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Biomedical subjects

J D Halverson

Publications and source records attributed to J D Halverson.

At least 37 records · Page 2Linked to original sources
PubMed1983

Cutaneous anergy and marrow suppression as complications of gastroplasty for morbid obesity.

Although serious morbidity from gastric restriction for morbid obesity is rare, outflow tract dilation after gastroplasty has become a well-recognized complication, and reoperation to decrease outflow tract size has become increasingly common. We report the case of a patient who developed outflow tract obstruction with subsequent malnutrition, recurrent infections, and marrow suppression. Extensive immunologic evaluation revealed impaired cutaneous reactivity to a battery of recall antigens. Other in vitro T cell functions, B cell functions, neutrophil respiration, and quantification of complements were within normal limits. The patient's immunodeficiency was attributed to protein-calorie malnutrition and was corrected with total parenteral nutrition. Recovery of immune function with renutriture was demonstrated, and coincident resolution of infection and marrow suppression also occurred. Because of the reversibility of the immunologic abnormality with appropriate nutritional therapy, it is important to consider and treat malnourishment in connection with any operation in which oral intake is severely limited.

Adult↗
PubMed1982

Radiographic abnormalities after gastric bypass.

Postoperative radiographic findings in the gastrointestinal tract were analyzed in 43 of 72 patients with gastric bypass for morbid obesity. In 15 patients studied because of early postoperative vomiting or abdominal pain, two showed leak from the proximal gastric pouch and six showed impairment of proximal pouch emptying at the anastomosis or proximal efferent loop. In four of the six, the impaired emptying was due to transient postoperative edema and improved spontaneously. Three patients had impairment of distal gastric pouch emptying due to pylorospasm. Five patients studied in the late postoperative period showed dehiscence of the gastric staple line, which can be difficult to demonstrate radiographically. Familiarity with the normal and the abnormal radiographic appearance after gastric bypass is important in elucidating the nature of the problems that can arise after this operation.

Digestive System↗
PubMed1982

Altered glucose tolerance, insulin response, and insulin sensitivity after massive weight reduction subsequent to gastric bypass.

We have studied an otherwise normal group of morbidly obese subjects and compared them with patients who had experienced massive weight loss after loop gastric bypass. Compared to normal controls (NLCs), morbidly obese control patients (OBCs) had abnormal glucose tolerance curves (after glucose ingestion), elevated basal insulin levels, and increased plasma insulin concentrations, suggesting insulin insensitivity. The latter has been corroborated by the measurement of decreased insulin binding in these patients. Postoperative (PO) patients were hyperglycemic after taking oral glucose, but all PO patients had a rapid decrease in plasma glucose concentration, half reaching hypoglycemic levels. PO basal insulin levels and insulin receptor number were not statistically different from those in NLCs, indicating up-regulation of insulin receptors (and therefore, increased insulin sensitivity) postoperatively. Hyperinsulinemia seen in the PO group (greater than that in OBCs, P less than 0.001) after administration of oral glucose occurred simultaneously with a doubling of plasma concentration of gastric inhibitory polypeptide. Massive weight loss in patients after gastric bypass was accompanied by an improvement in insulin receptor number, basal hyperinsulinemia, and glucose tolerance. In addition, postoperative patients demonstrated symptomatic reactive hypoglycemia which may have resulted from the hyperinsulinemia seen subsequent to ingestion of glucose.

Adult↗
PubMed1981

Gastric bypass for morbid obesity: a medical--surgical assessment.

With the operative modifications and dietary guidelines described in this report, death and complications from gastric bypass were minimal, and weight loss was marked. Ninety per cent of a group of 69 patients lost more than half of their excess weight within the first two years after operation. Stringent preselection of patients for operation was crucial to the success of the operation, and marked alterations of eating behavior was necessary to achieve the weight loss. Mild electrolyte deficiencies and hypovitaminosis occurred in up to one-fourth of the patients. While none of these abnormalities was harmful to the patients, and all were easily corrected, their occurrence demonstrates the importance of long-term follow-up after the operation. We conclude that gastric bypass, with a 50-60 cc pouch and a small (1-1.2 cm) gastrojejunostomy, remains the operation of choice for morbid obesity.

Adolescent↗
PubMed1981

Effects of atropine, glycopyrrolate, and cimetidine on gastric secretions in morbidly obese patients.

Gastric volume and pH were studied immediately after induction of anesthesia and endotracheal intubation in 40 morbidly obese patients undergoing gastric bypass procedures. Of 14 patients receiving intramuscular atropine (0.6 mg) preoperatively, 67% had gastric pH values < 2.5; 33% of these patients had both a gastric pH < 2.5 and a volume > 20 ml. When the drug administered was intramuscular glycopyrrolate (0.3 mg), 62% of the patients had gastric pH values > 2.5; 30% had both gastric pH values < 2.5 and volumes > 20 ml. Differences between the two drugs were not significant. Thirteen patients received cimetidine orally at midnight preoperatively and again 2 to 4 hours before the induction of anesthesia. Patients in this group had gastric pH values that were significantly higher than those observed in patients given anticholinergic drugs. Only 15% had gastric pH values < 2.5. Gastric volumes observed in patients receiving cimetidine were not significantly different from those receiving anticholinergic drugs. Whereas only 7.9% of patients receiving cimetidine had both low pH values and gastric volumes > 20 ml, this was not statistically different from the observations made in patients receiving atropine or glycopyrrolate. Despite this, it is concluded that cimetidine administered before the induction of anesthesia in morbidly obese patients may reduce the high risk of aspiration pneumonitis in such patients.

Adult↗
PubMed1981

Gastric bypass: analysis of weight loss and factors determining success.

Sixty-nine carefully selected patients underwent extensive behavioral modification training and a standard loop gastric bypass procedure. Patients were followed up at frequent intervals postoperatively to ensure their compliance with dietary requirements: (1) three small, solid meals a day, (2) slowly eaten meals with 5 minutes between bites, (3) no liquids with meals, and (4) cessation of eating immediately after hunger ceased. Analysis of weight loss data at a mean of 20 months postoperatively revealed that 90% of patients lost more than 50% of their excess weight, but that weight loss was inversely related to weight at operation (P less than 0.02) and to estimated pouch size (by upper gastrointestinal series) late postoperatively (P less than 0.01). Patients who failed to maintain regular follow-up visits postoperatively lost significantly less weight (P less than 0.01) than those who were seen regularly. Although fewer than half of the patients lost weight beyond the twelfth postoperative month, significant weight loss was seen in about one fourth of the patients as late as 2 years postoperatively when office follow-up was frequent and compliance with dietary measures complete. Abdominal pain and emesis occurred only when the patient failed to comply with the postoperative dietary regimen. Similarly, inadequate weight loss (premature plateau) was also associated with failure of patients to eat slowly and to stop eating when hunger ceased.

Behavior Therapy↗
PubMed1980

Jejunoileal bypass. Late metabolic sequelae and weight gain.

Of 101 patients originally operated on, the status of 98 is known. Given the mortality and reanastomosis rates, the operation must be considered an absolute failure in 28 percent of the patients. Given the other complications that appear (or persist) late postoperatively, only 18 percent of the entire series of patients have had what can be considered a good result. We therefore conclude that intestinal bypass is not an appropriate operation for morbid obesity and that complete long-term follow-up is essential for all patients who undergo the operation, despite what might seem to be a smooth course in the 1st 2 years postoperatively.

Body Weight↗
PubMed1980

Obesity surgery in perspective.

Increasing numbers of physicians are discontinuing the use of jejunoileal (JI) bypass as a surgical solution to morbid obesity in favor of gastric restriction procedures. However, there is a significant risk that, as with JI bypass several years ago, gastric bypass (or its variations) may be regarded shortly by many as a panacea without sufficient evidence to support this belief. Current evidence suggests that gastric restriction procedures are followed by weight loss similar to that seen with JI bypass, without the high incidence of complications, rehospitalization, reanastomosis, or conversion to another operation for further weight reduction. However, long-term prospective studies which demonstrate permanence of weight loss and absence of late complications of the gastric restriction procedures as yet are unavailable. Therefore, gastric bypass, gastroplasty, and the other variations of gastric restriction should be carried out only in a setting where long-term follow-up (by an experienced multispecialty team) and complete postoperative testing with statistical evaluation are available.

Body Weight↗
PubMed1979

Skeletal abnormalities after jejunoileal bypass.

Jejunoileal bypass surgery is fraught with many longterm complications, among which is hypovitaminosis D. The relationship, if any, of hypovitaminosis D to the skeletal disease which may occur following this operation is, however, unknown. Consequently, we studied eight patients with low circulating levels of 25-hydroxyvitamin D who had undergone jejunoileal bypass at least two and one-half years previously. Despite the absence of skeletal symptoms, the bone biopsies of six of these patients were abnormal. The volume of trabecular bone was diminished in the group as a whole, and half the patients had an excess of unmineralized skeletal matrix. However, no noninvasive diagnostic technique identified those patients with skeletal disease. We therefore conclude that recognition of those jejunoileal bypass patients potentially at risk to develop clinically significant bone disease requires biopsy of the skeleton.

Adult↗
PubMed1978

Jejunoileal bypass for morbid obesity. A critical appraisal.

One hundred one carefully screened morbidity obese patients underwent jejunoileal bypass and were followed closely over a mean follow-up period of 32 months. Although there were no operative deaths, three per cent of patients died postoperatively of liver failure or its complications. A fourth patient died of a pulmonary embolus after reoperation, and the fifth patient died cachectic with severe diarrhea after excessive weight loss. Nineteen per cent of the patients required restoration of intestinal continuity (reversal), most for either liver failure or late fluid and electrolyte derangements. All but two survived reversal and are doing well despite massive weight gain. Fifty-eight per cent of the patients had major complications which either required major reoperation (reversal, cholecystectomy or incisional hernia repair) or were potentially life-threatening (liver failure, hepatic fibrosis or urinary tract stones). As described in other series, abnormalities in serum electrolytes and vitamins were seen. In addition, hypovitaminosis D occurred in a number of patients and as with other serum parameters measured, was time-dependent in that improvement was seen in most patients over the postoperative interval studied. Because of the high rate of complications and reversals, we believe that jejunoileal bypass should be reserved for patients with morbid obesity whose lives are imminently threatened by obesity or its sequellae.

Adaptation, Physiological↗
PubMed1978

Computer-assisted instruction in surgery.

Computer-assisted instruction (CAI) is an educational medium which provides a highly interactive, adaptive, and individualized learning experience for the student or physician. A CAI system has benn developed to prepare a curriculum in general surgery. The surgical seminars written on this system have been used enthusiastically by students, residents, and interns for the past 18 months. Using a computer terminal (printer or television screen) connected by telephone to a minicomputer, the user participates in simulated seminars with the authors, viewing information and answering questions based on the material presented. The student responds by typing the answer in his own words, and the computer (author) responds with further information designed specifically for that answer. This response may support or contest what the student said, may branch the student to material covered previously, or instead may lead the student through as much remedial material as he needs. A more sophisticated student will progress rapidly through the seminar. Twenty-five surgeon/authors (at 15 medical schools) are preparing seminars, and it is planned that a complete library in general surgery will be available to departments of surgery nationally by September, 1978, via the Health Education Network.

Computer-Assisted Instruction↗
PubMed1978

Reanastomosis after jejunoileal bypass.

One hundred and one patients underwent jejunoileal bypass after careful preoperative evaluation. These patients were re-evaluated after operation on a frequent basis, and 23% have required restoration of intestinal continuity (reanastomosis) by a mean postoperative time of 44 months. The most frequent reasons for reanastomosis were liver dysfunction (5% of the entire series), severe malnutrition or weakness (5%), and late electrolyte imbalance (4%). Two patients did not survive reanastomosis, both having liver failure. Of the patients who did survive, weight gain (approaching prebypass weight) and improvement in liver function tests, electrolyte balance, serum vitamin levels, and diarrhea have been the rule. Of the entire series of 101 patients who underwent bypass, 58% either had life-threatening complications, had to be reanastomosed, or died. These morbidity and mortality rates raise the important question of whether jejunoileal bypass is an appropriate procedure for the treatment of morbid obesity.

Body Weight↗
PubMed1977

Abnormalities of circulating 25-OH vitamin D after jejunal-lleal bypass for obesity: evidence of an adaptive response.

Circulating levels of 25-OH vitamin D were measured in 44 patients who had undergone small intestinal bypass for obesity. Sixty-one percent had low circulating levels of the metabolite, which tended to normalize with time. This adaptive response also occurred for circulating total calcium, magnesium, albumin, and alkaline phosphatase. Serum concentrations of 25-OH vitamin D were directly related to total serum calcium and albumin. Impaired intestinal absorption of 25-OH vitamin D was seen in two patients. Following correction of total serum calcium for attendant hypoalbuminemia, 27% of patients remained hypocalcemic. The bone densities of two of 32 patients were low. In addition, skeletal biopsies of three of six patients were abnormal. It is concluded that small intestinal bypass results in at least transient deficits of circulating 25-OH vitamin D. As this operation may be associated with abnormal bone morphology, clinically significant skeletal disease may become apparent with long-term follow-up.

Adolescent↗