JOURNAL
OF SURGICAL
RESEARCH
18,
83-89 (1975)
RESIDENT RESEARCH AWARD
An Etiologic
Basis for Fatty
Liver after Jejunoileal
Bypass’
J. I. HOLLENBECK, M.D., J. P. O’LEARY, M.D., J. W. MAHER, M.D., AND E. R. WOODWARD, M.D. Department of Surgery, College of Medicine. University of Florida, Gainesville, Florida, 32610 Received November 8,1974 The experience with liver failure after jejunoileal bypass at the University of Florida [2] prompted this investigation. Liver failure in our patients is manifested by decreased serum protein and albumin, increased alkaline phosphatase and serum transaminase, and jaundice. Decreased uptake of technetium 99m as seen by liver scan has also been a constant finding [6]. The associated morphologic change in the liver is severe fatty metamorphosis. Eventually, this leads to periportal fibrosis and progressively to cirrhosis [5]. The etiology of this has been ascribed to malabsorption secondary to the short length of functional small intestine. However, treatment of patients with liver failure by combined oral and parenteral hyperalimentation for protracted periods of time does not reverse the process in all patients. The following investigation was undertaken in an attempt to prevent liver failure and fatty metamorphosis after jejunoileal bypass in experimental animals. METHODS Eight healthy mongrel dogs weighing between 12 and 20 kg were divided into two groups and an obesity bypass procedure was performed. The intestine was divided 24 in. from the pylorus and anastomosed end-toside to the terminal ileum 12 in. from the ‘This work has been supported by NIH grant AM02372. We express our thanks to Mr. Mike Prpich and Ptizer Laboratories for providing Vibramycin in this experimental trial.
ileocecal valve. The blind end of the bypassed intestine was closed and the liver was biopsied in a wedge fashion. At subse quent monthly intervals the animals were anesthetized with intravenous Nembutal and operated upon. Wedge biopsies were obtained. Aerobic and anaerobic cultures of bacterial flora were taken 12 in. from the proximal end of the excluded limb. In the postoperative period all dogs were fed a standard horsemeat diet with free access to water. The only difference was that the therapy group received doxycycline hyclate (Vibramycin), 100 mg/day orally, while the control group received no antibiotics. Aerobic and anaerobic bacteriologic cultures were plated and interpreted by a member of the Bacteriology Department and liver biopsies were interpreted by a member of the Pathology Department. The experimental groups from which the cultures and biopsies came were not known to the interpreters. RESULTS All of the dogs survived the original procedure and experienced diarrhea as a sequelae of the operation. The diarrhea subsided within 10 days of the operation. All the animals lost weight initially. Bacteriologic studies of the cultures taken from the defunctionalized intestine revealed Bacteroides fragilis, Bacteroides speciesor both in all of the animals in the control group while none of the animals treated with doxycycline hyclate grew Bacteroides (Tables 1 and 2).
83 Copyright @1975by Academic Press, Inc. All rights of reproduction in any form reserved.
84
JOURNAL OF SURGICAL RESEARCH VOL.l8,NO,2,FEBRUARY
1975
TABLE 1 Serial Anaerobic Cultures of the Bypassed Segment in the Control Animals Animal
lmo
w3115
Bacteroides fragilis (B.f.) Bacteroides species (B.S.) B.f. + B.S. B.S.
w35
W3120 w390
2mo
3mo
4mo
B.f.
Dead
B.f. + B.S.
B.f., B.S. + Fusobacterium (Fb.)
Dead
B.S. + Fb.
B.S. + Fb.
Dead B.S.
Aerobic cultures were not significally different in the two groups. Prebypass hepatic morphology was normal in both groups (Figs. 1 and 2). Henormal patic morphology remained throughout the experiment in the Vibramycin-treated dogs (Figs. 3 and 4) Table 3). The livers of the untreated dogs, however, exhibited evidence of progressive fatty degeneration and centrilobular necrosis (Fig. 5) (Table 4). Increased deposition of fat was demonstrated by fatspecific staining techniques. All control animals were dead within 122 days of the bypass operation with the earliest death coming 45 days after bypass. Each control animal died of liver failure demonstrating decreased serum protein and albumin and increasing bromsulphalein retention. Three of the four treated dogs survived the 6-mo experiment without evidence of liver compromise. One dog died as the result of an anesthetic overdose during the open liver biopsy at the 3-mo time period. At the time of death, this dog exhibited no evidence of
functional promise.
or
morphologic
Smo
Dead
liver
com-
DISCUSSION The initial response of the liver to a toxic substance is the acute deposition of fat. If the insult continues, permanent injury occurs with development of fibrosis and, ultimately, cirrhosis. Since the purpose of an intestinal bypass procedure is to produce malabsorption, it would seem reasonable to assume that the subsequent liver failure is secondary to nutritional deprivation. Moxley et al. [B] have shown a decrease in essential and nonessential amino acids in the serum of 12 patients 4 mo after jejunoileal bypass. They feel that oral amino acid supplementation may be of benefit in preventing postbypass liver failure. However, both oral and intravenous hyperalimentation does not reverse the process in all patients. Bondar and Pisesky [l] showed that an 80% small-bowel resection in the dog will lead to a 25% weight loss followed by weight stabilization without any demonstrable liver
TABLE 2 Serial Anaerobic Cultures of the Bypassed Segment in the Treated Animals Animal
lmo
2mo N.G.
N.G.a
BW342
No growth (N.G.) N.G.
N.G.
BW364 BW376
N.G. N.G.
N.G. N.G.
Bacteroides species N.G. N.G.
w349
aAnesthetic
death.
3mo
4mo
5mo
6mo
N.G.
N.G.
N.G.
N.G. N.G.
N.G. N.G.
N.G. N.G.
HOLLENBECK
ET AL.: FATTY
LIVER
FIG. I. Wedge liver biopsy of dog in doxycycline bypass(1OOx).
AFTER
JEJUNOILEAL
(Vibramycin)-treated
BYPASS
group prior to jejunoileal
FIG. 2. Wedge liver biopsy of dog in control group prior to jejunoileal bypass (100x).
85
FIG. 3. Wedge liver biopsy of dog in doxycycline (Vibramycin)-treated group 4 mo after jejunoileal bypass, demonstrating normal hepatic morphology (100x).
FIG. 4. Wedge liver biopsy of dog in doxycycline (Vibramycin>treated group 5 mo after jejunoileal bypass, demonstrating normal hepatic morphology (100x).
HOLLENBECK
ET AL.: FATTY LIVER AFTER JEJUNOILEAL
BYPASS
87
TABLE 3 SerialLiverBiopsies TreatedAnimals
2mo
4mo
5mo
6mo
N.L. N.L.
N.L. N.L.
N.L. N.L.
N.L. N.L.
N.L.
N.L.
N.L.
N.L.
3mo
Animal
Prebypass
lmo
w349
N.L.
N.L.
N.L.=
BW342 BW364
Normal liver (N.L.) N.L. N.L.
N.L. N.L.
BW376
N.L.
N.L.
N.L. Trace centrilobular vacuolization klycogen) N.L.
‘Anesthetic death.
injury. When an 80% small bowel bypass is done in the dog, and the bypassed segment left in siru, the operation is followed by a progressive decrease in hepatic function and ultimate death. This experimental work suggests that presence of the excluded limb directly contributes to the animal’s death from liver failure. McClelland et al. [7] have shown that if the proximal end of the excluded limb is brought through the skin as a
jejunostomy and predigested gelatin or medium chain triglycerides are placed in the excluded limb the animals do not die from liver failure. If methyl cellulose or sulfathalidine powder are placed in the jejunostomy, the animals die. This suggests that the stimulation of peristaltic activity in the excluded limb does not prevent liver complications nor does the presence of an antibiotic specific for aerobic GI tract flora prevent
FIG. 5. Wedge liver biopsy of dog in control group 2 mo after jejunoileal bypass, demonstrating extensive fatty infiltration (100x).
88
JOURNAL
OF SURGICAL
RESEARCH
VOL. 18, NO. 2, FEBRUARY
1975
TABLE 4 Serial Liver Biopsies Control Animals Animal
Prebypass
1 mo
2mo
w3115
2 + Centrilobular vacuolization (CLV)-fat Normal liver (N.L.) N.L. Trace CVL fat vs glycogen
2 + CVL-fat
2 + Fatty change
2 + Fatty change’
Trace CLV
l-CLV
Focal hepatic necrosis
N.L. 2 + CLV-fat
Hepatic necrosis’ 2 + CLV-fat
2 + CLV-fat
w35 W3120 w390
3mo
4mo
2 + Fatty change
‘Autopsy specimen.
liver failure. However, the placement of a digestible substrate protects the liver in the experimental animal. This suggests that the substrate is either providing the animal with nutrition lost because of the bypass or preventing bacterial overgrowth in the excluded limb by providing normally present concentration of GI bacteria with a nutritional substrate. The excluded limb is an extremely long segment of small intestine out of the direct path of nutritional flow. Since bacterial overgrowth occurs in other excluded limbs within the gastrointestinal tract, it would seem reasonable that overgrowth may occur in the bypassed segment. The data obtained in this experiment support the concept of bacteria1 overgrowth. The data also show that if the anaerobic bacterial component of this overgrowth is prevented by organismspecific antibiotics, fatty metamorphosis of the liver is prevented. In 1957, Rutlenberg et al. [lo] showed that the presence of intestinal bacteria was necessary for rats that had fatty livers from choline deficiency to develop cirrhosis. Rutlenberg also suggested that intestinal bacteria may have a direct effect on the cholinedeficient liver or the intestinal bacteria intra-intestinal produce “an absorbable which of bacterial activity” product damages the liver. Gastrointestinal bacterial endotoxin has been shown to enter the circulation without direct injury to the gas-
trointestinal tract [3, 41. There are documented effects of endotoxin injury to hepatic cell mitochondria [ 1I]. The development of severe fatty livers in rats secondary to intraperitoneal administered endotoxin has been shown by Nolan and Ali [9]. They demonstrated that an animal chronically choline deficient with mild fatty changes in the liver will develop severe fatty change if given Escherichia coli endotoxin intraperitoneally. We postulate that Bacteroides organisms within fhe bypassed segment produce an endotoxin that is hepatotoxic. This leads us to that after obesity bypass propose Bacteroides-specific antibiotics given orally may prevent the observed phenomenon of postbypass liver failure. REFERENCES 1. Bondar, G. F., and Pisesky, W. Complications of small intestinal shortcircuiting
for obesity. Arch.
Surg. 94:101(1967) 2. Brown, R. G., O’Leary, J. P., and Woodward, E. R.
Hepatic effects of jejunoileal bypass for morbid obesity. Amer. J. Surg. 12753 (1974). 3. Cuevas, P., Ishiyama, M., Koizumi, S., Woodruff, P., Kaufman, A., and Fine, J. Role of endotoxemia of intestinal origin in early death from large burns. Surg. Gynecol. Obstet. 138:725 (1974). 4. Gans, H., and Matsumoto, K. The escape of endotoxin from the intestine. Surg. Gynecol. Obstet. 139:395 (1974). 5. Halloran, L. G., Hutcher, N. E., Levinson, S. A.,
Schatzki, P. F., and Hume, D. M. Morphology of the liver before and after intestinal bypass for morbid obesity. Surg. Forum 25:3.59 (1974).
HOLLENBECK ET AL.: FATTY LIVER AFTER JEJUNOILEAL BYPASS
89
6. Hollenbeck,J. I., Brown, R. G., O’Leary, J. P., and Woodward,E. R. Liver scanas a measureof liver function following jejunoileal bypass for morbid obesity.Surg. Forum 24:402 (1973).
bypassfor morbid obesity. N. Engl. J. Med. 290: 921(1974). 9. Nolan, J. P., and Ali, M. V. Endotoxin and the liver. I. Toxicity in rats with cholinedeficientfatty
7. McClelland, R. N., DeShazo, C. V., Heimbach, D. M., Eigenbrodt, E. H., and Dowdy, A. B.C. Prevention of hepatic injury after jejuno-ileal bypass by supplemental jejunostomy feedings. Surg. Forum 21:368 (1970).
livers. Proc. Sot. Exp. Biol. Med. 129:29(1968). 10. Rutlenburg, A. M., Sonnenblick, E., Koven, I., Aprahamian, H. A., Reiner, L., and Fine, J. The role of intestinal bacteria in the development of dietary cirrhosis in rats. J. Exp. Med. 106:l (1957). 11. Schumer, W., Das Gupa, T. K., Moss, G. S., and Nyhus, L. M. Effect of endotoxemia on liver cell mitochondria in man. Ann. Surg. 171:875(1970).
8. Moxley, R. T., Pozefsky, T., and Lockwood, D. H. Protein nutrition and liver disease after jejunoileal
OF SURGICAL
RESEARCH
18,
83-89 (1975)
RESIDENT RESEARCH AWARD
An Etiologic
Basis for Fatty
Liver after Jejunoileal
Bypass’
J. I. HOLLENBECK, M.D., J. P. O’LEARY, M.D., J. W. MAHER, M.D., AND E. R. WOODWARD, M.D. Department of Surgery, College of Medicine. University of Florida, Gainesville, Florida, 32610 Received November 8,1974 The experience with liver failure after jejunoileal bypass at the University of Florida [2] prompted this investigation. Liver failure in our patients is manifested by decreased serum protein and albumin, increased alkaline phosphatase and serum transaminase, and jaundice. Decreased uptake of technetium 99m as seen by liver scan has also been a constant finding [6]. The associated morphologic change in the liver is severe fatty metamorphosis. Eventually, this leads to periportal fibrosis and progressively to cirrhosis [5]. The etiology of this has been ascribed to malabsorption secondary to the short length of functional small intestine. However, treatment of patients with liver failure by combined oral and parenteral hyperalimentation for protracted periods of time does not reverse the process in all patients. The following investigation was undertaken in an attempt to prevent liver failure and fatty metamorphosis after jejunoileal bypass in experimental animals. METHODS Eight healthy mongrel dogs weighing between 12 and 20 kg were divided into two groups and an obesity bypass procedure was performed. The intestine was divided 24 in. from the pylorus and anastomosed end-toside to the terminal ileum 12 in. from the ‘This work has been supported by NIH grant AM02372. We express our thanks to Mr. Mike Prpich and Ptizer Laboratories for providing Vibramycin in this experimental trial.
ileocecal valve. The blind end of the bypassed intestine was closed and the liver was biopsied in a wedge fashion. At subse quent monthly intervals the animals were anesthetized with intravenous Nembutal and operated upon. Wedge biopsies were obtained. Aerobic and anaerobic cultures of bacterial flora were taken 12 in. from the proximal end of the excluded limb. In the postoperative period all dogs were fed a standard horsemeat diet with free access to water. The only difference was that the therapy group received doxycycline hyclate (Vibramycin), 100 mg/day orally, while the control group received no antibiotics. Aerobic and anaerobic bacteriologic cultures were plated and interpreted by a member of the Bacteriology Department and liver biopsies were interpreted by a member of the Pathology Department. The experimental groups from which the cultures and biopsies came were not known to the interpreters. RESULTS All of the dogs survived the original procedure and experienced diarrhea as a sequelae of the operation. The diarrhea subsided within 10 days of the operation. All the animals lost weight initially. Bacteriologic studies of the cultures taken from the defunctionalized intestine revealed Bacteroides fragilis, Bacteroides speciesor both in all of the animals in the control group while none of the animals treated with doxycycline hyclate grew Bacteroides (Tables 1 and 2).
83 Copyright @1975by Academic Press, Inc. All rights of reproduction in any form reserved.
84
JOURNAL OF SURGICAL RESEARCH VOL.l8,NO,2,FEBRUARY
1975
TABLE 1 Serial Anaerobic Cultures of the Bypassed Segment in the Control Animals Animal
lmo
w3115
Bacteroides fragilis (B.f.) Bacteroides species (B.S.) B.f. + B.S. B.S.
w35
W3120 w390
2mo
3mo
4mo
B.f.
Dead
B.f. + B.S.
B.f., B.S. + Fusobacterium (Fb.)
Dead
B.S. + Fb.
B.S. + Fb.
Dead B.S.
Aerobic cultures were not significally different in the two groups. Prebypass hepatic morphology was normal in both groups (Figs. 1 and 2). Henormal patic morphology remained throughout the experiment in the Vibramycin-treated dogs (Figs. 3 and 4) Table 3). The livers of the untreated dogs, however, exhibited evidence of progressive fatty degeneration and centrilobular necrosis (Fig. 5) (Table 4). Increased deposition of fat was demonstrated by fatspecific staining techniques. All control animals were dead within 122 days of the bypass operation with the earliest death coming 45 days after bypass. Each control animal died of liver failure demonstrating decreased serum protein and albumin and increasing bromsulphalein retention. Three of the four treated dogs survived the 6-mo experiment without evidence of liver compromise. One dog died as the result of an anesthetic overdose during the open liver biopsy at the 3-mo time period. At the time of death, this dog exhibited no evidence of
functional promise.
or
morphologic
Smo
Dead
liver
com-
DISCUSSION The initial response of the liver to a toxic substance is the acute deposition of fat. If the insult continues, permanent injury occurs with development of fibrosis and, ultimately, cirrhosis. Since the purpose of an intestinal bypass procedure is to produce malabsorption, it would seem reasonable to assume that the subsequent liver failure is secondary to nutritional deprivation. Moxley et al. [B] have shown a decrease in essential and nonessential amino acids in the serum of 12 patients 4 mo after jejunoileal bypass. They feel that oral amino acid supplementation may be of benefit in preventing postbypass liver failure. However, both oral and intravenous hyperalimentation does not reverse the process in all patients. Bondar and Pisesky [l] showed that an 80% small-bowel resection in the dog will lead to a 25% weight loss followed by weight stabilization without any demonstrable liver
TABLE 2 Serial Anaerobic Cultures of the Bypassed Segment in the Treated Animals Animal
lmo
2mo N.G.
N.G.a
BW342
No growth (N.G.) N.G.
N.G.
BW364 BW376
N.G. N.G.
N.G. N.G.
Bacteroides species N.G. N.G.
w349
aAnesthetic
death.
3mo
4mo
5mo
6mo
N.G.
N.G.
N.G.
N.G. N.G.
N.G. N.G.
N.G. N.G.
HOLLENBECK
ET AL.: FATTY
LIVER
FIG. I. Wedge liver biopsy of dog in doxycycline bypass(1OOx).
AFTER
JEJUNOILEAL
(Vibramycin)-treated
BYPASS
group prior to jejunoileal
FIG. 2. Wedge liver biopsy of dog in control group prior to jejunoileal bypass (100x).
85
FIG. 3. Wedge liver biopsy of dog in doxycycline (Vibramycin)-treated group 4 mo after jejunoileal bypass, demonstrating normal hepatic morphology (100x).
FIG. 4. Wedge liver biopsy of dog in doxycycline (Vibramycin>treated group 5 mo after jejunoileal bypass, demonstrating normal hepatic morphology (100x).
HOLLENBECK
ET AL.: FATTY LIVER AFTER JEJUNOILEAL
BYPASS
87
TABLE 3 SerialLiverBiopsies TreatedAnimals
2mo
4mo
5mo
6mo
N.L. N.L.
N.L. N.L.
N.L. N.L.
N.L. N.L.
N.L.
N.L.
N.L.
N.L.
3mo
Animal
Prebypass
lmo
w349
N.L.
N.L.
N.L.=
BW342 BW364
Normal liver (N.L.) N.L. N.L.
N.L. N.L.
BW376
N.L.
N.L.
N.L. Trace centrilobular vacuolization klycogen) N.L.
‘Anesthetic death.
injury. When an 80% small bowel bypass is done in the dog, and the bypassed segment left in siru, the operation is followed by a progressive decrease in hepatic function and ultimate death. This experimental work suggests that presence of the excluded limb directly contributes to the animal’s death from liver failure. McClelland et al. [7] have shown that if the proximal end of the excluded limb is brought through the skin as a
jejunostomy and predigested gelatin or medium chain triglycerides are placed in the excluded limb the animals do not die from liver failure. If methyl cellulose or sulfathalidine powder are placed in the jejunostomy, the animals die. This suggests that the stimulation of peristaltic activity in the excluded limb does not prevent liver complications nor does the presence of an antibiotic specific for aerobic GI tract flora prevent
FIG. 5. Wedge liver biopsy of dog in control group 2 mo after jejunoileal bypass, demonstrating extensive fatty infiltration (100x).
88
JOURNAL
OF SURGICAL
RESEARCH
VOL. 18, NO. 2, FEBRUARY
1975
TABLE 4 Serial Liver Biopsies Control Animals Animal
Prebypass
1 mo
2mo
w3115
2 + Centrilobular vacuolization (CLV)-fat Normal liver (N.L.) N.L. Trace CVL fat vs glycogen
2 + CVL-fat
2 + Fatty change
2 + Fatty change’
Trace CLV
l-CLV
Focal hepatic necrosis
N.L. 2 + CLV-fat
Hepatic necrosis’ 2 + CLV-fat
2 + CLV-fat
w35 W3120 w390
3mo
4mo
2 + Fatty change
‘Autopsy specimen.
liver failure. However, the placement of a digestible substrate protects the liver in the experimental animal. This suggests that the substrate is either providing the animal with nutrition lost because of the bypass or preventing bacterial overgrowth in the excluded limb by providing normally present concentration of GI bacteria with a nutritional substrate. The excluded limb is an extremely long segment of small intestine out of the direct path of nutritional flow. Since bacterial overgrowth occurs in other excluded limbs within the gastrointestinal tract, it would seem reasonable that overgrowth may occur in the bypassed segment. The data obtained in this experiment support the concept of bacteria1 overgrowth. The data also show that if the anaerobic bacterial component of this overgrowth is prevented by organismspecific antibiotics, fatty metamorphosis of the liver is prevented. In 1957, Rutlenberg et al. [lo] showed that the presence of intestinal bacteria was necessary for rats that had fatty livers from choline deficiency to develop cirrhosis. Rutlenberg also suggested that intestinal bacteria may have a direct effect on the cholinedeficient liver or the intestinal bacteria intra-intestinal produce “an absorbable which of bacterial activity” product damages the liver. Gastrointestinal bacterial endotoxin has been shown to enter the circulation without direct injury to the gas-
trointestinal tract [3, 41. There are documented effects of endotoxin injury to hepatic cell mitochondria [ 1I]. The development of severe fatty livers in rats secondary to intraperitoneal administered endotoxin has been shown by Nolan and Ali [9]. They demonstrated that an animal chronically choline deficient with mild fatty changes in the liver will develop severe fatty change if given Escherichia coli endotoxin intraperitoneally. We postulate that Bacteroides organisms within fhe bypassed segment produce an endotoxin that is hepatotoxic. This leads us to that after obesity bypass propose Bacteroides-specific antibiotics given orally may prevent the observed phenomenon of postbypass liver failure. REFERENCES 1. Bondar, G. F., and Pisesky, W. Complications of small intestinal shortcircuiting
for obesity. Arch.
Surg. 94:101(1967) 2. Brown, R. G., O’Leary, J. P., and Woodward, E. R.
Hepatic effects of jejunoileal bypass for morbid obesity. Amer. J. Surg. 12753 (1974). 3. Cuevas, P., Ishiyama, M., Koizumi, S., Woodruff, P., Kaufman, A., and Fine, J. Role of endotoxemia of intestinal origin in early death from large burns. Surg. Gynecol. Obstet. 138:725 (1974). 4. Gans, H., and Matsumoto, K. The escape of endotoxin from the intestine. Surg. Gynecol. Obstet. 139:395 (1974). 5. Halloran, L. G., Hutcher, N. E., Levinson, S. A.,
Schatzki, P. F., and Hume, D. M. Morphology of the liver before and after intestinal bypass for morbid obesity. Surg. Forum 25:3.59 (1974).
HOLLENBECK ET AL.: FATTY LIVER AFTER JEJUNOILEAL BYPASS
89
6. Hollenbeck,J. I., Brown, R. G., O’Leary, J. P., and Woodward,E. R. Liver scanas a measureof liver function following jejunoileal bypass for morbid obesity.Surg. Forum 24:402 (1973).
bypassfor morbid obesity. N. Engl. J. Med. 290: 921(1974). 9. Nolan, J. P., and Ali, M. V. Endotoxin and the liver. I. Toxicity in rats with cholinedeficientfatty
7. McClelland, R. N., DeShazo, C. V., Heimbach, D. M., Eigenbrodt, E. H., and Dowdy, A. B.C. Prevention of hepatic injury after jejuno-ileal bypass by supplemental jejunostomy feedings. Surg. Forum 21:368 (1970).
livers. Proc. Sot. Exp. Biol. Med. 129:29(1968). 10. Rutlenburg, A. M., Sonnenblick, E., Koven, I., Aprahamian, H. A., Reiner, L., and Fine, J. The role of intestinal bacteria in the development of dietary cirrhosis in rats. J. Exp. Med. 106:l (1957). 11. Schumer, W., Das Gupa, T. K., Moss, G. S., and Nyhus, L. M. Effect of endotoxemia on liver cell mitochondria in man. Ann. Surg. 171:875(1970).
8. Moxley, R. T., Pozefsky, T., and Lockwood, D. H. Protein nutrition and liver disease after jejunoileal
