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Biomedical subjects

R E Brolin

Publications and source records attributed to R E Brolin.

At least 55 records · Page 3Linked to original sources
PubMed1992

Long-limb gastric bypass in the superobese. A prospective randomized study.

This study was designed to determine whether greater diversion of bile and pancreatic secretions away from the functional gastrointestinal tract would produce greater weight loss in superobese patients (greater than or equal to 200 pounds overweight) in comparison with conventional Roux-en-Y gastric bypass (RYGB). During the past 7 years, two modifications of RYGB were prospectively compared in 45 superobese patients: RYGB-1, in which the length of defunctionalized jejunum measured 75 cm, and RYGB-2, in which the defunctionalized jejunum measured 150 cm. Respective mean preoperative weight/body mass indexes were 393 pounds/63.4 for 22 RYGB-1 patients and 404 pounds/61.6 for 23 RYGB-2 patients. Two patients (5%) had nonfatal early complications. There were six late incisional hernias. There were no cases of protein deficiency, hepatic dysfunction, or diarrhea after operation. Mean follow-up was 43 +/- 17 months. Postoperative weight loss in pounds and daily calorie intake were compared at 6-month intervals. Weight loss stabilized by 24 months at a mean 50% excess weight lost in RYGB-1 patients and 64% excess weight lost in RYGB-2 patients. Nineteen of 23 RYGB-2 patients achieved at least 50% excess weight lost versus 11 of 22 RYGB-1 patients (p less than or equal to 0.03). Weight loss was significantly greater at 24 through 36 months in RYGB-2 versus RYGB-1 patients (p less than 0.02). There was no significant difference in either calorie intake or incidence of iron and vitamin B-12 deficiency between the two groups. These data show that gastric restriction and biliopancreatic diversion without intestinal exclusion resulted in significantly greater weight loss than conventional RYGB but did not cause additional metabolic sequelae or diarrhea. This long-limb modification of Roux-en-Y gastric bypass is a safe and effective procedure in patients who are 200 pounds or more overweight.

Adolescent↗
PubMed1991

Human intraepithelial lymphocytes. Immunomodulation and receptor binding of vasoactive intestinal peptide.

This study evaluates the immunomodulation and receptor binding of vasoactive intestinal peptide on human peripheral blood lymphocytes and intraepithelial lymphocytes. Vasoactive intestinal peptide (VIP, 10(-8) and 10(-12) M) had no effect on the concanavalin A-induced proliferation or the spontaneous cytotoxicity against K-562 targets by either lymphocyte type. Human peripheral blood lymphocytes had a mean of 927 vasoactive intestinal peptide receptors per cell with a Kd of 1.12 x 10(-10) M, as demonstrated by the competitive displacement of [125I]peptide by unlabeled peptide using Scatchard analysis. In contrast, intraepithelial lymphocytes had no high-affinity receptors as shown by the negligible binding of 50 pM [125I]VIP. Peptide binding by peripheral blood lymphocytes, although reduced by exposure to dithiothreitol and ethylenediamine tetraacetic acid, was still greater than binding by intraepithelial lymphocytes. As intraepithelial lymphocytes are mainly CD8+ T cells, the possibility that this phenotype may not bind VIP at all was tested by specifically depleting peripheral blood lymphocytes by antibody and complement lysis. Peripheral blood lymphocytes expressing CD8, CD4, and/or CD2 were responsible for most of the binding, indicating that CD8+ T lymphocytes in the peripheral blood and in the intestinal epithelium differ in their capacity to bind VIP.

Adjuvants, Immunologic↗
PubMed1991

Multivitamin prophylaxis in prevention of post-gastric bypass vitamin and mineral deficiencies.

One hundred forty patients were followed for a mean 24.2 months after gastric bypass. Postop multivitamin (MV) prophylaxis was recommended for all patients and 90 of 140 patients (64 percent) were regularly compliant. Deficiencies in iron, vitamin B-12 or folate were recognized in 88 of 140 patients (63 percent). Thirty of 45 patients (67 percent) with iron deficiency developed anemia. Forty-three of the 52 patients who did not have deficiencies were regularly taking MV vs 47 of 88 patients who developed deficiencies (P less than 0.001). MV prophylaxis was successful in preventing folate (P less than or equal to 0.05) and vitamin B-12 deficiencies (P less than or equal to 0.02) but did not prevent development of iron deficiency or subsequent anemia. There was no correlation between taking prescribed supplements and resolution of either iron deficiency of anemia. B-12 and folate supplements corrected deficiencies in 73 percent of cases. We conclude that oral MV prophylaxis is useful in preventing folate and B-12 deficiency after gastric bypass. Additional prophylactic iron supplements should be provided for women to prevent iron deficiency and associated anemia.

Anastomosis, Roux-en-Y↗
PubMed1991

Limitations of percutaneous catheter drainage of abdominal abscesses.

During the past eight years, 119 patients with abdominal abscesses underwent percutaneous catheter drainage (PCD), including 76 who had successful treatment by the initial PCD, 19 who had recurrent abscesses after removal of drainage catheters and 24 who were outright failures and either died of sepsis or required surgical drainage. This study was designed to identify outcome variables that might be used prospectively to assess the therapeutic efficacy of PCD. Outcome variables included abscess size, daily drainage volume and location, presence of a gastrointestinal fistula, age, bacteriologic factors and response of the pulse rate, body temperature and leukocyte count of the patient to PCD. Ninety of 119 patients (76 per cent) ultimately had successful drainage of abscesses by PCD alone. The over-all mortality rate was 16 per cent (19 of 119), with a 75 per cent mortality rate in the failure group. Neither abscess size, bacteriologic findings nor pulse rate correlated with outcome. PCD failure was significantly greater in patients greater than or equal to 60 years (p less than or equal to 0.01) and in patients with pancreatic abscesses versus other locations (p less than or equal to 0.04). Drainage volume was significantly greater in PCD failures than among PCD successes at greater than or equal to 3 days after PCD (p less than or equal to 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Abdomen↗
PubMed1990

Use of gastrointestinal contrast studies in obstruction of the small and large bowel.

Gastrointestinal contrast studies were performed in 96 (27 percent) of 342 patients with small-bowel obstruction including 57 upper gastrointestinal and 39 barium-enema examinations. In 34 patients, upper gastrointestinal examination disclosed either obstruction or failure of contrast to reach the cecum in 24 hours; all 34 patients required surgery. The remaining 23 patients who had upper gastrointestinal studies recovered with tube decompression. Barium enema demonstrated obstruction in 13 (33 percent) of 39 cases of suspected small-bowel obstruction and localized obstruction in the colon rather than small bowel in 9 of 13 cases. Barium enema was 100 percent predictive of surgery when obstruction was shown, but was not helpful in predicting surgery when obstruction was not demonstrated. Surgery was required in 42 percent of patients whose barium enema did not show obstruction. Barium enema also was performed in 19 of 23 patients with large-bowel obstruction and showed the level of obstruction in all cases. All patients with large-bowel obstruction required surgery except for three who recovered after barium-enema reduction of intussusception or volvulus. Barium upper gastrointestinal examination is recommended in small-bowel obstruction when plain films are nondiagnostic, and in selected cases of small-bowel obstruction that do not resolve with a short trial of tube decompression. Barium enema is not recommended in suspected small-bowel obstruction but should be performed in all cases of large-bowel obstruction, except when perforation is a possibility or when the cecum measures 10 cm or larger in diameter.

Barium Sulfate↗
PubMed1990

Changes in eating behavior after horizontal gastroplasty and Roux-en-Y gastric bypass.

Postoperative changes in eight dietary variables were compared at 6-mo intervals over 24 mo in 53 horizontal-gastroplasty (HGP) and 51 Roux-en-Y gastric-bypass (RYGB) patients; the variables included 1) calorie intake; percent intake of 2) protein, 3) carbohydrate, and 4) fat; 5) sweets and high-calorie beverages (SWS) and 6) milk and ice cream (MIC) as percent of calories; and 7) high-calorie liquids (HCL) and 8) nonliquid sweets (NLS) as percentage of dietary sugar. Weight and calorie intake were significantly less after RYGB than after HGP after 6 mo (p less than or equal to 0.01). Protein intake was significantly increased at all intervals after RYGB and at 6 and 12 mo after HGP (p less than 0.05). After RYGB, intakes of SWS, MIC, and HCL were significantly decreased at all intervals (p less than 0.05). SWS and MIC consumption was also significantly less after RYGB than after HGP (p less than or equal to 0.05). Decreased SWS and MIC consumption in RYGB patients suggests that food-preference differences are partially responsible for the lower calorie intake and greater weight loss after RYGB than after HGP.

Adult↗
PubMed1990

Changing patterns in perforated peptic ulcer disease.

We reviewed our experience with 88 consecutive patients (49 men and 39 women) treated for perforated peptic ulcer between January 1983 and May 1988. The mean age was 61 years (range, 15-89); 63 per cent were more than 60 years of age and 44 per cent were more than 70 years of age. One third of patients had a prior history of peptic ulcer disease. Thirty-nine patients (44%) were taking ulcerogenic drugs (28 were using nonsteroidal anti-inflammatory drugs, 6 were using steroids alone, and 5 were using both). Twenty-eight patients (32%) were taking antacid/H2-blockers, including 15 patients with history of ulcer disease and 11 patients taking ulcerogenic drugs. Concurrent systemic diseases were present in 63 per cent of patients; 12 patients were hospitalized for other illnesses at the time of perforation. Abdominal pain was the chief complaint in 83 patients (94%) and 52 patients (59%) had peritonitis. Leukocytosis was present in 49 patients (56%). Pneumoperitoneum was noted in 65 per cent. The duodenal bulb was the site of perforation in 62 per cent, the pyloric region in 20 per cent, and the gastric body in 18 per cent. A definitive ulcer procedure (V + P, V + A) was performed in 32 patients (38%); 51 patients (58%) had plication, and the remaining five patients did not undergo surgery. A delay in diagnosis and therapy of less than 24 hours occurred in 20 (23%) patients. Mortality was 24 per cent, and correlated significantly with age more than 60 years, but not with treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1990

Serum lipids after gastric bypass surgery for morbid obesity.

Thirty-eight of 151 consecutive patients (25 percent) undergoing bypass surgery for morbid obesity had increased serum levels of total cholesterol (TC), triglycerides (TG) or both preoperatively. Ten patients had isolated TC elevation, six had isolated TG elevation and 22 had both TC and TG elevation. High density lipoprotein-cholesterol (HDL-C) levels were subnormal in 28 of the 38 patients (74 percent). Fasting lipid profiles were determined in the 38 hyperlipidemic patients at 6-month intervals postoperatively. Mean follow-up period was 29 months. By 6 months postop, patients had a greater than or equal to 20 percent mean reduction in TC and greater than or equal to 50 percent mean reduction in TG which were significant in comparison with preop levels and correlated with weight loss (P less than or equal to 0.05). Mean HDL-C levels had increased significantly vs. preop levels by 12 months postop (P less than 0.05). Lipid profiles became normal in 32 of the 38 patients (84 percent). Improvements in lipid profile were sustained in all patients with satisfactory weight loss but regressed after 12 months in patients who did not lose greater than or equal to 50 percent of their excess weight. These results suggest that abnormal serum lipid profiles can be permanently improved with sustained weight loss after gastric restriction surgery for morbid obesity.

Adult↗
PubMed1990

Percutaneous catheter drainage of abdominal abscesses associated with perforated viscus.

Improvements in radiologic localization have made percutaneous catheter drainage (PCD) the initial procedure of choice for many intra-abdominal abscesses (IAA). During the past seven years 154 patients underwent PCD for treatment of abdominal abscesses. Fourteen of these patients had PCD as the initial treatment for IAA secondary to a perforated viscus and subsequently underwent an elective one-stage operation to treat the underlying disease. Etiologies of the abscesses included perforated appendicitis in six patients, sigmoid diverticulitis in three patients, Crohn's ileitis in two patients, and one case each of perforated gastric ulcer, perforated sigmoid carcinoma, and perforated gallbladder. Initial localization of the abscess was achieved by either CT or ultrasound. Seven abscesses were localized in the right lower quadrant, four were localized in the liver, and one was localized each in the left flank, right flank, subhepatic space, and pelvis. All patients subsequently underwent a definitive elective operation for their primary disease including six interval appendectomies, four sigmoid colectomies, two small-bowel resections, one subtotal gastrectomy and one cholecystectomy. There were no complications due to PCD and no deaths occurred. We conclude that PCD can be successfully performed as the initial treatment for IAA associated with a perforated viscus, obviating the first stage of the traditional two-stage surgical approach.

Abdomen↗
PubMed1989

Characterization of activated lymphocytes in colon cancer.

The percentages of activated lymphocytes in colon cancers were compared to clinical features of the tumors and to functional characteristics of the tumor-infiltrating lymphocytes (TIL) in order to evaluate the role of activated TIL in controlling tumor growth. The TIL isolated from colon cancers contained 80 +/- 6% T cells [cluster designation (CD) 2+], 42 +/- 9% CD4+ cells, 27 +/- 9% CD8+ cells, 17 +/- 5% cells (surface immunoglobulin or SIg+), 6 +/- 2% null cells (CD2-, SIg-), 6 +/- 4% Leu 7+ cells, 1 +/- 0% macrophages (CDw 14+), and no plasma cells (PCA+). The lamina propria lymphocytes (LPL) isolated from adjacent colonic mucosa contained a similar distribution but with fewer CD8+ (10 +/- 5%) and Leu 7+ (0.6 +/- 0.3%) lymphocytes (P less than 0.05). More TIL than LPL expressed the interleukin-2 (IL-2) receptor (9 +/- 8% vs 1 +/- 0.8% CD25+ cells; P less than 0.05) and the transferrin receptor (4 +/- 5% vs 0.3 +/- 0.6% T9+ cells; P less than 0.05). Those TIL expressing activation antigens were CD2+, SIg-. The percentage of TIL that were CD25+ did not correlate with the extent of tumor spread, with the degree of tumor differentiation, nor with the percentage of HLA-DR+ tumor cells. However, there were significantly more CD25+ TIL from tumors located in the left colon, particularly small lesions, than from tumors located in the right colon (P less than 0.05). The proliferation of TIL preparations cultured with medium alone, with mitogens, or with IL-2 did not vary according to the percentage of CD25+ lymphocytes in the TIL. T cells may be activated by foreign surface determinants on tumor cells, particularly in small, left-sided lesions.

Adenocarcinoma↗
PubMed1989

Comparison of five methods of assessment of intestinal viability.

A strain gauge device called the electronic contractility meter (ECM) was designed to measure quantitatively intestinal ischemic damage by delivering electrical stimuli to the intestine. Threshold stimulus level (TSL) was the minimum stimulus in milliamps necessary to produce a smooth muscle contractile response. TSL scale ranged from zero to 100 milliamps. Resection and anastomosis in ischemic intestinal segments was carried out in 30 dogs to compare TSL, intestinal color, peristalsis, Doppler ultrasound and resection margin histology with survival. There were five fatal anastomotic leaks, all resulting from intestinal necrosis. Doppler pulse in the marginal artery (MA) was absent at four of the five anastomoses that leaked versus eight of the 25 that healed (p less than or equal to 0.01). Mean TSL at the resection site was 38 +/- 7 milliamps in surviving dogs versus 51 +/- 4 milliamps in nonsurvivors (p less than or equal to 0.001). Mean TSL of normal intestine was 22 +/- 2 milliamps. Both TSL and Doppler ultrasound also correlated with resection margin histology (p less than or equal to 0.02 and p less than or equal to 0.005, respectively). Presence of peristalsis did not correlate with histologic grade or survival rate. Intestinal color correlated with resection margin histology (p less than or equal to 0.001) but not survival. The ECM and Doppler ultrasound were both superior to gross visual assessment in predicting intestinal survival. The ECM quantitatively measures tissue damage, a potential advantage over Doppler ultrasound, which provides only an estimate of local arterial blood flow.

Anastomosis, Surgical↗
PubMed1989

The dilemma of outcome assessment after operations for morbid obesity.

Outcome of 56 patients who underwent horizontal gastroplasty (HGP) and 126 who underwent Roux-en-Y gastric bypass (RYGB) was assessed at 18 months postoperatively according to three definitions of successful weight loss; also, outcome was evaluated in the context of amelioration of obesity-related medical problems. Outcome definitions included the following: I, loss of 25% or more of preoperative weight; II, loss of 50% or more of excess weight; III, loss to within 50% of ideal body weight. To evaluate the impact of preoperative weight on success rate, patients were divided into two weight groups: "morbidily" obese patients, who were 100 to 199 pounds overweight (n = 146), and "super"-obese patients who were 200 pounds or more overweight (n = 36). Weight loss was significantly greater with RYGB versus HGP by each of the three definitions of success. Medical problems either improved or resolved with weight loss in 95% of cases. There were statistically significant differences in success rate depending on outcome definition in both HGP and RYGB patients. Success rate ranged from zero in super-obese HGP patients by Definition III to 97% in super-obese RYGB patients by Definition I. Although super-obese patients lost more pounds than the lighter morbidly obese patients, a significantly lower number of super-obese patients lost within 50% of ideal weight. Super-obese patients must lose more weight to reduce their actuarial risk. These results show that the definition of successful outcome may significantly influence the overall success rate in a large series of bariatric surgical patients.

Adolescent↗
PubMed1988

Percutaneous catheter drainage of abscesses associated with enteric fistulae.

In the past six years, percutaneous catheter drainage (PCD) has been performed in the treatment of 99 patients with abdominal and retroperitoneal abscesses. Of these 99 patients, 15 had abscesses associated with an enteric fistula. Fistula sites included small bowel (five), colon (three), complex (three), duodenum (two) and one each for the stomach and common duct. Two of these 15 patients had an initially successful PCD, ten developed recurrent abscesses after the first PCD and the procedure failed in the remaining three patients. Of the ten patients with recurrent abscesses, eight were successfully treated by a second PCD while two required small-bowel resection. Of the three failures, all three required operation and eventually died of septic complications. The diagnosis of fistula was made at the initial PCD in only six of 15 cases. There was a significant correlation between PCD failure and presence of an enteric fistula (P less than 0.001 by chi-square test). These data suggest that the diagnosis of fistula associated with abdominal abscess is elusive, but once established, most recurrent abscesses can be successfully treated by a second PCD. Operative treatment of recurrent fistula-related abscesses should be reserved for persistent fistula drainage after a second PCD or for unresolved sepsis following the initial PCD.

Abscess↗
PubMed1987

Use of tubes and radiographs in the management of small bowel obstruction.

During the past 10 years 311 consecutive patients were admitted with 342 episodes of small bowel obstruction (SBO). There were 193 cases of partial small bowel obstruction (PSBO) and 149 cases of complete small bowel obstruction (CSBO) as determined by interpretation of the abdominal radiographs done on admission. The purpose of this review was to determine the reliability of the admission plain abdominal radiographs and subsequent upper gastrointestinal (UGI) contrast studies in predicting the need for operative intervention. The use of nasogastric tubes (NGT) versus nasointestinal (long) tubes (NIT) was correlated with the following outcome variables; length of hospital stay (LOS), timing of operative intervention, incidence of postoperative complications, and duration of postoperative ileus. Long tubes (NIT) were used in 64 episodes of PSBO and 81 episodes of CSBO, whereas nasogastric tubes (NGT) were used in 116 cases of PSBO and 68 cases of CSBO. Thirty-eight of 193 (19%) patients with PSBO required operation (20 of 116 with NGT and 18 of 64 with NIT), whereas 125 of 149 (84%) patients with CSBO required operation (60 of 68 with NGT and 65 of 81 with NIT). Need for operation was not correlated with whether or not long tubes passed beyond the pylorus; 50 passed versus 33 not passed in operative groups (p = 0.15). Twelve of 83 patients with NIT had operation within 24 hours versus 52 of 80 patients with NGT (p less than 0.001). In six of 64 patients who had surgery within 24 hours, complications developed versus in 39 of 99 patients operated on more than 24 hours after admission (p less than or equal to 0.001). In 29 of 83 patients treated with NIT, postoperative complications developed versus in 16 of 80 patients with NGT (p less than or equal to 0.04). The mean duration of postoperative ileus in patients with NIT was 7 days versus 4.1 days for NGT patients (p less than 0.001). The mean LOS was 12.2 days for NGT patients versus 21 days for patients with NIT (p less than 0.001). Barium UGI contrast studies were performed in 57 patients to establish the presence of obstruction. In 34 of 57 patients the UGI disclosed mechanical obstruction that required operative intervention. In the remaining 23 patients no obstruction was demonstrated, and all 23 patients recovered without operation. In conclusion, there is no inherent superiority of NIT versus NGT in the treatment of SBO.(ABSTRACT TRUNCATED AT 400 WORDS)

Humans↗
PubMed1987

A two-year analysis of DRG #288, procedures for obesity.

DRG #288 is composed of operative procedures performed for obesity, both gastric and plastic. A two-year cost analysis of 103 consecutive gastric reduction operations performed for morbid obesity was conducted at Robert Wood Johnson University Hospital. It showed a net loss to the hospital of $18,033 in 1984 and $24,126 in 1985. Although the mean length of stay was 1.43 days less in 1985 than in 1984, DRG #288 was still a money loser. A detailed cost breakdown of nine active cost-center categories showed large financial disincentives (losses) in surgical supplies, OR/recovery room time and X ray utilization during both years of the study. These losses were not offset by substantial profits in the room-and-board category, which is directly related to length of stay. It is intuitively obvious that plastic surgical procedures for obesity require less expensive surgical supplies, fewer X rays, and shorter OR/recovery room times than gastrointestinal operations performed for morbid obesity. We conclude that DRG #288 is improperly constructed because it contains a clinically incoherent, heterogeneous mixture of operations that cannot be expected to consume similar amounts of resources and incur similar costs. Hospitals in which the preponderance of operations performed for obesity are gastrointestinal as opposed to plastic are inherently penalized by the current aggregation of DRG #288.

Cost-Benefit Analysis↗
PubMed1987

Chemical respiratory drive as a determinant of postoperative ventilation in the non-Pickwickian obese patient.

Hypercapnia in patients with pulmonary disease is believed to result from an interaction between mechanical lung impairment and intrinsic chemical respiratory drive. We tested this hypothesis in this study by examining the ventilatory (delta VE/delta PCO2) and occlusion pressure (delta P100/delta PCO2) responses to CO2 in 12 obese patients with no history of alveolar hypoventilation and correlating these with their ventilatory responses to abdominal surgery. Preoperatively the mean vital capacity (VC) was 78% +/- 6% standard error of the mean predicted, the delta VE/delta PCO2 was 1.56 +/- 0.26 L/min/torr, delta P100/delta PCO2 was 0.25 +/- 0.08 cm H2O/torr, the mean PaCO2 37.9 +/- 1.1 mm Hg, and mean PO2 77.6 +/- 3.7 mm Hg. Postoperatively the VC decreased to 56% +/- 6% of the preoperative value. PCO2 values at 24 hours increased in six patients, were unchanged in three, and decreased in three patients. However, over the entire spectrum of PCO2 change, both indexes of CO2 chemosensitivity correlated strongly with the postoperative change in PCO2 (r = -0.86 for delta VE/delta PCO2 and r = -0.66 for delta P100/delta PCO2). All six patients with a delta VE/delta PCO2 of 1.5 L/min/torr or less manifested postoperative increases in PCO2, while those with greater values did not (p = 0.005). In contrast, neither preoperative nor postoperative VC showed high correlations with postoperative PCO2 (r = -0.56 and -0.43, respectively). Thus ventilatory responses to CO2 predicted postoperative PCO2 at both ends of the spectrum; low responders hypoventilated while high responders hyperventilated. We conclude that in obese subjects, CO2 chemosensitivity plays a permissive role in determining the net ventilatory responses to situations that either mechanically load the respiratory system or modulate ventilation such as postoperative pain or analgesia.

Adult↗