% operations involving groin incisions. Graft sepsis was usually late, affecting 6% aortofemoral, 2.9% femorodistal, and 7.7% extra-anatomic grafts, but no intra-abdominal aortic grafts. These figures are probably representative of the complication rates seen by many surgeons and serve as an example for comparison and criticism.     

Calcium in the treatment of diarrhoea and hyperoxaluria after jejunoileal bypass for obesity

Fourteen patients with jejunoileal bypass for obesity were treated for one week with a calcium supplement of 3g daily. During this period diarrhoea was significantly (P < 0.005) reduced by 23 per cent (97 per cent confidence limits: 7-46 per cent). Ten of the patients had hyperoxaluria (median value 961 mumol/24 h; range 633-2742 mumol/24 h). The treatment with calcium significantly (P < 0.005) decreased the concentration of oxalate in urine by 23 per cent (98 per cent confidence limits: -5-+54 per cent). The calcium supplement did not increase urinary calcium-excretion rate or albumin-corrected serum calcium.     

Liver transplantation for decompensated cirrhosis after jejunoileal bypass: a strategy for management

BACKGROUND: Although jejunoileal bypass results in end-stage liver disease in up to 100% of patients, little is known about outcome after liver transplantation. METHODS: The clinical courses of six patients who underwent liver transplantation at UCLA for decompensated cirrhosis owing to a jejunoileal bypass were reviewed. Liver function, allograft pathology, renal function, and nutritional status were assessed. RESULTS: Of the four patients with an intact jejunoileal bypass, two of the three who were biopsied had recurrent steatotic liver disease. The two patients whose jejunoileal bypass was reversed at the time of liver transplantation had lower alkaline phosphatase, lower creatinine, higher albumin, and higher cholesterol, and were more obese than their counterparts with intact bypasses. CONCLUSIONS: Patients undergoing liver transplantation for jejunoileal bypass-associated liver disease should, if possible, have their bypass reversed at the time of transplantation; otherwise, they must be followed closely and be biopsied routinely. Recurrent liver disease should prompt reversal of the jejunoileal bypass.     

Reducing early technical complications in gastric bypass surgery

BACKGROUND: The incidence of complications following gastric bypass surgery has decreased markedly over the last 30 years; nevertheless, significant morbidity and mortality is still associated with this procedure. Much of the improved risk of this technique can be attributed to the numerous modifications that have taken place in its evolution. METHODS: We compared our series of 640 primary cases of vertical banded gastroplasty-Roux-en-Y gastric bypass (VBG-RGB), a form of gastric bypass, with gastric bypass series reported in the literature from 1966 to 1996. Incidences considered were those of subphrenic abscess, gastrointestinal leaks, obstruction of the excluded segment of gastrointestinal tract, splenectomy and death. RESULTS: The overall trend during the last 30 years has been a reduction in the rate of major complications. In our series, we had one major complication, a subphrenic abscess. This compares favorably with the incidence of major complications reported in the literature. CONCLUSIONS: The gastric bypass is a significantly safer operation today than three decades ago. We believe that the relatively low complication rate of VBG-RGB results from: (1) the anatomic location of the gastric pouch; (2) the type of stapling device used in its construction; (3) a pouch outlet restricted by a prosthetic band rather than a narrow anastomosis; and (4) the construction of a retrocolic, retrogastric Roux-en-Y gastrojejunal anastomosis.     

Gastrointestinal complications after cardiac surgery

OBJECTIVE: Gastrointestinal (GI) complications after cardiac surgery with cardiopulmonary bypass (CPB) are uncommon complications with significant morbidity and mortality rates. METHODS: From 1988 to 1995, 36 GI complications were identified in 3158 patients who underwent cardiac surgery (1.14% incidence). The mortality rate was 13.9%. Complications included hemorrhage in the GI tract in 22, perforated ulcer in 3, acute cholecystitis in 3, pancreatitis in 2, mesenteric ischemia in 3, diverticulitis in 1 and liver failure in 2 patients. RESULTS: Clinical risk factors included advanced age, combined coronary artery bypass grafting (CABG)-valve operation, postoperative low cardiac output (LCO), prolonged ventilation time, re-exploration of the chest, sternal infection and a positive history of peptic ulcer. Patients with a prolonged pump time had an increased risk of GI complications (P < 0.001). CONCLUSIONS: Gastrointestinal complications, although of low incidence, carry a significantly high mortality, and the clinician must be alert to institute early appropriate treatment.     

Ophthalmic complications after spinal surgery

STUDY DESIGN: A retrospective review of 3450 spinal surgeries was performed. OBJECTIVES: To review ophthalmic complications and their etiologies, as well as treatments and outcomes, in patients who have undergone spinal surgery. SUMMARY OF BACKGROUND DATA: Ophthalmic complications after major spinal reconstructive surgery are rare and have not been adequately addressed in the orthopedic literature. METHODS: In a series of 3450 spinal surgeries at three institutions, the authors identified seven patients (incidence = 0.20%) whose postoperative course was complicated by loss of visual acuity. These perioperative ophthalmic complications included posterior optic nerve ischemia, occipital lobe infarcts, and central retinal vein thrombosis. Operative time, estimated blood loss, and medical history of peripheral vascular, cardiovascular, or ophthalmic disease were obtained from the charts, as were follow-up data. RESULTS: Three patients recovered completely, and one had partial return of visual function. In the remaining three patients, significant visual loss persisted. CONCLUSIONS: The risk of ophthalmic complications with spinal surgery has not been fully appreciated. Because ophthalmic complications in spinal surgery may be reversed with prompt recognition and intervention, it is important for clinicians to be aware of their possible occurrence.     

Infectious complications after heart surgery

In the paper the authors report their experience with the prophylaxis and treatment of infectious complications in 393 patients operated upon the heart. An increase of the specific weight of gram-negative bacteria as an etiological cause of infection and also the increase incidence of infection as the main or sole cause of mortality ill patients, operated upon under artifical circulation, were noted. Based on the study of various combinations of antibiotics against principal agents of surgical infection, it was found that a combination of bactericidal drugs such such as ampicillin with gentamycin or carbencillin with gentamycin proved to be the most effective and safe. Tetraolean was shown to be not effective enought against pyocyanic bacillus. Some information concerning the dosage and methods of using various antibiotics and their combinations for prophylaxis and treatment of suppurative complications is reported.     

Pulmonary complications after heart surgery

The authors present a detailed analysis of pulmonary complications after open-heart surgery and of their risk factors. The results of the presented study indicate that COPD patients with functional impairments are more sensitive to complicated postoperative outcome and to respiratory infections, in general. There is a clear relationship between artificial violation of the pleural cavity, diaphragmatic dysfunction and pleural effusion. Diaphragmatic dysfunction appears more frequently in mammarocoronary bypass patients in consequence of pleurotomy. The incidence of dysfunction could be reduced by the use of phrenic nerve insulation. Patients with pulmonary complications suffer from serious pulmonary function deficit. The possibilities of identification of the patients at risk, as well as the prevention and prophylaxis are analysed. (Tab. 7, Fig. 2, Ref. 71.)     

Neuropsychological disorders after coronary bypass surgery

Pettegrew et al (Arch Gen Psychiatry 48:563-568, 1991) were the first to determine abnormalities concerning phospholipids and high energy metabolites in the dorsolateral prefrontal cortex of drug-naive schizophrenics with 31P magnetic resonance spectroscopy (MRS). Other investigations could not replicate these findings. We included in our study 13 schizophrenic inpatients and 14 age-matched controls. Whereas Pettegrew et al found increased levels of phosphodiesters and decreased levels of phosphomonoesters we measured decreased levels of phosphodiesters in the schizophrenics as compared to controls. One possible explanation for the contradictory findings of the both trials might be the different localization techniques used.