Morbid obesity: with operative Richard Harrison
H. Dean,3 J. Shull,5
M.D., M.D.,
problems associated management”2 H. William and Frank
Scott,Jr.,4 W. Gluck,6
ABSTRACT
A review
obesity in a series
of 175 carefully
(3%).
Nonfatal
common.
fair
complications
Good
electrolyte dimensional
results
results
and only (secondary
Bypass
and for persistent
reversal
patients
was complicated selected
30: 90-97,
1977.
aberrations of end-to-end
in 21%,
diarrhea by severe will
There
in two), for
The
American
Journal
of Clinical
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wound
a good
jejunoileal
Five
were
infections
six deaths
weight
during
liver
failure
electrolyte
in three
depletion
instability.
This
response
tojejunoileal
the most significant
receiving the current An additional 13% had liver
and
patients in two
experience
morbid occurred
being
without
follow-up: in one,
for
deaths
(14 patients)
of ideal
infarction
bypass
postoperative
in 82% of the patients bypass (30 cm to 20 cm).
refractory
emotional have
extensive
to the range
myocardial
secondary
The basis for a surgical approach to massive obesity lies in the dual premise that severe obesity is a serious life-shortening disorder and that long-term medical therapy is usually unsatisfactory. Although various operative procedures have been suggested, reduction of the absorptive surface of the small bowel by extensive jejunoileal bypass has been used most widely. During the past 9 years we have made a clinical and metabolic investigation of morbid obesity and the role of surgical management; over 175 obese patients have been treated by extensive jejunoileal bypass. This brief review of the problems and response to operation will summarize the metabolic complications which occurred and their management. Patients in this series were selected for operation from a much larger group of obese subjects only after an extensive inhospital appraisal of clinical, endocrinological, metabolic, psychiatric, and body compositional parameters according to the following critna: I) massive obesity (weights of two to three times ideal levels) of at least 5-year duration; 2) validation from attending physician of failure of dietary efforts to correct obesity over a period of years; 3) evidence in 90
with
was observed jejunoileal
with
with
is presented.
reduction
results.
abuse
was necessary
patients
associated patients
by weight
5% had poor
abuse),
of carefully
occurred
to alcohol
causes.
problems selected
marked
or metabolic modification
patients
of the
M.D., M.D.
one
failure from
(two
patients.
suggests
bypass.
in four unknown
from
alcohol
One
of these
that Am.J.
the majority Clin
Nutr.
the patient’s history and evaluation of incapability to adhere to prescribed dietary regimen and/on exercise programs; 4) absence of any correctable endocrinopathy such as hypothyroidism or Cushing’s syndrome; 5) absence of any other unrelated significant disease which might increase operative risk; 6) presence of certain complications such as Pickwickian syndrome, hypenlipidemia, adult onset of diabetes, and hypertension, which might be alleviated by significant weight reduction; 7) assurance of patient’s cooperation in the conduct of pre- and postoperative nutritional studies and prolonged follow-up evaluation by a physician familiar with the complications consequent to this operation. In the 175 massively obese patients selected for jejunoileal bypass, ages ranged from 16 to 63 (average 36 years). There were 100 women and 75 men. Maximal weights before opera‘From the Departments of Surgery and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee 37232. 2 Reprint requests should be sent to: H. William Scott, Jr., M.D.,
Department of Surgery, Vanderbilt Universit’ Medical Center, Nashville, Tennessee 37232. Assistant Professor of Surgery. “Professor of Surgery. 5Clinical Professor of Medicine. “Assistant
Professor
Nutrition
of Medicine.
30: JANUARY
1977,
pp. 90-97.
Printed
in U.S.A.
PROBLEMS
IN
OPERATIVE
MANAGEMENT
tion ranged from 280 to 600 pounds (127 to 272 kgs). Immediately before operation weights ranged from 240 to 560 pounds (109 to 255 kgs). Each patient was evaluated preopenatively to detect possible endocrine causes of obesity, evaluate cardiopulmonary function, assess absorptive and nutnitional status, appraise psychiatric and psychological, profile and make isotopic measurements of body composition. Associated factors identified in this group included a family history of obesity in about one-half of the patients. About one-half had hyperlipidemia, exhibited by abnormal lipoprotein electrophoretograms in 69 patients with Fredenickson’s type IV hypenlipopnoteinemia, 13 patients with type II, and one with types V. Gallstones occurred in 32%, maturity onset diabetes in 28%, persistent diastolic hypertension in 15%, and clinically active gout requiring treatment in eight patients. Excluding diabetes, no significant endocninopathies were uncovered. Body compositional data based on 40K whole body counting indicated an average body fat content in the range of6O to 65% ofbody weight. Most patients had parameters of pulmonary function in the normal range except for a diminished PO2 six had clinical features of Pickwickian syndrome. Two patients had had previous myocandial infanctions and one had sustained a previous stroke. The end-to-side jejunoileal shunt described by Payne (1) (group I) was used in the first 11 patients of this series but abandoned after disappointing follow-up experience. Subsequently, we have used end-to-end anastomosis of a short segment of proximal jejunum to a short segment of distal ileum, while draining the bypassed long length of jejunoileum into transverse colon on sigmoid (2). In an effort to determine optimal dimensions of shortened bowel in alimentary continuity, three variations of this procedure have been studied: in 12 patients (group II) 12 inches of proximal jejunum were anastomosed end-toend to the distal 12 inches of ileum (30 cm to 30 cm); in group III (21 patients) the proximal 12 inches ofjejunum were joined to ileum 6 inches proximal to the ileocecal valve (30 cm to 15 cm); and in group IV, 131 patients had the proximal jejunum 12 inches from Treitz ligament anastomosed to the ileum 8
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OF
MORBID
91
OBESITY
inches from the ileocecal valve (30 cm to 20 cm). Procedures performed in conjunction with jejunoileal bypass are shown in Table 1 Most frequently performed were sim ultaneous cholecystectomy (26 patients) and umbilical hernia repair (13 patients). Although panniculectomy was performed in 13 patients, more recently it has been abandoned as a routine part of the operative procedure. In contrast, placement of an infranenal vena caval clip has been performed in the last 34 patients to reduce the incidence of clinically significant pulmonary thromboembolism. Appendectomy was routinely performed before construction of the bypass in all patients. Nasogastnic suction was discontinued 2 to 3 days after operation and oral liquids, usually restricted to 1,500 ml daily, were started. In the first few days after institution of oral liquids, multiple watery stools occurred. Low fat diet, restriction of fluids with meals, and diphenoxylate hydrochloride in a dosage of 5 mg three to four times a day or codeine 15 to 30 mg three to four times a day usually resulted in satisfactory control of the diarrhea during the early postoperative period. After discharge from the hospital each patient has been followed in conjunction with the family physician and in our clinic. An effort has been made to have all patients return repeatedly for both outpatient and inpatient studies of their clinical result, nutritional, metabolic, and body compositional status, psychiatric state, and degree of rehabilitation. Details of these results have been reported separately and exceed the scope of this report (3-6). .
TABLE Associated
I procedures
(175
Procedure Vena
caval
clipping
Cholecystectomy Previous removal Panniculectomy Umbilical hernia repair Ovarian cystectomy Tubal ligation Hysterectomy, D and C Hiatal hernia repair Ileal resection (carcinoid)
patients) No. 34 26 17 13 13 4 3 4 3 1
DEAN
92
Results The majority of patients recovered from operation without incident. There were, however, five postoperative deaths in the series of 175 patients (3%): one with bowel infarction from mesenteric venous thrombosis after intestinal bypass and extensive ileal and mesenteric resection for malignant ileal carcinoid with nodal metatases to the root of the mesentery; three from pulmonary embolism; and a fifth from diffuse thrombophlebitis, hemorrhagic pneumonia, and sepsis (Tabl’e
2). Nonfatal postoperative complications developed in 35 patients (Table 2). These included wound seroma in 14 patients and superficial wound infection in 14 others. One of these also developed stomal obstruction, which required revision, and venous thrombosis with pulmonary emboli. Three other patients had thromboembolic complications. Two patients developed early postoperative hepatitis attributable, we believe, to halothane anesthesia. There was only one early (1st day) evisceration. All patients with these complications recovered with appropriate treatment. During the follow-up period of a few months to 8 years there have been six deaths among the 170 patients who have survived jejunoileal shunt (Table 3). One young woman who made an apparently uneventful recovery from operation died TABLE 2 Complications bypass (175
after patients)
jejunoileal
Complications Operative Ileal
mortality and mesenteric
No.
resection
infarction of bowel Pulmonary embolism Thrombophlebitis, pneumonitis Nonfatal complications Wound infection Staph Coliform Wound seroma Hepatitis (halothane) Prolonged ileus stomal obstruction Thromboembolism Evisceration
sepsis,
hemorrhagic
with
5(3%) I 3 I 36(21%) 14 7 7 14 2 2 I 3 I
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ET
AL.
suddenly in her home 3 months later. No autopsy was done. A man of 60 years with severe generalized atherosclerosis died with myocardial infarction in his home 6 months after operation. Another young man of 25 years with a long history of excessive alcohol consumption died with vaniceal hemorrhage, alcoholic hepatosis, and liver failure 7 months after operation. A second patient with longstanding alcohol abuse died 3 #{189} years after operation from postalcoholic nutritional cirrhosis, portal hypertension, and bleeding esophageal vanices. Two other patients, both women, ages 57 and 34 years, died 15 and 6 months, respectively, after operation with unexplained hepatitis and hepatic failure. In the older woman there was a history of “social” drinking but no evidence of alcohol abuse. The other woman was a total abstainer. Overall mortality rate in 175 patients was-6.4%. Periods of follow-up in the groups under study range from 5 to 8 years in the patients with Payne’s operation (group I) and from 3 to 4 years in the patients of group II, from 2 to 3 years in the patients of group III (30 cm to 15 cm), and up to 2 years in the patients with the 30 cm to 20 cm jejunoileal shunt of group IV. The data comparing weight loss afterjejunoileal bypass in the patients of these several groups are presented in Figure 1. Although early precipitant weight loss occurred in each group, those with Payne’s operation (group I) and 50% of those with 30 cm to 30 cm end-to-end jejunoileal shunt (group II) subsequently lost weight more gradually and weights tended to plateau after 12 to 18 months at levels above ideal range. After 2 or more years a few patients in both of these groups had begun to regain weight. In contrast, patients in the group of end-toend jejunoileal shunt with 30 cm of jejunum joined to 15 to 20 cm of distal ileum (groups TABLE 3 Late deaths
after
jejunoileal
bypass
(1966-
1975)
Cause Alcoholic cirrhosis, variceal failure Hepatitis, liver failure Sudden death (? pulmonary Myocardial infarction Total no. deaths
No. bleeding,
liver
2 2
embolism)
I 1 6(35%)
PROBLEMS
IN
OPERATIVE
MANAGEMENT
III and IV) have had a more rapid rate of weight loss during the 1st year after operation. More than 70% of patients in these two groups followed for I year or more have achieved reduction to the range of ideal weight. Studies of body composition after jejunoileal bypass indicate that both body fat and lean body mass are lost in the early postoperative months. The loss of lean body mass has been greatest in group III (30 cm to 15 cm), concomitant with the most prolonged persistence of diarrhea. In all groups, however, potassium homeostasis has been usually achieved by 4 to 6 months, and subsequently fat is lost in preference to lean body mass (4). The results of clinical follow-up based on the criteria listed in Table 4 have been appraised in the surviving patients in each BODY
WEIGHT
% OF INITIAL
-I
Fz U-
0
OF
6
9
1215
Jejunoileal (1966-1975);
18 21 242730
93
OBESITY
group followed for 1 year or more after jejunoileal bypass and are summarized in Table 5. In 1 1 patients with Payne’s end-tosidejejunoileal shunt (group I) followed 5 to 8 years, the absence of good results and the predominance of poor results reflect the failure of satisfactory sustained weight reduction. In the 92 patients with end-to-end jejunoileal shunt who have been followed from 1 to 4 years the results have varied with the dimensions of surgical shortening of intestine. In group II (30 cm to 30 cm), six of the 12 patients (50%) achieved a good result. Fair results, achieved by five of this group, were secondary to an unsatisfactory degree of weight reduction. No significant metabolic or nutritional deficits have developed in any of these patients, and diarrhea has not persisted as a problem. One patient had a poor result because of totally inadequate weight loss. Among the 80 patients in groups III (30cm to 15 cm) and IV (30 cm to 20 cm) who have been followed I to 3 years, 61 (75%) have achieved a good result. Good results have been obtained by 8 1 % of the 60 patients in group IV who have had follow-ups of 1 to 2 years. The degree of rehabilitation in the patients who have had good results and most of these who are credited with fair results is difficult to measure objectively. Return to full preoperative work capacity and the assumption of fullor part-time new work has been accomplished by all but six patients. In the latter small group, retirement programs or wealth which precluded the need to work have been imporTABLE
PRE-3
MORBID
5 bypass for morbid obesity results of follow-up
MONTHS FIG. I. Chronology of weight loss four dimensional variations ofjejunoileal TABLE Criteria
4 in appraisal
Results Good Fair Poor
in patients bypass.
after
End-to-side (Payne procedure) 35cm to 10cm (group I)
of results Criteria
Weight lem; Weight
loss satisfactory; no diarrhea probno metabolic deficits loss not ideal; mild diarrhea on occa-
sion; Weight rhea;
minimal metabolic deficits loss unsatisfactory; persistent severe metabolic deficits
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Jejunoilealshunt group
diar-
End-to-end 3Ocmto3Ocm (group 2) 30cm to 15cm (group 3) 30cmto20cm (group 4)
No. patients
Yr
Il
Results Good
Fair
Poor
5-8
0
2
9
12
34
6
5
I
20
2-3
12
7
1
60
1-2
49
8
3
94
DEAN
tant influences. The new body image developed by those individuals who have brought their massively overweight status down to a normal or near normal weight range has been impressive to our medical and surgical team and in particular to our clinical psychologists and psychiatric consultants. A study of personality profiles and psychological aspects of the massively obese patients of this group before and afterjejunoileal bypass is reported separately (5, 6). Metabolic parameters which were assessed before operation have been studied in the period of follow-up. Reduction in carbohydrate absorption is indicated by impairment in d-xylose absorption and by flattening of oral glucose tolerance curves in the postoperative period. A large increase in fecal fat loss (20 to 85 g/day) has occurred in each of the 30 patients in whom it has been possible to measure this in the follow-up period after jejunoileal bypass (3). Malabsorption of fat and bile acids has been accompanied by an impressive and sustained fall in the serum cholesterol and triglyceride levels in all groups of patients. Irrespective of base-line concentrations there has been a consistent fall in both serum cholesterol and serum triglyceride to levels of 160 mg/lOO ml or less after operation, and these levels have been sustained throughout the periods of follow-up. Li popnotei n elect rophoretogram s have returned to normal in all patients with type II hyperlipoproteinemia and in all but four patients with type IV. Sequential follow-up has shown no recurrence of the original lipoprotein abnormality in any patient (7). Late
complications
Persistent deficits
diarrhea:
water
and
electrolyte
Diarrhea ceased within 1 to 3 months after bypass in all patients in group 11(30 cm to 30 cm) and in eight of 11 patients in group I except after overindulgence in excessive liquid or fat intake. Postoperative diarrhea has persisted for a slightly longer period in most of the patients of Groups III and IV. Persistent diarrhea has been a problem for 45% of patients in group III (30 cm to 15 cm). In contrast only 17% of the patients in group IV (30 cm to 20 cm) have had this problem.
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ET
AL.
Electrolyte deficits requiring supplementation have occurred only in patients with persistent diarrhea. The major cations, potassium, magnesium, and calcium, have been given as oral supplements as required in such cases until the diarrhea has come under control; however, seven patients with more severe deficits have required hospitalization during the penod of follow-up for panenteral supplementation. Excessive intake of liquids with meals and of foods rich in fat and lactose have been frequent factors in refractory diarrhea. After 12 to 18 months, the postoperative adaptive changes in the shortened bowel described by Wright and Tilson (8) which increase absorptive capability not only curtail continued weight loss but increase dietary fat and lactose tolerance and diarrhea of earlier months usually ceases. Buchwald et al., (9) advise routine oral supplementation after jejunoileal bypass with 45 to 60 mEq of potassium and 6 to 12 g of calcium carbonate daily in prophylactic therapy. Fatty
liver
and
hypoproteinemia
Accumulation of neutral fat in hepatocytes is a common finding in massive obesity. In 100 obese patients submitted to wedge biopsy of the liver, we found gross and microscopic evidence of hepatic steatosis in 74% before jejunoileal bypass. Similar observations have been made by many authors but the causative mechanism remains obscure (1, 9-11). After jejunoileal bypass, an increase in fat accumulation in the liver in most patients ha been documented by many observers (1, 9-11). Serum protein concentrations have tended to decline with notably lowered albumin levels (3). This appears to reflect protein-calorie malabsorption. The enhanced fatty metamorphosis of the liver coupled with protein-calorie malnutrition resembles an adult form of the tropical protein deficiency disorder known as kwashiorkor (12). Our clinical and body compositional data (4) support the concept that massively obese patients treated by jejunoileal bypass will recover satisfactorily from this phase of protein deficiency and hepatic fatty metamorphosis after 12 to 24 months if no added hepatotoxic factors are imposed.
PROBLEMS
Hepatotoxic
factors
and
IN
OPERATIVE
hepatic
MANAGEMENT
failure
Excessive alcohol intake after jejunoileal bypass led to alcoholic hepatosis, vaniceal hemorrhage, and death in one patient and hepatic failure and death in another of our patients. Further, alcohol probably contnibuted to death from hepatic failure in one other patient. Alcohol abuse promoted hepatomegaly in three other patients in group I, reliefwas obtained by cessation ofdninking in two and by restoration of alimentary continuity in one other. We advise all patients to abstain from alcohol aftenjejunoileal bypass. Another possible cause of hepatic injury after jejunoileal bypass is the potential for bacterial colonization and overgrowth in the shortened bowel and/or bypassed jejunoileum with toxic absorption of bacterial metabolites, deconjugates such as lithocolic acid, or bacterial endotoxin. The experimental work of O’Leary and his associates (13, 14) supports this possibility and suggests the use of broad spectrum antibiotics in preventive thenapy. Careful close clinical observation of all patients who are submitted to jejunoileal bypass is mandated by the rare but hazardous potential for development of toxic damage to the liver, especially during the phase of protein-calonie malnutrition. The clinical symptoms are those of a “flu-like” syndrome of malaise, myalgias, weakness, and easy fatigue coupled with anorexia and nausea. Elevation of serum alkaline phosphatase, lactic dehydrogenases, and transaminases (SGOT) usually precedes a rise in bilirubin on clinical jaundice. Australian antigen is usually negative. In six patients in the present series who developed those clinical manifestations within 3 to 12 months after jejunoileal bypass, treatment with 3 to 8 weeks of tetracyclines (on doxycycline) coupled with elemental dietary supplements has resulted in subsidence of symptoms and reversion of the serum enzyme alterations and liver biopsies to normal. Failure of response to such a treatment regimen is an indication to take down the intestinal bypass and restore alimentary continuity. This has been necessary in one patient in this series, with subsequent subsidence of symptoms and early beneficial results. Failure to take down the shunt in two other patients alluded to previously whose response to tetnacyclines and elemental diet was inadequate by
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OF
MORBID
OBESITY
95
retrospective analysis resulted in death from hepatic failure in each instance. Similar expenience has been reported by Woodward’s group (References 13 and 14 and E. R. Woodwand, personal communication). In the early years of this series, halothane anesthesia was used commonly. Two young women developed Australian antigen-negalive hepatitis in the immediate postoperative period after jejunoileal bypass under halothane. Each recovered fully, without evidence of liver damage, after supportive therapy. No hepatotoxic agent other than halothane could be elicited to explain the hepatitis. We have discontinued the use of the agent as an anesthetic in obese subjects. Ga//stones Gallstones occurred before jejunoileal bypass in 52 of 175 patients (30%); cholecystectomy was done in each. In the period of follow-up after bypass five other patients have developed symptomatic cholelithiasis and have had cholecystectomy. Neshat and Flye (15) have recently described a patient thought to have developed gallstones S weeks after jejunoileal bypass. Our experience suggests that it is more likely in such a case that stones were already present before operation. Whether bile becomes more or less lithogenic after jejunoileal bypass is a topic for investigation. Renal
stones and hyperoxa/uria
One on more bouts of uretenal colic attributed to stone formation have occurred in 15 of 175 patients after jejunoileal bypass. Hyperoxalunia is a common finding (16, 17). According to Stankloffet al. (17), 60% of 300 postoperative patients had elevated urinary oxalate levels which may be caused by increased absorption of exogenous oxalate, possibly owing to decreased calcium binding in the gut. Six percent of Stankloff’s preoperative patients developed renal calculi. The preventive regimen he prefers is low-oxalate diet with high calcium intake to increase intestinal oxalate binding Gout Although mon after
transitory hypenunicemia bypass, clinical gout is rare
is com(3, 17).
96
DEAN
Nine of 175 patients had gout which required treatment before operation. Four new cases have developed since operation. Amelioration of gouty attacks has occurred in four of the older cases and five are unchanged. One patient who rapidly lost over 200 pounds in an 18-month period developed severe gouty attacks with gouty nephropathy requiring repeated hospitalizations for control. A nemia
and
vitamin
deficiency
Persistent iron deficiency anemia with chronic low-grade melena has developed since operation in three patients. Repeated endoscopies and x-ray studies of the gastrointestinal tract have failed to reveal a bleeding site. Response to oral iron has been good. Serum concentrations of vitamins A, B12, C, D, and folate have been measured repeatedly during follow-up in the majority of patients after jejunoileal bypass. Transient deficiencies in the early postoperative months have been observed sporadically in A, E, folate, and C concentrations in about onethird of the patients and have been treated with oral supplements. No chronic avitaminoses have occurred. No evidence of B12 deficiency has developed in any patient of this series. Bypass
reversal
The potential reasons for jejunoileal bypass reversal are limitless. Nevertheless, improper selection of poorly motivated patients and severe refractory metabolic aberrations consequent to jejunoileal bypass constitute the most frequent problems necessitating reconstitution of complete gastrointestinal continuity. Five patients in this series had bypass reversal 7 months to 2 years after operation. Liver failure secondary to continued alcohol abuse required bypass reversal in two of these. In one of these individuals, takedown was performed after admission to another hospital for hepatic decompensation, portal hypertension, and bleeding esophageal varices. However, death occurred 2 weeks after operation. A third patient requiring takedown 9 months after jejunoileal bypass had developed hepatitis and severe hepatic steatosis unre-
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ET
AL.
sponsive to parenteral nutrition and tetracydine therapy. As previously stated, absorption of hepatotoxic substances from the bypassed segment was suggested but unproven in this case. Another patient received bypass reversal elsewhere 7 months postoperatively for excessive diarrhea and weight loss. Attempted management of these problems without bypass takedown was complicated by severe emotional instability in this patient. The final reversal was performed in conjunction with operative management of an intractable duodenal ulcer and partial gastric outlet obstruction occurring 10 months after jejunoileal bypass. This patient also had sustamed an inappropriately rapid weight loss of 200 pounds during this period secondary to persistent diarrhea. One year after bypass takedown, selective gastric vagotomy, and pyloroplasty, all metabolic derangements have resolved and his weight has been maintamed slightly above desired levels. Bypass
revision
Anastomotic revisions for partial obstruction were performed in three patients. One end-to-end jejunoileostomy was revised 15 days after operation. Another was revised for symptoms of chronic partial obstruction 7 months postoperatively. The final anastomotic obstruction occurred at the ileosigmoidostomy for drainage of the bypassed segment. This was corrected 3 weeks after jejunoileal bypass. Each of these patients recovered from reoperation and has had no subsequent gastrointestinal obstructive symptoms. Inadequate weight loss prompted revision in two additional patients. One of these individuals was converted from an end-to-side jejunoileal bypass (Payne’s operation) to the 30 cm to 30 cm end-to-end modification 5 years postoperatively. The second revision for inadequate weight loss was performed 4 years after a 46 cm to 30 cm end-to-end jejunoileal bypass. In this patient, the proximal 25 cm of jeiunum were joined to the distal 20 cm of ileum. Subsequently, both of these subjects have sustained weight loss to the range of their ideal weights. Striking in these patients and routinely seen in the follow-up
PROBLEMS
IN
OPERATIVE
MANAGEMENT
gastrointestinal studies of others was the marked degree of lengthening and hypertrophy of the bowel left in alimentary continuity after the first bypass procedure. References 1. PAYNE, W. H. Sixteen
J. H.,
L.
T.
DEWIND,
Surgical
KERN. years
treatment
of experience.
C.
E. SCHWAB AND of morbid obesity. Arch. Surg. 106: 432,
1973. 2. SCoTT, H. W., JR., H. H. SANDSTEAD, A. B. BRILL, H. BURKO AND R. K. YOUNGER. Experience with a new technic of intestinal bypass in the treatment of morbid obesity. Ann. Surg. 174: 560, 1971. 3. SCorr, H. W., JR., R. DEAN, H. J. SHULL, H. S. ABRAM, W. WEBB, R. K. YOUNGER AND A. B. BRILL. New considerations in use of jejunoileal bypass in patients with morbid obesity. Ann. Surg. 177: 723,
1973. 4.
SCOTT,
H.
W.,
JR.,
A.
B. BRILL
AND
R.
R.
PRICE.
Body composition in morbidly obese patients before and after jejunoileal bypass. Ann. Surg. 182: 395, 1975. 5. ABRAM, H. S., S. A. MEIXEL, W. W. WEBB AND H. W. SCOTT, JR. Psychological adaptation to jejunoilcal bypass for obesity. J. Am. Med Assoc. In press. 6. WEBB, W. W., R. PHARES, H. S. ABRAM, S. A. MEIXEL, H. W. SCOTT, JR. AND J. T. GERDES. Jejunoileal bypass procedures in morbid obesity. Preoperative psychological findings. J. Clin. Psychol. In press. 7. SCoir, H. W., JR., R. H. DEAN, R. K. YOUNGER AND W. H. BUTTS. Changes in hyperlipidemia and hyperlipoproteinemia in morbidly obese patients treated by jejunoileal bypass Surg. Gynecol. Obstet.
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OF 138:
8.
353,
WRIGHT,
drome:
MORBID
OBESITY
97
1974. K.,
AND
M.D.
pathophysiology
Problems in Surgery. Publishers, 1971.
TILs0N and
Chicago
The
treatment.
Year
short In:
Book
gut
syn-
Current
Medical
9. BUCHWALD, H., R. L. VARCO, R. B. MOORE AND M. Z. SCHWARTZ. Intestinal bypass procedures. Curr. Probl. Surg. April, 1975. 10. HOLZBACH, R. T., R. G. WEILAND, C. S. LIEBER, L. M. DECARLI, K. R. KOEPKE AND S. G. GREEN. Hepatic lipid in morbid obesity: assessment at and subsequent to jejunoileal bypass. New EngI. J. 11.
12.
Med. 290: 296, 1974. SALMON, P. A., AND K. L. REEDY. Fatty metamorphosis in patients with jejunoileal bypass. Surg. Gynecol. Obstet. 141: 75. 1975. WHITE, J. J., R. T. MOXLEY, T. POZEFSKY AND D. H. LoCKWOoD. Transient Kwashiorkor: a cause of fatty liver following
small
bowel
bypass.
Surgery
75: 829, 1974. 13. O’LEARY, J. P., J. W. MAHER, J. I. HOLLENBECK AND E. R. WOODWARD. Pathogenesis of hepatic failure after jejunoileal bypass. Surg. Forum 25: 356, 1974. 14. BROWN, R. G., J. P. O’LEARY AND E. R. WooDWARD. Hepatic effects of jejunoileal bypass for morbid obesity. Am. J. Surg. 127: 53, 1974. NESHAT, A. A., AND M. W. FLYE. Early formation of gallstones following jejunoileal bypass for treatment of morbid obesity. Am. Surg. 41: 486, 1975. 16. O’LEARY, J. P., W. C. THOMAS, AND E. R. WooDWARD. Urinary tract stone after small bowel bypass for morbid obesity. Am. J. Surg. 127: 142, 1974. 17. STARKLOFF, G. B., J. F. DONOVAN, K. R. RAMACH AND B. M. WOLFE. Metabolic intestinal surgery. 15.
Arch.
Surg.
110: 652, 1975.
H. Dean,3 J. Shull,5
M.D., M.D.,
problems associated management”2 H. William and Frank
Scott,Jr.,4 W. Gluck,6
ABSTRACT
A review
obesity in a series
of 175 carefully
(3%).
Nonfatal
common.
fair
complications
Good
electrolyte dimensional
results
results
and only (secondary
Bypass
and for persistent
reversal
patients
was complicated selected
30: 90-97,
1977.
aberrations of end-to-end
in 21%,
diarrhea by severe will
There
in two), for
The
American
Journal
of Clinical
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wound
a good
jejunoileal
Five
were
infections
six deaths
weight
during
liver
failure
electrolyte
in three
depletion
instability.
This
response
tojejunoileal
the most significant
receiving the current An additional 13% had liver
and
patients in two
experience
morbid occurred
being
without
follow-up: in one,
for
deaths
(14 patients)
of ideal
infarction
bypass
postoperative
in 82% of the patients bypass (30 cm to 20 cm).
refractory
emotional have
extensive
to the range
myocardial
secondary
The basis for a surgical approach to massive obesity lies in the dual premise that severe obesity is a serious life-shortening disorder and that long-term medical therapy is usually unsatisfactory. Although various operative procedures have been suggested, reduction of the absorptive surface of the small bowel by extensive jejunoileal bypass has been used most widely. During the past 9 years we have made a clinical and metabolic investigation of morbid obesity and the role of surgical management; over 175 obese patients have been treated by extensive jejunoileal bypass. This brief review of the problems and response to operation will summarize the metabolic complications which occurred and their management. Patients in this series were selected for operation from a much larger group of obese subjects only after an extensive inhospital appraisal of clinical, endocrinological, metabolic, psychiatric, and body compositional parameters according to the following critna: I) massive obesity (weights of two to three times ideal levels) of at least 5-year duration; 2) validation from attending physician of failure of dietary efforts to correct obesity over a period of years; 3) evidence in 90
with
was observed jejunoileal
with
with
is presented.
reduction
results.
abuse
was necessary
patients
associated patients
by weight
5% had poor
abuse),
of carefully
occurred
to alcohol
causes.
problems selected
marked
or metabolic modification
patients
of the
M.D., M.D.
one
failure from
(two
patients.
suggests
bypass.
in four unknown
from
alcohol
One
of these
that Am.J.
the majority Clin
Nutr.
the patient’s history and evaluation of incapability to adhere to prescribed dietary regimen and/on exercise programs; 4) absence of any correctable endocrinopathy such as hypothyroidism or Cushing’s syndrome; 5) absence of any other unrelated significant disease which might increase operative risk; 6) presence of certain complications such as Pickwickian syndrome, hypenlipidemia, adult onset of diabetes, and hypertension, which might be alleviated by significant weight reduction; 7) assurance of patient’s cooperation in the conduct of pre- and postoperative nutritional studies and prolonged follow-up evaluation by a physician familiar with the complications consequent to this operation. In the 175 massively obese patients selected for jejunoileal bypass, ages ranged from 16 to 63 (average 36 years). There were 100 women and 75 men. Maximal weights before opera‘From the Departments of Surgery and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee 37232. 2 Reprint requests should be sent to: H. William Scott, Jr., M.D.,
Department of Surgery, Vanderbilt Universit’ Medical Center, Nashville, Tennessee 37232. Assistant Professor of Surgery. “Professor of Surgery. 5Clinical Professor of Medicine. “Assistant
Professor
Nutrition
of Medicine.
30: JANUARY
1977,
pp. 90-97.
Printed
in U.S.A.
PROBLEMS
IN
OPERATIVE
MANAGEMENT
tion ranged from 280 to 600 pounds (127 to 272 kgs). Immediately before operation weights ranged from 240 to 560 pounds (109 to 255 kgs). Each patient was evaluated preopenatively to detect possible endocrine causes of obesity, evaluate cardiopulmonary function, assess absorptive and nutnitional status, appraise psychiatric and psychological, profile and make isotopic measurements of body composition. Associated factors identified in this group included a family history of obesity in about one-half of the patients. About one-half had hyperlipidemia, exhibited by abnormal lipoprotein electrophoretograms in 69 patients with Fredenickson’s type IV hypenlipopnoteinemia, 13 patients with type II, and one with types V. Gallstones occurred in 32%, maturity onset diabetes in 28%, persistent diastolic hypertension in 15%, and clinically active gout requiring treatment in eight patients. Excluding diabetes, no significant endocninopathies were uncovered. Body compositional data based on 40K whole body counting indicated an average body fat content in the range of6O to 65% ofbody weight. Most patients had parameters of pulmonary function in the normal range except for a diminished PO2 six had clinical features of Pickwickian syndrome. Two patients had had previous myocandial infanctions and one had sustained a previous stroke. The end-to-side jejunoileal shunt described by Payne (1) (group I) was used in the first 11 patients of this series but abandoned after disappointing follow-up experience. Subsequently, we have used end-to-end anastomosis of a short segment of proximal jejunum to a short segment of distal ileum, while draining the bypassed long length of jejunoileum into transverse colon on sigmoid (2). In an effort to determine optimal dimensions of shortened bowel in alimentary continuity, three variations of this procedure have been studied: in 12 patients (group II) 12 inches of proximal jejunum were anastomosed end-toend to the distal 12 inches of ileum (30 cm to 30 cm); in group III (21 patients) the proximal 12 inches ofjejunum were joined to ileum 6 inches proximal to the ileocecal valve (30 cm to 15 cm); and in group IV, 131 patients had the proximal jejunum 12 inches from Treitz ligament anastomosed to the ileum 8
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OF
MORBID
91
OBESITY
inches from the ileocecal valve (30 cm to 20 cm). Procedures performed in conjunction with jejunoileal bypass are shown in Table 1 Most frequently performed were sim ultaneous cholecystectomy (26 patients) and umbilical hernia repair (13 patients). Although panniculectomy was performed in 13 patients, more recently it has been abandoned as a routine part of the operative procedure. In contrast, placement of an infranenal vena caval clip has been performed in the last 34 patients to reduce the incidence of clinically significant pulmonary thromboembolism. Appendectomy was routinely performed before construction of the bypass in all patients. Nasogastnic suction was discontinued 2 to 3 days after operation and oral liquids, usually restricted to 1,500 ml daily, were started. In the first few days after institution of oral liquids, multiple watery stools occurred. Low fat diet, restriction of fluids with meals, and diphenoxylate hydrochloride in a dosage of 5 mg three to four times a day or codeine 15 to 30 mg three to four times a day usually resulted in satisfactory control of the diarrhea during the early postoperative period. After discharge from the hospital each patient has been followed in conjunction with the family physician and in our clinic. An effort has been made to have all patients return repeatedly for both outpatient and inpatient studies of their clinical result, nutritional, metabolic, and body compositional status, psychiatric state, and degree of rehabilitation. Details of these results have been reported separately and exceed the scope of this report (3-6). .
TABLE Associated
I procedures
(175
Procedure Vena
caval
clipping
Cholecystectomy Previous removal Panniculectomy Umbilical hernia repair Ovarian cystectomy Tubal ligation Hysterectomy, D and C Hiatal hernia repair Ileal resection (carcinoid)
patients) No. 34 26 17 13 13 4 3 4 3 1
DEAN
92
Results The majority of patients recovered from operation without incident. There were, however, five postoperative deaths in the series of 175 patients (3%): one with bowel infarction from mesenteric venous thrombosis after intestinal bypass and extensive ileal and mesenteric resection for malignant ileal carcinoid with nodal metatases to the root of the mesentery; three from pulmonary embolism; and a fifth from diffuse thrombophlebitis, hemorrhagic pneumonia, and sepsis (Tabl’e
2). Nonfatal postoperative complications developed in 35 patients (Table 2). These included wound seroma in 14 patients and superficial wound infection in 14 others. One of these also developed stomal obstruction, which required revision, and venous thrombosis with pulmonary emboli. Three other patients had thromboembolic complications. Two patients developed early postoperative hepatitis attributable, we believe, to halothane anesthesia. There was only one early (1st day) evisceration. All patients with these complications recovered with appropriate treatment. During the follow-up period of a few months to 8 years there have been six deaths among the 170 patients who have survived jejunoileal shunt (Table 3). One young woman who made an apparently uneventful recovery from operation died TABLE 2 Complications bypass (175
after patients)
jejunoileal
Complications Operative Ileal
mortality and mesenteric
No.
resection
infarction of bowel Pulmonary embolism Thrombophlebitis, pneumonitis Nonfatal complications Wound infection Staph Coliform Wound seroma Hepatitis (halothane) Prolonged ileus stomal obstruction Thromboembolism Evisceration
sepsis,
hemorrhagic
with
5(3%) I 3 I 36(21%) 14 7 7 14 2 2 I 3 I
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ET
AL.
suddenly in her home 3 months later. No autopsy was done. A man of 60 years with severe generalized atherosclerosis died with myocardial infarction in his home 6 months after operation. Another young man of 25 years with a long history of excessive alcohol consumption died with vaniceal hemorrhage, alcoholic hepatosis, and liver failure 7 months after operation. A second patient with longstanding alcohol abuse died 3 #{189} years after operation from postalcoholic nutritional cirrhosis, portal hypertension, and bleeding esophageal vanices. Two other patients, both women, ages 57 and 34 years, died 15 and 6 months, respectively, after operation with unexplained hepatitis and hepatic failure. In the older woman there was a history of “social” drinking but no evidence of alcohol abuse. The other woman was a total abstainer. Overall mortality rate in 175 patients was-6.4%. Periods of follow-up in the groups under study range from 5 to 8 years in the patients with Payne’s operation (group I) and from 3 to 4 years in the patients of group II, from 2 to 3 years in the patients of group III (30 cm to 15 cm), and up to 2 years in the patients with the 30 cm to 20 cm jejunoileal shunt of group IV. The data comparing weight loss afterjejunoileal bypass in the patients of these several groups are presented in Figure 1. Although early precipitant weight loss occurred in each group, those with Payne’s operation (group I) and 50% of those with 30 cm to 30 cm end-to-end jejunoileal shunt (group II) subsequently lost weight more gradually and weights tended to plateau after 12 to 18 months at levels above ideal range. After 2 or more years a few patients in both of these groups had begun to regain weight. In contrast, patients in the group of end-toend jejunoileal shunt with 30 cm of jejunum joined to 15 to 20 cm of distal ileum (groups TABLE 3 Late deaths
after
jejunoileal
bypass
(1966-
1975)
Cause Alcoholic cirrhosis, variceal failure Hepatitis, liver failure Sudden death (? pulmonary Myocardial infarction Total no. deaths
No. bleeding,
liver
2 2
embolism)
I 1 6(35%)
PROBLEMS
IN
OPERATIVE
MANAGEMENT
III and IV) have had a more rapid rate of weight loss during the 1st year after operation. More than 70% of patients in these two groups followed for I year or more have achieved reduction to the range of ideal weight. Studies of body composition after jejunoileal bypass indicate that both body fat and lean body mass are lost in the early postoperative months. The loss of lean body mass has been greatest in group III (30 cm to 15 cm), concomitant with the most prolonged persistence of diarrhea. In all groups, however, potassium homeostasis has been usually achieved by 4 to 6 months, and subsequently fat is lost in preference to lean body mass (4). The results of clinical follow-up based on the criteria listed in Table 4 have been appraised in the surviving patients in each BODY
WEIGHT
% OF INITIAL
-I
Fz U-
0
OF
6
9
1215
Jejunoileal (1966-1975);
18 21 242730
93
OBESITY
group followed for 1 year or more after jejunoileal bypass and are summarized in Table 5. In 1 1 patients with Payne’s end-tosidejejunoileal shunt (group I) followed 5 to 8 years, the absence of good results and the predominance of poor results reflect the failure of satisfactory sustained weight reduction. In the 92 patients with end-to-end jejunoileal shunt who have been followed from 1 to 4 years the results have varied with the dimensions of surgical shortening of intestine. In group II (30 cm to 30 cm), six of the 12 patients (50%) achieved a good result. Fair results, achieved by five of this group, were secondary to an unsatisfactory degree of weight reduction. No significant metabolic or nutritional deficits have developed in any of these patients, and diarrhea has not persisted as a problem. One patient had a poor result because of totally inadequate weight loss. Among the 80 patients in groups III (30cm to 15 cm) and IV (30 cm to 20 cm) who have been followed I to 3 years, 61 (75%) have achieved a good result. Good results have been obtained by 8 1 % of the 60 patients in group IV who have had follow-ups of 1 to 2 years. The degree of rehabilitation in the patients who have had good results and most of these who are credited with fair results is difficult to measure objectively. Return to full preoperative work capacity and the assumption of fullor part-time new work has been accomplished by all but six patients. In the latter small group, retirement programs or wealth which precluded the need to work have been imporTABLE
PRE-3
MORBID
5 bypass for morbid obesity results of follow-up
MONTHS FIG. I. Chronology of weight loss four dimensional variations ofjejunoileal TABLE Criteria
4 in appraisal
Results Good Fair Poor
in patients bypass.
after
End-to-side (Payne procedure) 35cm to 10cm (group I)
of results Criteria
Weight lem; Weight
loss satisfactory; no diarrhea probno metabolic deficits loss not ideal; mild diarrhea on occa-
sion; Weight rhea;
minimal metabolic deficits loss unsatisfactory; persistent severe metabolic deficits
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Jejunoilealshunt group
diar-
End-to-end 3Ocmto3Ocm (group 2) 30cm to 15cm (group 3) 30cmto20cm (group 4)
No. patients
Yr
Il
Results Good
Fair
Poor
5-8
0
2
9
12
34
6
5
I
20
2-3
12
7
1
60
1-2
49
8
3
94
DEAN
tant influences. The new body image developed by those individuals who have brought their massively overweight status down to a normal or near normal weight range has been impressive to our medical and surgical team and in particular to our clinical psychologists and psychiatric consultants. A study of personality profiles and psychological aspects of the massively obese patients of this group before and afterjejunoileal bypass is reported separately (5, 6). Metabolic parameters which were assessed before operation have been studied in the period of follow-up. Reduction in carbohydrate absorption is indicated by impairment in d-xylose absorption and by flattening of oral glucose tolerance curves in the postoperative period. A large increase in fecal fat loss (20 to 85 g/day) has occurred in each of the 30 patients in whom it has been possible to measure this in the follow-up period after jejunoileal bypass (3). Malabsorption of fat and bile acids has been accompanied by an impressive and sustained fall in the serum cholesterol and triglyceride levels in all groups of patients. Irrespective of base-line concentrations there has been a consistent fall in both serum cholesterol and serum triglyceride to levels of 160 mg/lOO ml or less after operation, and these levels have been sustained throughout the periods of follow-up. Li popnotei n elect rophoretogram s have returned to normal in all patients with type II hyperlipoproteinemia and in all but four patients with type IV. Sequential follow-up has shown no recurrence of the original lipoprotein abnormality in any patient (7). Late
complications
Persistent deficits
diarrhea:
water
and
electrolyte
Diarrhea ceased within 1 to 3 months after bypass in all patients in group 11(30 cm to 30 cm) and in eight of 11 patients in group I except after overindulgence in excessive liquid or fat intake. Postoperative diarrhea has persisted for a slightly longer period in most of the patients of Groups III and IV. Persistent diarrhea has been a problem for 45% of patients in group III (30 cm to 15 cm). In contrast only 17% of the patients in group IV (30 cm to 20 cm) have had this problem.
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ET
AL.
Electrolyte deficits requiring supplementation have occurred only in patients with persistent diarrhea. The major cations, potassium, magnesium, and calcium, have been given as oral supplements as required in such cases until the diarrhea has come under control; however, seven patients with more severe deficits have required hospitalization during the penod of follow-up for panenteral supplementation. Excessive intake of liquids with meals and of foods rich in fat and lactose have been frequent factors in refractory diarrhea. After 12 to 18 months, the postoperative adaptive changes in the shortened bowel described by Wright and Tilson (8) which increase absorptive capability not only curtail continued weight loss but increase dietary fat and lactose tolerance and diarrhea of earlier months usually ceases. Buchwald et al., (9) advise routine oral supplementation after jejunoileal bypass with 45 to 60 mEq of potassium and 6 to 12 g of calcium carbonate daily in prophylactic therapy. Fatty
liver
and
hypoproteinemia
Accumulation of neutral fat in hepatocytes is a common finding in massive obesity. In 100 obese patients submitted to wedge biopsy of the liver, we found gross and microscopic evidence of hepatic steatosis in 74% before jejunoileal bypass. Similar observations have been made by many authors but the causative mechanism remains obscure (1, 9-11). After jejunoileal bypass, an increase in fat accumulation in the liver in most patients ha been documented by many observers (1, 9-11). Serum protein concentrations have tended to decline with notably lowered albumin levels (3). This appears to reflect protein-calorie malabsorption. The enhanced fatty metamorphosis of the liver coupled with protein-calorie malnutrition resembles an adult form of the tropical protein deficiency disorder known as kwashiorkor (12). Our clinical and body compositional data (4) support the concept that massively obese patients treated by jejunoileal bypass will recover satisfactorily from this phase of protein deficiency and hepatic fatty metamorphosis after 12 to 24 months if no added hepatotoxic factors are imposed.
PROBLEMS
Hepatotoxic
factors
and
IN
OPERATIVE
hepatic
MANAGEMENT
failure
Excessive alcohol intake after jejunoileal bypass led to alcoholic hepatosis, vaniceal hemorrhage, and death in one patient and hepatic failure and death in another of our patients. Further, alcohol probably contnibuted to death from hepatic failure in one other patient. Alcohol abuse promoted hepatomegaly in three other patients in group I, reliefwas obtained by cessation ofdninking in two and by restoration of alimentary continuity in one other. We advise all patients to abstain from alcohol aftenjejunoileal bypass. Another possible cause of hepatic injury after jejunoileal bypass is the potential for bacterial colonization and overgrowth in the shortened bowel and/or bypassed jejunoileum with toxic absorption of bacterial metabolites, deconjugates such as lithocolic acid, or bacterial endotoxin. The experimental work of O’Leary and his associates (13, 14) supports this possibility and suggests the use of broad spectrum antibiotics in preventive thenapy. Careful close clinical observation of all patients who are submitted to jejunoileal bypass is mandated by the rare but hazardous potential for development of toxic damage to the liver, especially during the phase of protein-calonie malnutrition. The clinical symptoms are those of a “flu-like” syndrome of malaise, myalgias, weakness, and easy fatigue coupled with anorexia and nausea. Elevation of serum alkaline phosphatase, lactic dehydrogenases, and transaminases (SGOT) usually precedes a rise in bilirubin on clinical jaundice. Australian antigen is usually negative. In six patients in the present series who developed those clinical manifestations within 3 to 12 months after jejunoileal bypass, treatment with 3 to 8 weeks of tetracyclines (on doxycycline) coupled with elemental dietary supplements has resulted in subsidence of symptoms and reversion of the serum enzyme alterations and liver biopsies to normal. Failure of response to such a treatment regimen is an indication to take down the intestinal bypass and restore alimentary continuity. This has been necessary in one patient in this series, with subsequent subsidence of symptoms and early beneficial results. Failure to take down the shunt in two other patients alluded to previously whose response to tetnacyclines and elemental diet was inadequate by
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OF
MORBID
OBESITY
95
retrospective analysis resulted in death from hepatic failure in each instance. Similar expenience has been reported by Woodward’s group (References 13 and 14 and E. R. Woodwand, personal communication). In the early years of this series, halothane anesthesia was used commonly. Two young women developed Australian antigen-negalive hepatitis in the immediate postoperative period after jejunoileal bypass under halothane. Each recovered fully, without evidence of liver damage, after supportive therapy. No hepatotoxic agent other than halothane could be elicited to explain the hepatitis. We have discontinued the use of the agent as an anesthetic in obese subjects. Ga//stones Gallstones occurred before jejunoileal bypass in 52 of 175 patients (30%); cholecystectomy was done in each. In the period of follow-up after bypass five other patients have developed symptomatic cholelithiasis and have had cholecystectomy. Neshat and Flye (15) have recently described a patient thought to have developed gallstones S weeks after jejunoileal bypass. Our experience suggests that it is more likely in such a case that stones were already present before operation. Whether bile becomes more or less lithogenic after jejunoileal bypass is a topic for investigation. Renal
stones and hyperoxa/uria
One on more bouts of uretenal colic attributed to stone formation have occurred in 15 of 175 patients after jejunoileal bypass. Hyperoxalunia is a common finding (16, 17). According to Stankloffet al. (17), 60% of 300 postoperative patients had elevated urinary oxalate levels which may be caused by increased absorption of exogenous oxalate, possibly owing to decreased calcium binding in the gut. Six percent of Stankloff’s preoperative patients developed renal calculi. The preventive regimen he prefers is low-oxalate diet with high calcium intake to increase intestinal oxalate binding Gout Although mon after
transitory hypenunicemia bypass, clinical gout is rare
is com(3, 17).
96
DEAN
Nine of 175 patients had gout which required treatment before operation. Four new cases have developed since operation. Amelioration of gouty attacks has occurred in four of the older cases and five are unchanged. One patient who rapidly lost over 200 pounds in an 18-month period developed severe gouty attacks with gouty nephropathy requiring repeated hospitalizations for control. A nemia
and
vitamin
deficiency
Persistent iron deficiency anemia with chronic low-grade melena has developed since operation in three patients. Repeated endoscopies and x-ray studies of the gastrointestinal tract have failed to reveal a bleeding site. Response to oral iron has been good. Serum concentrations of vitamins A, B12, C, D, and folate have been measured repeatedly during follow-up in the majority of patients after jejunoileal bypass. Transient deficiencies in the early postoperative months have been observed sporadically in A, E, folate, and C concentrations in about onethird of the patients and have been treated with oral supplements. No chronic avitaminoses have occurred. No evidence of B12 deficiency has developed in any patient of this series. Bypass
reversal
The potential reasons for jejunoileal bypass reversal are limitless. Nevertheless, improper selection of poorly motivated patients and severe refractory metabolic aberrations consequent to jejunoileal bypass constitute the most frequent problems necessitating reconstitution of complete gastrointestinal continuity. Five patients in this series had bypass reversal 7 months to 2 years after operation. Liver failure secondary to continued alcohol abuse required bypass reversal in two of these. In one of these individuals, takedown was performed after admission to another hospital for hepatic decompensation, portal hypertension, and bleeding esophageal varices. However, death occurred 2 weeks after operation. A third patient requiring takedown 9 months after jejunoileal bypass had developed hepatitis and severe hepatic steatosis unre-
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ET
AL.
sponsive to parenteral nutrition and tetracydine therapy. As previously stated, absorption of hepatotoxic substances from the bypassed segment was suggested but unproven in this case. Another patient received bypass reversal elsewhere 7 months postoperatively for excessive diarrhea and weight loss. Attempted management of these problems without bypass takedown was complicated by severe emotional instability in this patient. The final reversal was performed in conjunction with operative management of an intractable duodenal ulcer and partial gastric outlet obstruction occurring 10 months after jejunoileal bypass. This patient also had sustamed an inappropriately rapid weight loss of 200 pounds during this period secondary to persistent diarrhea. One year after bypass takedown, selective gastric vagotomy, and pyloroplasty, all metabolic derangements have resolved and his weight has been maintamed slightly above desired levels. Bypass
revision
Anastomotic revisions for partial obstruction were performed in three patients. One end-to-end jejunoileostomy was revised 15 days after operation. Another was revised for symptoms of chronic partial obstruction 7 months postoperatively. The final anastomotic obstruction occurred at the ileosigmoidostomy for drainage of the bypassed segment. This was corrected 3 weeks after jejunoileal bypass. Each of these patients recovered from reoperation and has had no subsequent gastrointestinal obstructive symptoms. Inadequate weight loss prompted revision in two additional patients. One of these individuals was converted from an end-to-side jejunoileal bypass (Payne’s operation) to the 30 cm to 30 cm end-to-end modification 5 years postoperatively. The second revision for inadequate weight loss was performed 4 years after a 46 cm to 30 cm end-to-end jejunoileal bypass. In this patient, the proximal 25 cm of jeiunum were joined to the distal 20 cm of ileum. Subsequently, both of these subjects have sustained weight loss to the range of their ideal weights. Striking in these patients and routinely seen in the follow-up
PROBLEMS
IN
OPERATIVE
MANAGEMENT
gastrointestinal studies of others was the marked degree of lengthening and hypertrophy of the bowel left in alimentary continuity after the first bypass procedure. References 1. PAYNE, W. H. Sixteen
J. H.,
L.
T.
DEWIND,
Surgical
KERN. years
treatment
of experience.
C.
E. SCHWAB AND of morbid obesity. Arch. Surg. 106: 432,
1973. 2. SCoTT, H. W., JR., H. H. SANDSTEAD, A. B. BRILL, H. BURKO AND R. K. YOUNGER. Experience with a new technic of intestinal bypass in the treatment of morbid obesity. Ann. Surg. 174: 560, 1971. 3. SCorr, H. W., JR., R. DEAN, H. J. SHULL, H. S. ABRAM, W. WEBB, R. K. YOUNGER AND A. B. BRILL. New considerations in use of jejunoileal bypass in patients with morbid obesity. Ann. Surg. 177: 723,
1973. 4.
SCOTT,
H.
W.,
JR.,
A.
B. BRILL
AND
R.
R.
PRICE.
Body composition in morbidly obese patients before and after jejunoileal bypass. Ann. Surg. 182: 395, 1975. 5. ABRAM, H. S., S. A. MEIXEL, W. W. WEBB AND H. W. SCOTT, JR. Psychological adaptation to jejunoilcal bypass for obesity. J. Am. Med Assoc. In press. 6. WEBB, W. W., R. PHARES, H. S. ABRAM, S. A. MEIXEL, H. W. SCOTT, JR. AND J. T. GERDES. Jejunoileal bypass procedures in morbid obesity. Preoperative psychological findings. J. Clin. Psychol. In press. 7. SCoir, H. W., JR., R. H. DEAN, R. K. YOUNGER AND W. H. BUTTS. Changes in hyperlipidemia and hyperlipoproteinemia in morbidly obese patients treated by jejunoileal bypass Surg. Gynecol. Obstet.
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OF 138:
8.
353,
WRIGHT,
drome:
MORBID
OBESITY
97
1974. K.,
AND
M.D.
pathophysiology
Problems in Surgery. Publishers, 1971.
TILs0N and
Chicago
The
treatment.
Year
short In:
Book
gut
syn-
Current
Medical
9. BUCHWALD, H., R. L. VARCO, R. B. MOORE AND M. Z. SCHWARTZ. Intestinal bypass procedures. Curr. Probl. Surg. April, 1975. 10. HOLZBACH, R. T., R. G. WEILAND, C. S. LIEBER, L. M. DECARLI, K. R. KOEPKE AND S. G. GREEN. Hepatic lipid in morbid obesity: assessment at and subsequent to jejunoileal bypass. New EngI. J. 11.
12.
Med. 290: 296, 1974. SALMON, P. A., AND K. L. REEDY. Fatty metamorphosis in patients with jejunoileal bypass. Surg. Gynecol. Obstet. 141: 75. 1975. WHITE, J. J., R. T. MOXLEY, T. POZEFSKY AND D. H. LoCKWOoD. Transient Kwashiorkor: a cause of fatty liver following
small
bowel
bypass.
Surgery
75: 829, 1974. 13. O’LEARY, J. P., J. W. MAHER, J. I. HOLLENBECK AND E. R. WOODWARD. Pathogenesis of hepatic failure after jejunoileal bypass. Surg. Forum 25: 356, 1974. 14. BROWN, R. G., J. P. O’LEARY AND E. R. WooDWARD. Hepatic effects of jejunoileal bypass for morbid obesity. Am. J. Surg. 127: 53, 1974. NESHAT, A. A., AND M. W. FLYE. Early formation of gallstones following jejunoileal bypass for treatment of morbid obesity. Am. Surg. 41: 486, 1975. 16. O’LEARY, J. P., W. C. THOMAS, AND E. R. WooDWARD. Urinary tract stone after small bowel bypass for morbid obesity. Am. J. Surg. 127: 142, 1974. 17. STARKLOFF, G. B., J. F. DONOVAN, K. R. RAMACH AND B. M. WOLFE. Metabolic intestinal surgery. 15.
Arch.
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110: 652, 1975.
