A N IUA11F111I\1EFNTAL l\Al ATI()N OF TIII1 N TIITIO()NAL IMPORTANCEOF PlOlX\lMAL AND DISTAL SAIALL INTESTINE*

ARNOLD .1. I\REEN,ME.l).. JouN H. LINNNER, A.D. A-ND CHARLEs H. NIESON, AM.D..MINNEAPOLIS, MINNESOTA

FROMI rHE;, DE.P'.ARTMEl-.NTr OF- SURGE'RY, UNIVE'RSIIY OF MIINNESOTA, THE UNIVERSITY St-RGICAL SERV-ICE, MNOUNT SINAI HOSP'ITAI.,MINNEAPOLIS, MINN., AND HE EXIERIMENIAL SU RGICAL LABORATORY OF THE 'MINNEAPOLIS VETERANS' HOSPITAL

ACCUNIULATED CLINICAL experience haslong suggested that man not uncommonlysurvives the sacrifice of large segments ofsmall intestine. 4 0 . 11 14The results, how-ever, are variable, and for every favorablecase that finds its way into the literature,there ale withotut question a considerablel)blt unknowvn ntumber of patients who do notsurlvive suclh a catastrophe. Since in clinicalpractices, resections for the most part arepei formed under tincontrolled conditions,istilally for extensive neoplastic disease or

for infarcted gut, reliable data concerningessential functions of specific levels of theintestine cannot be gathered in this fashion.

Experimental sttudies in dogs reveal thatanimals also can, wvith rieasonable assurance,be deprived of from 50 to 70 per cent of theirsmall intestine and maintain a neali normalnuttritional status. However, mole detailedinformation relating to the relative nttri-tional importance of the various levels of thesmall intestine is sparse and conflicting. Re-ports of Flint,5 Althauser,' WVeckesser,15Jensenius and others' I suggests that theprincipal deficiency following such piroce-(lures is a moderate to severe interferencewith absorption of fat; protein absorption isless severely affected, and carbohydrate re-mains relatively unaffected.The present study was undertaken to de-

fine differences of nutritional adjustment* This investigation was stupported by U. S. P.

H. S. grant No. C-1876.Read before the American Surgical Association,

Cleveland, Ohio, April 29, 1954.

after sacrifice of comparable segments ofproximal and distal small intestine. As a re-

sult of these studies it is apparent that in thedog, the major discernible abnormality afterloss of the distal small bowel is a markeddiminution in efficiency of fat absorption as-sociated with loss of weight. On the otherhand, after sacrifice of comparable lengthsof the proximal small intestine, the animal'sweight is satisfactorily maintained near pre-operative levels, and no great interferencewith fat absorption is observed.

METHOD OF PREPARATION

Dogs were operated upon under asepticconditions. Measurements were made alongthe mesenteric border of the gut from theligament of Treitz to the ileocecal valve.Fifty to 70 per cent of the mesenteric smallbowel was then removed from the intestinalstream. The defunctionated bowel had itsblood supply preserved and its proximal anddistal ends were exteriorized as a cutaneousstoma. Intestinal continuity was re-estab-lished by end-to-end anastomosis exceptwhen the ileocecal valve was bypassed. Onthese occasions the intestinal-colic anasto-mosis was made end-to-side.

Five groups of animals with three animalsper group were originally prepared. Figure1 illustrates the various groups. Group I hadthe proximal 50 per cent of small bowel re-moved from intestinal continuity. In GroupII the distal 50 per cent of small bowel wasremoved from 3 cm. proximal to the ileoce-cal valve extending the necessary measured

439

KREMEN, LINNER AND NELSON

EXPERIMENTAL PREPARATIONS

Annals of SurgerySeptember, 1954

FIG. 1. Experimental animal preparations. (I) The proximal 50 per cent of small intestineremoved from intestinal continuity as a Thiry-Vella fistula. Anastomosis at ligament of Treitz.(IA) Group I animals reoperated upon after 24 weeks with bypass of ileocecal valve. Distal twocentimeters of ileum inverted and closed. (II) The distal 50 per cent of small intestine removedfrom intestinal continuity as a Thiry-Vella fistula. Anastomosis two to three centimeters proximalto ileocecal valve. (IIA) Group II animals reoperated upon after 24 weeks of observation. Thepreviously excluded distal bowel replaced into the intestinal stream and the proximal 50 per centof small bowel excluded as a Thiry-Vella fistula. (III) The distal 50 per cent of small intestineremoved from intestinal continuity as a Thiry-Vella fistula. The terminal three centimeters ofileum closed and inverted. Anastomosis end-to-side to right colon. (IIIA) Group III animalsreoperated upon after 24 weeks. The anastomosis to the right colon taken down with reanasto-mosis to the previously closed three-centimeter stump of terminal ileum. (IV) The proximal 70per cent of small intestine removed from intestinal continuity as a Thiry-Vella fistula. Anastomosisat ligament of Treitz. (V) The distal 70 per cent of small intestine removed from intestinal con-tinuity as a Thiry-Vella fistula. Anastomosis two to three centimeters proximal to ileocecal valve.

distance cephalad. Group III was similar toGroup II, except that the ileocecal valve wasbypassed. The terminal ileum was tran-sected 3 cm. proximal to the ileocecal valve.The distal transected ileum was invertedand closed, and an anastomosis to restoreintestinal continuity performed end-to-sideonto the right colon, just distal to the ileo-cecal junction. Group IV was similar toGroup I except that the proximal 70 per centof small bowel was removed from continu-

ity. Group V was similar to Group I1 exceptthat the distal 70 per cent of small bowelwas removed from intestinal continuity.Group IA, IIA and IIIA were conversions

of the original groups after a 24-week periodof observation which served as a control forthe further study. In Group I, in order to testfurther the effect of the ileocecal valve, atreoperation the original anastomosis at theterminal ileum three cm. proximal to theileocecal valve was taken down. The remain-

440

PROXIMAL AND DISTAL SMALL INTESTINE

ing stump of terminal ileum was closed andinverted. The residual small intestine was

anastomosed end-to-side to the right colon.In Group II at reoperation, the proximal 50per cent of small intestine was removedfrom its position in the intestinal stream andconverted to a Thiry-Vella fistula. In itsplace the distal 50 per cent of small bowel,which previously had been out of intestinalcontinuity in the original preparation, was

returned to the intestinal stream. One of thethree dogs in this group died following re-

conversion, two survived in good health forfurther observation. In Group III at reopera-tion, the anastomosis of small intestine toright colon was taken down and intestinalcontinuity was re-established by reanasto-mosis to the previously closed 3 cm. stumpof the residual terminal ileum. This group ofdogs had lost the most weight and were inthe poorest condition at the time of reopera-

tion. One animal died of pneumonia, one

died of postoperative obstruction, and one

survived the reoperation without complica-tion.

After a suitable time had elapsed follow-ing an intestinal preparation (usually in ex-

cess of four weeks), each dog participatingin the balance study was fed 700 Gm. of a

canned dog food (Pard) daily for threedays. On the last two days the feedings werecolored with carmine red and during this48-hour period all carmine-colored stoolswere collected. Studies were also done usingthe canned dog food with added lard, thusincreasing the fat content from approxi-mately 5 per cent to 18 per cent. Each ani-mal was studied for at least four periods dur-ing the time of observation.The water, fat and nitrogen content of

the carmine-colored food and stool was thendetermined. The water content was meas-

ured by weighing, dehydrating and reweigh-ing an aliquot sample of food or stool. Thenitrogen concentration of food and stool wasdetermined by a standard Kjeldahl technic.The total fat content was determined by a

GROUP I aIAAVERAGE % GAIN OR LOSS OF WEIGHT

+30%-

+20%

+10%-

0%

-10%

-20%

-30%

GROUP I

.GROUP IA

SURGERY

-2 246 12 142 164 6 122224WEEKS POST - OP

FIG. 2. Weight curve of Group I and IA animalscharted as the percentage of gain or loss from initialnormal weight before the first operation.

GROUP I EBHA

AVERAGE % GAIN OR LOSS OF WEIGHT

GROUPGROUP A

+30% -

+20% -

+ 10%

0%

-10%-

-20%

-30%SURGERY

-1 22 4 £ 8 10 12 14 16 18 20 22 24WEEKS POST- OP.

FIG. 3. Weight curve of Group II and' IIA ani-mals charted as the percentage of gain or loss frominitial normal weight before the first operation.

wet method developed by Van de Kamerand his associates.13 In brief, the methodconsists of first saponifying a weighed sam-

ple of the well-mixed stool (or dog food)with a concentrated alcoholic solution ofKOH. The soaps thus formed are convertedto fatty acids with HCL and the fatty acidsthen extracted with petroleum ether. Afterevaporation of the ether, the fatty acids are

titrated against 0.1 N NaOH, using thymolblue as an indicator. The calculation is car-

ried out assuming an average molecularweight of 284 for fatty acids. The methodhas a margin of error of less than two per

cent.441

Volume 140Number 3

- i i 1- -4 --.-4

l

KRENIEN, LINNER AND NELSON

RESULTS

Animals were carefully weighed at weeklyintervals. Figures 2, 3, 4, 5 and 6 depict theaverage of the deviations from the preopera-tive normal weights of all animals in thegroup. Group I animals, with loss of theproximal 50 per cent of small bowel, lost 15

ity as a Thiry-Vella fistula. Following thisprocedure the animals steadily gainedweight and in 14 weeks had regained theiroriginal normal weight, which they main-tained to 22 weeks.Group III animals, which were similar to

Group II except for bypass of the ileocecalvalve, lost weight steadily and progressively,

GROUP mSt&MAAVERAGE % GAIN OR LOSS OF WEIGHT

- GROUP m---- GROUP m A

+30%

+20% -

+10%-

0%

-10% -

-20% -

-30%-

-40% -

--r IT

_ 2 4 6 8 10 12 14 16 18 20 22

SURGERY POST-OP

GROU P IAVERAGE % GAIN OR LOSS OF WEIGHT

SURGERY

-2 0 2 4 6 8 10 12 14 16 18 20 22 24

WEEKS POS. -OP

FIG. 4. Weight curve of Group III and IIIA ani-mals charted as the percentage of gain or loss frominitial normal weight before the first operation.

per cent of their preoperative weight byseven weeks, but by 24 weeks had regainedtheir normal weight. When these animalswere converted to Group IA, with bypass ofthe- ileocecal valve, no change in their nor-

mal weight was observed.Group II animals, with loss of the distal

50 per cent of small bowel, on the otherhand, exhibited progressive weight lossequal to 15 per cent of their body weight by15 weeks postoperatively, and then ap-

peared to hold their weight stable to 24weeks, but did not regain the weight theyhad lost. At this time they were reoperatedupon and converted to Group IIA. The distal50 per cent of small bowel which previouslyhad been out of the intestinal stream was re-

placed and the proximal 50 per cent of smallbowel was removed from intestinal continu-

FIG. 5. Weight curve of Group IV animalscharted as the percentage of gain or loss from initialnormal weight before operation.

and exhibited the most profound cachexia ofall the groups. There did not appear to beany tendency in this group of animals to-ward compensation and stability of theirweights. When these animals were reoper-

ated upon and converted to Group IIIA byre-establishing intestinal flow through theileocecal valve, two animals in the group

died soon postoperatively from inanitionand technical difficulties. However dog 147,which had suffered the most profoundweight loss (50 per cent of its preoperativebody weight), survived. It remains in goodhealth, although still undernourished. Itsprogressive weight loss was halted, and itwas able to regain the weight loss incidentto its reoperation.Group IV animals, which were similar to

Group I except that 70 per cent instead of 50442

Aninials of SuirgerySeptember, 1954

+ 30%/, -

+20% -

+ 10% -

0% -

-10%-*

-20% -

-30% -

-40% -

-50% -

i i =.

L,.%%% 'o---./

0.1

PROXINMAL ANI) DISTAL SMALL INTESTINE

per cent of proximal small bowel was re-

moved from intestinal continuity, lost aboutfive per cent of their preoperative weightand then stabilized at about this level.Group V animals, which again were similarto Group II except that 70 per cent of thedistal small bowel was removed from intes-

GROUP xAVERAGE % GAIN OR LOSS OF WEIGHT

+30%

+20% -.

0%

10%/.

-20% -

-30% -

.40%-SURGERY

O 2 4 6 8 10 12 14 16 18 20 22 24

WEEKS POST - OP.

FIG. 6. Weight curve of Group V animals chartedas the percentage of gain or loss from initial normalweight before operation.

tinal continuity, lost one-fifth of their pre-

operative weight, and then appeared to holdtheir weight at that level without any otherapparent ill effects.

BALANCE STUDIES

Pard dog food was selected for the testdiet during study periods because of itsready availability and its standard consist-ency. Each batch was separately analyzedfor nitrogen and fat during the study peri-ods, with closely reproducible results. Onthis diet, normal control animals consistentlyexhibited a greater fecal nitrogen excretionthan one would normally expect, averaging28 per cent the ingested nitrogen in the food.This finding was observed on many animalson repeated occasions, and remained con-

stant. When the method was checked on

normal dogs on a horsemeat diet, expectednormal values were consistently obtained,averaging six per cent of ingested nitrogen

appearing in the stools. According to themanufacturer, over 50 per cent of the pro-

tein of Pard is of animal origin and the re-

mainder (under 50 per cent) of the protein isfrom cereal, fiber and soya flour. It wouldappear that these vegetable proteins are

more poorly digested and absorbed in thedog, accounting for the high values of nitro-gen in the stools of the control dogs. Com-parison of experimental animals to thesecontrol values are nevertheless reproducibleand valid for the purposes of this study. Fatlosses on the Pard diet, however, were uni-formly within expected normal levels in allcontrol animals tested.

Figure 7 presents in summary the aver-

ages of two or more balance studies of allanimals in each group for both the low andhigh fat diet. The data are tabulated as thepercentage of ingested fat and nitrogen ap-

pearing in the stools, the water content ofthe stools, and as the percentage of fat indessicated stool.

In Groups II, III, IIIA and V, where thedistal small bowel is out of the intestinalstream, there is a consistently high loss offat in the stools. Whereas percentage of fatlosses in the control animals on the Pard dietwere 10 per cent of the intake, fecal lossesin these animals varied from 80 to 90 per

cent of fat intake. In Groups I, IA, IIA andIV, where the proximal small bowel is out ofintestinal continuity and the distal smallbowel is in place, the fecal fat losses wereonly slightly above control values.On the high fat intake ( 18 per cent fat)

studies, control animals showed an 8 percent loss in the stool. This apparent decreasein percentage of ingested fat lost in thestools as the fat intake increased has beenpointed out by Magnus-Levy8 and Wollae-ger and associates.16 Even under starvationconditions, fats can be found in the stool as

was observed by F. Mueller.10 When the in-take of fat is low, the percentage of loss ofingested fat appears to be higher, even

though the actuial output of fat is not in-443

V'oilumiie sI40Number 3

KREMEN, LINNER AND NELSON

creased over the normal. In these studies thepercentage of ingested fat appearing in thefeces in all comparable experimental groupswas quite similar in both the high and lowfat intake periods, but averaged somewhatless on the high fat diet.The percentage of fat of fecal solids on

the low fat diet was not greatly increasedwhen the distal small bowel was in the in-testinal stream (Groups I, IA, IIA and IV),and was increased markedly when the distalsmall bowel was excluded (Groups II, III,IIIA and V). On the high fat diet, the per-centage of fat in fecal solids was increasedin all groups, but again exhibited similarpatterns of distribution in the various groupsof preparations. No striking changes in H20content of the stool was observed in any ofthe groups of animals studied.

Bypass of the ileocecal valve by conver-sion of Group I to IA in the-proximal bowelexclusion group did not appear to alter theefficiency of fat absorption in any discern-ible way. Similarly, in Group III and IIIA,animals with the distal small bowel ex-cluded, no significant effect of the ileocecalvalve on fat absorption was observed, al-though there was a slight decrease in thepercentage of fat in fecal solids when theileocecal valve was in the intestinal stream.

Reoperation upon Group II animals, withconversion to Group IIA, produced the moststriking changes in fat absorption. When thedistal bowel was excluded from the intesti-nal stream the fat losses in the stool were87.9 per cent on the low fat diet and 72.5per cent on the high fat diet. After re-opera-tion with substitution of the distal small in-testine for the proximal small bowel, the fatlosses in these animals fell to normal levelsof 7 per cent on the low fat diet, and to 4.59per cent on the high fat diet. Similar changesin percentage of fecal fat solids were ob-served, with a fall from 40 per cent to 7 percent on the low fat diet, and from 65 per centto 15 per cent on the high fat diet.

Nitrogen losses in the stool, although lessstriking and less marked, were observed tofollow similar patterns to fat losses for the

Annals of SurgerySeptember, 1954

various groups of animals. No significant in-creases of fecal nitrogen loss over controlswere observed when the proximal smallbowel was defunctionated, whereas moder-ate but significant increases in fecal nitrogenexcretion occurred on loss of the distal smallbowel.

TRANSIT TIME

Efforts were made to determine transittime through the small intestine, to evaluatethe effect of this item on nutritional adjust-ment, and to correlate, if possible, speed ofintestinal transport to its various levels. It isnotoriously difficult to obtain exact measure-ments, indeed to know exactly what themeasurements mean. A number of factorsappear to be important in this regard,namely gastric emptying time, speed oftransit of material through the small bowel,and the time of complete emptying of thesmall bowel. These factors may or may notbe interdependent, but any or all could havean effect on nutritional adjustment.Measurements were made by taking serial

roentgenograms after the ingestion of 75 cc.of a suspension of barium sulfate and cerealin water. The time from feeding to the firstappearance of barium in the cecum was con-sidered the transit time, and the time of ap-parent complete emptying of the smallbowel of barium was also noted. Compari-son of average results in various groups re-veal a slightly shorter transit time in thosegroups of preparations where the distalsmall bowel was excluded. Interpretation ofthese findings were difficult, however, sincevariations of animals within each group onoccasion exceeded intergroup variations.Under the conditions of these experimentsthe alterations in motility did not appear toreflect the more marked differences in ab-sorptive capacity of the proximal and distalsmall bowel. In the preparations where theileocecal valve was bypassed (Group IA andGroup III), the transit time was consider-ably more rapid than it was in Groups I andIIIA. Similarly, Group III animals exhibiteda more rapid transit time than did Group II.

444

PrR1ONIMIAL AM1) I)ISTAL SMIALL INTESTINE

* % INGESTED FAT LOST IN STOOLSOYV FAT OF FECAL SOLIDS

INTAKE: 700 gm Pard Dog Food35gm. Fat, 105gm N 63.8gm Prot.

100]

60

40

20

I [A IIhA' IffIIA I V Control

* % INGESTED N2 LOST IN STOOLS

E % H20 CONTENT OF STOOLSINTAKE: 700 gm. Para Dog Food

35 gm Fat, 10.5grr, N2. 63.8grrm Prot.

100

80

60

40

20 -

I IA llA' Iam A' ISZ 7 Control

* °/. INGESTED FAT LOST IN STOOLSL: % FAT OF FECAL SOLIDS

INTAKE 600gm Pard Dog Food + 100 gm Lard130 gm Fat, 9.0gm N 56 gm Prot.

2

100]

80

60

40

20

I IA II IIA M MA II Y Control

* % INGESTED N2LOST IN STOOLS= % H20 CONTENT OF STOOLS

INTAKE: 600 gm. Pard Dog Food + 100 gm. Lord130 gm Fat, 9.0 gm N2 - 56.gm. Prot

100

80

60

40

20

0I ALI IA UI rLIA ,XI xr r.,-r-I

Fic. 7. Balance study data charting averages of all anim11als in each grotlup of the percentage ofingested fat lost in the stools, the percentage of fat in fecal solids, the percentage of iingestediitrogen recovered in stools aind( the wvater colitent of stools on lowr aid hiigrh fat (liets.

D)IUt5 I1ON

The vast lengtlh of small intestinie with itscomlbinedl ftunctions of digestioni, tranisport,aind absorption has received very little in-tensive scrutiny regarding essential ftunc-tions of its various levels. Although consider-able segments of the small bowel can l)esacrificed, a portion of it is absoluitely essen-tial to life, in contradistiinctioin to the stoIml-ach, duodenum or colon, 'which caii besacrificed in toto. In clinical practice, exteni-sive resections of the small bo-wel are uisuiallytlictated bv the exigencyT of the sittuatiolnimmediatelv at hand; most commonly, in-farcted bow%el or extensive neoplastic in-volvement, and the suirgeon has little choicebut to remove the ar-ea of involvement. How-ever, even uinder these cir-ctumiistances aL

certaiin latitude of judgmnient may be aL\ail-able to the suirgeoni, and it is of rieal impor-tance to have factual data reurardina iil)or-tianlt physiolo(gic funiictioins of the variouslevels of the guit. Another consideration,which to (late has not receixved clinictl trizal,is the possibility of treating extreme cases ofobesity by removing from intestinal contintu-itv sufficient simiall bowel to prodluce weightloss without any other serious hazard oI im-pairment. It is entirely possible that stich an1effect couild le obtained bv the sacrifice ofmost of the ileumini with preservation of theileocecfal jtunctture. One suclh case has re-centlv beeni tr-eatedl in this fashioin, aind willbe reported in at subsequent publication.

Trzebickv 1 2in 1894 first studied the prol)-lem of comparative functioni of the simallb)ow7el experimentally, an(ti conicliide(I that

445

\ ,1 tlri,e I 1 0N.'111I1hr :.

I IA II UA' m MA ly y ontrol

KRENIEN, LINNER AND NELSON Annals ofuhr.erySepItemb\er. D!.5-I

proximal resectioin produce(I more markednutritional sequelae than did(listal resec-tions. Clatworthy et al.:, mlore recentlvstudied the effects of extensive intestinal re-sections on growth of newborn dogs. Theyobserved no difference in stubsequentgrowth, with sacrifice of comparable lengthsof proximal, middle or distal small intestine.Similarly, Weckesser et al.'--, in 1951 re-ported that he was unable to observe anymarked difference in nutritional adjustmentbetween proximal and distal resections ofthe small bowel. In the proximal resections,two-thirds of the measured gut, beginningat the level of the ampula of Vater, was re-moved; and in the distal resections, two-thirds of the measured small bowel was re-moved from the ileocecal juncture upward.Vagotomy was also performed in an effortto increase the transit time and thereby im-prove the nutritional adjustment. However,although transient beneficial results wereobtained thereby, there was no lasting bene-fit derived from the latter procedure.

Jensenius,7 on the other hand, found avery definite difference in fat absorption be-tween proximal and distal small bowel re-sections, noting increased loss of fat in thestools after ileal resections. Our own resuiltscorroborate the observations of Jensenius,showing the ileum to be the primary area offat absorption in the dog. Markedly in-creased fat losses on all balance studieswhere the distal small bowel is out of intesti-nal continuity (Groups II, III, IIIA and V)was consistently observed, whereas rela-tively normal values were noted when onlythe proximal bowel was excluded from theintestinal stream. Moreover, the striking fallin fat loss to normal values associated withgain in weight when Group II animals wereconverted to Group IIA appears to jtstifythis conclusion.

Protein absorption also appears to occurin considerable measure in the ileum, sincefecal nitrogen losses were increased in allpreparations where the ileum was removed.However, this may in part be due to the

presenee of higher concentrations of fatbeing lost from the intestinal stream uinderthese ciretumstances. A further suggestion inthis direction is the observation that greaterfecal nitrogen losses occurred when theseanimals were on a high fat diet, restulting ingreater concentrations of fat being lost inthe stool.

CONCLUSIONS

The proximal 50 to 70 per cent of the smallintestine of dogs can be removed with noapparent ill effects. Weight is maintained,and protein and fat absorption are not sig-nificantly altered.

Sacrifice of the distal 50 per cent of thesmall intestine produces a profound inter-ference with fat absorption associated wvithloss of weight.The ileocecal valve appears to have an im-

portant effect on the nutritional adjustmentto sacrifice of the distal small bowel, but ap-pears less important in sacrifice of the proxi-mal small bowel.

BIBLIOGRAPHY

Althauser, T. L., K. Vyeyama, and R. G. Simp-son: Digestion and Absorption after 'MassiveResection of the Small Intestine. Gastroen-terol., 12: 795, 1949.

2 Cattel, R. B.: Massive Resection of the SmallIntestine. Lahey Clin. Bull., 4: 167, 1945.

Clatworthy, H. WV., Jr., R. Saleeby, and C. Lov-ingood: Extensive Small Bowel Resection inYoung Dogs: Its effect on Growth and Devel-opment. An experimental study. Surgery, 32:.341, 1952.

4 Doerfler, H.: Kann der Mensch ohne Dunndarmleben?, Zentralb. f. Chir., 50: 1502, 1923.

Flint, J. MI.: Effect of Extensive Resections ofSmall Intestine. Bull. Johns Hopkins Hosp.,23: 127, 1912.

Haymond, H. E.: Massive Resection of the SmallIntestine: An Analysis of 257 Collected Cases.Surg. Gynec. and Obst., 61: 693, 1935.

Jensenius, Hans: Results of Experimental Resec-tions of the Small Intestine on Dogs. Uni-versitetsforlaget, NYT Nordisk Forlog, Copen-hagen, Arnold Busck, 1945.

NIagnus-Levy, Adolf: Vol. I, Von Noorden:Mletabolism and practical medicine, Chicago,WV. T. Keener and Co., 1907. Vol. I, pp. 54-57.

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Voltume RI40 PROXINIAL AND DISTAL SMALL INTESTINENutiber 3

Meyer, H. WV.: Acute Superior MIesenteric Ar-tery Thrombosis: Recovery Following Exten-sive Resection of the Large and Small Intes-tine. Arch. Surg., 53: 298, 1946.

'lMueller, F.: Virchows Arch. f. Path. Anat. Suppl.,131: 17, 64, 1893.

Todd, W. R., M. Ditterbrandt, J. R. Montague,and E. I. West: Digestion and Absorption ina Man with all but Three Feet of Small Intes-tine Removed Surgically. Am. J. Digest. Dis.,7: 295, 1940.

12 Trzebicky, R.: Uber die Grenzen der Zulassigkeitder Dunndarm-resection. Arch. f. Klin. Chir.,48: 54, 1894.

13 Van de Kamer, J. H., Huinink, H. Ten Bokkeland H. A. Weyers: Rapid Method for the De-

termination of Fat in Feces. J. Biol. Cheml.,177: 347, 1949.

14 Weckesser, E. C., A. B. Chinii, M. W. Scott andJ. W. Price: Extensive Resection of the SmallIntestine. Am. J. Surg., 78: 706, 1949.

"Weckesser, E. C., J. L. Ankenny, A. F. Portman,J. W. Price and F. A. Cebul: Extensive Resec-tion of the Small Intestine Followed by Vago-tomy. Surgery, 30: 465, 1951.

Wollaeger, E. E., M. W. Comfort, J. F. Weir andA. E. Osterberg: The Total Solids, Fat andNitrogen in the Feces. I. A Study of NormalPersons and of Patients with Duodenal Ulceron a Test Diet Containing Large Amounts ofFat. Gastroenterology, 6: 83, 1946.

DISCUSSION.-DR. HERBERT WILLY MEYER, NewYork, New York: I have been tremendously inter-ested in this beautiful study by Dr. Kremen, andI would like to take just one minute to give aclinical report on a young soldier whom I had theopportunity of operating on during the Battle ofthe Bulge in Luxemburg.

He had had a minor shell fragment wotnd, andduring his stay in the hospital developed actutethrombosis of the superior mesenteric artery justdistal to the mid-colic artery. I had to resect allof the small intestine except the upper 18 inchesof the jejunum, all of the cecum, ascending colon,and a portion of the transverse colon. I then per-formed a jejuno-transverse colostomy.

This soldier was evacuated to England andthen brought to the United States to the MayoGeneral Hospital. Colonel John Gibbon, Jr., whowas chief of surgery, was kind enough to studyhim. They found that he had very little digestionof carbohydrates and fats. He was later discharged.The interesting part of the story, and the onlyreason I speak about it is that it is now over nineyears since that extensive resection. I know thatmany cases have appeared in the literature, butthis follow-up of nine years is of interest becausehis original weight at the time of operation was138 pounds. His low weight was 99 pounds andhe now weighs 125 pounds. He is married and hastwo children and works daily.

He has three or four soft bowel movements,but they have found that he suffers from avitamino-sis. He lives in Waterloo, Iowa, and has beenstudied at the Veterans Hospital at Des Moinesand by a doctor in Waterloo. He also has devel-

oped some anemia, and has had to have liverinjections.

I would like to show you two slides that weremade in Waterloo.

(Slide) This is a postevacuation film after abarium clysma. You will note in the lower righthandcorner the empty sigmoid colon. The large amountof barium that you see is in the distended jejunum-the residual 18 inches. You also will note thatthe barium clysma has partly outlined the duodenalcap, and a little of it has run into the stomach.

(Slide) This shows a photograph of the pa-tient nine years after the removal of all of the smallintestine and half of the large intestine. A reportof this case appeared in the Archives of Surgery, 53:208, September, 1946.

DR. PHILIP SANDBLOM, Lund, Sweden: A Swe-dish surgeon, Dr. V. Henrikson of Gothenburg,tried to control obesity in a woman whose appetitewas better than her character, by resection of anappropriate amount of the small intestine. Hefound that although the lady lost very much weight,it was difficult to keep her in balance. After thisbeautiful study by Dr. Kremen et al, this question-able method of controlling obesity will have thenecessary experimental foundation.

DR. ARNOLD J. KREMEN, Minneapolis, Minne-sota: I would like to thank Dr. Meyer for bringingus up-to-date on this remarkable case of his. Iremember reading the original report in 1946. Itis one of the few cases that I know of where sucha remarkable convalescence has occurred after

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