A survey of surgical techniques for treatment of obesity and a remark on the bilio-intestinal bypass method.
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Biomedical subjects
Publications and source records attributed to D Hallberg.
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The possible influence on blood polymorphonuclear (PMN) granulocyte functions of the small intestinal shunt operation for obesity was studied in 10 massively overweight patients. They were investigated prior to operation and for 9 months afterwards, when they had lost an average of 32 kg body weight. Preoperatively they showed reduced PMN bactericidal capacity and increased PMN adherence compared with controls of normal weight. During the first 2--4 months postoperatively all patients displayed a gradually increasing bactericidal capacity, which then reached levels similar to the controls and remained so for the rest of the follow-up period. This enhancement was more easily assessed by a new in vitro assay in which each PMN was provided with 30--40 bacteria, than by a standard assay using 2--4 bacteria per granulocyte. PMN adherence decreased during the first postoperative months and then returned to preoperative levels. The changes in PMN functions were not statistically related either to each other or to the continuous loss of body wieght. Thus, impairment of PMN killing function occurring in extremely obese patients became normalized after small bowel shunt operation, while the high adherence remained unchanged.
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Previous studies have shown that the small-bowel shunt operation for morbid obesity may be followed by signs of enhanced cell-mediated immunity and polymorphonuclear (PMN) granulocyte bactericidal capacity. In the present study seven patients, operated 4 months--4.5 years previously and exhibiting postoperative arthralgias, arthritis, and/or skin rashes, were investigated with regard to their PMN adherence and bactericidal capacity and plasma levels of complement factors 3 and 4 (C3 and C4). There patients showed a decreased PMN bactericidal capacity compared both with 10 other shunt-operated patients without skin and joint symptoms and with healthy controls, whereas PMN adherence was lower than for the non-symptomatic patients but similar to that of the controls. Two patients had C3 levels above the reference value; all had normal C4 values. Thus, a small-bowel shunt operation for obesity, complicated by skin and joint symptoms, might be associated with decreased PMN bactericidal capacity.
Jejuno-ileal bypass operations have been used for more than 20 years for the treatment of massive obesity. This treatment results in malabsorption with diarrhoea, especially during the first year after operation. A high incidence of urinary tract calculi was found in these patients (Backman & Hallberg, 1972; Dickstein & Frame, 1973; O'Leary, Thomas & Woodward, 1974; Backman et al., 1975; Gregory et al., 1975). Other known late complications are transient disturbances in liver function and electrolyte balance (Backman et al., 1975). Different types of operations result in different frequencies of kidney stones.
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Serum lipoproteins were determined in grossly-obese patients 24 to 59 months after jejuno-ileal bypass surgery. Only minor further changes had occured compared to results obtained after about one year. The main findings were: hypertriglyceridaemia, if present, was normalised; LDL-cholesterol was reduced by about 40 per cent and HDL-cholesterol did not increase in spite of the VLDL-TG normalisation and mean weight losses of about 40 kg for males and 50 kg for females. It is possible that in obesity the well-known negative relationship between VLDL-TG and HDL-cholesterol is disturbed, and that the low HDL concentration represents a primary lipoprotein abnormality directly linked to obesity, rather than an association with the serum TG increase often found in obesity.
Jejunoileal bypass operations have been used for more than 20 years for the treatment of massive obesity. This treatment results in malabsorption with diarrhoea, especially during the first year after the operation. A high incidence of urinary tract calculi have been found in these patients (4, 5, 15, 19, 24). Other known late complications are transient disturbances in liver function and electrolyte balance (5).
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After bypass operations for obesity many patients had signs of liver injury (SLI). It has not earlier been possible to correlate changes in the preoperative liver function test with occurrence of postoperative SLI. The present study shows that those patients who before the intestinal bypass operation had a moderate to significant change in serum activity of S-LD 5 (isoenzyme 5 of the enzyme lactate dehydrogenase) were at risk of developing SLI after the operation. All five patients with SLI, of whom three died, preoperatively had an increase in S-LD 5 exceeding five times the normal mean value. The pattern in the transaminases and serum alkaline phosphatase were not as conclusive.
Five anaesthetized dogs were given 20 infusions of 1--9 min duration of somatostatin in a dosage of 0.2--15 micrograms.kg-1.min-1. Cardiac output was measured by thermodilution. Electromagnetic blood flow measurements were simultaneously performed in the hepatic artery proper, the left gastric artery, the superior pancreatico-duodenal artery, the superior mesenteric artery and in the portal vein. Mean arterial blood pressure was recorded continuously. Somatostatin reduced all splanchnic blood flows measured by 15--35%, except for the hepatic artery flow, which was increased by 5% or unaffected. Cardiac output and mean arterial pressure were unchanged. Somatostatin was thus demonstrated to exert a specific vasoactivity in the splanchnic area without influencing central circulation. It is suggested that somatostatin acts directly on the vascular smooth muscle.
Diarrhea is a drawback in all types of small intestinal bypass operations for the treatment of morbid obesity. One of the causes of diarrhea is excessive amounts of bile acids in the colon. Therefore in five obese subjects, we complemented the usual jejuno-ileostomy end to side procedure with an anastomosis between the proximal end of the excluded blind loop and the gallbladder (bilio-intestinal shunt). In this way the enterohepatic circulation of bile acids is assumed to be preserved. The patients, subjected to this new methods, were compared to matched patients (age, sex, height, preoperative body-weight, Brocas index and total small intestinal length) following four other types of jejuno-ileostomies. The frequency of diarrhea in the subjects with the bilio-intestinal shunt was significantly less than in the other groups. Other parameters, such as rate and magnitude of weight reduction, changes in blood cholesterol and triglycerides, were the same in the control groups.
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Two cases of tuberculous infections occurred after intestinal shunt operations for obesity among 161 patients observed for more than one year. One died of generalized tuberculosis. Another 2 patients, who before the operation had had tuberculosis, managed well without signs of postoperative activation of the tuberculous infection seems to be unpredictable.