LETTERS
938
TO THE
EDITOR
I have just read the two papers on jejunoileal bypass in the April issue of The American Journal of Clinical Nutrition and I was interested that neither paper made reference to the paper of Kremen, A. J., Linner, J. H. and Nelson, C. H.: An experimental evaluation of the nutritional importance of proximal and distal small intestine. Ann. Surg. 140: 439, 1954. They bypassed 50% of the small bowel and compared proximal and distal, with and without the ileocecal valve, and with two levels of fat in the diet. Bypass of ileum and ileocecal valve and high dietary fat all increased protein loss. Kremen knew from this work that protein malnutrition would be a potential hazard but he reported use of small bowel bypass in the treatment of obesity. Kremen did not feel that this was a very physiological procedure and soon abandoned it but the operation he used is the one that Scott, Salmon and Buchwald are now recommending; an end-to-end anastomosis with the bypassed segment drained into the colon by a separate anastomosis. Since the majority of protein in the digestive tract is derived from digestive enzymes, mucosal cells, plasma
leakage, or other endogenous sources, the profound protein depletion that occurs early, and which, in some patients contributes to liver failure, is due primarily to loss of body protein in the stool and not just to poor protein absorption. We have been able to correct the protein depletion by intensive use of parenteral amino acids, glucose, vitamins, and minerals, Mason, E. E. and Printen, K. J.: Metabolic considerations inreconstitution of the small intestine after jejunoileal bypass. Surg. Gynecol. Obstet. 142: 177, 1976. We see only patients with severe problems after small bowel bypass but this experience and the many complications reported in the literature suggest that some other operation should be, considered. We have developed a subtotal bypass of the stomach which has been used in over 500 patients at The University of Iowa and is beginning to be used by others. It is a somewhat more demanding operation but can be performed with a 1 % operative mortality rate and with weight loss that is as great as after intestinal bypass. When the patients leave the hospital they are not in danger of potassium, calcium, protein
Department B-022 University La Jolla,
4.
5.
of California San California 92093
1. CHRISTOPHER, RIPLEY, P.
Dear
3.
of Biolog, Diego
6.
References
Jejunoileal
2.
J.,
L.
SALTMAN
bypass
Sir:
Downloaded from https://academic.oup.com/ajcn/article-abstract/29/9/938/4649732 by guest on 04 February 2019
HATLEN. J. HEGENALER, L. AN!) C. WARD. Radioim-
munoassay of ferritin in rat serum: correlation of serum ferritin with liver ferritin iron stores. In: Proteins of Iron Storage and Transport in Biochemistry and Medicine, edited by R. R. Crichton. Amsterdam: North-Holland, 1975, p. 411. PLA, G. W., AND J. C. FRITZ. Availability of iron. J. Assoc. Off. Anal. Chem. 53: 791, 1970. LAHEY, M. E., C. J. GUBLER, M. S. CHASE, G. E. CARTWRIGIIT AND M. M. WINTROBE. Studies on copper metabolism. II. Hematologic manifestations of copper deficiency in swine. Blood 7: 1053, 1952. HINT0N, J. J. C., J. E. CARTER AND T. MORAN. The addition of iron to flour. I. The solubility and some related properties of iron powders including reduced iron. J. Food Technol. 2: 129, 1967. HINTON, J. J. C., AND T. MORAN. The addition of iron to flour. II. The absorption of reduced iron and some other forms of iron by the growing rat. J. Food Technol. 2: 135, 1967. AVOL, E., D. CARMICHAEL, J. HEGENACER AND P. SALTMAN. Rapid induction of ferritin in laboratory animals prior to its isolation. Prep. Biochem. 3: 279, 1973.
of food and water, whole cow milk supplemented with vitamins (5), 0.5 mi FeSO4, and 0.05 mM CuSO4; b) feeding a semi-synthetic “low-iron” diet (2) supplemented with 250 ppm Fe (as FeSO4) and 25 ppm Cu (as CuSO4); or c) feeding rodent chow and administering 0.05 mvi CuSO4 in the drinking water. Jack Hegenauer Paul Saliman
LETTERS
TO THE
EDITOR
939
and associated depletion complications such as renal stones and liver failure (Mason, E. E., Printen, K. J., Hartford, C. E. and Boyd, W. C. Optimizing results of gastric bypass.
enquiries or input by surgeons who are interested in the surgical treatment of obesity. Edward E. Mason, M.D.
Ann. Surg. 182: 405, functioning as a registry the technical aspects, results of this operation
Professor of Surgery University of Iowa Iowa City Iowa 52242
1975.) We of information complications, and would
are
now about and welcome
Hospitals
and
Clinics
Downloaded from https://academic.oup.com/ajcn/article-abstract/29/9/938/4649732 by guest on 04 February 2019
938
TO THE
EDITOR
I have just read the two papers on jejunoileal bypass in the April issue of The American Journal of Clinical Nutrition and I was interested that neither paper made reference to the paper of Kremen, A. J., Linner, J. H. and Nelson, C. H.: An experimental evaluation of the nutritional importance of proximal and distal small intestine. Ann. Surg. 140: 439, 1954. They bypassed 50% of the small bowel and compared proximal and distal, with and without the ileocecal valve, and with two levels of fat in the diet. Bypass of ileum and ileocecal valve and high dietary fat all increased protein loss. Kremen knew from this work that protein malnutrition would be a potential hazard but he reported use of small bowel bypass in the treatment of obesity. Kremen did not feel that this was a very physiological procedure and soon abandoned it but the operation he used is the one that Scott, Salmon and Buchwald are now recommending; an end-to-end anastomosis with the bypassed segment drained into the colon by a separate anastomosis. Since the majority of protein in the digestive tract is derived from digestive enzymes, mucosal cells, plasma
leakage, or other endogenous sources, the profound protein depletion that occurs early, and which, in some patients contributes to liver failure, is due primarily to loss of body protein in the stool and not just to poor protein absorption. We have been able to correct the protein depletion by intensive use of parenteral amino acids, glucose, vitamins, and minerals, Mason, E. E. and Printen, K. J.: Metabolic considerations inreconstitution of the small intestine after jejunoileal bypass. Surg. Gynecol. Obstet. 142: 177, 1976. We see only patients with severe problems after small bowel bypass but this experience and the many complications reported in the literature suggest that some other operation should be, considered. We have developed a subtotal bypass of the stomach which has been used in over 500 patients at The University of Iowa and is beginning to be used by others. It is a somewhat more demanding operation but can be performed with a 1 % operative mortality rate and with weight loss that is as great as after intestinal bypass. When the patients leave the hospital they are not in danger of potassium, calcium, protein
Department B-022 University La Jolla,
4.
5.
of California San California 92093
1. CHRISTOPHER, RIPLEY, P.
Dear
3.
of Biolog, Diego
6.
References
Jejunoileal
2.
J.,
L.
SALTMAN
bypass
Sir:
Downloaded from https://academic.oup.com/ajcn/article-abstract/29/9/938/4649732 by guest on 04 February 2019
HATLEN. J. HEGENALER, L. AN!) C. WARD. Radioim-
munoassay of ferritin in rat serum: correlation of serum ferritin with liver ferritin iron stores. In: Proteins of Iron Storage and Transport in Biochemistry and Medicine, edited by R. R. Crichton. Amsterdam: North-Holland, 1975, p. 411. PLA, G. W., AND J. C. FRITZ. Availability of iron. J. Assoc. Off. Anal. Chem. 53: 791, 1970. LAHEY, M. E., C. J. GUBLER, M. S. CHASE, G. E. CARTWRIGIIT AND M. M. WINTROBE. Studies on copper metabolism. II. Hematologic manifestations of copper deficiency in swine. Blood 7: 1053, 1952. HINT0N, J. J. C., J. E. CARTER AND T. MORAN. The addition of iron to flour. I. The solubility and some related properties of iron powders including reduced iron. J. Food Technol. 2: 129, 1967. HINTON, J. J. C., AND T. MORAN. The addition of iron to flour. II. The absorption of reduced iron and some other forms of iron by the growing rat. J. Food Technol. 2: 135, 1967. AVOL, E., D. CARMICHAEL, J. HEGENACER AND P. SALTMAN. Rapid induction of ferritin in laboratory animals prior to its isolation. Prep. Biochem. 3: 279, 1973.
of food and water, whole cow milk supplemented with vitamins (5), 0.5 mi FeSO4, and 0.05 mM CuSO4; b) feeding a semi-synthetic “low-iron” diet (2) supplemented with 250 ppm Fe (as FeSO4) and 25 ppm Cu (as CuSO4); or c) feeding rodent chow and administering 0.05 mvi CuSO4 in the drinking water. Jack Hegenauer Paul Saliman
LETTERS
TO THE
EDITOR
939
and associated depletion complications such as renal stones and liver failure (Mason, E. E., Printen, K. J., Hartford, C. E. and Boyd, W. C. Optimizing results of gastric bypass.
enquiries or input by surgeons who are interested in the surgical treatment of obesity. Edward E. Mason, M.D.
Ann. Surg. 182: 405, functioning as a registry the technical aspects, results of this operation
Professor of Surgery University of Iowa Iowa City Iowa 52242
1975.) We of information complications, and would
are
now about and welcome
Hospitals
and
Clinics
Downloaded from https://academic.oup.com/ajcn/article-abstract/29/9/938/4649732 by guest on 04 February 2019
