[Pregnancy after surgical therapy of obesity. Bibliographic review and our experience with biliopancreatic diversion]

BACKGROUND

An increasing number of women in childbearing age are submitted to surgical treatment of obesity; for this reason pregnancy represents a frequent event in operated patients.

METHODS

In this study pregnancy in patients with morbid obesity submitted to jejunoileal bypass (JIB) and gastric bypass (GB) are reviewed from the literature and the analysis of our experience with biliopancreatic diversion (BPD) is reported.

RESULTS

In 113 pregnancies after JIB reviewed from the literature, the results seem to be debated either about the course of pregnancy or about maternal and neonatal status. The data of literature concerning the pregnancies following GB are less debated but rather slight. One hundred and fifty-two pregnancies after BPD have a complete documentation concerning maternal conditions, modality of outcome and neonatal situation.

CONCLUSIONS

Pregnancy occurred in the obese women represents an increased maternal-fetal risk. The excess weight loss, the weight maintenance and the reduced weight changes during pregnancy are an advantage in the operate women who, in any case, need accurate controls of the nutritional status during the whole gestational period. Keeping these cautions pregnancy following surgical treatment of obesity represents an event not only possible but even with less problems than in pregnancy in obese women.

Effect of methionine on the fatty acid composition of cellular membranes in rats with chronic ethanol consumption and jejunoileal bypass

The objective of this study was to investigate the effect of alcohol administration on jejunoileal bypass (JIB)-induced liver dysfunction in rats resulting in abnormalities of fatty acid composition of cell membranes, and whether methionine is able to reverse these changes. Male Wistar rats were subjected to a jejunoileal bypass operation. For 12 weeks, all groups were pair-fed either an alcohol-containing (36% of total calories) liquid diet or a liquid diet in which alcohol was replaced isocalorically by starch. Methionine supplementation in three control groups was 0, 32, 160 and 224 mg/kg body weight/day and the rats in the four alcohol feeding groups received 0, 32, 160 and 224 mg/kg body weight/day. In the alcohol group without any methionine supplementation, higher proportions of oleic and linoleic acid and lower proportions of docosahexaenoic and arachidonic acid became evident in tissue samples of liver and jejunum, in comparison with the other alcohol group. A possible explanation for this reduction in tissue polyunsaturated fatty acid (PUFA) may be a decrease in the activities of delta 6-and delta 5-desaturases, and subsequently a displacement of PUFA from lipid fractions by other fatty acids. Interestingly, in the alcohol group with the highest methionine supplementation, compared to all other alcohol groups, lower proportions of oleic acid and higher proportions of docosahexaenoic acid, appeared. A possible explanation for this increase of PUFA in tissue may be increased activities of delta 6- and delta 5-desaturases.

Short-chain fatty acids increase proglucagon and ornithine decarboxylase messenger RNAs after intestinal resection in rats

BACKGROUND

Intestinal adaptation is a complex physiological process that is not completely understood. Systemic administration of short-chain fatty acids (SCFAs) has been shown to facilitate adaptation to small bowel resection; however the mechanisms underlying this phenomena are unknown.

METHODS

Forty-six male Sprague-Dawley rats underwent an 80% jejunoileal resection and jugular catheterization. After surgery, rats were randomly assigned to receive standard total parenteral nutrition (TPN) or an isoenergetic, isonitrogenous TPN supplemented with SCFAs. On day 3 or 7 after surgery, ileal samples were removed for determination of mucosal wet weight, DNA, RNA, and protein concentrations. Total cellular RNA was extracted for use in Northern blot analysis to quantify proglucagon and ornithine decarboxylase messenger RNAs (mRNAs).

RESULTS

Total, mucosal, and submucosal weights were increased (p < .05) in the SCFA group both 3 and 7 days after surgery. Ileal DNA and RNA concentrations were increased (p < .05) in the SCFA group at both time points; however ileal protein concentration did not differ between groups until 7 days after resection. Levels of proglucagon and ornithine decarboxylase messenger RNAs were higher (p < .05) in the SCFA group at both time points.

CONCLUSION

The upregulation of proglucagon and ornithine decarboxylase gene expression may be the mechanism by which SCFAs facilitate intestinal adaptation.

The role of anatomic factors in nutritional autonomy after extensive small bowel resection

BACKGROUND

It is difficult to predict which patients with a postsurgical short bowel will require long-term parenteral nutrition.

METHODS

We performed a retrospective prognostic study for the time to home parenteral nutrition or death from malnutrition (nonautonomy), on the basis of 103 patients with a residual short bowel of 17 to 150 cm. The influence of anatomic variables was summarized through the use of Cox regression model.

RESULTS

Of the 103 patients included, 24 lost nutritional autonomy. Three anatomic variables were identified as having independent predictive information; remaining small bowel length (measured on small bowel x-rays; p = .0001), and jejunoileal anastomosis (p = .01) promoted autonomy, whereas end jejunostomy (p = .002) increased the risk of losing nutritional autonomy.

CONCLUSIONS

On the basis of these results and on the relative weight of these variables, high-risk patients for loss of nutritional autonomy were defined as those with jejunoileal anastomosis and a remaining small bowel length < 35 cm, patients with jejunocolic anastomosis and remaining small bowel length < 60 cm, and patients with an end jejunostomy and remaining small bowel length < 115 cm. This classification was thereafter validated on a prospective series of 32 patients.

Bile acids in health and disease

Over the last quarter of a century Danish research on bile acids has comprised studies of their physical and chemical properties, their physiology, pathophysiology, metabolism, and kinetics, and their clinical applicability. In the beginning of the period a major contribution was made to the understanding of the factors involved in the solubility of cholesterol in bile. The growing international understanding of the potential importance of the bile acids in health and disease gave raise to a substantial Danish contribution in the 1970s and 1980s in parallel with international achievements. Emphasis was on the possible clinical implications of bile acids. Studies on physiology and pathophysiology were in focus. Patients who have had an intestinal bypass operation for obesity served as a model for obtaining new knowledge on various aspects of the properties of the bile acids. Also the analytical methods were improved. Important physiological research on the mechanisms of hepatic bile flow was conducted. An intestinal perfusion model served as a tool providing information on absorption kinetics and on transmucosal water and electrolyte movements. The gallstone disease, liver diseases, inflammatory bowel disease, fat malabsorption, and other intestinal disorders were studied. The 'idiopathic ileopathy' as a cause for bile acid malabsorption causing diarrhoea was established as a new disorder. Thus, in the time period concerned, substantial Danish contributions emerged on major and minor topics of the bile acid field.

[Crohn's disease and intestinal carcinoma: presentation of 2 cases and review of the literature]

We present the cases of two patients with Crohn's disease with consequent adenocarcinoma of the bowel. The first patient underwent an ileo-colic bypass 23 years before, a mucinous adenocarcinoma (Duke's stage C) was found on the anastomotic tract and on the excluded bowel, in areas within histologically recognizable Crohn's disease. In the second patient both the adenocarcinoma (Duke's stage C) of the transverse colon and the Crohn's disease (without any clinical evidence) in active phase has been found at the same time. We underline that such association seems to be not so rare as it seemed in the past. Accurate observation of patients, long time sufferers from the Crohn's disease, is advised to single out possible neoplastic complications at an early stage.

Lipid-lowering interventions in angiographic trials

This analysis examines the pooled data from all 14 published randomized angiographic trials (with 16 treatment arms) by type of cholesterol-lowering intervention evaluated, and for all the trials combined. All interventions reduced low density lipoprotein (LDL) cholesterol levels (average reduction, 26%), whereas the effects on high density lipoprotein (HDL) cholesterol and triglycerides varied by type of intervention. Meta-analyses of the angiographic outcomes indicated that treatment reduced the odds for disease progression by 49%, increased the odds for no change by 33%, and increased the odds for regression by 219%. Cardiovascular events were reduced by 47%. Thus, lipid reduction is effective for modifying the angiographic outcome and for reducing the incidence of coronary artery disease events. All types of intervention (lifestyle, drugs, or surgery) had overall favorable effects on angiographic and clinical outcomes. There was no class effect for the statin group of drugs. Surgery (partial ileal bypass) had the most favorable angiographic outcome, possibly because of a longer duration of therapy. Trials with higher baseline LDL levels tended to have more favorable angiographic outcomes. Analyses of in-trial levels of LDL were confounded by baseline levels, and analyses of change in LDL levels in the treatment groups were confounded by not including zero change (i.e., no treatment). It is hypothesized that lowering LDL levels by 30 mg/dl (0.8 mmol/liter) is sufficient on average to modify the angiographic outcome, with modest gains from further reductions in LDL levels.

Disease-free intervals after partial ileal bypass in patients with coronary heart disease and hypercholesterolemia: report from the Program on the Surgical Control of the Hyperlipidemias (POSCH)

OBJECTIVES

We sought to analyze the disease-free intervals and calculate the freedom from atherosclerosis events in the Program on the Surgical Control of the Hyperlipidemias (POSCH).

BACKGROUND

The POSCH study was a randomized, secondary lipid/atherosclerosis intervention trial that provided strong evidence for reduction in atherosclerosis progression as demonstrated by clinical and arteriographic end points. The 417 control group patients received American Heart Association phase II diet instruction, and the 421 intervention group patients received identical dietary instruction and underwent a partial ileal bypass operation.

METHODS

Four outcome measures were determined: 1) overall mortality, 2) coronary heart disease mortality, 3) coronary heart disease mortality and confirmed nonfatal myocardial infarction, and 4) coronary/cardiac interventions.

RESULTS

An overall mortality rate of 10% occurred at 6.7 years in the control group and 9.4 years in the intervention group, for a gain in disease-free interval of 2.7 years in the intervention group (p = 0.032). A coronary heart disease mortality rate of 8% occurred at 7.2 years in the control group and 11 years in the intervention group, for a gain of 3.8 years (p = 0.046). Twenty percent of patients demonstrated the combined end point of coronary heart disease mortality and confirmed nonfatal myocardial infarction at 5.9 years in the control group and 11.4 years in the intervention group, for a gain of 5.5 years (p < 0.001). Twenty-five percent of patients underwent either coronary artery bypass graft surgery, percutaneous transluminal coronary angioplasty or heart transplantation at 5.4 years in the control group and 12.4 years in the intervention group, for a gain of 7 years (p < 0.001).

CONCLUSIONS

The marked lipid modification achieved by partial ileal bypass in the POSCH trial led to demonstrable increases in the disease-free intervals for overall mortality, coronary heart disease mortality, coronary heart disease mortality and confirmed nonfatal myocardial infarction, and coronary intervention procedures. For the clinician and the patient, estimation of disease-free intervals may be more relevant than assessment of differences in incidence rates and risk ratios.

Subgroup analyses of the major clinical endpoints in the Program on the Surgical Control of the Hyperlipidemias (POSCH): overall mortality, atherosclerotic coronary heart disease (ACHD) mortality, and ACHD mortality or myocardial infarction

The Program on the Surgical Control of the Hyperlipidemias (POSCH) was a secondary atherosclerosis intervention trial employing partial ileal bypass surgery as the intervention modality. For this report, we analyzed 105 subgroups in 35 variables in POSCH, chosen predominantly for their potential relationship to the risk of atherosclerotic coronary heart disease (ACHD). We defined potential differential effects as those with: (1) an absolute z-value > or = 2.0 for the subgroup, if the absolute z-value for the overall effect was < 2.0; and (2) an absolute z-value > or = 3.0 for the subgroup and a relative risk < or = 0.5, if the absolute z-value for the overall effect was > or = 2.0. For each of three major POSCH endpoints of overall mortality, ACHD mortality and ACHD mortality or confirmed nonfatal myocardial infarction, we found seven subgroups with a differential risk reduction in the surgery group as compared to the control group. Allowing for identical subgroups for more than one endpoint, there were 13 individual subgroups with differential effects. Of these, seven demonstrated internal consistency across endpoints, and five of these seven displaced external consistency with known ACHD risk factors and for biological plausibility: triglyceride concentration > or = 200 mg/dl; cigarette smoking; overt or borderline diabetes mellitus; a Minnesota ECG Q-QS code of 1-1; and obesity. A greater risk reduction, in comparison to the overall treatment effect, by the reduction of a single risk factor, hypercholesterolemia, in patients with at least two major ACHD risk factors was a provocative and an hypothesis-generating outcome of this analysis. The clinical implications of this finding may lead to more aggressive cholesterol intervention in patients with multiple ACHD risk factors.

Inverse relationship between plasma cholestanol concentrations and bile acid synthesis in sitosterolemia

We investigated the relationship between plasma cholestanol (5 alpha-dihydrocholesterol) concentrations and the activity and mRNA levels of cholesterol 7 alpha-hydroxylase, the rate-controlling enzyme for bile acid synthesis, in three female sitosterolemic homozygotes. In this lipid storage disease, large amounts of plant sterols and cholestanol accumulate because of hyperabsorption and endogenous synthesis, respectively. Plasma cholestanol concentrations were 14 times greater in the three sitosterolemic homozygotes than the mean for five control subjects. To investigate the cholestanol biosynthetic pathway, tracer doses of two putative precursors, [1,2-3H]4-cholesten-3-one and [4-14C]7 alpha-hydroxycholesterol were injected intravenously into a homozygote, and radioactivity was sought in cholestanol, bile acids, cholesterol, and sitosterol fractions isolated from plasma and bile. Tritium was concentrated only in cholestanol; neither cholesterol, sitosterol nor bile acids were derived from [1,2-3H]4-cholesten-3-one. In contrast, bile acids were labeled exclusively with 14C from [4-14C]7 alpha-hydroxycholesterol; no 14C radioactivity was detected in cholestanol. Mathematical analysis of specific activity versus time curves for [3H]cholestanol revealed very slow decay, large exchangeable pools, and enhanced synthesis in the sitosterolemic homozygote. Measurements of cholesterol 7 alpha-hydroxylase activity were 39% lower in whole liver microsomes from three sitosterolemic homozygotes that contained 19% plant sterols as compared to the mean value for six control microsomal specimens that contained 0.1% plant sterols. Removal of the excess plant sterols from the microsomes, in vitro, normalized microsomal cholesterol 7 alpha-hydroxylase activity in the homozygotes but did not affect enzyme activity in the controls. Equal amounts of cholesterol 7 alpha-hydroxylase mRNA were detected in the livers of both control and sitosterolemic subjects. Bile acid malabsorption after ileal bypass surgery stimulated cholesterol 7 alpha-hydroxylase activity 78% in sitosterolemic whole liver microsomes and reduced plasma cholesterol, sitosterol, and cholestanol levels 61%, 55% and 91%, respectively, producing a pronounced decrease in the cholestanol/cholesterol ratio without changing the sitosterol/cholesterol ratio. These results demonstrate that increased cholestanol is synthesized from 4-cholesten-3-one and not 7 alpha-hydroxycholesterol in sitosterolemia. Enhanced pools and plasma concentrations are related inversely to hepatic cholesterol 7 alpha-hydroxylase activity. Competitive inhibition of cholesterol 7 alpha-hydroxylase by the large microsomal plant sterol pool diverts cholesterol into cholestanol. Alternatively, stimulating cholesterol 7 alpha-hydroxylase activity after ileal bypass surgery markedly diminished plasma cholestanol levels.(ABSTRACT TRUNCATED AT 400 WORDS)

Effect of calcium supplementation on rectal epithelial hyperproliferation in intestinal bypass subjects

BACKGROUND/AIMS

Fatty acids and bile acids are tumor promoters of experimental colon cancer in rats. Calcium can inhibit their effects. After intestinal bypass (IB), fecal bile acid and lipid levels increase markedly. In rats, IB increases colonic cell proliferation and carcinogen-induced colon tumor incidence. Whether fecal bile acids and lipids influence rectal epithelial proliferation in humans is uncertain. This study compared rectal epithelial proliferation in IB subjects and in controls matched for age, sex, and body mass index and investigated the effects of calcium carbonate supplementation (2400 or 3600 mg Ca2+/day for 12 weeks) on proliferation indices in IB subjects.

METHODS

Epithelial proliferation was studied by in vitro incubation of rectal biopsy specimens with [3H] thymidine. Twenty-four-hour stool collections were assayed for bile acids, lipids, and calcium.

RESULTS

Whole crypt labeling index (LI) and upper crypt LI were increased in IB subjects compared with controls (P < 0.005). Calcium reduced whole crypt LI by 38% (P < 0.001) and upper crypt LI by 56% (P < 0.05). Levels of fecal bile acids (4.5 mmol/day) and lipids (131.9 g/day) were markedly elevated in IB subjects (P < 0.005).

CONCLUSIONS

IB induces rectal hyperproliferation and expansion of the proliferative zone in association with excessive output of fecal bile acids and lipids. Oral calcium reverses the proliferative changes.

Nonsteroidal anti-inflammatory drug-induced diaphragm disease arising in a bypassed ileal segment

The formation of mucosal ileal diaphragms has been previously reported in patients receiving nonsteroidal anti-inflammatory drugs over extended periods of time. Whether this effect is the result of a local or systemic action by the medication has remained unknown. We report the first known instance of diaphragm disease arising in a segment of ileum that had been bypassed for many years and therefore was not exposed normally to luminal contact with the drug. This case supports at least a partial systemic mechanism in the production of the lesion.

Calcium reduces the increased fecal 1,2-sn-diacylglycerol content in intestinal bypass patients: a possible mechanism for altering colonic hyperproliferation

Diacylglycerol (DAG) is a second messenger for protein kinase C, an enzyme with a key role in cellular signal transduction and growth control. In previous studies, it was demonstrated that DAG is produced by intestinal microflora. Bacterial DAG production is increased by bile acids and phospholipids, both of which may be precipitated by calcium. We have demonstrated that fecal total lipids, bile acids, and rectal epithelial proliferation are increased in intestinal bypass (IB) patients. Calcium was shown to alter fecal lipid composition and to reduce cell proliferation. In the present study, fecal DAG content and 14C-labeled DAG, 14C-phosphatidylcholine, and 14C-phosphatidylinositol metabolism were measured in 24-h stool collections in 15 stable IB patients before and after 3-month therapy with oral elemental calcium, 2.4 or 3.6 g/day. Fecal DAG concentration and output in IB patients were > 25- and > 200-fold greater than in normal controls. Oral calcium markedly reduced fecal DAG concentration and output and increased DAG, phosphatidylcholine, and phosphatidylinositol metabolism without enhancing DAG production. We conclude that fecal DAG content is markedly elevated post-IB and that calcium supplementation in these patients reduces fecal DAG and accelerates bacterial metabolism of DAG and its precursors. In separate studies, we have found that calcium supplementation also decreases rectal hyperproliferation in IB patients. Taken together, these findings suggest that a high luminal level of DAG enhances colonic cell proliferation and that calcium reduces cell proliferation in part by decreasing the level of DAG.

[Effects of jejunoileal shunting operation on the blood circulation system in patients with morbid obesity]

With the use of radiocardiography, the indices of central hemodynamics were studied in 22 patients with III-IV degree morbid obesity who underwent the operation of jejunoileal shunting. A special attention should be paid to the state of the patients within the first 18 months after the operation, because at this period, reformation of the cardiovascular system is most pronounced. The formulas for prediction of the state of the central hemodynamics at the late postoperative period are suggested.

Morbid obesity: a comparison between a general population and obesity surgery patients

Characteristics of morbidity obese adults in the general population and morbidly obese adults presenting for obesity surgery were compared. Black morbidly obese women in the general population were less obese than black women obesity surgery patients, showed less emotional distress, and had fewer abnormal eating behaviours; age and socio-economic status were similar. A greater proportion of morbidly obese surgery patients were white women than would be expected either on the basis of the prevalence of morbid obesity in the general population or on census data. It was hypothesized that black women and white men avoid obesity surgery until they are physically debilitated by their overweight, while white women elect for obesity surgery when the emotional distress associated with obesity becomes debilitating.

[Level of beta endorphins and insulin in blood of obese subjects. Effect of surgical treatment for obesity on higher exchange parameters]

The basal and hyperglycaemia-stimulated secretion of glucose, IRI and beta-endorphin (BE) were studied in subjects who had gone surgical treatment for obesity few years ago and the results were compared with those of obese subjects and lean controls. 58 persons were divided into the following groups: A-obese subjects BMI > 30, B--obese subjects 25 < BMI < 30, C--subjects treated by truncal vagotomy and gastric banding, D--subjects treated by jejunoileostomy, E--control group BMI < 25. Oral glucose (75 g) tolerance test was performed in all subjects. Blood concentration of glucose, and serum concentration of IRI and BE were studied before and 30, 60, 90 and 120 minutes after ingestion of glucose. The basal levels and areas over basal values (AOBV) of investigated parameters were evaluated. Both the basal and glucose stimulated levels of IRI and BE were higher in the obese subjects than in the control group. Truncal vagotomy and gastric banding or jejunoileostomy resulted in reduction of IRI secretion without any decrease in BE levels. The alteration of the opioid system may play some role in the pathogenesis of obesity.

Therapeutic strategies in the surgical management of pancreatic neoplasms in the elderly

The clinical records of all consecutive patients aged 65 and older undergoing surgical treatment for pancreatic neoplasms between January 1980 and January 1992 were reviewed in order to establish a clinical trial based on the morbidity and mortality rates related to the different surgical procedures. In early diagnosed neoplasms, in patients in good general condition, even in the geriatric age a radical surgical procedure is preferred. In other cases, a palliative surgical procedure has to be performed if possible, namely a bilio-digestive anastomosis, associated if necessary with a gastro-enteric anastomosis.

Dermal complication of the bowel bypass syndrome: a case report

Bowel bypass surgery, which involves shortening the small bowel to about 45 cm, is a modality of treatment for morbid obesity. Although this procedure is not routinely performed today, patients with complications from this procedure are still seen by physicians. The case of a patient who had bowel bypass surgery and experienced subsequent complications is discussed.

Morphological and functional alterations to a sub-group of regulatory peptides in human pancreas and intestine after jejuno-ileal bypass

The effect of ileo-gastrostomy on insulin and cholecystokinin secretion and the endocrine cells containing cholecystokinin, somatostatin, motilin, secretin, neurotensin and enteroglucagon was studied. Fasting and postprandial plasma samples collected pre- and post-operation demonstrated significant changes in circulating insulin and cholecystokinin. Fasting and postprandial insulin levels decreased three months after ileo-gastrostomy (postprandial pre-operation 40 +/- 8 microU/ml compared to 15 +/- 24 microU/ml post-operation, P < 0.02). The postprandial levels of cholecystokinin were significantly increased (pre-operation 7.1 +/- 1.1 pg/ml compared to 12.2 +/- 1.7 pg/ml post-operation, P < 0.02). Quantification of the endocrine cell populations in the jejunum in-continuity three months after ileo-gastrostomy demonstrated an hyperplasia of cholecystokinin-, secretin-, gastric inhibitory polypeptide-, motilin- and somatostatin-containing cells. In samples of the ileum taken from within the bypass loop the neurotensin- and somatostatin-containing cells were unaffected while the enteroglucagon-containing cells were significantly increased in number. Ileo-gastrostomy resulted in significant alterations to the abundance of regulatory peptide-containing endocrine cells and to circulating levels of insulin and cholecystokinin. These changes are implicated in the dramatic weight loss associated with the operation.

[Regression of coronary atherosclerosis evaluated by angiography. A review of principal trials and critical study]

The concepts of acceleration of atherosclerosis with fat rich diets and the regression or at least stabilisation of atherosclerosis by suppressing the cholesterol, introducing exercise programmes or administering calcium antagonists or aspirin, have been validated in the animal model. In the clinical situation, repeat coronary angiography has demonstrated that hyperlipidemia and the interval between two investigations are the main factors influencing the progression of atherosclerosis. However, the factors underlying the appearance and progression of atheromatous plaques remain unknown. Interventional trials based on the principle of introducing treatment after reference angiography have been undertaken. The results were assessed after variable time intervals. The general conclusion is that there is a direct relationship between the lowering of plasma cholesterol, the intensity of exercise and the slowing of progression of atherosclerosis as far as can be evaluated by repeat angiography. The data concerning the effect of calcium antagonists is confusing. The main criticism of these trials is the instrument of measurement and the practical significance or even the reality of the observed changes. In the present state of our knowledge, trials of the regression of atherosclerosis can not replace longitudinal studies of the long-term effects of drugs on cardiovascular and general morbidity and mortality.