Small Bowel Bypass Research Articles

The Role of Bile Acid in Improving Glucose Tolerance of Non-Obese Diabetic Rats After Proximal Small Bowel Bypass.

An increase in bile acid (BA) levels after metabolic surgery is an important mechanism for improving glucose metabolism. However, the mechanisms underlying elevated BA levels and the regulatory mechanism of glucose metabolism remain unclear. In this study, we used the Goto-Kakizaki rat model to investigate the mechanism of BA elevation by comparing side-to-side jejunoileal bypass plus proximal loop ligation (SSJIBL) and bile ileum diversion (BID) as well as to explore the mechanism of BA metabolism in regulating blood glucose. The results showed that the fed blood glucose of rats in both the SSJIBL and BID groups was significantly lower than that of the SHAM group on days 2 and 14 after the operation. The oral glucose tolerance test (OGTT) improved in the SSJIBL and BID groups at day 14 postoperatively. The expression of CYP27A1 in the livers of the SSJIBL and BID groups was significantly increased. In addition, total serum BA levels in the SSJIBL and BID groups were significantly increased. Moreover, serum levels of lithocholic acid (LCA) and deoxycholic acid (DCA) were significantly higher in the SSJIBL group than in the SHAM group and negatively correlated with the area under the glucose tolerance curve (AUC-OGTT). In conclusion, increased BA synthesis may be an important cause of elevated total serum BA levels, and LCA and DCA are closely associated with improved glucose metabolism.

Endoscopic Treatment of Obesity and Nutritional Aspects of Bariatric Endoscopy.

Obesity is a significant problem worldwide. Several serious diseases that decrease patient quality of life and increase mortality (high blood pressure, dyslipidaemia, type 2 diabetes etc.) are associated with obesity. Obesity treatment is a multidisciplinary and complex process that requires maximum patient compliance. Change of lifestyle is fundamental in the treatment of obesity. While pharmacotherapeutic options are available, their efficacy is limited. Surgical treatment though highly effective, carries the risk of complications and is thus indicated mostly in advanced stages of obesity. Endoscopic treatments of obesity are less invasive than surgical options, and are associated with fewer complications and nutritional deficits. Currently, there is a large spectrum of endoscopic methods based on the principles of gastric volume reduction, size restriction and gastric or small bowel bypass being explored with only few available in routine practice. The aim of this publication is to present an up-to-date summary of available endoscopic methods for the treatment of obesity focusing on their efficacy, safety and nutritional aspects.

Short versus long biliopancreatic limb in Roux-en-Y gastric bypass surgery for treatment of type 2 diabetes mellitus.

IntroductionAlthough laparoscopic Roux-en-Y gastric bypass (RYGB) is still widely accepted as a valid procedure in the treatment of obesity and type 2 diabetes mellitus (T2DM), there continues to be a significant controversy about how long the Roux and biliopancreatic limb should be bypassed for optimum results.AimTo assess the effect of a longer biliopancreatic limb (BPL) length on glycemic control after RYGB in T2DM patients.Material and methodsEighty-four patients with uncontrolled T2DM who underwent RYGB between May 2010 and April 2017 were collected from the prospectively designed database. Forty patients (S-BPL group) received BPL lengths ≤ 50 cm, including 30 cm (n = 1), 40 cm (n = 1), and 50 cm (n = 38). Forty-four patients (L-BPL group) received 100 cm BPL. Anthropometry, serum glucose and lipid metabolic parameters were measured at baseline and 1, 3, 6, 12, 24 and 36 months after surgery.ResultsComparing the two groups, there were no significant differences in anthropometric and biochemical measures, except the weight and body mass index, which were higher in the S-BPL group (85.91 ±20.32 vs. 76.25 ±16.99, p = 0.038; 31.87 ±6.61 vs. 28.7 ±4.29, p = 0.005) compared to the L-BPL group. The body weight, glucose and lipid metabolic parameters decreased over time and then remained essentially stable from the first year in both groups. Two years after surgery, the remission (HbA1c% ≤ 6%) of T2DM was 31.2% in the S-BPL group and 37.5% in the L-BPL group (p = 0.685).ConclusionsWith consistent total small bowel bypass (AL + BPL) lengths, lengthening of the BPL from 30 to 100 cm did not affect the post-RYGB glycemic control and weight loss.

Endogenous Endophthalmitis successfully treated with Intravitreal Povidone-iodine injection: a case report

BackgroundThe usefulness of povidone-iodine as an alternative to antimicrobial agents, for endophthalmitis, has recently been documented. We report a case of endogenous endophthalmitis successfully treated with intravitreal injection of povidone-iodine.Case presentationAn 88-year-old woman underwent small bowel bypass surgery for postoperative ileus following rectal cancer resection. She developed a fever during total parenteral nutrition and was diagnosed with gram-positive cocci bacteremia of central venous catheter origin. The patient was referred to our department with chief complaints of ocular pain, hyperemia and decreased vision in the right eye, which had manifested during the febrile period. The initial examination revealed the visual acuity in her right eye to be finger counting and that in her left eye 0.2. The right eye showed a severe inflammatory reaction in the anterior chamber, fibrin deposition, and hypopyon. The fundus was difficult to visualize. Endogenous endophthalmitis due to bacteria was diagnosed.Surgical treatment was judged to be difficult based on the patient’s poor general condition and mental status, and intravitreal injection of 0.1 ml of 1.25% povidone-iodine was performed on the same day. The inflammation rapidly diminished, and the hypopyon had disappeared 4 days after treatment. The fundus became visible 7 days after treatment and there was no recurrence of endophthalmitis findings. The visual acuity in her right eye recovered to that in the left eye (0.2).ConclusionIntravitreal injection of povidone-iodine is potentially useful and effective as an alternative treatment of antibiotics for endogenous endophthalmitis patients, especially in whom surgical therapy is difficult.

Endoscopic bariatric and metabolic therapies for non-alcoholic fatty liver disease: Evidence and perspectives.

Non-alcoholic fatty liver disease (NAFLD) has become the most common liver disease in industrialized countries because of the worldwide epidemic of obesity. Beyond metabolic complications, a subset of patients with NAFLD develop non-alcoholic steatohepatitis (NASH) with fibrosis, which is emerging as a leading cause of liver transplantation due to progression to cirrhosis and cancer. For these reasons, NAFLD is considered a public health burden. In recent years endoscopic bariatric and metabolic therapies (EBMT) have emerged as safe and effective for the treatment of obesity and type 2 diabetes mellitus. EBMT include gastric and duodenal devices and techniques such as intragastric balloons, endoscopic sleeve gastroplasty, endoscopic small bowel by-pass and duodenal mucosal resurfacing. Observational studies and pilot trials have revealed beneficial effects of EBMT on NAFLD as assessed by non-invasive parameters or histology. In this review we summarise current evidence for the efficacy and safety of EBMT in obese patients with NAFLD and examine future clinical applications.

Measuring the small bowel length may decrease the incidence of malnutrition after laparoscopic one-anastomosis gastric bypass with tailored bypass limb

BackgroundLaparoscopic one (single)-anastomosis gastric bypass (OAGB) is an effective and durable treatment for morbidly obese patients. However, the ideal length of the small bowel bypass remains controversial. ObjectivesThe study aimed to report the clinical results of using a tailored bypass based on the total length of the small bowel. SettingAcademic medical center. MethodsSince 2005, we have performed OAGB with tailored limb according to preoperative body mass index. From July 2014, we modified our technique, measuring the whole small bowel length to keep the common channel at least 400-cm long. Data from 470 patients treated with the new technique (Group II) were compared with those of a matched group treated with tailored bypass only (Group I). The preoperative clinical data and outcomes were analyzed. All clinical data were prospectively collected and stored. ResultsBoth groups had similar clinical profiles at baseline. All procedures were completed laparoscopically. Group II had a significant longer operation time (161.9 versus 122.6 min; P < .001), but shorter hospital stay (2.9 versus 5.3 d; P < .001) and lower complication rate (.2% versus 1.5%; P = .002) than Group I. One year after surgery, the mean body mass index (27.4 versus 26.8 kg/m2; P = .244), percent total weight loss (32.0% versus 34.0%; P = .877), and diabetes remission rate (84.7% versus 84.1%; P = .876) were comparable between the 2 groups. However, Group II patients had a significantly lower incidence of anemia (5.9% versus 11.1%; P < .001), secondary hyperparathyroidism (21.7% versus 33.8%; P < .001) and hypoalbuminemia (1.5% versus 2.8%; P < .001) than did Group I. ConclusionRoutine measurement of the whole bowel length to keep the common channel at least 400-cm long may reduce the incidence of malnutrition after OAGB with tailored limb bypass, without compromising efficacy in weight loss and diabetes resolution.

Distal small bowel bypass for weight regain after gastric bypass: safety and efficacy threshold occurs at

BackgroundFor patients with poor weight loss (WL) after Roux-en-Y gastric bypass (RYGB) there are few well-tolerated and effective surgical options. Revision to distal bypass by shortening of the common channel (CC) induces significant WL but often produces protein calorie malnutrition (PCM) and severe diarrhea. ObjectiveThe aim of this study was to identify a safe and effective threshold for distal small bowel bypass when done for revision of gastric bypass. SettingAcademic Institution, United States. MethodsWe performed revision of RYGB for WL in 20 patients by shortening the CC to a new length of 120–300 cm. The Roux limb length was unchanged. WL and PCM were monitored. A threshold for percent of small bowel bypassed at which PCM was avoided was retrospectively determined. WL was then compared in patients above and below this threshold. Five patients completed a 250-kcal mixed meal challenge before and 3 months after revision to determine selected gut hormone responses. ResultsBypassing≥70% small bowel resulted in PCM in 4 of 10 patients but in none of 10 patients below that threshold. PCM was observed as late as 2 years after revision and necessitated rerevision by lengthening of the CC in 3 patients. Additionally, nocturnal diarrhea was more common and more intractable when≥70% bypass was done. Both groups had significant excess body WL over 2 years, but it was greater in patients with≥70% bypass (47±19 versus 26±17; P<.05). A favorable gut hormone response was observed with 3-hour decrease in glucose-dependent insulinotropic peptide (GIP) by 25% and increase in glucagon-like peptide-1 (GLP-1) by 25%, whereas fasting peptide-YY (PYY) increased by 71% (P<.05 for all). ConclusionsRevision of RYGB to distal bypass when it is<70% of a patient’s small bowel length results in an acceptable balance of WL and a positive safety profile. WL may be mediated through an enhanced gut hormone effect, an aversion to ingested fat, and possibly other mechanisms.

Enterocutaneous fistulae in familial adenomatous polyposis patients with abdominal desmoid disease

Enterocutaneous fistula is a severe complication of intra-abdominal desmoid disease. It is hard to repair because of the presence of the desmoid itself, the possibility of distal obstruction and the complexity of multiple laparotomies. Here we report the outcome of a series of patients presenting with abdominal desmoid disease and associated enterocutaneous fistula. This is a retrospective, descriptive study of patients presenting to a hereditary colorectal cancer registry with familial adenomatous polyposis-related intra-abdominal desmoid disease and associated enterocutaneous fistulae. Patients were identified through the registry database and aspects of their treatment and outcome were abstracted. Sixteen patients (11 women, five men) were treated. The mean age at index surgery was 25.2 years and mean time to first fistula was 115.6 (± 92.7 standard deviation) months from index surgery. Index surgery included restorative proctocolectomy with ileal pouch (n = 9), colectomy with ileorectal anastomosis (n = 4) and proctocolectomy with end ileostomy (n = 1). One patient had only a small bowel bypass and another did not have any index surgery. Ten patients underwent laparotomy for the enterocutaneous fistula; eight had a repair ± resection, one had a diversion and one a bypass. All eight patients who had a repair healed, and the bypassed fistula was successfully palliated. Three fistulae recurred and two were successfully repaired at a second procedure. One patient was explored but nothing could be done for the fistula. Two surgery patients died of causes unrelated to the fistula. Six patients received medical treatment, four of whom died. Selected desmoid-related enterocutaneous fistulae can be repaired successfully.

The evolution of minimally invasive bariatric surgery

BackgroundObesity is a pandemic associated with significant morbidity and mortality. This historical article charts the progress of successful strategies that have been used to tackle weight loss from dietary modifications to the development of surgical interventions that have subsequently evolved. It also provides a précis of the reported outcome data following minimally invasive bariatric procedures. MethodsA literature review was performed. All articles relevant to the progression of bariatric surgery and minimally invasive surgery were assessed, as were those articles that described the ultimate evolution, combination, and establishment of the two techniques. ResultsThis article charts the progression of early weight loss strategies, from early dietary modifications and pharmacologic interventions to initial techniques in small bowel bypass procedures, banding techniques, and sleeve gastrectomies. It also describes the simultaneous developments of endoscopic interventions and laparoscopic procedures. ConclusionsA range of procedures are described, which differ in their success in terms of loss of excess weight and in their complication rates. Weight loss is greatest for biliopancreatic diversion followed by gastric bypass and sleeve gastrectomy and least for adjustable gastric banding. Bariatric surgery is an evolving field, which will continue to expand given current epidemiologic trends. Developments in instrumentation and surgical techniques, including single access and natural orifice approaches, may offer further benefit in terms of patient acceptability.

Iatrogenic Persistent Hypophosphatemia In A Simultaneous Liver-Kidney Transplant Recipient

Hypophosphatemia from renal phosphate wasting during the immediate postoperative kidney transplant period is common and improves with supplementation. We report a case of hypophosphatemia secondary to small bowel bypass surgery and over the counter antacid use in a patient with stage 4 chronic kidney disease (CKD) many years after simultaneous liver-kidney transplant (SLKT). A 43-year-old man with a history of alcoholic end-stage liver disease and hepatorenal syndrome status post SLKT 5 years prior presented with recurrent small bowel obstruction which persisted despite conservative treatment. Following exploratory laparotomy, he had a jejunal bypass surgery due to the intra-operative finding of jejunum adherent to a single mass. Due to the friability of the tissue, lysis of the adhesions was felt to be unsafe. Postoperatively, he developed hypophosphatemia and severe malnutrition due to short bowel syndrome. He required total parenteral nutrition which led to improvement in serum phosphorus. However, hypophosphatemia recurred and the lowest level of 1.1 mg/dl occurred during the transition from parenteral nutrition to partial enteral nutrition. On review of medication, he had been taking over the counter antacids for “indigestion”. Serum calcium was low normal and intact parathyroid hormone was within normal range. The patient also had vitamin D deficiency with a total 25-OH vitamin D of 23 ng/ml. The serum phosphorus improved after stopping antacids but remained persistently low normal despite oral supplementation, and he continues to require intermittent intravenous phosphate supplementation. Although hyperphosphatemia is common in CKD, hypophosphatemia can occur from overzealous dietary restrictions and use of phosphate binders. Aluminum hydroxide is a potent phosphate binder commonly found in over the counter antacids. Ongoing review of medications (both prescription and over the counter) is important to prevent hypophosphatemia. In addition, intestinal bypass, especially jejunal bypass, contributes to hypophosphatemia, and our case underscores the importance of the jejunum in phosphate absorption.

Endoscopic Management of Colo-Cutaneous Fistula Masquerading as Unexplained Diarrhea and Malabsorption

Purpose: 82-year old woman with dysphagia secondary to stroke, who underwent placement of a percutaneous endoscopic gastrostomy (PEG) 6 months earlier presented with chronic diarrhea. On exam, the external bolster of the PEG was only 2 cm outside the skin, suggesting migration of the PEG, with a freely mobile and functioning tube. Laboratory data revealed severe hypokalemia and hypomagnesaemia due to chronic diarrhea and malnutrition. CT scan showed PEG tube located in distal parts of the transverse colon. EGD confirmed healing and closure of the gastric site of PEG. On colonoscopy, the bumper of the PEG was located in transverse colon. The tip of the PEG tube at skin level was severed and the bumper was snared and retrieved out from colon. Four Resolution ® endoclips were deployed to close the colonic defect (Figure A). Antibiotics were administered for 48 hours. No leak was reported, and patient's diarrhea resolved. A new PEG was inserted uneventfully 7 days later.Figure A: Closed fistula after endoclips placement.Discussion: The practice of PEG placement had revolutionized the delivery of human nutrition in certain clinical settings. While this is a relatively safe procedure, complications may rarely occur such as tube migration. This is suspected when the external part of the tube is pulled into the abdominal cavity. Enterocutaneous fistulae are direct complications of tube migration. Gastro-cutaneous fistula is a rare sequel following the removal of the PEG. Colocutaneous fistula, on the other hand, is an extremely rare complication of PEG placement, yet the management can be quite challenging. Our case illustrates an unusual presentation of PEG migration as chronic diarrhea and malabsorption, primarily due to small bowel bypass. Successful endoscopic extraction of the PEG tube from colon and closure of the fistula tract with resolution clips promptly restored the continuity of the bowel and reversed the pathophysiological derangement. Conclusion: We presented a case of colo-cutaneous fistula, a rare and unusual complication of PEG placement, with successful endoscopic retrieval of the migrated PEG tube and closure of the colonic defect utilizing endoclipping technique.

Small Bowel Bypass as Treatment for Functional Gastric Obstruction

Multiple bariatric operations performed on the same patient can cause loss of normal peristaltic function of the stomach. Bariatric revisions, especially when combined with previous truncal vagotomy, can lead to functional gastric obstruction. These patients complain of severe nausea and intractable vomiting. This can cause excessive weight loss and malnutrition, requiring at times total parenteral nutrition (TPN) or forms of enteral feeding. These patients frequently require a total or subtotal gastric resection with an esophago-jejunal anastomosis to relieve symptoms. We present two patients with a functional gastric obstruction treated by a small bowel bypass, which successfully relieved all symptoms of obstruction and allowed normal food intake.

Weight Gain Following Bariatric Surgery As a Result of Large Gastric Stoma: Stomal Revision Using Endoscopic Suturing Technology

Obesity has reached epidemic proportions in US. Roux-en-Y gastric bypass (RYGB) is a commonly done surgical procedure with proven efficacy. RYGB involves creation of a small gastric pouch with a stomal diameter of approx 12 mm combined with distal small bowel bypass causing both volume restriction and malabsorption which results in weight loss. Complications of RYGB include dilation of the gastric stoma resulting in loss of the restrictive component which causes weight gain. Revision surgery is complex with high morbidity. Endoscopic stomal revision might be a reasonable alternative. Data on endoscopic stomal revision are limited. There are no data on feasibility of endoscopic suturing to reduce the stomal diameter and to see if this would result in resumption of weight loss. Methods: Patients noted to have weight gain after RYGB and noted to have stomal dilation on imaging and/ endoscopy were referred for endoscopic therapy. All procedures were done under general anesthesia. Standard upper endoscopy was initially performed and electrocautery with heater probe was used to denude the surface of the stoma to obtain proper surgical anastomosis with the suturing device. Using the Sew-Rite (Wilson-Cook, Salem, NC) endoscopic suturing device, suturing was done circumferentially to achieve a stomal diameter ≦12 mm. Successful endotherapy was defined as reduction of stomal diameter ≦12 mm and >75% loss of gained weight after initial weight loss. Results: 7 patients (6F, 1M, age 31-47) underwent endoscopic stomal revision over 2-year-period. Stomal diameter was ≧2 cm in all patients prior to endoscopic therapy. 5 of 7 patients underwent successful endoscopic revision of the gastric stoma. Revision was not possible in 2 patients due to extreme angulation of the stoma preventing successful placement of sutures. Post revision, the stomal diameter was 8-12 mm. All patients were followed at 4-8 week intervals and weight was recorded. Mean pre RYGB weight was 318 lbs. Following surgery, weight decreased to a mean of 168 lbs. After the initial weight loss, there was a mean weight gain of 72 lbs that was directly attributed to the large stoma size. There were no complications related to endoscopic stomal revision. Conclusions: 1) Endoscopic stomal revision using a suturing device is feasible and safe. 2) Endoscopic suturing of a large gastric stoma results in reclaiming the restrictive component of the bypass surgery as shown by subsequent weight loss, which is sustained. 3) Larger studies and longer term follow-up data are needed.

Relative effects of ileal resection and bypass on intestinal adaptation and carcinogenesis.

Since ileal resection and ileal bypass are commonly performed in man and might stimulate colonic hyperplasia, their co-carcinogenic potential was explored in male Sprague-Dawley rats (n = 135). One week after 33 per cent distal small-bowel resection, 33 per cent distal small-bowel bypass or distal ileal transection (control), animals started a 6-week course of azoxymethane injections (total dose 90 mg/kg ip). Findings in rats killed at 20 and 25 weeks were similar: bypass produced a higher yield of colorectal tumours (4.0 +/- 0.6 per rat: mean +/- s.e.) than controls (2.4 +/- 0.4; P less than 0.05), but resection caused maximal enhancement (5.2 +/- 0.5: P less than 0.01). In rats killed at 30 weeks, however, tumour yields were almost identical. Overall, resection increased colonic tumour yield by 55 per cent (P less than 0.02) and bypass by 32 per cent. Stathmokinetic measurements of crypt cell production rate (CCPR) at 20 weeks showed similar increases after resection and bypass both in residual functioning small bowel (109-200 per cent: P less than 0.01) and in colorectum (63-100 per cent: P less than 0.05). At 30 weeks these adaptive effects persisted, despite an overall increase in CCPR with age. Loss of functioning ileum enhances experimental colorectal carcinogenesis principally by reducing the latent period for tumour development. Resection has a greater effect than bypass probably by producing earlier hyperplasia, though later adaptive effects are similar.

Pay Status as a Predictor of Outcome in Surgical Treatment of Obesity.

BACKGROUND: Higher complication rates and lower success in surgery for severe obesity have been reported for patients with government pay status. We examined the effect of pay status upon outcome in surgical treatment of obesity. METHODS: This was an observational study from an aggregate data set of individual patient information. Government pay status (G) was defined as full or partial medical care payment through Medicare, Medicaid, or Veterans Administration. Payment entirely by private insurance was defined as private (P). Operations were classified as either simple (S, gastric restriction) or complex (C, gastric restriction with small bowel bypass). Two measures of outcome, perioperative complication rate and weight loss success (</= 50% excess weight), were examined to determine pay status effect. RESULTS: More G than P patients were treated with simple procedures (79% vs 51%, p < 0.05). Perioperative complication rates were more common for G than P patients (14.4% vs 9.1%, p < 0.05). One-year weight loss success was higher for P than G, regardless of operation type. CONCLUSION: Pay status should be included in characterization of patient groups and in the analysis of results when effectiveness of surgical treatment for severe obesity is reported.

Nephrolithiasis due to primary hyperparathyroidism and enteric hyperoxaluria: a case report

Enteric hyperoxaluria and primary hyperparathyroidism have been associated with the development of nephrolithiasis. We report a case involving a patient who had hyperparathyroidism due to a parathyroid adenoma and enteric hyperoxaluria resulting from a small bowel bypass and who had severe stone-related complications. This combination of stone-generating factors has heretofore not been reported. The pathophysiology of these entities is discussed.

Lesson of the Week: Vitamin A deficiency and xerophthalmia in the United Kingdom

Vitamin A was discovered at the turn of the century.1 It is required for normal cellular growth and differentiation and has an important role in the visual process.2 The effects on the eye of vitamin A deficiency are often seen in developing countries. It occurs primarily in children of school age and is usually seen in association with other nutritional deficits, such as multiple vitamin deficiencies and protein calorie malnutrition (marasmus). Over 124 million children worldwide are estimated to be deficient in vitamin A.3 This deficiency causes between one and two million deaths annually among children aged 1-4 years3 and is the commonest cause of childhood blindness in the world; over five million children develop xerophthalmia annually, a quarter of a million or more becoming blind. Sporadic cases of dietary vitamin A deficiency are rare in the Western world,4 5 but patients with abnormal metabolism can manifest signs and symptoms of vitamin deficiency. These secondary deficiencies can occur with drugs and after small bowel bypass surgery, chronic alcoholic pancreatitis, and severe liver disease. In severe liver disease there is reduced production of retinol binding protein, reduced amounts of zinc, and reduced storage of vitamin A esters in the liver. ### CASE 1 A 53 year old man presented with a one month history of poor dark-light adaptation and “everything appearing orange in the morning.” His nutritional problems developed after a complicated myocardial infarction had resulted in a superior mesenteric artery embolism. This necessitated extensive resection of the small bowel, leaving him with …

Effect of Acetylcysteine on Intestinal Smooth Muscle after Small Bowel Bypass in Rats

Transit through the bypassed intestine is initially depressed in rats that have 70% of their jejunoileum bypassed. In this study, the influence of intraluminal infusion of the mucolytic N‐acetyl‐L‐cysteine on the depressed transit was determined. Beginning on the first postoperative day, the bypassed intestines were infused continuously with either saline or a 6% solution of acetylcysteine. In one group of animals, transit was determined on the third day after operation. In another group, segments of intestine were evaluated morphometrically on the twelfth day. Transit rates in bypassed intestines of those animals infused with acetylcysteine were higher than those in bypassed intestines of animals infused with saline. Compared to saline infusion, acetylcysteine infusion resulted in the following structural changes in the bypassed intestine: decreases in the total cross‐sectional area of the gut, the wet weight and cross‐sectional area of the intestinal muscle, and the thickness of the circular muscle layer. These findings support the hypothesis that the reduced transit and muscular hypertrophy seen in the uninfused bypassed intestine of rats early after operation may be due to alterations in intestinal contents which include mucus.

Short-chain fatty acids in bowel contents after intestinal surgery

Short-chain fatty acids are produced in the human colon by bacterial fermentation of dietary fibers and other saccharides escaping absorption in the small bowel. Short-chain fatty acid concentrations were determined together with production rates in 6- and 24-h incubations of intestinal outputs from 56 patients with various types of intestinal resections. Concentrations and 6- and 24-h production rates in feces from 9 healthy persons (controls; median ± SD) were 98.9 ± 21.4 mmol/L and 17.2 ± 5.1 and 9.3 ± 1.5 mmol/L · h, respectively. Colectomized patients with short bowel syndrome had extremely low concentrations (0.8 mmol/L) compared with controls (p < 10-5), patients with ileostomy (p = 0.003), and ileal reservoirs (p < 10-5), and showed low 6- and 24-h production rates (1.5 and 0.9 mmol/L · h, respectively; p < 10-5 vs. controls). Short-chain fatty acids in ileostomic digesta (11.1 mmol/L) were decreased (p = 0.011) compared with outputs from ileal reservoirs (51.5 mmol/L), although production rates were in the same order of magnitude—all below control values (p < 0.001). Patients partially colectomized and patients with small bowel bypass or short bowel syndrome with preserved colon had normal fecal concentrations with decreased production rates of short-chain fatty acids vs. controls (p < 0.01). Only minor changes in ratios between individual acids were found. Reciprocal values of short-chain fatty acid concentrations correlated to volumes of outputs from both small intestine (r = 0.86, p < 10-6) and colon (r = 0.79, p < 10-6) when results were cumulated. It is concluded that partial resections of colon and the small bowel do not influence the fecal concentration level of short-chain fatty acids as long as colon is not totally resected.

Radiation enteritis in children

Six children with intestinal radiation injury following cancer therapy are presented. The radiation dose varied from 3500 rads to 6600 rads. Symptoms of radiation enteritis took from 3 weeks to 3 years to develop. All patients received concomitant chemotherapy. Incomplete bowel obstruction was the most common presenting feature (four cases); five came to laparotomy. Simple adhesiolysis was successful in two cases; two children required more extensive surgical manoeuvres (small-bowel bypass and bowel resections). All are alive and well 4 to 13 years following therapy although five have other radiation effects. Radiation injury to the bowel and its management are discussed.