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Jejuno-ileal bypass has been widely used for the surgical treatment of morbid obesity since 1954, but from 1978 onwards the operation has met with increasing disfavor, especially in the USA as a result of its unacceptably high complication rate. From 1982 onwards, 235 morbidly obese patients had a side-to-side jejuno-ileal bypass in our Department. Our data concerning weight loss and the overall incidence of complications show that jejuno-ileal bypass can still play a role in the surgical treatment of morbid obesity.

Horizontal gastroplasty has been performed on 100 pathologically obese patients over the last nine years. In our series, the mean age was 39.3 +/- 8.2 years and the mean body weight was 120.8 +/- 19.6 kg. One year after surgery the average weight loss was 29.7 kg which corresponds to a reduction of 24.6% of the preoperative weight (BMI:-24%). After three years, the body weight stabilised, reaching a total weight reduction of 30.5% (BMI:-28.7%), corresponding to 36.8 kg. The incidence of complications directly related to surgery was generally acceptable. The absence of specific malabsorption problems, the low incidence of severe complications and the satisfactory weight loss induced and maintained make, in our opinion, horizontal gastroplasty one of the most suitable and effective interventions in the long-term management of morbid obesity.

The authors relate their experience with surgery for massive obesity, reporting the results obtained in 76 severely obese patients submitted to jejunoileal bypass. The average body-weight of the 76 operated patients is 151 kg. With a maximum follow-up of 8 years, 88% of bypassed patients have returned to a normal body weight, their occupation, and a full social life.

203 patients submitted in the last 20 years to surgery, first by Smithwick's sympathectomy, then by Adson's gangliectomy and lastly by Telford's gangliectomy, were controlled. The frequency of true Raynaud's disease is with time decreasing and is found today in the minority of the patients suffering from Raynaud's phenomenon and surgically treated. Immunological tests detect frequent associated autoimmune disorders to be treated before surgery. Surgical indication is today selective. For this reason long term results are improving: 90% of positive results in the last series against 73% and 60% respectively in the previous series.

Transient hypomagnesiaemia was noted postoperatively, particularly on the 1st day in patients submitted to intestinal procedures. Slight hypocalcaemia was also observed; this was often related to a low plasma Mg value. A hormonal mechanism is presumed to be the cause of this stress-linked fall in blood magnesium.

The classical indications for the surgical treatment of morbid obesity is weight of at least 50% (males) and 80% (females) over the ideal body weight, in patients between 14 and 55 years of age. These limits are now being extended both to less overweight patients and to patients over 55 years of age. Jejunoileal bypass is the treatment of choice for severely overweight patients in good general condition, allowing them to continue with their eating habits. Gastric bypass is indicated in elderly patients or in patients with previous liver diseases. It should not be performed in younger patients because of the irreversibility of the procedure. A careful postoperative long-term follow-up is necessary to prevent the complications associated with each type of operation.

This problem of the treatment of perianal fistulas is examined and current principles of correct, effective therapeutic conduct set out. The techniques available vary with the type of fistula and the school of proctology. The as yet controversial point revolves about the way and the extent of possible sphincteric section. 80 cases reported provide a basis for some practical considerations.

One case of pouch ileitis after restorative proctocolectomy for ulcerative colitis is described. Diagnosis was made by endoscopy, histology and electron microscopy. The most prominent feature was intense inflammation of the mucosa and submucosa, with atrophy of the villi, and colonic metaplasia, occurring before closure of the loop ileostomy. The patient improved after a course of metronidazole therapy, but ileostomy closure was postponed. It appears that the ileum mucosa of patients with ulcerative colitis is highly prone to the development of inflammation and careful, regular follow-up is recommended.

The aim of this study was to estimate efficacy, safety, and tolerance of monooctanoin in 16 patients with retained radiolucent biliary stones and indwelling biliary drainage. Monooctanoin was infused continuously at a rate of 3-4 ml/h. Monitoring of pressure with a manometer broken off at 20 cm prevented the development of excessive pressure in the common bile duct. The mean volume of the compound instilled (+/- SD) was 848 +/- 393 ml (range 80-1450) and the mean duration of treatment was 13 +/- 6 days (range 2-23). Monooctanoin induced disappearance of stones in 11 of 16 patients giving a success rate of 69%. Three patients exhibited a partial dissolution of stones which were then successfully removed through the postoperative T-tube. The two failures can be attributed to the type of stones mainly composed of bile pigments. Side effects from the infusion of monooctanoin were only minor and easily controlled by reducing the infusion rate of the solution. Laboratory tests, including hepatic and pancreatic enzymes, remained stable. In one subject endoscopic and histological evidence of mild duodenitis was found when pre- and posttreatment features were compared. On the basis of these data, we recommend monooctanoin to treat biliary-retained cholesterol stones.

The results of jejunoileal bypass for morbid obesity were studied in 192 operated patients. Mean weight loss was 39.3% of initial weight and 80.5% of overweight. Medical benefits (such as improved glucose tolerance, lowered blood pressure, healed Pickwick syndrome, etc.) were maintained during the follow-up (average five years). The most feared complication of the jejunoileal bypass is severe hepatic failure, which appeared in 2.3% of the cases, only after the end-to-end jejunoileal bypass, and never more than 12 months after surgery. Most patients had satisfactory and lasting results due to a careful and assiduous postoperative follow-up, and to the strict co-operation between the medical staff and the patient. Medical therapy in the preoperative period was useful to control the weight gain by administration of a hypocaloric definite diet. In the postoperative period, we usually got benefits for the bypass induced intestinal malabsorption by administration of supportive vitamins and electrolytes. To prevent liver diseases we often found intestinal-specific antibiotics, aminoacidic solutions, hyperproteical diet and anti-steatosis agents helpful.