Partial Reconstruction of Intestinal Continuity in the Treatment of Severe Side Effects Following Intestinal Shunt Operation for Obesity P. DAN@, 0. VAGN NIELSEN & L. STORGAARD Medical Dept. P, Division of Gastroenterology, and Dept. of Surgical Gastroenterology C,
Scand J Gastroenterol Downloaded from informahealthcare.com by QUT Queensland University of Tech on 11/21/14 For personal use only.
Rigshospitalet, Copenhagen, Denmark
Dano, P., Nielsen, 0.Vagn & Storgaard, L. Partial reconstruction of intestinal continuity in the treatment of severe side effects following intestinal shunt operation for obesity. Scand. J. Gastroent. 1919, 14, 161-112. Severe side effects of intestinal shunt operation were the indication for reoperation ofeight patients. To maintain the acquired weight loss, complete revision of the bypass and return to normal gastrointestinal continuity was omitted. The shunt was taken down and moved 20 cm in proximal direction on the terminal ileum. After this procedure weight loss was converted to a small gain in weight, diarrhoea decreased, and electrolyte disturbances turned out to be a minor problem. At the same time quality of life improved. We suggest that this type of reoperation is adequate in most patients suffering from severe side effects after intestinal bypass operation.
Key words: Bypass; electrolyte disturbances: obesity: reconstruction; shunt operation; side effects; weight loss
P. Dan&, M.D., Medical Dept. P,Division of Gastroenterology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen 0,Denmark
In obese patients subjected to intestinal shunt operation, it is not possible to predict the rate and amount of weight loss when the functioning small intestine is 48 cm. There seems to be a narrow margin between bypassing too much bowel and bypassing too little bowel. Possibly, the height and degree of overweight are important factors as well, since the weight loss is correlated with these factors (1). The average weight loss is approximately 50 kg during the first postoperative year (4). The results of jejunoileal bypass are generally satisfactory in more than 80% of the patients. In the remaining 10-20% one or more problems may require revision of the bypass. These problems may be
categorized as inadequate weight loss, excessive weight loss, persistent uncontrollable diarrhoea or associated severe anorectal problems, severe uncontrollable electrolyte disturbances, and progressive liver failure (3). In case of excessive weight loss, liver insuffciency, and electrolyte disturbances complete revision of the bypass has been the usual treatment, most frequently leading to normal liver function, cessation of diarrhoea, a d a rapid weight gain up to initial values or more (2, 14, 21, 22). This paper gives detailed information of the results of partial lengthening of the existing bypass in eight patients, in whom the complications after intestinal shunt
168
P. Dand, 0. Vagn Nielsen & L . Storgaard
operation were managed without regaining initial, preoperative weight.
Scand J Gastroenterol Downloaded from informahealthcare.com by QUT Queensland University of Tech on 11/21/14 For personal use only.
CASE MATERiAL The study was based on eight patients out of 90 subjected to shunt operation for obesity since 1970. Five were female, three were male. Age range was 25-50 years (mean 36 years). Preoperative weight was 147 kg on an average (range 107-188 kg), the degree of overweight 127% (range 79-180%). Time from intestinal shunt operation to revision of the shunt was 20 months (median; range 8-84 months). The average weight loss was 80 kg (range 39-105 kg), the weight at the time of reoperation being 67 kg on an average (range 56-89 kg). In all patients 48 cm of small intestine was left in function with various jejunum/ileum ratios: type I , 36 cm of jejunum anastomosed end-to-side to 12 cm terminal ileum (four patients); type IZ, 24 cm + 24 cm (one patient); and type ZZZ, 12cm + 36 cm (three patients). Selection of patients, method of operation, and investigations before and after the operation have been published previously (4, 6). The time from reoperation to the final registration was 36 months on an average (range 2-78 months).
Because of uncontrollable diarrhoea (patients 1, 2, and 8), electrolyte disturbances (patients 1, 2, 4, 5, and 7), continuous loss of weight (patients 1-7), and development of liver cirrhosis and liver insufficiency (patients 1, 3, and 6), the patients were reoperated upon and the anastomosis moved 20 cm in proximal direction; Before the reoperation parenteral hyperalimentation (1000 ml saline with 9 mmol calcium, 5 0 mEq potassium, and 8 mmol magnesium per litre, 1000 ml aminofucin lo%, and 500 ml Intralipid 20% per day) was attempted in order to treat the symptoms or to improve preoperative status. After the initial shunt operation all patients received peroral supplementation of calcium, potassium, and multivitamins, occasionally magnesium as well. OPERATIVE PROCEDURE In all patients the end-to-side jejunoileostomy was moved 20 cm in proximal direction. In this way the total intestine in function should be increased to 68cm. This was, however, not the case in all patients; on the contrary, the original 48-cm shunt had changed considerably in three patients. At the time of reoperation the intestine in function was 63,
Fig. 1. Weight at the time of intestinal shunt operation ( t t ). and after revision of the shunt.
( t ), at the time of reoperation
Reconstruction of Intestinal Continuitji
patient it increased from three to four. In three patients with 10 watery stools per day the number decreased to 1-4. The transitory increase in diarrhoea from five to seven in patient 5 may be caused by a psychogenic polydipsia. The concentration in serum of calcium (Fig. 2), magnesium (Fig. 3), and potassium (Fig. 4) increased in almost all patients (patient 2 had no increase in serum calcium, patient 3 no increase in serum magnesium, and patient 5 no increase in serum potassium). All values normalized in one patient only. However, none of the patients required parenteral electrolyte supplementation after the revision of the bypass. Before the revision parenteral hyperalimentation (including water and electrolyte) was given to five patients (patients 1,2, 3,6. and 8). Parenteral electrolyte substitution-particularly potassium-was given to one patient (patient 5) with psychogenic polydipsia and a heavy loss of potassium in the stools. This supplementation before the revision of the bypass is the most reasonable explanation of the decrease in diarrhoea and increase in serum electrolytes at the time of revision (Figs. 2-4). Serum albumin was decreased in six patients before and in three patients after the reoperation. Schilling’s test was abnormal in two patients subjected to type I operation and normalized after the revision (7-16% and 3-12%). In one patient sub-
80, and 80 cm, and the intestine was characterized by marked hypertrophy. In one patient the proximal jejunum measured 9 cm in diameter. The three patients in question had had the shunt for the longest period oftime, namely 3 1 (patient 5), 33 (patient 3), and 84 months (patient 8).
Scand J Gastroenterol Downloaded from informahealthcare.com by QUT Queensland University of Tech on 11/21/14 For personal use only.
RESULTS Although the patients concerned did not differ in preoperative height or weight from other shuntoperated patients in our department, weight loss was much higher than usually seen: 80 kg on an average, compared with about 50 kg (4). Lengthening of the shunt with 20 cm of terminal ileum immediately converted continuous and uncontrolled weight loss to stabilization or a slow increase in weight in six of the patients (Fig. 1). The bypass of the last patient has just been revised (patient 8), and the last patient but one (patient 2) had a complete revision of the bypass 3 months later because of continuous side effects, probably initiated by a very abnormal psychiatric status, which was the case in a further three patients (patients 3,4. and 5). The weight gain 2-78 months (average 36 months) after the revision of the bypass was 14 kg on an average (range-6 to 32 kg). The number of stools decreased from 6 (range 1&3) to 3 (range 5-1) after the revision. In two patients the number was unchanged, and in one
mmol / I
2.40
5
I
2.20
1
2.00 1.80 2
4
6
169
8
10
12
20
28
Fig. 2. Serum calcium concentration. Lowest value before reoperation of reoperation ( t t ). and after revision of the shunt.
36 Months
( t ). at the time
110
P. D a d , 0. Vagn Nielsen & L . Storgaard
rnmol/ I
_ _ _ - - _ _ - _ _ _ _ _ _ - - _ _ - _ - - - - 5
Scand J Gastroenterol Downloaded from informahealthcare.com by QUT Queensland University of Tech on 11/21/14 For personal use only.
L 7
2
4
6
8
10
12
20
28
36
Months
Fig. 3. Serum magnesium. Symbols as in Fig. 2.
jected to type I11 operation the Schilling test increased from 13% to 18%. Liver cirrhosis developed in one (patient 6) 15 months after bypass operation. After revision of the shunt serum albumin and prothrombin concentrations increased, but alkaline phosphatase, aminotransaminase, and transferrin concentrations were unchanged and normal as before the revision. No liver biopsy has been performed after revision of the shunt. Another patient (patient 3) without liver biopsy before the bypass operation had micronodular liver cirrhosis in the biopsy 4$ years after the bypass operation; at the time of revision of the shunt fibrosis only could be demonstrated, and repeated
liver biopsies from 3 months up to 3 years after the revision were unchanged-as were all the slightly abnormal liver parameters, except prothrombin, which increased. In one patient with very abnormal liver parameters (patient 1) all parameters normalized after the revision. Quality of life ( 5 ) improved in 6 patients. As previously mentioned, one patient (No. 2) had a complete revision of the bypass 3 months after the revision of the shunt. Patient 8’s bypass has just been revised; she was the only patient remitted from another department because of severe side effects of the bypass operation, and for this reason she cannot be listed in Figs. 2-4.
rneq /I
4
I
5
2
4
6
8
10
Fig. 4. Serum potassium. Symbols as in Fig. 2.
12
20
28
36 Months
Scand J Gastroenterol Downloaded from informahealthcare.com by QUT Queensland University of Tech on 11/21/14 For personal use only.
Reconstruction of Intestinal Continuity
171
metamorphosis or fibrosis of the liver after shunt DISCUSSION Complete reversal of jejunoileal bypass for severe operation, although liver parameters improved in metabolic problems has been reported several times two of five patients with increased alkaline phospha(2, 14, 21, 22). This technique solves most of all tase; it is well known that histological changes in the undesirable problems associated with the bypass but liver after bypass operation are reversible after a also nullifies the beneficial effects of the bypass, with total reanastomotic procedure (13, 16, 17, 19) and weight gain to the preoperative level. Therefore, a that no consistent correlation between the extent of procedure that corrects the complications of the first hepatic steatosis or cirrhosis and the degree of aboperation without depriving the patient of the bene- normality of liver function tests is evident (12). ficial effect of a proper weight loss should be used. After intestinal shunt operation intestinal adapta- CONCLUSION takes place within a year' A considerable inWe conclude that uncontro~~ed weight loss, electrocrease in length, circumference, and mucosal thicklyte disturbances, and diarrhoea after intestinal ness occurs in the functioning small intestine (1 5, shunt operation for obesity may be well treated by 18), accompanied by a marked mucosal villus hylengthening the ileal segment by 20cm without perplasia, particularly in the ileum (9), without depriving the patient of the beneficial effects of an hyperplasia in the bypassed intestine (18). Absorpadequate and irreversible weight loss. tion of water, saline, and glucose in the functioning small intestine increases after surgery (8, 20). Animal experiments indicate that this absorptive adap- REFERENCES 1. Backman, L. Acta Chir. Scand. 1975,141,424-430 tation is most pronounced in the ileum, which maintains the absorptive capacity when bypassed, 2. Buchwald, H., Schwartz, M. Z. & Varco, R. L. Advanc. Surg. 1973, 7 , 235-255 whereas the jejunum loses the absorptive capacity 3. Cegielski. M. M., Organ, C. H. & Saporta, J. A. Surg. Gynec. Obstet. 1976, 1 4 2 , 829-839 when bypassed ( 10). Biochemically, the increased absorption is caused by an increase in specific en- 4. Dana, P. Intestinal Shunt Operation for Adipositas. Thesis, Copenhagen, 1976 zyme activity in the functioning ileum (9, 11) and 5. Dana, P. & Hahn-Pedersen, J. Scand. J . Gastroent. 1977, I 2 , 769-774 unchanged activity in the functioning jejunum (7, 6. Dan@,P., Jarnum, S. & Nielsen, 0. Vagn. Scand. J . 11). Gastroent. 1973, 8, 457-464 Increasing the length of the existing bypass by 7. Dan@,P., Nielsen, 0. Vagn, Petri, M. & Jsrgensen, B. Scand. 1. Gastroent. 1976, I I , 129-134 increasing the length of the functioning ileum in 8. Dowling, R. H. & Booth,C. C. Lancet 1966.11, 146order to terminate uncontrolled weight loss, diar147 rhoea, or electrolyte disturbances seems rational. In 9. Dudrick, S. J., Daly, J. M., Castro, G. & Akhtar, M. Ann. Surg. 1977, 18s. 642-648 five patients Cegielski et al. (3) lengthened the ileal segment from 4 to 18 in. (35 cm), and weight gradu- 10. Gleeson, M. H.. Cullen, J. & Dowling, R. H. Chir. Sci. 1972, 43, 73 1-742 ally increased and stabilized 7 to 23 kg above the 1 I. Gudmand-Hoyer, E., Asp, N-G. & Andersen, B. Scand. J . Gastroent. 1976, Suppl. 38, 32 lowest weight from 6 months to 3 years after the revision; at the same time metabolic abnormalities 12. Holzbach, R. T., Wieland, R. G., Lieber, C. S., DeCarli, L. M., Koepke, K. R. & Green, S. G. New disappeared. Engl. J . Med. 1974, 290: 296-299 In the present study the shunt was lengthened 13. Maxwell, J. G., Richards, R. C . & Albo, D., Jr. Amer. J. Surg. 1968, 116, 648-652 with 20 cm of terminal ileum only, and weight loss 14. McGill. D. B.. Humpherys, S. R., Baggenstoss, A. H. was converted to a small and slow weight increase of & Dickson, E. R. Gastroenterology 1972, 63. 87214 kg on an average from 2-78 months after the 877 revision. Diarrhoea decreased and metabolic abnor- 15. Parkinson, R. S. & Walker-Smith, J. A. Med. J . Aust. 1973, 2, 205-210 malities-particularly the electrolyte disturb- 16. Salmon, P. A. & Reedyk, L. Surg. Gynec. Obstet. ances-turned out to be a minor problem requiring 1975, 141, 75-84 no parenteral supplementation. This study does not 17. Shibata, H. R., Mackenzie, J. R. & Huang, S. Arch. Surg. 1971, 103, 229-237 answer the question whether a lengthening of the 18. Solhaug, J. H. Scand. J. Gastroent. 1976, 11, 155shunt by 20cm is sufficient to reverse the fatty 160
172
P. Danb. 0. Vagn Nielsen & L . Srorgaard
19. Soyer, T. S.. Ceballos, R. & Aldrete. J. S . Surgery 1976, 79, 601-604 20. Weinstein, L. D.. Shoemaker, C. P., Hersh, T. & Wright, H. K. Arch. Surg. 1969, 99, 560-562
Scand J Gastroenterol Downloaded from informahealthcare.com by QUT Queensland University of Tech on 11/21/14 For personal use only.
Received 19 June 1978 Accepted 10 September 1978
21. Weismann, R. W. Amer. J . Surg. 1973, 125, 437447 22. Wills, C. E., Jr.J. Med. Ass. Ga 1969,58, 456-461
Scand J Gastroenterol Downloaded from informahealthcare.com by QUT Queensland University of Tech on 11/21/14 For personal use only.
Rigshospitalet, Copenhagen, Denmark
Dano, P., Nielsen, 0.Vagn & Storgaard, L. Partial reconstruction of intestinal continuity in the treatment of severe side effects following intestinal shunt operation for obesity. Scand. J. Gastroent. 1919, 14, 161-112. Severe side effects of intestinal shunt operation were the indication for reoperation ofeight patients. To maintain the acquired weight loss, complete revision of the bypass and return to normal gastrointestinal continuity was omitted. The shunt was taken down and moved 20 cm in proximal direction on the terminal ileum. After this procedure weight loss was converted to a small gain in weight, diarrhoea decreased, and electrolyte disturbances turned out to be a minor problem. At the same time quality of life improved. We suggest that this type of reoperation is adequate in most patients suffering from severe side effects after intestinal bypass operation.
Key words: Bypass; electrolyte disturbances: obesity: reconstruction; shunt operation; side effects; weight loss
P. Dan&, M.D., Medical Dept. P,Division of Gastroenterology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen 0,Denmark
In obese patients subjected to intestinal shunt operation, it is not possible to predict the rate and amount of weight loss when the functioning small intestine is 48 cm. There seems to be a narrow margin between bypassing too much bowel and bypassing too little bowel. Possibly, the height and degree of overweight are important factors as well, since the weight loss is correlated with these factors (1). The average weight loss is approximately 50 kg during the first postoperative year (4). The results of jejunoileal bypass are generally satisfactory in more than 80% of the patients. In the remaining 10-20% one or more problems may require revision of the bypass. These problems may be
categorized as inadequate weight loss, excessive weight loss, persistent uncontrollable diarrhoea or associated severe anorectal problems, severe uncontrollable electrolyte disturbances, and progressive liver failure (3). In case of excessive weight loss, liver insuffciency, and electrolyte disturbances complete revision of the bypass has been the usual treatment, most frequently leading to normal liver function, cessation of diarrhoea, a d a rapid weight gain up to initial values or more (2, 14, 21, 22). This paper gives detailed information of the results of partial lengthening of the existing bypass in eight patients, in whom the complications after intestinal shunt
168
P. Dand, 0. Vagn Nielsen & L . Storgaard
operation were managed without regaining initial, preoperative weight.
Scand J Gastroenterol Downloaded from informahealthcare.com by QUT Queensland University of Tech on 11/21/14 For personal use only.
CASE MATERiAL The study was based on eight patients out of 90 subjected to shunt operation for obesity since 1970. Five were female, three were male. Age range was 25-50 years (mean 36 years). Preoperative weight was 147 kg on an average (range 107-188 kg), the degree of overweight 127% (range 79-180%). Time from intestinal shunt operation to revision of the shunt was 20 months (median; range 8-84 months). The average weight loss was 80 kg (range 39-105 kg), the weight at the time of reoperation being 67 kg on an average (range 56-89 kg). In all patients 48 cm of small intestine was left in function with various jejunum/ileum ratios: type I , 36 cm of jejunum anastomosed end-to-side to 12 cm terminal ileum (four patients); type IZ, 24 cm + 24 cm (one patient); and type ZZZ, 12cm + 36 cm (three patients). Selection of patients, method of operation, and investigations before and after the operation have been published previously (4, 6). The time from reoperation to the final registration was 36 months on an average (range 2-78 months).
Because of uncontrollable diarrhoea (patients 1, 2, and 8), electrolyte disturbances (patients 1, 2, 4, 5, and 7), continuous loss of weight (patients 1-7), and development of liver cirrhosis and liver insufficiency (patients 1, 3, and 6), the patients were reoperated upon and the anastomosis moved 20 cm in proximal direction; Before the reoperation parenteral hyperalimentation (1000 ml saline with 9 mmol calcium, 5 0 mEq potassium, and 8 mmol magnesium per litre, 1000 ml aminofucin lo%, and 500 ml Intralipid 20% per day) was attempted in order to treat the symptoms or to improve preoperative status. After the initial shunt operation all patients received peroral supplementation of calcium, potassium, and multivitamins, occasionally magnesium as well. OPERATIVE PROCEDURE In all patients the end-to-side jejunoileostomy was moved 20 cm in proximal direction. In this way the total intestine in function should be increased to 68cm. This was, however, not the case in all patients; on the contrary, the original 48-cm shunt had changed considerably in three patients. At the time of reoperation the intestine in function was 63,
Fig. 1. Weight at the time of intestinal shunt operation ( t t ). and after revision of the shunt.
( t ), at the time of reoperation
Reconstruction of Intestinal Continuitji
patient it increased from three to four. In three patients with 10 watery stools per day the number decreased to 1-4. The transitory increase in diarrhoea from five to seven in patient 5 may be caused by a psychogenic polydipsia. The concentration in serum of calcium (Fig. 2), magnesium (Fig. 3), and potassium (Fig. 4) increased in almost all patients (patient 2 had no increase in serum calcium, patient 3 no increase in serum magnesium, and patient 5 no increase in serum potassium). All values normalized in one patient only. However, none of the patients required parenteral electrolyte supplementation after the revision of the bypass. Before the revision parenteral hyperalimentation (including water and electrolyte) was given to five patients (patients 1,2, 3,6. and 8). Parenteral electrolyte substitution-particularly potassium-was given to one patient (patient 5) with psychogenic polydipsia and a heavy loss of potassium in the stools. This supplementation before the revision of the bypass is the most reasonable explanation of the decrease in diarrhoea and increase in serum electrolytes at the time of revision (Figs. 2-4). Serum albumin was decreased in six patients before and in three patients after the reoperation. Schilling’s test was abnormal in two patients subjected to type I operation and normalized after the revision (7-16% and 3-12%). In one patient sub-
80, and 80 cm, and the intestine was characterized by marked hypertrophy. In one patient the proximal jejunum measured 9 cm in diameter. The three patients in question had had the shunt for the longest period oftime, namely 3 1 (patient 5), 33 (patient 3), and 84 months (patient 8).
Scand J Gastroenterol Downloaded from informahealthcare.com by QUT Queensland University of Tech on 11/21/14 For personal use only.
RESULTS Although the patients concerned did not differ in preoperative height or weight from other shuntoperated patients in our department, weight loss was much higher than usually seen: 80 kg on an average, compared with about 50 kg (4). Lengthening of the shunt with 20 cm of terminal ileum immediately converted continuous and uncontrolled weight loss to stabilization or a slow increase in weight in six of the patients (Fig. 1). The bypass of the last patient has just been revised (patient 8), and the last patient but one (patient 2) had a complete revision of the bypass 3 months later because of continuous side effects, probably initiated by a very abnormal psychiatric status, which was the case in a further three patients (patients 3,4. and 5). The weight gain 2-78 months (average 36 months) after the revision of the bypass was 14 kg on an average (range-6 to 32 kg). The number of stools decreased from 6 (range 1&3) to 3 (range 5-1) after the revision. In two patients the number was unchanged, and in one
mmol / I
2.40
5
I
2.20
1
2.00 1.80 2
4
6
169
8
10
12
20
28
Fig. 2. Serum calcium concentration. Lowest value before reoperation of reoperation ( t t ). and after revision of the shunt.
36 Months
( t ). at the time
110
P. D a d , 0. Vagn Nielsen & L . Storgaard
rnmol/ I
_ _ _ - - _ _ - _ _ _ _ _ _ - - _ _ - _ - - - - 5
Scand J Gastroenterol Downloaded from informahealthcare.com by QUT Queensland University of Tech on 11/21/14 For personal use only.
L 7
2
4
6
8
10
12
20
28
36
Months
Fig. 3. Serum magnesium. Symbols as in Fig. 2.
jected to type I11 operation the Schilling test increased from 13% to 18%. Liver cirrhosis developed in one (patient 6) 15 months after bypass operation. After revision of the shunt serum albumin and prothrombin concentrations increased, but alkaline phosphatase, aminotransaminase, and transferrin concentrations were unchanged and normal as before the revision. No liver biopsy has been performed after revision of the shunt. Another patient (patient 3) without liver biopsy before the bypass operation had micronodular liver cirrhosis in the biopsy 4$ years after the bypass operation; at the time of revision of the shunt fibrosis only could be demonstrated, and repeated
liver biopsies from 3 months up to 3 years after the revision were unchanged-as were all the slightly abnormal liver parameters, except prothrombin, which increased. In one patient with very abnormal liver parameters (patient 1) all parameters normalized after the revision. Quality of life ( 5 ) improved in 6 patients. As previously mentioned, one patient (No. 2) had a complete revision of the bypass 3 months after the revision of the shunt. Patient 8’s bypass has just been revised; she was the only patient remitted from another department because of severe side effects of the bypass operation, and for this reason she cannot be listed in Figs. 2-4.
rneq /I
4
I
5
2
4
6
8
10
Fig. 4. Serum potassium. Symbols as in Fig. 2.
12
20
28
36 Months
Scand J Gastroenterol Downloaded from informahealthcare.com by QUT Queensland University of Tech on 11/21/14 For personal use only.
Reconstruction of Intestinal Continuity
171
metamorphosis or fibrosis of the liver after shunt DISCUSSION Complete reversal of jejunoileal bypass for severe operation, although liver parameters improved in metabolic problems has been reported several times two of five patients with increased alkaline phospha(2, 14, 21, 22). This technique solves most of all tase; it is well known that histological changes in the undesirable problems associated with the bypass but liver after bypass operation are reversible after a also nullifies the beneficial effects of the bypass, with total reanastomotic procedure (13, 16, 17, 19) and weight gain to the preoperative level. Therefore, a that no consistent correlation between the extent of procedure that corrects the complications of the first hepatic steatosis or cirrhosis and the degree of aboperation without depriving the patient of the bene- normality of liver function tests is evident (12). ficial effect of a proper weight loss should be used. After intestinal shunt operation intestinal adapta- CONCLUSION takes place within a year' A considerable inWe conclude that uncontro~~ed weight loss, electrocrease in length, circumference, and mucosal thicklyte disturbances, and diarrhoea after intestinal ness occurs in the functioning small intestine (1 5, shunt operation for obesity may be well treated by 18), accompanied by a marked mucosal villus hylengthening the ileal segment by 20cm without perplasia, particularly in the ileum (9), without depriving the patient of the beneficial effects of an hyperplasia in the bypassed intestine (18). Absorpadequate and irreversible weight loss. tion of water, saline, and glucose in the functioning small intestine increases after surgery (8, 20). Animal experiments indicate that this absorptive adap- REFERENCES 1. Backman, L. Acta Chir. Scand. 1975,141,424-430 tation is most pronounced in the ileum, which maintains the absorptive capacity when bypassed, 2. Buchwald, H., Schwartz, M. Z. & Varco, R. L. Advanc. Surg. 1973, 7 , 235-255 whereas the jejunum loses the absorptive capacity 3. Cegielski. M. M., Organ, C. H. & Saporta, J. A. Surg. Gynec. Obstet. 1976, 1 4 2 , 829-839 when bypassed ( 10). Biochemically, the increased absorption is caused by an increase in specific en- 4. Dana, P. Intestinal Shunt Operation for Adipositas. Thesis, Copenhagen, 1976 zyme activity in the functioning ileum (9, 11) and 5. Dana, P. & Hahn-Pedersen, J. Scand. J . Gastroent. 1977, I 2 , 769-774 unchanged activity in the functioning jejunum (7, 6. Dan@,P., Jarnum, S. & Nielsen, 0. Vagn. Scand. J . 11). Gastroent. 1973, 8, 457-464 Increasing the length of the existing bypass by 7. Dan@,P., Nielsen, 0. Vagn, Petri, M. & Jsrgensen, B. Scand. 1. Gastroent. 1976, I I , 129-134 increasing the length of the functioning ileum in 8. Dowling, R. H. & Booth,C. C. Lancet 1966.11, 146order to terminate uncontrolled weight loss, diar147 rhoea, or electrolyte disturbances seems rational. In 9. Dudrick, S. J., Daly, J. M., Castro, G. & Akhtar, M. Ann. Surg. 1977, 18s. 642-648 five patients Cegielski et al. (3) lengthened the ileal segment from 4 to 18 in. (35 cm), and weight gradu- 10. Gleeson, M. H.. Cullen, J. & Dowling, R. H. Chir. Sci. 1972, 43, 73 1-742 ally increased and stabilized 7 to 23 kg above the 1 I. Gudmand-Hoyer, E., Asp, N-G. & Andersen, B. Scand. J . Gastroent. 1976, Suppl. 38, 32 lowest weight from 6 months to 3 years after the revision; at the same time metabolic abnormalities 12. Holzbach, R. T., Wieland, R. G., Lieber, C. S., DeCarli, L. M., Koepke, K. R. & Green, S. G. New disappeared. Engl. J . Med. 1974, 290: 296-299 In the present study the shunt was lengthened 13. Maxwell, J. G., Richards, R. C . & Albo, D., Jr. Amer. J. Surg. 1968, 116, 648-652 with 20 cm of terminal ileum only, and weight loss 14. McGill. D. B.. Humpherys, S. R., Baggenstoss, A. H. was converted to a small and slow weight increase of & Dickson, E. R. Gastroenterology 1972, 63. 87214 kg on an average from 2-78 months after the 877 revision. Diarrhoea decreased and metabolic abnor- 15. Parkinson, R. S. & Walker-Smith, J. A. Med. J . Aust. 1973, 2, 205-210 malities-particularly the electrolyte disturb- 16. Salmon, P. A. & Reedyk, L. Surg. Gynec. Obstet. ances-turned out to be a minor problem requiring 1975, 141, 75-84 no parenteral supplementation. This study does not 17. Shibata, H. R., Mackenzie, J. R. & Huang, S. Arch. Surg. 1971, 103, 229-237 answer the question whether a lengthening of the 18. Solhaug, J. H. Scand. J. Gastroent. 1976, 11, 155shunt by 20cm is sufficient to reverse the fatty 160
172
P. Danb. 0. Vagn Nielsen & L . Srorgaard
19. Soyer, T. S.. Ceballos, R. & Aldrete. J. S . Surgery 1976, 79, 601-604 20. Weinstein, L. D.. Shoemaker, C. P., Hersh, T. & Wright, H. K. Arch. Surg. 1969, 99, 560-562
Scand J Gastroenterol Downloaded from informahealthcare.com by QUT Queensland University of Tech on 11/21/14 For personal use only.
Received 19 June 1978 Accepted 10 September 1978
21. Weismann, R. W. Amer. J . Surg. 1973, 125, 437447 22. Wills, C. E., Jr.J. Med. Ass. Ga 1969,58, 456-461
