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BACKGROUND: Previous studies have documented a significantly better weight loss for gastric bypass (GBP) than for vertical banded gastroplasty (VBG). Additional problems associated with VBG include intractable vomiting or gastroesophageal (GE) reflux, intragastric migration of the polypropylene band, staple line disruption, or inadequate weight loss due to excessive ingestion of high-calorie liquid or soft carbohydrates. PATIENTS AND METHODS: Fifty-eight morbidly obese patients underwent conversion from VBG to GBP for either weight-loss failure (15) or complications of VBG (43), including 2 who were referred with anastomotic leaks and peritonitis, 3 with band erosion, 15 with staple line disruption, and 23 with stomal stenosis, of whom 6 had severe GE reflux, with a Barrett's esophagus in 1. RESULTS: Percentage of excess weight loss in the 53 patients followed up for at least 1 year after conversion increased from 36% [+ or -] 24% to 67% [+ or -] 18%, and in the 15 'sweets eaters' from 20% [+ or -] 19% to 70% [+ or -] 19% (both P

BACKGROUND: Incisional hernia is a serious complication of abdominal surgery. We compared incisional hernia frequency following gastric bypass (GBP) for morbid obesity versus total abdominal colectomy and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis. A prefascial polypropylene mesh repair was also evaluated. PATIENTS AND METHODS: All patients had midline incisions, xiphoid to umbilicus in GBP patients and midepigastrium to pubis in IPAA patients. Fascia were closed with running No. 2 polyglycolic acid suture. Ninety-eight patients underwent prefascial polypropylene mesh repair; 80 were GBP patients, 46 had 1 previous repair, and 17 had 2 to 9 previous repairs (6 with properitoneal mesh). RESULTS: Incisional hernia occurred in 20% (198/968) of GBP patients (19% without versus 41% with a previous hernia, P < 0.001) versus 4% (7/171) of the IPAA patients (P < 0.001), of whom 102 (60%) were taking prednisone (32 [+ or -] 2 mg/d) and 5 were quite obese (body mass index 230 kg/m2). Additional risk factors for hernia in GBP patients included wound infection, diabetes, sleep apnea, and obesity hypoventilation. For the 98 patients who underwent prefascial polypropylene mesh repair, the mean follow-up was 20 [+ or -] 2 months (range 6 to 104), and complications occurred in 35% of patients, including minor wound infection (12%), major wound infection (5%), seroma (5%), hematoma (3%), chronic pain (6%), and recurrent hernia (4%). CONCLUSIONS: Severe obesity is a greater risk factor for incisional hernia and hernia recurrence than chronic steroid use in nonobese colitis patients. A prefascial polypropylene mesh repair minimizes recurrence. Am J Surg. 1996;171:80-84.

BACKGROUND: Previous studies have documented a high incidence of gallstone formation following gastric-bypass (GBP)-induced rapid weight loss in morbidly obese patients. This study was designed to determine if a 6-month regimen of prophylactic ursodiol might prevent the development of gallstones. METHODS: A multicenter, randomized, double-blind, prospective trial evaluated 3 oral doses of ursodiol: 300, 600, and 1,200 mg versus placebo beginning within 10 days after surgery and continuing for 6 months or until gallstone development, for patients with a body mass index (BMI) [greater than or equal to] 40 kg/[m.sup.2]. All patients had normal intraoperative gallbladder sonography. Transabdominal sonography was obtained at 2, 4, and 6 months following surgery, or until gallstone formation. RESULTS: Of 233 patients with at least one postoperative sonogram, 56 were randomized to placebo, 53 to 300 mg ursodiol, 61 to 600 mg ursodiol, and 63 to 1,200 mg ursodiol. Preoperative age, sex, race, weight, BMI, and postoperative weight loss were not significantly different between groups. Gallstone formation occurred at 6 months in 32%, 13%, 2%, and 6% of the patients on the respective doses. Gallstones were significantly (P

The Pickwickian syndrome can be divided into two primary breathing disorders, which can affect patients alone or in combination: sleep apnea syndrome (SAS) and obesity hypoventilation syndrome (OHS). Between 1980 and 1990, 126 patients with respiratory insufficiency underwent gastric surgery for morbid obesity, 12.5% of the entire series. These patients weighed more (164 [+ or -] 36 vs 135 [+ or -] 25 kg, P < 0.000 1) and were more often men (62% vs 14%, P < 0.001) than those without pulmonary dysfunction. Sixteen had OHS alone, 65 had SAS alone, and 45 had both. Of those with OHS, 38 have been followed for 5.8 [+ or -] 2.4 y since surgery and 29 are currently asymptomatic. In the 12 patients in whom arterial blood gases were available > 5 y since surgery, the [PaO.sub.2] increased from 54 [+ or -] 10 to 68 [+ or -] 20 mm Hg (P < 0.0001) and [PaCO.sub.2] fell from 53 [+ or -] 9 to 47 [+ or -] 11 mm Hg (P = 0.05). Of the 110 patients with SAS, 57 were available for follow-up an average of 4.5 [+ or -] 2.3 y since surgery and 38 were completely asymptomatic, 15 had mild SAS, and 4 had both SAS and OHS. In 40 patients with pre-and post-weight reduction sleep polysomnograms, the sleep apnea index fell from 64 [+ or -] 39 to 26 [+ or -] 26 (P < 0.000 1). Although respiratory insufficiency of obesity patients had a higher operative mortality than did patients without pulmonary dysfunction (2.4% vs 0.2% after gastric bypass), weight loss was associated with significant improvements in sleep apnea, arterial blood gases, pulmonary hypertension, left ventricular dysfunction, lung volumes, and polycythemia. Am J Clin Nutr 1992;55:597S-601S.

Gastric bypass (RY-GBP) has a very small gastric pouch with a 1-cm diameter Roux-Y gastrojejunostomy. RY-GBP is associated with early satiety and an aversion to sweets secondary to dumping syndrome symptoms and has a significantly better weight loss than various gastroplasty procedures, including the vertical banded gastroplasty. However, it may be associated with vitamin B-12 deficiency and iron deficiency anemia in menstruating females, preventable with prophylactic oral iron and vitamin B-12. With an 80% 5 y follow-up, RY-GBP patients lose two-thirds of their excess weight within 2 y, 60% at 5 y, and > 50% at 9 y. The RY-GBP can be beaten by nibbling junk foods' (potato or corn chips). Conversion to a malabsorptive procedure may cause severe malnutrition and fat-soluble vitamin deficiencies and should be used only for 'superobese' patients who fail a standard RY-GBP and have severe comorbidity. RY-GBP is the most effective procedure for morbid obesity, especially in patients addicted to 'sweets.' Am J Clin Nutr 1992;55:560S-6S.

Bacterial sepsis is a bacterial infection of the blood. Bacterial sepsis has been associated with the development of adult respiratory distress syndrome (ARDS) and acute lung injury (ALI). ARDS and ALI are conditions characterized by the presence of damaged lung tissue and pulmonary edema (the leakage of fluid from blood vessels into the lungs). Animal models have been developed to study the changes in lung physiology that occur during ALI. The procedure involves inoculating animals with a bacteria (Pseudomonas aeruginosa) that causes sepsis and lung damage similar to that observed in humans who have ALI. A technique called bronchoalveolar lavage (BAL) is used to obtain samples of lung fluid and cells. BAL is performed by placing a tube in the mouth that reaches down into the lungs. A sterile saline solution is delivered through the tube into the lungs and then removed by gentle suction. The fluid removed from the lungs is called the BAL fluid, and contains lung cells and proteins. When sepsis and ALI are present, the BAL fluid will contain blood proteins and white blood cells. In order to determine if the drug ibuprofen is an effective way of preventing sepsis-induced ALI, pigs were inoculated with bacteria to create an animal model of sepsis, as described above. BAL fluid from inoculated pigs contained blood proteins and white blood cells. Pretreatment with ibuprofen prior to inoculation with bacteria completely prevented the leakage of blood proteins and cells from the blood vessels into the lung tissue. Ibuprofen may be beneficial in preventing sepsis-induced ALI. Further studies are needed to determine if ibuprofen will be an appropriate treatment for ALI or ARDS in humans. (Consumer Summary produced by Reliance Medical Information, Inc.)

OBESITY IS a serious problem in the United States, and surgical therapy for obesity is an increasingly common and accepted medical practice. Various types of surgical procedures are available. A [...]