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Background: Roux-en-Y gastric bypass (RYGBP) and biliopancreatic diversion (BPD) are highly beneficial operations for type 2 diabetes mellitus (T2DM) in obese patients, leading to complete T2DM resolution in 75-90 and 97-99% of cases, respectively. In both RYGBP and BPD, the foregut is excluded from the food stream and the distal small bowel receives the food stimulation, while following BPD fat intestinal absorption is also extremely limited. This study was carried out to identify clinical features that could give insight on the different mechanisms of action on diabetes resolution., Methods: The files of 443 severely obese patients with T2DM undergoing BPD from May 1976 to May 2007 were examined, and the presence of T2DM (fasting serum glucose >125 mg/ml) at 1-2 months, at 1 year, at 10 years, and at > or =20 years following the operation was recorded., Results: The percentage of patients cured (fasting serum glucose reduced to < or =110 mg/dl, on free diet and with no therapy) was 74% at 1 month, 97% at 1 and 10 years, and 91% at > or =20 years, the 26% of uncured patients at 1 month being those with most severe preoperative T2DM., Conclusions: As the early results after BPD resemble those reported after RYGBP, it can be hypothesized that the duodenal exclusion and the distal small bowel stimulation are the first mechanisms acting in BPD, immediately after the operation, that only subsequently the myocellular fat depletion, which cannot be immediate, takes over, and that the minimal fat absorption is the mechanism accounting for the long-term results of BPD.

Background: The benefits of bariatric surgery in adult obese patients are well known, but data are lacking regarding the outcome of the surgery in adolescents. The aim of this study was to retrospectively assess the operative morbidity and mortality, percentage of loss of initial excess weight, and the incidence of long-term complications and reoperations in a cohort of obese patients who underwent biliopancreatic diversion (BPD) before their 18th birthday., Methods: A total of 76 adolescent subjects underwent BPD between 1976 and 2005. Of these 78 patients, 7 had Prader-Willi syndrome and 1 had Turner syndrome and were excluded from the study., Results: The patient population comprised 52 girls and 16 boys. Their mean age was 16.8 years, mean body weight at operation was 125 kg (mean body mass index 46 kg/m2). Operative mortality was nil. The mean follow-up was 11 years (range 2-23). The mean percentage of loss of initial excess weight at each patient's longest follow-up was 78%. Before surgery, 33 patients were hypertensive (49%), 11 were dyslipidemic (16%), 3 were hyperglycemic, and 2 had type 2 diabetes. At the longest follow-up period after surgery, only 6 patients were hypertensive, and none were dyslipidemic or diabetic. A total of 19 reoperations were performed in 14 patients (20%), including 7 revisions. Eleven patients developed protein malnutrition 1-10 years after BPD. The long-term mortality rate was 4%. At 4 to 23 years after BPD, 18 of the women had given birth to 28 healthy babies. Three women had had a complicated pregnancy., Conclusion: Adolescents can undergo malabsorptive bariatric surgery with excellent long-term weight loss results and an incidence of long-term complications similar to that observed during the 30-year evolution of BPD in our experience.

Objectives: The objectives were to evaluate QT interval (QTc) and QT-interval dispersion (QTd) in severely obese individuals and to determine the effects of biliopancreatic diversion (BPD) and weight loss after BPD on ventricular repolarization parameters., Background: People with severe obesity (SO) have a 50% to 100% increased risk of death associated with a 1.6-fold increased risk of sudden death. BPD surgery induces rapid and considerable weight loss through severe lipid malabsorption, thus achieving long-term weight control., Research Methods and Procedures: A total of 85 subjects with SO (age, 42 +/- 12 years; 66 females; mean body weight, 120 +/- 29 kg; BMI, 45 +/- 11 kg/m(2)) of 330 who had a bariatric surgical consultation between January 2001 and July 2002 were enrolled. Inclusion criteria were sinus rhythm, unremarkable 12 leads surface electrocardiogram, no atrioventricular blocks and/or bundle branch blocks, normal serum electrolyte profile, and no medical therapies exerting known effects on QTc. Exclusion criteria were previous diagnosis of coronary artery disease, known cardiovascular disease, atrial fibrillation or any other known cardiac arrhythmias, cancer, or renal dysfunction., Results: A total of 86% of patients had QTc >440 ms and/or QTd >60 ms. Subjects with SO showed a mean maximum QTc of 446 +/- 28 ms and a mean QTd of 52 +/- 20 ms. A close correlation was found between QTc and QTd (p < 0.0001; R(2) = 0.33). One month after BPD, mean QTc was 420 ms and remained stable at follow-up; QTd was 32 ms at 1 and 6 months and became 35 ms at 1 year., Conclusions: Ventricular repolarization abnormalities are significantly increased in subjects with SO. Reduction of QT abnormalities after BPD is independent of weight loss and is caused by the 100% reduction of glucose plasma shortly after surgery. This effect may be related to surgical interruption of the entero-insular axis.

Background: Bariatric operations are the most powerful means of curing type 2 diabetes mellitus (T2D) and the other major components of the metabolic syndrome. Despite the very frequent occurrence of metabolic disturbances in patients with BMI from 30 to 35, there is a general reluctance to operate on these patients, as their disease is considered less severe., Methods: 7 T2D obese patients with mean BMI < 35 underwent BPD between 1976 and 1996 at the Azienda Ospedaliera Universitaria San Martino of Genoa, Italy. Mean age was 49 years, mean body weight 91 kg, and mean waist circumference 115 (M) and 98 (F) cm. The mean follow-up was 13 (10-18) years. All 7 patients had abnormally high values of serum triglyceride, serum cholesterol, and arterial pressure., Results: In all patients, serum glucose was normalized at 1,2, and 3 years. In 5 patients, a slight increase of serum glucose above 125 mg/dl was observed at or around 5 years, the values being maintained at all subsequent times, with no one value higher than 160 mg ever being recorded. The other 2 patients showed full resolution of diabetes at all follow-up times. Both serum cholesterol and triglyceride values fell to normal 1 year after BPD, and remained within the normal range in all 7 patients during the entire follow-up observation. Arterial pressure normalized in 6 cases and was improved in 1 case. No patient had excessive weight loss at any postoperative time., Conclusions: T2D patients with BMI < 35 have very severe metabolic disturbances. Surgical therapy for these patients is warranted, and it should be performed as soon as possible, before the rapid evolution of the pattern leads them to a point where even the most effective metabolic surgery operation could be insufficient to yield complete and permanent control of their diabetes.

Although rare, patients with biliopancreatic diversion for morbid obesity will be subject to obstruction of the biliopancreatic limb. This condition is commonly due to postoperative adhesions and intussusception and usually presents with misleading clinical and radiographic features that can delay the diagnosis and the treatment. We recently encountered a patient with obstruction of the biliopancreatic limb due to involvement from Crohn disease. We report this case to highlight the clinical and imaging findings of this rare condition.

Background: Intramyocellular content of lipid (IMCL) appears to be important in the pathogenesis of insulin resistance, and the improvement of insulin activity observed following biliopancreatic diversion (BPD) for obesity has to be related to reduction of IMCL. This study evaluates the possibility of detecting changes after BPD in IMCL by means of H1 magnetic resonance spectroscopy., Methods: The investigation was carried out in obese patients undergoing BPD prior to and at 1 month following the operation. Insulin sensitivity was assessed according to the homeostatic model of assessment (HOMA), and IMCL was determined by the spectroscopy of the tibialis anterior muscle., Results: At 1 month following BPD, an improvement in insulin action was observed in all subjects, and in nearly all cases the IMCL signal decreased., Conclusion: The data from this study indicate that magnetic resonance spectroscopy can detect IMCL changes following BPD and is fully suitable for longitudinal studies on muscle metabolic status.

Background: The authors evaluated the predictive efficacy of preoperative resting energy expenditure (REE) on long-term weight loss maintenance following vertical banded gastroplasty (VBG). In the long-term following VBG, low energy expenditure could lead to regain of weight, and thereby REE data might be a reliable predictor of long-term weight outcomes., Methods: A prospective study was conducted, taking into account the relationship between preoperative REE values and the results at 3 and 5 years following VBG in terms of both weight loss and success of the operation., Results: Long-term weight loss and outcome following VBG appeared to be completely independent of the preoperative REE., Conclusion: Preoperative REE cannot predict long-term weight outcome following VBG.

Background: Despite its simplicity, safety and good short-term results, progressive weight regain and a high incidence of complications have been reported after the adjustable silicone gastric banding (ASGB). The aim of this study is to evaluate the long-term results of this operation in our patient population., Methods: Between 1990 and 1996, 45 morbidly obese patients underwent insertion of an ASGB. The trend of the patients' BMI over time was studied using a linear mixed effect model adjusted for the preoperative BMI. So as to estimate the cumulative probability of band removal and the cumulative hazard function, Lambda(t) Kaplan-Meier analysis was used., Results: 1 year after the operation, the average BMI was 79% of its preoperative value, which then increased linearly over time. The slope of the regression line was estimated at beta =0.42, indicating an average increase of 0.42 BMI units per year. 27 bands (60%) were removed because of specific late complications. The cumulative risk of band removal increased linearly with time. The hazard rate was estimated to be lambda =0.008 events/patient/month, corresponding to 0.1 events/patient/year., Conclusions: ASGB yielded good short-term results, but the progressive weight regain and constant risk of complications in the long term tend to nullify the optimism.

Background: Preoperative clinical and biochemical data and intraoperative liver biopsy of 1,000 obese patients submitted to biliopancreatic diversion (BPD) were analyzed, and correlations investigated., Methods: Of 2,645 patients submitted to BPD between May 1976 and November 2002, the last 1,000 consecutive obese patients with no history of alcohol consumption or infectious hepatitis were selected. Clinical data included: age, body weight, BMI, waist-to-hip ratio (W/H), arterial blood pressure, serum glucose, triglycerides, cholesterol, albumin/gamma-globulin ratio, total, conjugated and unconjugated bilirubin, gamma-GT, alkaline phosphatase, AST, ALT, and prothrombin time. The degree of steatosis, inflammation and fibrosis on intraoperative wedge liver biopsy was determined and scored. Liver steatosis >70% and presence of bridging fibrosis were analyzed separately., Results: Mean BMI was 48 kg/m(2). 263 patients had steatosis of >70%, and 79 had bridging fibrosis. Regression analysis showed an association between steatosis and AST, ALT, AST/ALT ratio, body weight, W/H, serum glucose, serum tryglicerides, BMI, gamma-GT, age, and unconjugated bilirubin. Inflammation was significantly greater in older patients. Patients with bridging fibrosis had significantly higher values of serum glucose, AST, gamma-GT, serum cholesterol and were significantly older. Bridging fibrosis was associated with diabetes, W/H >1, hypertension, albumin/gamma-globulin ratio <1., Conclusion: Severe steatosis and bridging fibrosis seem to be associated with the metabolic syndrome. No reliable biochemical data could identify patients with severe chronic liver damage with sufficient sensitivity to avoid liver biopsy for diagnosis and staging of the disease.

Background: Biliopancreatic diversion (BPD) is the most effective bariatric procedure in terms of weight loss. However, analysis of the quality of life (QoL) has never been reported. The BAROS, giving a score to each operated patient on weight loss, improvement in medical conditions, QoL, complications and reoperations, has proven to be a standard reference for evaluating bariatric surgery outcomes., Methods: In order to apply the BAROS to BPD, we sent a questionnaire to 1,800 BPD patients who had been operated between 1984 and 1998. The response-rate was 51.2%. Out of 1,709 questionnaires which actually reached their destination, we had 858 fully compiled returned. There were 615 women. 596 patients had had an ad hoc stomach (AHS) BPD, and 262 had had an ad hoc stomach ad hoc alimentary limb (AHS-AHAL) BPD., Results: According to the scoring key, 3.5% were classified as a failure, 11% were fair results, 22.8% good, 39.5% very good, and 23.2% excellent results. Considering AHS BPD and AHS-AHAL BPD separately,while the mean excess weight percent loss was 70.5+/-23 and 64.7+/-17 respectively, the failure rate was 6% in the first group and 2% in the AHAL group, while 11% and 6% of cases respectively were fair results, 24% and 20% good, 36% and 47% very good, 23% and 25% excellent results., Conclusion: The BAROS evaluation of BPD highlights the importance of its flexibility: the new policy of adapting the procedure to individual characteristics caused a drop in the failure rate and an increase in good, very good and excellent results.

Background: Liver failure after biliopancreatic diversion (BPD) has been reported. Although in our series of 2,515 BPD with a minimum follow-up of 12 months we have never observed this complication, a transitory and significant rise in serum AST and ALT has been detected in some cases, suggesting the occurrence of transient liver damage. To assess if risk factors for acute liver damage after BPD could be identified, we studied the evolution of hepatic biochemistry in a sample of our operated subjects., Methods: We studied 99 consecutive patients submitted to the same type of BPD (ad hoc stomach, ad hoc alimentary limb). Patients with a history of alcohol consumption or positive hepatic serology were excluded. Preoperative body weight (BW), body mass index (BMI), excess weight (EW), % excess weight (%EW), fasting serum glucose level (SG), hepatic histology (HI), weight loss (WL) at 2, 4 and 12 months, and excess weight % loss (IEW%L) at the same time were correlated with preoperative and 2, 4 and 12 months hepatic biochemistry., Results: Compared with preoperative values, AST levels at 2 months significantly increased (Student's t-test, P=0.0003) and significantly decreased at 12 months (P=0.0001). Spearman's Rank test showed significant correlations between 2 months AST levels and WL at 2 months (P =0.005), preoperative BW (P <0.0001), SG (P =0.01), and HI (inflammation P<0.0001, fibrosis P=0.001)., Conclusion: Hepatocellular necrosis in our series peaks at 2 months, and decreases afterwards.WL at 2 months, preoperative BW, SG and HI seem to be of help in identifying patients at increased risk for acute liver damage, prompting the need for an enhanced surveillance.

Objective: To gain insight into the specific mechanisms by which biliopancreatic diversion (BPD) can improve insulin action., Materials and Methods: Nondiabetic severely obese patients (n=20) undergoing BPD were included. Waist-to-hip ratio and serum concentration of glucose, insulin, and leptin were determined before, at 4-day, and at 2 months after the operation. Insulin sensitivity was calculated according to the homeostatic model assessment (HOMA IR)., Results: A marked increase of insulin sensitivity was observed by the fourth day after the operation; at the second postoperative month, when body weight was still in the obese range and the food intake was substantially similar to the preoperative one, a further improvement of insulin action towards normality was found. Moreover, before BPD HOMA IR data were independently correlated both to BMI and waist-to-hip ratio values, whereas at 2 months after the operation data were in positive correlation only with the BMI., Discussion: In obese patients, BPD seems to achieve recovery of insulin sensitivity by specific mechanisms independent of weight loss: the main causes of this sharp improvement might be both the intramyocellular fat depletion and the interruption of enteroinsular axis.

Background: The authors investigated the interrelationships between the components of the metabolic syndrome in severe obesity., Methods: In non-diabetic, severely obese women, the degree of obesity (BMI), the insulin sensitivity (from the Homeostatic Model of Assessment, HOMA), the serum leptin concentration and the presence of dyslipidemia and arterial hypertension were evaluated., Results: In insulin-resistant patients, an overall impaired metabolic status and a greater cardiovascular risk were observed, while serum leptin concentration was higher than in the insulin-sensitive ones. Leptin levels and HOMA data correlated independent of BMI findings, while the presence of dyslipidemia and hypertension was unrelated to the other metabolic syndrome factors., Conclusion: In severely obese women, although other factors independently intervene, serum leptin has a role in developing the metabolic syndrome.

Background: The authors evaluated the relationship between leptin and the clinical, anthropometric and metabolic variables connected to the metabolic syndrome in obese individuals., Methods: A large group of patients with different degrees of obesity was investigated: body mass index (BMI) values, serum leptin, fasting glucose and insulin, triglycerides and HDL-cholesterol concentrations, insulin resistance index and blood pressure were measured., Results: On multiple regression analysis, serum leptin levels appeared to be positively correlated to the BMI and to the serum HDL-cholesterol concentration. Principal component factor analysis revealed three factors, explaining 61.3% of the total variance of the sample. General features of these factors were: factor 1--BMI values and serum leptin and fasting glucose concentration; factor 2--systolic and diastolic blood pressure and serum triglycerides and HDL-cholesterol concentration; factor 3--fasting serum insulin concentration and insulin resistance index., Conclusions: In obese subjects multiple factors underlie the metabolic syndrome and therefore more than one mechanism may account for the clustering characteristics. In obese patients leptin loads only one factor, and therefore leptin does not appear to be a key feature in the metabolic syndrome. On the contrary, multiple correlation and factor analysis data give rise to the hypothesis that in obese patients, leptin may play a protective role against cardiovascular risk.

Background: A technique for standard laparoscopic BPD was developed., Methods: Standard laparoscopic BPD was performed in 26 morbidly obese patients with mean BMI 43. Details of the technique, using 6 trocars, and instrumentation are described. Intestinal limb lengths were measured fully stretched, and the gastric remnant volume was also measured. Both enteroenteral and gastrointestinal anastomoses were fashioned with a side-to-side technique using the endoGIA, the conjoined defect being closed with a manual running seromuscular suture., Results: 6 and 12 month weight loss results were similar to those obtained in open BPD., Conclusion: Laparoscopic standard BPD is a feasible alternative to the open operative procedure, the major advantage being the likely near total avoidance of wound hernia.

Background: The authors evaluated the usefulness of routine traditional radiology in the management of patients submitted to VBG., Methods: Radiological findings in 65 subjects who had undergone VBG were evaluated. Post-surgical clinical and radiological examinations were performed 3 days, 1, 4 and 12 months after surgery. Upper GI symptoms, gastroesophageal imaging and 80% solid meal pouch emptying time were recorded., Results: The routine postoperative study, in the absence of clinical symptoms, showed no unsuspected complication in any patient, both in the early and in the late postoperative period. There was no significant correlation at 4 and 12 months between emptying time and duration of satiation, emptying time and percent excess weight loss (%EWL), and duration of satiation and %EWL., Conclusions: Traditional radiological studies can be safely omitted from both the immediate postoperative period and from the long-term follow-up in asymptomatic VBG patients. The studies were not helpful in understanding functional changes leading to weight loss after VBG.

Background: The authors assessed the prevalence of diabetes, hypertension, dyslipidemia and metabolic syndrome in patients with a high degree of obesity., Methods: A retrospective investigation was planned in a cohort of obese patients with a wide range of body mass index (BMI) referred to a large University Hospital for weight loss., Results: An increase in prevalence of diabetes and hypertension with increase in the degree of obesity was observed, while the prevalence of dyslipidemia and metabolic syndrome appeared to be independent of the BMI values., Conclusion: In severely obese patients a still unknown factor which affects differently glucose and lipid metabolism cannot be excluded.

Objective: To evaluate the predictive efficacy of preoperative resting energy expenditure (REE) on weight loss after vertical banded gastroplasty (VBG). When subjected to a gastric restriction procedure of similar extent, the patients with higher energy expenditure should experience a greater negative energy balance than those with lower-energy expenditure, and thus, lose more weight, thereby making REE a reliable predictor of weight loss after VBG., Research Methods and Procedures: This was a prospective investigation after VBG, taking into account the relationship between preoperative REE values and the results at 1-year follow-up in terms of weight loss and success of the procedure. The correlations were evaluated by multiple and logistic regression analysis., Results: The weight loss and the outcome at 1 year after VBG seemed to be completely independent of preoperative energy expenditure., Discussion: These findings suggest that, despite gastric restriction, patients may voluntarily adjust their energy intake, and that the weight outcome after VBG is influenced more by behavioral and cognitive variables than by biological or surgical factors.

Background: In Prader-Willi Syndrome (PWS), mental retardation and compulsive hyperphagia cause early obesity, the co-morbidities of which lead to short life-expectancy, with death usually occurring in their 20s. Long-term weight loss is mandatory to lengthen the survival; therefore, the lack of compliance in voluntary food restriction requires a surgical malabsorptive approach., Methods: 15 PWS subjects were submitted to biliopancreatic diversion (BPD) and followed (100%) for a mean period of 8.5 (4-13) years. BPD consists of a distal gastrectomy with a long Roux-en-Y reconstruction which, by delaying the meeting between food and biliopancreatic juices, causes an intestinal malabsorption. Indication for BPD was BMI > 40 or > 35 with metabolic complications. Preoperative mean age was 21 +/- 5 years, mean weight 127 +/- 26 kg, and mean Body Mass Index (BMI, kg/m2) 53 +/- 10. According to Holm's criteria, all of the subjects had a total score > or = 8. IQ assessment was performed in each subject, with a mean score of 72 +/- 10. An arbitrary lifestyle score was given to each subject., Results: No perioperative complications were observed. Percent excess weight loss (%EWL) was 59 +/- 15 at 2 years and 56 +/- 16 at 3 years, and then progressive regain occurred; at 5 years %EWL was 46 +/- 22 and at 10 years 40 +/- 27. Spearman rank test failed to demonstrate any correlation between weight loss at 5 years and patient data, except with lifestyle score (Spearman r = 0.8548, p < .0001). Current mean age is 31 +/- 7 years., Conclusion: BPD has to be considered for its value in prolonging and qualitatively improving the PWS patient's life.

Background: The influence of the new anatomico-functional structure created by biliopancreatic diversion (BPD) in the postoperative fall of serum leptin concentration was evaluated., Methods: Serum leptin concentration was determined in obese women before and immediately after BPD, before the usual postoperative intestinal rest. The measurements were repeated at the second postoperative month, when oral intake had nearly totally resumed and the patients had lost the first amount of weight., Results: 5 days following BPD, a sharp reduction of serum leptin concentration was observed. At the second postoperative month the values remained nearly unchanged and were indistinguishable from those observed in a group of obese non-operated patients with a closely similar body weight., Conclusions: Changes in the upper gastrointestinal tract due to BPD appear to have no influence in the postoperative reduction of serum leptin concentration, which appears to be substantially related only to the patientís adiposity.

Objective: To describe a 7-year experience with recurrent inguinal hernia repair performed mainly with tension-free mesh or plug technique under local anesthesia through the anterior approach, and to evaluate the safety and effectiveness of this method of treatment., Methods: One hundred forty-five elective and 1 emergency herniorrhaphies for recurrent groin hernia were performed in 141 subjects (134 men and 7 women) with a mean age of 65 years (range 30-89). Concomitant medical and surgical problems were present in 73% and 8% of subjects, respectively. In 28 instances, the relapsed hernia had already been operated on once or twice for recurrence. A traditional hernioplasty had been previously performed in the vast majority of cases (136). Tension-free mesh or plug techniques through an anterior approach under local anesthesia were performed in 144 reoperations. Preperitoneal mesh repair and general or spinal anesthesia were used in all but one case when herniorrhaphy was performed during simultaneous operations., Results: Mean hospital stay after surgery was 1.5 days (range 3 hours-14 days). No perioperative deaths occurred in this series. General complications were one case of acute intestinal bleeding and two cases of urinary retention. Local complications consisted of eight (5.5%) minor complications and one case of orchitis (0.7%) followed by testicular atrophy. In no instance was postoperative neuralgia or chronic pain reported. Two re-recurrences occurred., Conclusions: Given the low complication rate in this and other reported series and the absence of surgical or general complications described after preperitoneal open or laparoscopic repair and after general and spinal anesthesia, anterior mesh repair under local anesthesia seems to be a low-cost surgical technique that can be safely and effectively used even in a teaching hospital for the treatment of the majority of patients with recurrent groin hernias.

Biliopancreatic diversion (BPD) has made reacceptable the malabsorptive approach to the surgical treatment of obesity. The procedure, in a series of 2241 patients operated on during a 21-year period, caused a mean permanent reduction of about 75% of the initial excess weight. The indefinite weight maintenance appears to be due to the existence of a threshold absorption capacity for fat and starch, and thus energy, and the weight loss is partly due to increased resting energy expenditure. Beneficial effects other than those consequent to weight loss or reduced nutrient absorption included permanent normalization of serum glucose and cholesterol without any medication and on totally free diet in 100% of cases, both phenomena being due to a specific action of the operation. Operative mortality was less than 0.5%. Specific late complications included anemia, less than 5% with adequate iron or folate supplementation (or both); stomal ulcer, reduced to 3.2% by oral H2-blocker prophylaxis; bone demineralization, increasing up to the fourth year and tending to decrease thereafter, with need of calcium and vitamin D supplementation; neurologic complications, totally avoidable by prompt vitamin B administration to patients at risk; protein malnutrition, which was reduced to a minimum of 3% with 1.3% recurrence, in exchange with a smaller weight loss, by adapting the volume of the gastric remnant and the length of the alimentary limb to the patient's individual characteristics. It is concluded that the correct use of BPD, based on the knowledge of its mechanisms of action, can make the procedure an effective, safe one in all hands.

Recent advances in anesthetic and surgical techniques have increased the survival of patients after extensive bowel exclusions. This, in addition to the increased use of intestinal bypass for the treatment of obesity, has substantially increased the number of persons living with a short bowel. Proper management of these individuals is based on a thorough understanding of the pathophysiology of the shortened gastrointestinal tract.

Background: An increasing number of women in childbearing age are submitted to surgical treatment of obesity; for this reason pregnancy represents a frequent event in operated patients., Methods: In this study pregnancy in patients with morbid obesity submitted to jejunoileal bypass (JIB) and gastric bypass (GB) are reviewed from the literature and the analysis of our experience with biliopancreatic diversion (BPD) is reported., Results: In 113 pregnancies after JIB reviewed from the literature, the results seem to be debated either about the course of pregnancy or about maternal and neonatal status. The data of literature concerning the pregnancies following GB are less debated but rather slight. One hundred and fifty-two pregnancies after BPD have a complete documentation concerning maternal conditions, modality of outcome and neonatal situation., Conclusions: Pregnancy occurred in the obese women represents an increased maternal-fetal risk. The excess weight loss, the weight maintenance and the reduced weight changes during pregnancy are an advantage in the operate women who, in any case, need accurate controls of the nutritional status during the whole gestational period. Keeping these cautions pregnancy following surgical treatment of obesity represents an event not only possible but even with less problems than in pregnancy in obese women.

BACKGROUND AND METHODS: The relationships between cognitive restraint and the tendency to disinhibition, as assessed by the Three Factor Eating Questionnaire (TFEQ), and the weight loss at 1 year following gastric banding are evaluated. RESULTS: A significant predictability of the TFEQ Disinhibition score on the postoperative weight reduction was observed, while the amount of weight lost was negatively related to the preoperative TFEQ Cognitive Restraint score. CONCLUSION: It must then be hypothesized that the operated subjects feel a strong aversive stimulus and then they are led to reduce their food consumption only when they lose control and tend to overeat. The discomfort due to proximal gastric pouch distention facilitates the development of food aversion and then both the decrease of food intake and a change in eating behavior. The subjects must therefore be encouraged to adopt an eating style that cannot allow them to avoid such a feeling.

The dilatation of the vascular grafts is a well known phenomenon. It is usually evaluated by means of ultrasounds or, in selected cases, by CT scans or MRI; nevertheless its characteristics are far beyond to be fully recognized. Following our promising preliminary experience with helical CT as sole preoperative imaging for AAA, we have evaluated its reliability in the postoperative follow-up. We have studied 12 patients with aorto-iliac and 11 with aorto-femoral bypass for AAA, with a follow-up ranging between 1 and 3 years. A helical CT acquisition was performed during a single breath-holding with a 5-mm slice thickness, thus resulting in a 30 cm z-axis coverage. Axial images were reconstructed at 2-mm increments and used to generate high quality multiplanar reformatted (MPR) and three-dimensional (3D) surface rendered images. For each patient we evaluated the characteristics of the graft, the maximal diameters and the wall modifications. The average expansion was 28% at 1 year, stable at 2 years and then increased up to 44% at 3 years. Considering the different types of Dacron grafts, the dilatation was ranging between 22% and 46% (21 cases). The mean expansion was 31.3% and 29.5% for the trunk and for the branches of the graft respectively. No perigraft seroma nor anastomotic aneurysms were detected. A peculiar observation, both with and without contrast medium injection, was that all the grafts made on Dacron were not anymore depictable from the aortic wall after 1 year; the contrary was observed for the ePTFE grafts.

The determination of glomerular or non-glomerular origin of urinary red blood cells (U-RBC) is an important goal in the management of haematuric children. Morphological changes of glomerular RBC are secondary to cell membrane damage, due, in part, to the hypotonic osmotic stress to which U-RBC are submitted during their passage through tubular segments. This study was performed on 2 urine specimens obtained from 30 patients with a known cause of haematuria. After centrifugation, both sediments were resuspended in two saline solutions (at 200 mosm/l and at 300 mosm/l) where they remained for 90 min. The number of U-RBC per microliters in each (U-RBC 200 and U-RBC 300) was determined by microscopic count in Burker's chamber. The U-RBC 200/U-RBC 300 ratio was calculated for all patients. We found that in non-glomerular haematuria the ratio was near to 1, whereas cases of glomerular origin had lower values. The discriminant threshold between this ratio was 0.76 (p < 0.001). We suggest that determination of osmotic resistance of U-RBC may be a reliable method to differentiate the origin of bleeding in haematuric children.

Between January 1979 and December 1989, an end-to-end arteriovenous fistula for chronic haemodialysis was performed at the anatomical snuffbox (AVF-AS) in 140 patients (49 females and 91 males) with mean age 51 years (range 14-81) referred to our Center from 12 different Hospitals. The choice of the site, on the non dominant arm, depends on the characteristics of the vessels and on the arterial blood pressure. No operative mortality no major complications occurred no distal symptoms related to venous hypertension or arterial steal syndrome or ischaemia. The median survival was 36 months with a patency rate of 77.3% at 1 year, 36.3% at 5 and 18.9% at 10 years. The high incidence of thromboses (52.9%) reflects an excessive compliance with this technique and a lack of expertise on the choice of the proper vessels or an inadequate management of the vascular access. Compared to the graft vascular access, the patency rate is superimposable but with higher rate of complications and lower cost-benefit rate for the grafts. In our experience, the AVF-AS should be, whenever possible, the first step as vascular access for chronic haemodialysis, but the surgical procedure should be reserved only to experienced surgeons. It is safe, cheap and allow to save and use for a longer period the patient's own vessels.

Hyperthermic antiblastic isolated perfusion is a method largely used for the treatment of locally advanced limb melanoma. The method requires vascular isolation and hyperthermic perfusion of the limb using an extracorporeal circuit and administering the melphalan as antiblastic drug. Twenty-six patients with primary or recurrent melanoma of the limbs have undergone this treatment at our Institute. There were no cases of operative mortality and systemic toxicity was negligible. The local complications were transitory and no patient showed symptoms of nervous toxicity or permanent functional damage. Two cases of deep thrombophlebitis and two of lymphocele were documented a few months after treatment. Four clinically complete responses, 3 partial and 2 cases of stable disease were observed in the 9 patients treated with unexcised lesions. Our data like the totality of the present experience points to the safety of this method in the therapy of locally advanced limb melanoma. Nevertheless further controlled studies are required to define its role in order to improve survival.

During the period 1977-1984, 53 patients with peptic ulcer resistant to H2-blockers (29 gastric and 24 duodenal ulcers) were submitted to distal gastrectomy with Roux-en-Y gastroenteroanastomosis not associated with vagotomy. The indication was used as an alternative to proximal vagotomy in cases with delayed gastric emptying, high acid output, perforation or bleeding. The study plan consisted of serial clinical and instrumental controls including determination of basal (BAO) or maximal (MAO) acid output. Operative mortality was nil. At various times after the operation, 4 patients died for unrelated reasons and 3 were lost to follow-up. Median follow-up was 84 months with an interval of from 4 to 137 months. Fifty-one patients were followed up for at least one year and 49 for at least two. Five patients (2 gastric and 3 duodenal ulcers) developed peptic recurrences (Visick IV, 9.8%) by the end of the first postoperative year and, in all cases but one, healed stably by the second year after medical (3 cases) or surgical (1 case) therapy. In the remaining patients, Visick was grade III in 6 cases (4 gastric and 2 duodenal ulcers), grade II in 6 and grade I in 34. Before operation, mean values (+/- SD) of BAO and MAO were respectively 5.84 +/- 5.03 and 29.6 +/- 18.6 mEq/h. In the immediate postoperative period there was a considerable reduction in BAO (p less than 0.02) and MAO (p less than 0.03) which continued up to the third postoperative year with a tendency to further progressive reduction in MAO. In spite of a considerable individual variability in dimensions and temporal evolution, the phenomenon occurred qualitatively in all cases. No significant difference was observed in the behaviour of BAO and MAO in gastric ulcers by comparison with duodenal ulcers and in cases with recurrence and Visick III compared to those with a favourable clinical result.

Renal clearances of transeferrin, IgG and C'3 were determined by the immunodiffusion method in 51 healthy children. Statistical elaboration shows the great dispersion around the mean values. The results of other Authors in healthy adults are confirmed.

Bioelectric impedance was analysed before and after dialysis to assess the body composition of 36 patients suffering from chronic kidney failure in fair nutritional condition: resistance values were used to quantify total body water and reactance values as dimensional indices of the intracellular spaces and cell mass. Before dialysis, total body water was significantly higher than that of healthy subjects comparable for height, sex, age and weight, while it was not possible to obtain direct data on the dimensions of the cell mass. After dialysis, total body water values normalised and the dimensions of the intracellular spaces and cell mass became almost comparable to those of the controls: data analysis shows that during treatment, weight loss occurs almost exclusively in the extracellular compartments of the organism. Notwithstanding the fact that the absolute values are similar to those of the controls, body composition did not normalise as relationships between the dimensions of the various sectors remain altered.

Mean reticulocyte volume (MRV) and reticulocyte/nonreticulated erythrocyte (R/E) area ratio were determined by a planimetric method in normals and in heterozygous beta-thalassaemia subjects. The MRV in beta-thalassaemia group was significantly less, whereas no difference in the R/E area ratio was observed. These data suggest that in both groups the extent of splenic surface remodeling of the red cells should overlap, whereas the small reticulocyte size of beta-thalassaemia is determined by some alteration of bone marrow function. We suggest that a small MRV in beta-thalassaemia trait could also account for ineffective erythropoiesis, a major bone marrow feature of heterozygous beta-thalassaemia.

The effect of Basic-trypsin-inhibitor (BPTI) on the in vitro PHA-induced blastic transformation of lymphocytes is reported. Cultures of lymphocytes from healthy subjects were added with PHA, BPTI and PHA + BPTI; simple control-cultures were also performed. The blastic transformation was evaluated by morphologic method after 72 h incubation at 37 degrees C. The results are compared with Wilcoxon's test; it was observed that BPTI reduces the PHA-induced blastic transformation, but it has no effect on cultures without PHA. The hypothesis that BPTI inhibits only PHA-stimulated lymphocytes is suggested.

Urinary activity of Leucine arylamidase, lactate dahydrogenase and Alkaline phosphatase in 14 healt subjects, ranging from 2 to 10 years are described. Some correlations between enzymatic activities, ratios enzymatic activities/creatininuria and enzymatic activities/dayly proteic clearance are investigated.

On the basis of sodium Naproxene plasma wash-out curve a computerized system to obtain pharmacokinetic constants in an open bi-compartment model is described. The system could be used to optimize and enhance drug administration in clinics and anaesthesiology.

Since anaemia of varying degree is a quite common finding in heterozygous beta-thalassaemia, a research was done to see if beta-thalassaemia heterozygotes occupationally exposed to long-term continuous external radiation should be more susceptible to haematopoietic damage than non thalassaemic subjects. We examined peripheral haematological findings of 20 beta-thalassaemia heterozygotes previously exposed to a mean of 10.7 mSv, compared with 22 non thalassaemic subjects exposed to 6 mSv, and with 50 not exposed beta-thalassaemia heterozygotes. The obtained results suggest that whole-body external irradiation--with the mean doses reported--does not cause noteworthy changes in beta-thalassaemia heterozygotes.

The daily urinary output was calculated on the basis of creatininuria, starting from an accepted formula that evaluates ClCr, employing the subject's height and creatininemia. Results are satisfactory. The new formula estimates the daily urinary volume on the basis of the mean of the three creatininuria values of the day.