Marjorie Sue Yaughan, RN, MSN
Surgery for the morbidly obese Nonendocrine-related obesity has been prevalent sporadically in society for centuries. Exogenous obesity is now recognized as a major health problem in the United States. Studies indicate increased mortality and morbidity in even the moderately obese individual. For example, individuals who are 10% to 30% overweight have an increased incidence of heart disease, cerebral hemorrhage, diabetes, and diseases
Marjorie Sue Vaughan, RN, MSN, is administrative assistant, director of nursing, DePaul Community Health Center, S t Louis, Mo. She is a graduate of St John’s Hospital School of Nursing, Springfield, Mo, and St Louis University.
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of the digestive system (eg cholelithiasis and cirrhosis) . l Additionally, the greater the degree of obesity, the greater the mortality. These statistics do not even begin to estimate the morbidity in the superobese individual who may be 60% to 150% or more over his ideal weight. Statistics support the assumption that mortality and morbidity significantIy decrease as weight decreases, so that effective, sustained weight loss for the morbidly obese individual is mandatory.2 In certain persons, conservative means of controlling moderate obesity are ineffective. Consequently, their obesity progresses to a morbid, superobese state. Persons who weigh more than 100 pounds over their ideal weight for height have generally been classified as morbidly obese.3 Intestinal bypass procedures have been developed to relieve this massively obese condition. As a result, operating room nurses are becoming increasingly aware of nursing care problems peculiar to the morbidly obese individual. Solutions to these problems can also be applied to the moderately obese surgical patient.
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Goal of surgery. The goal of jejunoileal bypass surgery is to produce a controlled, malabsorption state with subsequent weight loss. Thus, morbid obesity is traded for a malabsorption state which can be more readily controlled. By shortcircuiting the normal intestinal flow, decreased transit time results. Reduced absorption of food stuffs or chyme can then occur. This derangement of normal bowel continuity is not without consequences, and careful patient selection is critical (Table 1).4 Surgical intervention to control morbid obesity has evolved from animal studies demonstrating sustained weight loss after massive small bowel resections and observations in patients who underwent small bowel resection necessitated by occlusion of mesenteric vessek5 In 1954, an experimental surgical model based on animal studies for producing weight loss was proposed. The procedure consisted of a 90% jejunoileal bypass with end-to-end anastomosis 4 cm from the ileocecal valve. The bypassed segment of small bowel was then anastomosed to the ascending colon. Shortly thereafter at a meeting of the American Surgical Association, A J Kremen described a patient in whom a bypass procedure had been performed secondary to mesenteric vascular thrombosis when 90 cm of the jejunum and 48 cm of ileum were left in physiologic alignment. In a short term follow-up, Dr Kremen observed that the patient was slowly losing weight. Since then, three surgical options for weight loss have evolved: jejunocolic, jejunoileal, and gastric bypass (exclusion) procedures. In the jejunocolic shunt (fig 11, employed by Payne in 1963, the
Table 1 Criteria for patient selection
1. Obesity of massive degree (weight two to three times ideal level) of at least five years duration.
2. Evidence from attending physician indicating failure of dietary efforts to correct obesity over a period of years.
3. Evidence from
patient's history and evaluation indicating patient's apparent incapability of adhering to prescribed dietary regimens and/or exercise programs.
4. Absence of any correctable endocrinopathy (such as hypothyroidism or Cushing's syndrome) which might be the cause of obesity.
5. Absence of any other unrelated significant disease which might increase operative risk.
6. Presence of certain complications such as Pickwick syndrome (the complex of exogenous obesity, somnolence, hypoventilation, and erythrocytosis), adult onset of diabetes, and hypertension, which might be alleviated by Significant weight reduction.
7. Assurance of patient's cooperation in conduct of preoperative and postoperative metabolic and body compositional studies plus prolonged follow-up evaluation.
initial 37.5 to 50 cm of jejunum is anastomosed to the mid-transverse colonG Although significant weight loss occurred, 50.6 kg (123 pounds) in 52 weeks, many patients experienced severe disturbances of fluid and electrolyte balance beginning immediately po~toperatively.~
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Fig 1 . Payne I jejunoco/ic bypass. The initial 37.5 to 50 crn of jejunum is anastomosed to the mid-transverse colon.
Fig 2. Payne I1 jejunoileal bypass. The small bowel is interrupfed 35 cm distal to the ligament of Treifz and 10 crn from the ileocecal valve.
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Subsequently, the jejunocolic bypass was converted to a jejunoileal shunt, leaving the ileocecal valve intacta to allow reabsorption of bile salts, vitamins, and water. In this procedure, known as the Payne I1 (fig 2), the small bowel is interrupted 35 cm distal to the ligament of Treitz and 10 cm from the ileocecal valve. The distal jejunum is completely closed leaving an afferent limb of the jejunum in continuity down t o an end-to-side anastomosis 10 cm from the ileocecal valve. A second type of jejunoileal bypass is the Scott procedure (fig 3)' in which the jejunum is resected 30 cm distal to the ligament of Treitz and 30 cm proximal to the ileocecal valve and an end-to-end jejunoileal anastomosis completed. The excluded jejunoileal segment is then anastomosed end-to-side to the transverse or sigmoid colon and the distal jejunum closed. Later, Scott modified his
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procedure by resecting the jejunum 30 cm from the ligament of Treitz and 20 ern from the ileocecal valve. An end-to-end anastomosis of the jejunum and ileum is then performed.'O A modification of the Scott pro-
cedure is that by Wise in which about 35 cm of the proximal jejunum is anastomosed end-to-end to the distal 10 cm of the ileum (fig 4). The excluded segment of small bowel is anastomosed to the cecum instead of the transverse or sigmoid colon.11
Fig 3. Scott jejunoileal bypass. The jejunum is resected 30 cm disfal to the ligament of Treitz and 30 cm proximal to the ileocecal valve and an end-to-end jejunoileal anastomosis
is completed.
Fig 4. Wise (modified Scott) jejunoileal bypass. The proximal jejunum is anastomosed end-to-end to the distal ileum.
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Gastric bypass is a third and totally different type of surgical shunt to produce weight loss in the morbidly obese. In gastric bypass, Mason and Ito (fig 5) I 2 anastomosed a 15% to 30% fundic segment of the stomach to the upper jejunum and closed the distal segment of the stomach. In the above described procedures no part of the intestinal tract is removed. Instead, a portion is merely bypassed but remains in the body. Generally, the two most untoward complications of small bowel bypass are liver dysfunction, characterized by fatty infiltration and in some cases liver failure, and fluid and electrolyte imbalance manifested particularly by potassium and/or calcium deficiency. Jejunocolic complications. The jejunocolic bypass procedure (fig 1) was abandoned because it led to unalterable steatorrhea or excessive loss of fats in the feces. With the jejunocolic shunt, the ileocecal value was completely bypassed, obviating its
physiologic braking effect. In addition, the enterohepatic circuit for bile salt absorption was interrupted. Not only was a large portion of the jejunum (necessary for absorption of fats, proteins, and carbohydrates) removed from alignment, but the terminal ileum, the specialized site for bile salt transport, was also bypassed. This resulted in steatorrhea as ingested fats were not being emulsified. Both fatty acids and bile salts which escaped absorption were irritating to the colonic mucosa and probably produced diarrhea on that basis a1one.I3 Other reported complications of the jejunocolic procedure were fluid and electrolyte imbalance occurring secondary to severe diarrhea, polyarthritis, fatty infiltration of the liver, as well as measurable liver dysfunction which can progress to liver fail~re.'~,'~ Jejunoileal complications. (Payne 11, Scott, Wise procedures) The jejunoileal bypass procedure has fewer complications than its predecessor, Fig 5. Mason and Ito gastric bypass. A 15% to 30% fundic segment of the stomach is anastomosed to the upper jejunum and the distal segment of the stomach is closed.
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atty infiltration of the liver is more likely to increase if weight reduction is rapid.
the jejunocolic shunt. However, fatty infiltration of the liver continues to be a problem. Postoperatively, during the course of weight reduction, the liver increases in fat content. Fatty infiltration accompanied by malnutrition, hypoproteinemia, nausea, or vomiting is more likely to increase if weight reduction is rapid. In a follow-up of 165 intestinal bypass patients, 12 jejunocolic and 153 jejunoileal, Payne reported an overall mortality of 9.75%.The mortality as a direct result of the bypass procedure itself was 6 % ; five of 16 deaths were a result of hepatic failure.16 Early and late complications of jejunoileal bypass are a result of severe diarrhea. Although jejunoileal anastomosis allows for some reabsorption of bile salts by the ileum, and thus, adequate absorption of some dietary fat, severe diarrhea can occur. In the majority of patients, diarrhea can be managed by dietary restriction of long-chain triglycerides. Reports indicate that patients empirically adopt low-fat diets and curtail food c o n ~ u m p t i o n . ~ ~ With intractable diarrhea, water is lost in combination with electrolytes. Specific losses include potassium, calcium, magnesium, sodium, and bicarbonate ions. An early manifestation is severe metabolic acidosis
with hypokalemia. With prolonged diarrhea, hypocalcemia and hypomagnesemia occur. Severe loss of fat soluble vitamins (A, D, E, K) occurs secondary to fat malabsorption. Since the ascending colon remains in continuity in jejunoileal procedures, reabsorption of water, potassium, and sodium is improved. However, supplements of oral calcium, potassium, and parenteral magnesium may be necessary. Although the Payne jejunoileal bypass procedure has proved to be satisfactory in producing weight loss, a few markedly obese patients tend to plateau at a higher than desirable weight. Reflux of nutritive chyme into the excluded segment of the small bowel with the resulting absorption probably accounts for this plateau. Reflux into the bypassed segment could account for the observation that vitamin B,, deficiency has not been demonstrated in patients with a Payne I1 procedure. Gastric bypass complications. Complications of the Mason and Ito gastric bypass procedure closely resemble the dumping syndrome occasionally seen following the Bilroth I1 gastric resection. Patients are no longer able to regulate the rate at which chyme enters the small intestine, and consequently, stomach con-
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tents are rapidly dumped into the jejunum. Weakness, profuse perspiration, nausea, dizziness, flushing, epigastric fullness, and palpitation result. The postoperative symptoms in the gastric bypass patient range from a feeling of warmth t o occasional vomiting and diarrhea. Nursing considerations in the operating room. Prevention is the key to avoiding complications in the operating room. From the outset, the OR nurse is confronted with a sizable technical problem. The normal-sized stretcher used for transporting patients from their hospital room to the operating room is not adequate for the morbidly obese patient. It may be safer for some patients to walk to the operating room. If the patient must ambulate to the operating room, he cannot be prernedicated and will be fully awake, invariably anxious, and in need of firm, but kind, attention from anesthesia and OR personnel. The nurse becomes the prime provider of psychological support, basic communication, assurance, and instruction. Physical support or assistance from orderlies or others must be requested in advance. If the patient is transferred via stretcher to the operating room, special care must be taken when he is transferred from the stretcher to the
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OR table. Careful stabilization of the transport cart and the table is essential to prevent the patient from falling. It is also essential to recognize and plan for additional manpower in holding the transport cart adjacent to the operating table. Warning the patient in advance of the extremely narrow table and asking the patient to feel for both sides of the table will prevent unnecessary startling of the patient and accidental falling. As early a s feasible, restraints placed above the knees should be secured. Any patient movement must be accomplished carefully and with prior instructions. Prior t o anesthesia and while the patient is fully awake, the patient should be asked to assist in moving for proper placement of the prewarmed ground plate. Caution must be taken to prevent the plate from becoming trapped between skin folds thus allowing a knife edge contact with the skin. Such curling of skin folds around the plate may lead t o serious burns. During the intestinal bypass operation, the patient may need to be placed in Fowler’s and/or Trendelenburg position. Consequently, table braces for shoulders and feet are essential. Care must also be taken to protect the patient from the hard
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t mav be safer for some obese patients to walk to the operating room.
metal surface of the operating table and anesthesia screen by providing adequate padding. An increased incidence of postoperative wound infections has been reported in the massively obese surgical patient. Both hypoperfusion and enormous potential dead space predispose to development of infection. Adipose tissue normaIly has a poor blood supply, and the potential space for infection is the thick abdominal fat pad between the peritoneum and the skin which may be from 8 to 10 cm thick. A sterile, closed drainage system is commonly employed with tubes inserted into this subcutaneous space. The OR nurse should realize the importance of informing recovery room, and eventually, ward staff concerning this appliance. The necessity of correct positioning of the drainage system, avoidance‘ of tube kinking, and periodic observation of drainage is fundamental in this high risk group predisposed to wound infections. If the drainage system is closed by a spring compression device rather than gravity, the appliance must be compressed to provide suction. Special care to prevent infection in the subcutaneous fat area is doubly important, because obese patients tend to have a higher incidence of wound dehiscence.
Upon completion of surgery and anesthesia, the OR nurse is confronted with movement of a semiconscious patient three to five times the nurse’s size. Movement may be facilitated by the use of a transfer roller. If at all possible, transfer should be from the operating table to an electric ward bed, to avoid having to move the patient twice. An electric bed is preferable so that in the operating room the patient’s head may be elevated 45 degrees. Correct positioning of the patient with a huge abdominal mass is crucial to maintaining ventilatory ability. As soon after surgery as possible, the patient should be placed in Fowler’s position unless contraindicated by his cardiovascular status. The secret to expert nursing care of the morbidly obese patient in the operating room depends on knowledge of the special needs and physiologic differences these individuals present to the nursing staff. These include the following: 1. increased physical size and the problem of transport preoperatively and intraoperatively 2. preoperative anxiety and the need for firm but kind physical and mental support 3. proper placement and maintenance of the drainage system with
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instruction to postoperative nursing personnel 4. proper positioning preoperatively, intraoperatively, and postoperatively (consider prevention of accidents, protection and safety) 5. acknowledgement of the increased incidence of wound infection and propensity toward dehiscence. Careful preventive preparation is the key to avoiding some of the potential complications which are due to these differences. Summarg. The need for weight reduction of extremely overweight individuals coupled with unsuccessful conservative forms of weight reduction has led physicians to choose surgery as a course of therapy, The most frequently used and apparently most successful surgical option to date is the jejunoileal bypass. This derangement of normal bowel continuity produces a malabsorption state initiating weight loss. Liver changes, fluid, and electrolyte imbalance continue t o be a problem postoperatively. Careful investigative research and meticulous preoperative, intraoperative, and postoperative care and followup is warranted. OR nurses are becoming more cognizant of the problems continually encountered with the morbidly obese patient intraoperatively and should be well informed t o anticipate patient needs and subsequently guide effective management.
4. H W Scott, Jr, e t al, "Jeiunoileal shunt i n surgical treatment of morbid obesity," Annals of Surgery, I71 ( M a y 1970) 771. 5. A J Kremen, J Linnet, C Nelson, "An experimental evaluation o f the nutritional importance of proximal and distal small intestine," Annals of Surgery, 140 (September 1954) 439. 6. J H Payne, L T DeWind, R B Commons, "Metabolic observations i n patients with ieiunocolic shunts," American Journal of Surgery, 106 (1963) 274. 7. Ibid, 282. 8. J H Payne, L T DeWind, "Surgical treatment of obesity," The American Journof o f Surgery, i 18 (August 1969) 141. 9. H W Scott, Jr, e t al, "Experience with a new technic of intestinal bypass i n the treatment of morbid obesity," Annols of Surgery, 174 (1971)
562. 10.
H W Scott, Jr, "Intestinal bypass operations in treatment o f massive obesity," Hospital Practice, 7 ( 1972) 105. I I. L Wise, personal communication, Chief of Surgery, S t Louis County Hospital: ( S t Louis: Washington University School of Medicine, 19731974). 12. E E Mason, C Ito, "Gastric bypass," Annals of Surgery, 170 (1969) 329. 13. H K Wright, D M Olson, "The short gut syndrome,"
Current Problems in Surgery,
H Duncan, "Polyarthritis i n obese patients with intestinal bypass," Annals of Internal Medicine, 75 (September 1971 ) 377. 15. P J Snodgrass, "Obesity, small-bowel bypass and liver disease," New England Journal of Medicine, 282 ( A p r i l 9, 1970) 872. 16. J H Payne, e t al, "Surgical treatment of morbid obesity: sixteen years o f experience," Archives of Surgery, 106 ( A p r i l 1973) 434. 17. D B Mulcare, H F Dennin, E J Drenick, "Effects o f d i e t on malabsorption after small bowel bypass," Journol of the Dietetic Association, 57 (October 1970) 334.
Notes I. Statistical Bulletin, Metropolitan Life Insurance Company, 41 (January, February, March, 1960). 2. Statirficol Bulletin, Metropolitan Life Insurance Company, 40 ( A p r i l 1960). 3. Society of Actuaries: Build and Blood Pressure Study, Vols I & I I (Chicago: Society of Actuaries, 1959).
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(June
1971) 14-15. 14. J W Shagrin, B Frame,
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