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Background: The regulation of leptin in patients with critical illness is poorly understood. Sex, diet, body mass, and cytokines may all play a role. Objective: The aims of this study were to determine the factors influencing leptin concentrations in hospitalized patients beginning total parenteral nutrition (TPN) and whether a 3-d regimen of TPN would further increase plasma leptin concentrations above baseline. Design: Twenty-six patients requiring TPN were enrolled in this prospective, nonintervention study. Only 20 (11 women and 9 men) completed all 3 d of TPN. Results: Baseline plasma leptin in the TPN patients ranged from 62.5 to 1625 pmol/L ([bar] [+ or -] SD: 419 [+ or -] 387; n = 26) and was not significantly different between men (444 [+ or -] 494 pmol/L) and women (363 [+ or -] 244 pmol/L). Baseline plasma insulin ranged from 76 to 695 pmol/L (271 [+ or -] 188; n = 26) and was not correlated with plasma leptin. Leptin concentrations increased after 3 d of TPN, from 356 [+ or -] 300 to 794 [+ or -] 600 pmol/L (P < 0.05) in parallel with an increase in insulin from 257 [+ or -] 187 to 979 [+ or -] 917 pmol/L (P < 0.01) in the 20 patients who completed the study; however, the changes were not correlated when expressed as percentages. Although the men and women had insulin responses to feeding that were not significantly different, leptin concentrations did not increase significantly in men but increased 3-fold in women (to 1094 [+ or -] 638 pmol/L; P < 0.01). Conclusions: Leptin regulation in patients with a critical illness differs substantially from that in healthy persons. The importance of glucose and insulin in leptin secretion remains unclear, especially in men. KEY WORDS Total parenteral nutrition, TPN, leptin, insulin, fasting, critical illness, cytokines, sex differences, body mass

BACKGROUND: A National institutes of Health Consensus Conference in 1991 established gastric surgery as accepted therapy for the treatment of severe obesity. The increasing prevalence of obesity in the United States, and the increasing numbers of patients undergoing gastric surgery for severe obesity, result in substantial numbers of patients being considered for revisional surgery. The indications and efficacy of revisional surgery remain controversial. METHODS: Sixty-three patients were followed prospectively after undergoing revisional surgery for obesity between 1981 and 1994. All patients had previously undergone obesity operations. Weight data were recorded at the time of original obesity surgery, at revisional surgery, and at most current follow-up. Complications following revisional surgery were monitored. RESULTS: The follow-up in the group is 98%. Revisional surgery after obesity surgery was associated with a 0% mortality rate and a serious complication rate of 16%. Body mass index (BMI) at the time of original surgery was associated revisional surgery after obesity surgery was 50 + 10 kg/[m.sup.2], at follow-up 34 [+ OR -] 10 kg/[m.sup.2] (P. 50 kg/[m.sup.2] lost significantly more weight (P

Dienoic eicosanoids derived from phospholipid arachidonic acid (AA) in lung and liver macrophages promote leukosequestration, thrombosis, and tissue injury. Current enteral diets (diet A) are enriched with linoleic acid (LA), a precursor of AA. Novel diets low in LA and containing eicosapentaenoic acid (EPA) and y-linolenic acid (GLA) foster formation of less inflammatory eicosanoids. The study objective was to assess the rapidity and extent of LA and AA displacement in vivo from alveolar macrophage (AMO, lung, and liver Kupffer and endothelial (KE) cell phospholipids in rats fed enterally with diets enriched with 5.3% (by wt) EPA and either 1.2% or 4.6% GLA (diets B and C, respectively). After surgical placement of catheters, the rats were fed enterally and co-infused intravenously with either endotoxin or vehicle continuously for 3 or 6 d. Rats given either diet B or C had significantly lower (P < 0.01) relative percentages of AA and LA within the AM[phi], lung, and KE cell phospholipids, and concomitantly higher percentages of EPA compared with rats infused with diet A after 3 d of enteral feeding irrespective of endotoxin co-infusion. Incorporation of dihomo-[gamma]-linolenic acid (DHGLA), the metabolite of GLA, into lung and KE phospholipids was significant in rats given diet C. Most of the changes in fatty acid composition occurred by day 3. The polyunsaturated fatty acid composition of AM[phi], lung, and KE cell phospholipids can be rapidly modified by continuous short-term enteral feeding with EPA- and GLA-enriched diets irrespective of concurrent endotoxemia.

Severe obesity affects the health and quality of life of 4 moon Americans. The major cost of treating severe obesity and its associated comorbidities of hypertension, diabetes, cardiovascular disease, pulmonary insufficiency, cancer, and degenerative arthritis as well as the poor long-term results of medical, drug, and behavioral therapy has increased the numbers of patients being referred for surgical treatment. Gastric bypass and vertical banded gastroplasty are the two procedures recommended for severely obese patients. These operations currently have low morbidity and mortality. Surgery should he considered adjuvant therapy and must be part of a multidisciplinary approach. The significant long-term weight control resulting from the surgical therapy is associated with improvement and, often, resolution of comorbidities, including diabetes, hypertension, hyperlipidemia, and pulmonary insufficiency.

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Despite current radiologic imaging capabilities, 40% to 70% of patients with primary or metastatic hepatic malignancies are found to have unresectable disease at the time of laparotomy. The present study evaluates the use of laparoscopy in the staging of hepatic malignancy. Twenty-nine patients underwent staging laparoscopy prior to a planned laparotomy for resection of a hepatic malignancy that was deemed resectable by computed axial tomographic scan and ultrasonography. Twelve patients had primary hepatic malignancies, and 17 had metastatic malignancies. Laparoscopy demonstrated evidence of unresectability in 48% (14 of 29) of patients studied. Four patients had unsuspected cirrhosis, and 10 had unresectable or extrahepatic metastatic disease. Patients who underwent laparoscopy alone had shorter mean hospital lengths of stay than historical controls who underwent laparotomy alone. We conclude that diagnostic laparoscopy should precede laparotomy for planned resection of hepatic malignancies.

Therapeutic modalities that downregulate macrophage and endothelial production of eicosanoid mediators by displacing membrane arachidonic acid (20:4[omega]6) may benefit patients at increased risk of septic complications. The objective of this study in rats was to assess the incorporation of fish or olive oil fatty acids into hepatic Kupffer and endothelial (K&E) cell phospholipids after 4 d of continuous enteral feeding during endotoxemia. Either endotoxin (ETX) (0.5-1 [mg.sup.-1][multiplied by][kg.sup.-1][multiplied by][day. or vehicle was infused intravenously during the last 72 h. Dietary fish and olive oil fatty acids were rapidly incorporated into both K&E and plasma phospholipids irrespective of ETX cotreatment. Rats infused with the fish oil-enriched diet had a significantly lower relative percent of both K&E linoleic acid (18:2[omega]6) and 20:4[omega]6, whereas rats infused with the olive oil-enriched diet only had a lower relative percent of 18:2[omega]6 compared with control rats receiving corn oil. Provision of specific dietary lipids by continuous enteral infusion may prove efficacious for the rapid modulation of hepatic sinusoidal cell membrane fatty acids under either normal or endotoxemic conditions. Am J Clin Nutr 1993;57:643-9.

The study objective was to assess hepatic utilization of exogenous adenosine or adenine to enhance ATP recovery in rat liver after cold ischemia. ATP was measured noninvasively by [P.sup.31] nuclear magnetic resonance (NMR) in perfused livers before and after 18 h of cold ischemia. The hepatocellular concentration of ATP during the initial postischemic reperfusion without adenosine or adenine coinfusion was 60% of that in fresh liver. The ATP increased significantly (P < 0.001) to 139% and 82% of baseline in postischemic livers coinfused for 90 min with adenosine or adenine final concentration, 1 mmol/L), respectively. Less than 0.5% of the excess adenosine was catabolized to uric acid. In conclusion, adenosine and, to a lesser extent, adenine are salvaged by liver after extended cold ischemia to enhance ATP restoration. Provision of these ATP precursors, as components of an enteral formulation may facilitate the repletion of liver ATP and foster early resumption of liver function after an ischemic insult.

A prospective, randomized trial comparing vertical banded gastroplasty (VBG) and vertical gastric bypass (GB) for obesity was completed in 106 patients who did not differ in baseline body mass index (BMI -- kg/[m.sup.2]) or length of follow-up. The goal of this surgery was to return patients to within 50% of their ideal weight, i.e., a body mass index less than 35 kg/[m.sup.2], and to accomplish this while maintaining a low risk for malnutrition as well as other morbidity and mortality. Success was defined as a BMI less than 35 kg/[m.sup.2] because the mortality risk increases rapidly above this degree of obesity. Surgical failures were encountered in 43% of the 54 patients in the VBG group, all of whom had division between the vertical staple lines. The main causes of failure were stenosis and enlargement of the gastroplasty orifice. Surgery failed in 23% of the GB-treated patients, due to perforation of the vertical staple line. An isolated gastric bypass (IGB) not dependent on staples was performed as the remedial operation for the failures of both VBG and GB. IGB was significantly better than VBG or GB, with a success rate of 83% compared with 39% for VBG and 58% for GB. Subsequent experience since completion of this randomized trial in 54 consecutive patients supports IGB for primary, as well as remedial, operations for the morbidly obese (BMI -- 40 to 50 kg/[m.sup.2]), as well as for patients who are super obese (BMI greater than 50 kg/[m.sup.2]).