Fulminant onset of spontaneous bacterial peritonitis.
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Ascites↗
Biomedical subjects
R E Brolin
Publications and source records attributed to R E Brolin.
Historical perspective of surgery for morbid obesity.
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Body Weight↗
Emergency operation for upper gastrointestinal hemorrhage.
From January 1973 through December 1977, 580 patients presented with 624 episodes of upper gastrointestinal hemorrhage at the University fo Pittsburgh Health Center Hospitals. Ninety-one patients (15%) underwent operation for uncontrollable hemorrhage. Operative mortality was 30 per cent for all patients and 21 per cent for patients with gastroduodenal bleeding (duodenal ulcer, gastric ulcer, erosive gastritis). In patients with gastroduodenal bleeding, seven of 15(47%) with preoperative hypotensive shock (systolic b.p. less than or equal to .02). Twenty-five patients had vagotomy and pyloroplasty with suture ligation of bleeding ulcers, while 34 patients underwent gastric resection. The operative mortality for resection was 21 per cent (7/34) compared with 16 percent (4/25) for vagotomy and pyloroplasty. The incidence of rebleeding was 15 per cent (5/34) for resection and 8 per cent (2/25 for vagotomy and pyloroplasty. Nine patients (26%) has suture-line leaks following resection, and none were found after vagotomy and pyloroplasty. Severe of nine patients (78%) who had leaks after resection had hypotensive shock prior to operation. Six of the seven patients who died following gastric resection had complication (either leak or rebleeding) directly related to the operative procedure, while the four deaths following vagotomy and pyloroplasty occurred in patients not having procedure-related complications. Procedure-related morbidity (leaks and rebleeding) with resection (41%) was significantly higher than with vagotomy and pyloroplasty (8%) (P less than or equal to .01). These data show vagotomy and pyloroplasty to be the safer operation for patients with uncontrollable gastroduodenal hemorrhage, particularly those with preoperative hypotension.
Duodenal Ulcer↗
Experimental evaluation of techniques of gastric partitioning for morbid obesity.
Fifty stapled gastric partitions were performed upon dogs using five techniques, three of which used strips of Marlex or Teflon to reinforce the staple line. At autopsy, five weeks after operation, 22 of 50 partitions were intact and 19 of 50 were completely disrupted. Nine of 50 dogs died of leak and peritonitis within three days of operation. The incidence of disruption was not significantly reduced by reinforcing the stapled partitions with Teflon or Marlex, but the incidence of leak and peritonitis which resulted in death was significantly higher with reinforced partitions, P less than or equal to 0.05. Disruption of the staple line appears to begin at the partition opening and proceeds laterally from that point. Distortion of staples was noted in most of the intact partitions, and in several, the staples remained closed but pulled through the full thickness of the anterior gastric wall. Dilation of the partition opening was noted with each technique. It is our impression from the experiments and the reported clinical experience with ever-changing operative techniques that mucosa-to-mucosa stapling of the undivided stomach is not a reliable technique for gastric partitioning and that additional measures to ensure the success of this simple technique may lead to other complications. At this point, we do not know of an operative technique for the treatment of morbid obesity which we consider to be both safe and effective enough for us to use.
Animals↗
Studies in intestinal healing VI. Effect of pharmacologically induced peristalsis on fresh intestinal anastomoses in dogs.
This study was devised to disclose any harmful effect of stimulation of the bowel by neostigmine (Prostigmin), alone, or in combination with castor oil in 220 canine anastomoses (60 stapled, 60 two-layer silk and catgut inverted, and 100 one-layer silk everted) performed in enteroenterostomies, ileocolostomies, and colocolostomies. Two techniques were used for the one-layer everted anastomoses--a through-and-through simple interrupted ("Navy") and a horizontal mattress interrupted. One hundred and ten experimental dogs received neostigmine intramuscularly on each of the first three postoperative days. Forty-five of these dogs also received castor oil orally on the first two postoperative days. Peristalsis induced by neostigmine, alone or in combination with castor oil, has no deleterious effect on stapled or conventional two-layer inverted or one-layer Navy everted anastomoses of small bowel or colon, but adversely affects the one-layer "mattress" closure in the colon. Dogs with induced peristalsis had their first evacuation sooner and ate sooner.
Animals↗
The manifestations of bypass enteritis following jejunoileal bypass.
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Adult↗
The price of weight loss by jejunoileal shunt.
In the performance of end-to-end jejunoileal shunt, operative mortality can be nearly eliminated and late deaths largely prevented by assiduous care and follow-up. We attempted to prevent serious complications by regular outpatient visits. However, 703 outpatient visits costing $49.00 per visit failed to improve results. There were 170 readmissions among 64 patients lasting 4--57 days (average hospital stay--16 days per admission at $3,000.00). Twenty-four of those patients alive and followed 18 months or more (53%) sustained adequate weight loss and were free of major problems. Patient satisfaction nevertheless appears high, and when there has been a good weight loss, even severe problems tend to be glossed over by the patient. The ultimate outcome is still unknown, but it seems clear that many of the patients are in a state of controlled malnutrition, which may lead to progressive penalties. We have documented gross pathologic lesions in the bypass enteritis syndrome and draw attention to neurologic sequelae of the bypass, which probably represents deficiency manifestations. Despite brilliant results in some patients and satisfactory results in perhaps half, the cost in life, suffering, dollars, patient and physician time, the uncertain long-term effects, and the unpredictability of the weight loss, all place in question the appropriateness of jejunoileal shunt as the remedy for morbid obesity.
Adult↗
Lipid risk profile and weight stability after gastric restrictive operations for morbid obesity.
There are no longitudinal data that address weight loss stability and lipid levels in bariatric surgical patients. The goal of this study was to determine whether weight regain adversely affected reduction in lipid levels after gastric bariatric operations. Of 651 consecutive patients undergoing gastric restrictive surgery for morbid obesity, 227 (35%) had increased serum levels of total cholesterol (TC), triglycerides, or both preoperatively. High-density lipoprotein cholesterol (HDL-C) levels were subnormal (</=35 mg/dl) in 45 (20%) of the hyperlipidemic patients. Fasting lipid profiles were determined at 6-month intervals postoperatively. This series included the following three operations: gastroplasty (GP; N = 13), standard Roux-en-Y gastric bypass (RYGB; N = 205), and distal Roux-en-Y gastric bypass (DRY; N = 9). By 6 months postoperatively, patients had a >/=15% mean reduction in TC and a >/=50% mean reduction in triglycerides, both of which were significant in comparison with preoperative levels (P </=0.05). Mean HDL-C levels had increased significantly vs. preoperative levels by 12 months postoperative y (P <0.05) and continued to increase through 5 years. By 18 months both HDL-C and TC were significantly lower after DRY than after GP or RYGB. In 91 patients who were followed for 2 years or longer (mean 48 +/- 25 months), mean excess weight loss was 55% with mean body mass index reduced from 48 to 33 kg/m(2). This group was divided into patients whose weight remained stable (N = 54) and patients who regained >/=15% of their lost weight or lost less than 50% of excess weight (N = 37). Although mean excess weight loss and body mass index were significantly different between the two groups (P <0.0001) at 2 years, there was no difference in the lipid profile (TC/HDL) between the two groups at any interval through 5 years. These results show that abnormal lipid profiles can be permanently improved after gastric bariatric surgery and are not adversely affected by mediocre weight loss or regaining >/=15% of lost weight. DRY appears to be a superior operation for TC reduction in comparison with GP and RYGB.
Adult↗
Comparison of ischemic and reperfusion injury in canine bowel viability assessment.
The purpose of these experiments was to evaluate two methods of bowel viability assessment in two distinct models of intestinal ischemia. Bowel viability was assessed in 32 dogs by means of three methods: (1) a probe that quantified the intestinal electromyographic (EMG) measurements in millivolts (mV), (2) Doppler ultrasonography, and (3) perfusion fluorometry, which quantified serosal blood flow in indexed dye fluorescence units (dfi). Ischemia was created using one of two methods: (1) a chronic model in which the blood supply to 40 cm of ileum was ligated and viability assessed 24 hours later, or (2) an acute model in which the main superior mesenteric artery was occluded for 3 1/2 hours and then released. Viability parameters were assessed every 5 minutes for 30 minutes after release. After viability assessment was completed, the ischemic bowel was resected and anastomosed at the site where the EMG measurements approximated 50% of the values obtained in normal bowel. In the chronic group 3 of 20 dogs died of necrosis in contrast to none of 12 dogs in the acute reperfusion group. In the acute model EMG values steadily increased after reperfusion, stabilizing by 15 minutes after release. Mean EMG values at 15 through 30 minutes after release were significantly greater than the 5- and 10-minute postrelease and prerelease values, suggesting that the electromyogram is affected by reperfusion. Conversely, postrelease fluorometry measurements rapidly increased to levels that exceeded measurements obtained in normal bowel. There was a significant difference in the number of audible Doppler signals in the marginal artery of survivors of the acute vs. the chronic model. Fluorometry measurements in survivors of the acute model (99+/-9 dfi) were significantly greater than measurements in the chronic model (54+/-4 dfi, P<or=0.004). Conversely, intermodel differences in the EMG measurements were not significant. These results show significant differences in the magnitude of ischemic damage induced by reperfusion vs. mesenteric ligation, which had a significant impact on the objective blood flow measurements that were used to predict bowel viability. The results also suggest that intestinal reperfusion injury in dogs has a negligible impact on bowel survival.
Animals↗
Are vitamin B12 and folate deficiency clinically important after roux-en-Y gastric bypass?
Although iron, vitamin B12, and folate deficiency have been well documented after gastric bypass operations performed for morbid obesity, there is surprisingly little information on either the natural course or the treatment of these deficiencies in Roux-en-Y gastric bypass (RYGB) patients. During a 10-year period, a complete blood count and serum levels of iron, total iron-binding capacity, vitamin B12, and folate were obtained in 348 patients preoperatively and postoperatively at 6-month intervals for the first 2 years, then annually thereafter. The principal objectives of this study were to determine how readily patients who developed metabolic deficiencies after Roux-en-Y gastric bypass responded to postoperative supplements of the deficient micronutrient and to learn whether the risk of developing these deficiencies decreases over time. Hemoglobin and hematocrit levels were significantly decreased at all postoperative intervals in comparison to preoperative values. Moreover, at each successive interval through 5 years, hemoglobin and hematocrit were decreased significantly compared to the preceding interval. Folate levels were significantly increased compared to preoperative levels at all time intervals. Iron and vitamin B12 levels were lower than preoperative measurements and remained relatively stable postoperatively. Half of the low hemoglobin levels were not associated with iron deficiency. Taking multivitamin supplements resulted in a lower incidence of folate deficiency but did not prevent iron or vitamin B12 deficiency. Oral supplementation of iron and vitamin B12 corrected deficiencies in 43% and 81% of cases, respectively. Folate deficiency was almost always corrected with multivitamins alone. No patient had symptoms that could be attributed to either vitamin B12 or folate deficiency Conversely, many patients had symptoms of iron deficiency and anemia. Lack of symptoms of vitamin B12 and folate deficiency suggests that these deficiencies are not clinically important after RYGB. Conversely, iron deficiency and anemia are potentially serious problems after RYGB, particularly in younger women. Hence we recommend prophylactic oral iron supplements to premenopausal women who undergo RYGB.
Anastomosis, Roux-en-Y↗
Clinical experience with the multiple lumen central venous catheter.
One hundred four multiple lumen central venous catheters (MLC) were evaluated in 74 seriously ill patients. Eighty percent of the catheters were placed in an intensive care unit. Each MLC served as access for a mean of 4.5 different functions, including infusions, central venous monitoring and phlebotomy. Complications occurred with 16 MLC (15.4%), including two aberrant placements, 10 mechanical problems, and four septic catheters (3.8%). Simultaneous administration of TPN and other infusions through MLC did not affect the rate of catheter sepsis. MLC are well tolerated and cost effective. They increase the comfort of patients who require complex venous access or who lack peripheral veins. They allow safe concurrent administration of TPN, medications, and central venous monitoring.
Bacterial Infections↗
Diagnosis-related group impact of nutrition support in cardiac surgery patients.
We studied the diagnosis-related groups (DRG) impact of nutrition support on 80 consecutive cardiac surgery patients operated upon during a 6-month period. Six of 80 patients were nutritionally depleted preoperatively. Seven received postoperative supplemental nutrition, all of whom had major postoperative complications. Patients were arbitrarily placed into three outcome groups: group I consisted of seven patients who received postoperative nutrition support; group II included 38 patients who received no nutrition support and did not develop complications; Group III consisted of 35 patients who received no nutrition support but developed postoperative complications. All group I patients were length of stay (LOS) outliers. Group I patients were significantly older than groups II and III (p less than 0.0003) and had a significantly longer average length of stay (ALOS) (p less than 0.001), ALOS in SICU (p less than 0.0001) and greater incidence of both septic complications (p less than 0.02) and mortality (p less than 0.02). Nutrition support in cardiac surgery patients warrants special DRG consideration in light of the significantly increased hospitalization and resource utilization as compared with all other patients in cardiac surgery.
Adult↗
Comparison of isomolar vs hyperosmolar enteral diets in experimental ileus.
The diarrhea observed after infusing hypertonic enteral alimentation solutions may be due to the high osmolality. We compared Vivonex HN (810 mOsm) to Osmolite (300 mOsm) in two canine ileus models. After having bipolar electrodes implanted in the stomach, duodenum, jejunum, and colon, four dogs sequentially underwent operations to produce intestinal obstruction (SBO) or perforation/peritonitis (PER). The SBO was released and the perforation closed 24 hr later. GI myoelectric activity (MEA) was monitored during the first 4 postoperative days and again on the 10th day to determine steady-state MEA. Fasting MEA was recorded for 1 hr, followed by 1-hr recordings after intragastric cannula infusion of either Vivonex HN or Osmolite. There was no significant difference in MEA produced by Osmolite vs Vivonex at any recording site. The 24-hr postop gastric and small bowel MEA was significantly decreased (p less than 0.05) vs postoperative days 2 to 4 and 10 under both fasting and fed conditions. The ileus operations had no effect on colonic MEA. These data show that SBO and PER cause significant decreases in gastrointestinal MEA for 24 hr. There was no difference in MEA response of Osmolite vs Vivonex HN. These results suggest that infusion of hypertonic enteral alimentation solutions does not produce increases in GI myoelectric responsiveness vs isotonic solutions.
Animals↗
Intraoperative assessment of bowel viability.
Viability of ischemic bowel was assessed in 30 dogs after mesenteric arterial ligation in a 40-cm length of ileum. Viability was evaluated using two gross features, color and peristalsis, and four objective methods including bowel wall surface oximetry (pO2), Doppler ultrasound, quantitative fluorescein fluorimetry, and myoelectric activity measured by a strain gauge probe. Each parameter was measured at 2-cm intervals within the 40-cm ischemic segment before resection and anastomosis was performed. There were seven fatal anastomotic leaks, all due to further bowel necrosis. Survival did not correlate with bowel color, presence of peristalsis, bowel wall pO2 Doppler ultrasound, or the myoelectric parameters. However, fluorescein fluorimetry was predictive of long-term viability. These results suggest that quantitative fluorescein fluorimetry may be a useful adjunct in intraoperative bowel viability assessment.
Animals↗
Bacterial translocation after mesenteric ligation in dogs.
These experiments were designed to determine the relationship between translocation of Escherichia coli and viability of ischemic small bowel. Twenty beagles were gavaged with 14C-labeled E. coli at two time intervals (3 and 24 h) prior to ligation of the blood supply to a 40-cm segment of ileum. Mesenteric lymph node (MLN) biopsies and bacterial cultures of the peritoneal fluid, peripheral arterial blood, and splanchnic venous blood were taken immediately prior to ligation and 24 h later both before and after the ischemic bowel was resected and anastomosed. Biopsies of each resection margin were taken to measure translocation of E. coli into the bowel wall. Several hemodynamic hemodynamic parameters were also measured before and 24 h after ligation. Seven of the 20 dogs died of further bowel necrosis. In survivors A-alpha DO2 was significantly decreased 24 h after mesenteric ligation vs. preligation, whereas in dogs that died DO2 was significantly increased after ligation vs. preligation. The incidence of mesenteric venous cultures positive for E. coli was significantly higher 24 h after ligation vs. preligation. However, there was no correlation between survival and the incidence of positive E. coli cultures in the blood or peritoneal fluid. Mean MLN counts were significantly higher in dogs gavaged at 3 h vs. those gavaged 24 h prior to laparotomy. However, there was no correlation between survival and translocation into either the bowel wall or MLN at either time interval. Viability of ischemic small bowel in this canine model was not affected by translocation of E. coli. Hemodynamic parameters that are altered during the course of sepsis also did not correlate with survival.
Animals↗
Use of nutrition support in patients with AIDS: a four-year retrospective review.
A series of 55 patients with AIDS and opportunistic infections were admitted a total of 75 times to Robert Wood Johnson University Hospital over a 4-year period, and supplemental nutrition support--intravenous (IV), enteral, or both--was given during 32 of these admissions. Use of nutrition support was correlated retrospectively with pretreatment nutritional status, length of hospital stay (LOS), and survival and was found to be positively correlated with weight loss greater than or equal to 10% or weight less than or equal to 90% of ideal body weight (p less than 0.001), admission hemoglobin less than or equal to 10g (p less than 0.001), and LOS less than or equal to 21 days (p less than or equal to 0.003). Nutrition support intervention did not correlate with survival, admission total lymphocyte count (TLC), or serum albumin level. Survival was negatively correlated with LOS (p less than or equal to 0.04) and continuous daily fever for greater than or equal to 6 days (p less than 0.001). Survival was also significantly lower in patients who received IV rather than enteral nutrition support (p less than or equal to 0.03). Weight loss, admission TLC, albumin, and hemoglobin levels did not correlate with survival. These results suggest that nutrition support generally was given to the sickest patients with AIDS. There was no measurable benefit associated with use of supplemental nutritional support in this series. Properly designed trials will be necessary to define the optimum route, timing, and type of nutritional support for patients with AIDS.
Acquired Immunodeficiency Syndrome↗
Current therapy for subungual melanoma.
Malignant subungual melanoma is an infrequently encountered but often misdiagnosed clinical entity. The podiatric surgeon plays a major role in the early diagnosis and surgical management. An illustrative case report of its clinical presentation and a thorough review of current therapeutic modalities are presented.
Aged↗
Evaluation of quantitative approaches to assessment of bowel viability.
Predicting the survivability of intestine that has been made ischemic by impairment of blood flow is a major unsolved problem in gastrointestinal surgery. Currently, the surgeon must rely on qualitative, often subjective assessments that are known to have marginal reliability. This review describes various approaches to quantitatively assess the survivability of intestine compromised by ischemic disease. Much of the review centers on work done in the authors' laboratory to evaluate various approaches to predicting long-term survival and to develop new assessment parameters. Towards that end the authors have designed and developed techniques based on intestinal contractility and myoelectric activity (the intestinal EMG). Their evaluations of these and other methods of viability assessment utilize a highly representative canine model of intestinal ischemia that closely follows the development and treatment of ischemic intestinal disease in humans. Results to date suggest that the myoelectric measurements are more reliable than parameters based on blood flow or visual evaluation in terms of predicting bowel survival. However, improvements in instrumentation and technique are needed before this approach is suitable for clinical use.
Angiography↗