Prog. Surg., νο1.14, pp. 46-83 (Karger, Basel 1975)

Surgical Treatment of Obesity D. HALLBERG, L. BACKMAN and S. ESPMARK Departments of Surgery and Psychiatry and Surgical Research Laboratory, Karolinska Sjukhuset, Stockholm

Contents Introduction Historical Remarks The Obese Patient at the Time of Surgery Social Disturbances Somatic Disturbances Psychic Disturbances Indications and Contraindications for Surgery The Operation Kinetics of Weight Loss after Operation In-Hospital Morbidity and Mortality Complications and Signs of Metabolic Aberrations and their Management Results Suñmarq References

46 48 51 51 52 53 54 55 59 61 63 74 76 77

Obesity is encountered in most civilnations. In some societies it is considered a positive factor, in most western countries, however, a negative factor of life. The incidence of moderate obesity in Europe is between 20 and 40 % [100, 127]. No studies have been made regarding the occurrence of pronounced obesity, 100 Ο/o overweight or more, as these subjects in general are reluctant to discuss their problems and even to supply data for a population study. The influence of massive obesity on health is difficult to evaluate. It is generally said that obese subjects have a high mortality rate [93], but

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Introduction

47

HALLBERG(BACKMAN/ESPMARK

Table Ι. Costs, benefits and somatic complications of various treatments for massive obesity Cost

Benefit (effect on body weight) short-term

long-term

Complication rate

Conservative therapy Calorie reduction Starvation Pharmacological Psychological

low high low high

moderate effective moderate moderate

ineffective ineffective ineffective ?

low moderate high low

Surgical therapy Plastic Gastrointestinal Neurosurgical

moderate high moderate

ineffective effective ineffective

ineffective effective ineffective

low moderate moderate

it has not been proved that obesity per se is the cause of the increased mortality. On the contrary, some recent studies indicate lower incidence of some diseases [90, 91]. Yet, obesity obviously increases the incidence of other diseases, such as arteriosclerotic heart disease, hypertension, diabetes mellitus, varices, and perhaps skin disorders. In addition, social and mental consequences of obesity are perhaps even more important to the patient and the community [109]. This makes it urgent to treat subjects with massive obesity by effective methods. The problem of treatment of obesity has engaged many medical specialities : internal medicine, pediatrics, psychiatry, pharmacology, biochemistry, endocrinology, gastroenterology, plastic and gastrointestinal surgery, and neurosurgery and also psychology. Table I is a summary of how we consider the costs and benefits of various kinds of treatment. Until the beginning of the 1950s the only way of treating obesity was by conservative means. Numerous kinds of diets have been offered the obese ; appetite-reducing agents or hormones such as glucagon and thyroid hormones have also been used [27]. Side effects, such as drug addiction and anorexia, are frequent. Reduced calorie intake or starvation has been in practice during many years [26, 54] and both give immediate, good weight loss but cause morbidity and mortality [55, 88]. Psychological treatment — alone or in combination with other forms of treatment — has also been used for several decades. There was a flood of publications on psychoanalytic treatment of neurotic obesity

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Treatment

HAI.LBERß/BACKMAN/FSPMARK

48

during the 1940s, but subsequently considerable doubt has been expressed about the efficacy of psychoanalysis, or of psychotherapy in general [30, 135]. The experienced psychoanalyst, Hire BRucii [30], recommends `a fact-finding, noninterpretative approach' in psychotherapy with these patients. Others [134] claim that behavior therapy, utilizing primarily operant (skimie an) conditioning, should be the treatment of choice. Conservative methods in general seem to be inadequate in the long run [129, 134], but are still of short-term value, especially in cases of moderate overweight. Obese subjects are also encouraged by mass media to take slimming agents, diets or to try various professional cures. In many studies the patients have not been observed for a sufficient time — an observation period of at least 2-5 years seems to be necessary before evaluation of the end result. In series with long observation periods the rates of success are in the order of 2-5 0/ο, which is lower than placebo effects [19]. Because of the poor long-term results after conservative therapy, and surgical methods such as neurosurgery [115] and plastic surgery [40], gastrointestinal surgery has now been tried in several thousand cases.

The literature contains a number of examples of subjects who survived extensive small bowel resections [2, 76, 111, 141]. In a survey, Hnυµονr [72] found that up to 70 0 /o of the small intestine could be resected without giving rise to uncontrollable malabsorption. In some cases the patients survived after virtually total resection of the small intestine. One of these is MEYER'S [96, 97] classical case of a man who survived intestinal resection of all but 18 in of the proximal jejunum. The first case in which surgery on the small intestine was performed with the aim of treating obesity seems to have been published by the Swedish surgeon, HENRIKSSON, [73] in 1952. He resected a segment of small intestine in an obese woman. She lost weight and was obviously satisfied with the result, as she had no postoperative trouble; 20 years later this woman reported to be in good health. The experimental work by KREMEN et al. [82] showed that up to 70 Ο /ο of the small intestine could be bypassed without harm and that the distal ileum was essential for the absorption of fat and also that the ileocecal valve seemed to be of great importance in the nutritional adjustment,

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Historical Remarks

Surgical Treatment of Obesity

49

especially after bypassing the distal small intestine. These results verified earlier clinical experiences with massive resections in man. In a discussion to a paper read in April, 1954, ص~?ν reported a small intestinal bypass operation on a very obese woman with primarily good results. In 1956 ΡλυνΕ and his colleagues started a clinical trial with jejunocolic shunts. When weight reduction was considered sufficient, reestablishment of the intestinal continuity was intended. Α report of the results was published in 1963 [106], when the complications after the operation were considered `minimal' However, in a new report, [107] it was stated that because of `intractable diarrhoea, abdominal discomfort, electrolyte depletion, and liver failure' jejunocolic shunts were abandoned. From that time on, various types of jejunoileal shunt operations were studied in many centers [34, 108, 114, 117, 119, 142]. Two types of jejunoileostomy are now made, the difference being the way of performing the anastomosis between the proximal jejunum and distal ileum in function. The first type, performed by ΡλvνΕ and DEWIND, was an endto-side enteroanastomosis; about 40 cm of jejunum were anastomosed to the ileum, 15 cm oral to the colon (fig. 1). In a number of cases inadequate weight loss followed the operation [106]. The cause of this was thought to be reflux into the blind loop, demonstrated by intestinal barium series [33]. This prompted the development of other types of jejunoileostomy which were performed as end-to-end anastomoses with drainage of the blind loop to the cecal pole or to the transverse or sigmoid colon (fig. 2) [33, 117, 120, 145]. However, there is still no proof that end-to-end anastomoses mean less reflux and, consequently, better results [114]. Α possibility of preventing reflux into the blind loop after end-to-end jejunoileostomy

Fig.]. The intestinal anatomy before (1) and after (2) jejunoileostomy end-to-side.

20 cm). Shaded part (b) represents the blind loop.

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a =Proximal jejunum (~ 40 cm); b = middle part of the intestine; c = distal ileum ( i10-

50

ΗΑιτ.αεκα/BACxMAx/ESPMARx

Fig. 2. The intestinal anatomy after three different jejunoileostomies (3-5) end-to-end. Symbols are the same as in figure 1.

8

Fig. 3. Methods (6-8) suggested to prevent reflux into the blind loop. Symbols are as in figure 1. Β = Valvula Bauhin.

Gastroplasty

Fig. 4. Two gastrosurgical methods for treatment of obesity.

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Gastric bypass

Surgical Treatment of Obesity

51

has recently been described by ΤΙL.ØΕR [138], who anastomoses the blind loop to the retained ileocecal valve and makes a new ileocecal anastomosis immediately distal to the ileocecal valve (8 in fig. 3). Another possibility is to create an artificial valve towards the blind loop (fig. 3) [67, 71a,139]. Another way of inducing malnutrition and subsequent weight loss was introduced by Μλsoν and Iτο [94]. They excluded 90 0/0 of the stomach with a retrocolic gastrojejunostomy to reestablish continuity (fig. 4). In 1973 they reported another type of gastric surgery for treatment of obesity, so-called gastroplasty [113], which implied partial division of the stomach with a 1.5-cm wide channel between the upper and lower pouches along the greater curvature. The latter method was evidently abandoned because of less weight loss. According to these authors, dumping seems to be a `desirable' complication, perhaps necessary for adequate weight loss after gastric bypass. Gastric bypass is an interesting way of attacking the problem of reducing the calorie intake in the massively obese. This method avoids the main drawbacks of intestinal bypass, namely diarrhea, electrolyte disturbances, and liver injury. However, published studies do not give any details on factors such as operative morbidity, long-term weight loss, incidence of dumping, or stomal ulcers [113].

The Obese Patient at the Time of Surgery

Social Disturbances The massively obese patients all have great difficulties to fit into social life. They often have problems with activities of daily living. They cannot find clothes in ordinary shops. They sometimes cannot get through

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There are several reasons which make the obese subject seek medical help. Some reasons are obvious while others are not, because of lack of awareness. The assessment of the patient before performing intestinal surgery must include social, somatic and mental factors. The surgical treatment aims to reduce the body weight. This at first sight, simple process may start a number of other reactions, which are linked together. The relation between some such factors are illustrated in figure 5. The change in body weight may adjust the preoperation balance and a new life situation may appear for the patient. In the postoperative course it is important to help the patient to cope with the new situation.

52

HALLBERG/:sACKMAN/ESPMARK PreupPoetop,

Preoµ PoStop. Social attitudes

j

Self-evaluation

l

Interpersonal relations

~ ~ι„ ?s; )?r

Sexual relations

~t /•y

Anxiety tolerance Mood

Education Employment-Economy Clothing Housing

χ

Emotional maturity

~ι ` y /

4 \ y

Self-assertion

* 1

>'„

Emotional relations

w Preo0.Fiixtop.

Body weight

1

Cardiobascular function

4

Respiration

4

Liver function

·.'

%r

Water-electrolyte balance Body hygiene Joint functions

\ / 4

1

1

1

change from normal

Fig.S. An analysis of the situation of the massively obese before and after intestinal surgery. Arrows (upright in squares) indicate positive or (down in squares) negative changes from normal. Slanting arrows indicate positive or negative tendencies.

Somatic Disturbances (1) Obesity can roughly be classified into two categories, hyperplastic and hypertrophic, depending on the aberrations in fat-cell morphology noted [21, 75]. Ιn hyperplastic obesity the number of fat cells is increased and the onset of obesity is at an early age, whereas the hypertrophíc obesity with a normal number of enlarged fat cells often starts later in life. This later type is often correlated to a number of metabolic sequels,

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ordinary doors or sit in ordinary chairs or in ordinary seats in trains, cars or airplanes. Standard measurements used for industrial production of things for use in dally life are usually too small for these subjects. Α limited number of professions are suitable to these individuals ; in general, sitting work with the negativ effect of inactivity. Especially the younger subjects become stigmatized by their body dimensions, which causes a distorsion of their personality development during an especially sensitive phase of their lives. This fact makes it important to treat the overweight early and efficiently.

Surgical Treatment of Obesity

53

Psychic Disturbances Psychic disturbances are found in a high number of obese subjects. Out of 96 massively obese subjects who underwent psychiatric examination before intestinal surgery, two thirds had earlier sought medical help for mental disturbances, mostly anxiety neuroses and depressions, and among

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such as derangements in carbohydrate and lipid metabolism. The most common form of obesity is a mixed type [22, 23]. Altered lipolytic parameters in enlarged fat cells are a reflection of this metabolic derangement [105, 106]. The massively obese patient thus often has an impaired gulcose tolerance and elevation of serum lipoproteins, mainly of Fredrickson types II and IV [24, 36, 121]. Another effect of the massive obesity is increased hepatic steatosis in several subjects [35, 80]. There is evidence that the degree of fat infiltration is related to the overweight [80]. Signs of impaired liver function as noted by increases in aspartate aminotransferase (ASAT), alanine aminοtransferase (ALAT) and lactate dehydrogenase (LD) are clearly related to body weight [15]. (2) The respiratory and cardiovascular functions are to some extent altered in massive obesity. The obese subjects have a tendency to underventilate and, hence, increased risks of atelectasis and pulmonary complications after surgery [38, 41]. Elevation of blood pressure is common in the massively obese [79]. In a study of 19 subjects prior to small intestinal bypass operation we found an elevated filling pressure of the heart ventricles and a high systemic and pulmonary vascular resistance, suggesting a deleterious effect on cardiovascular function in the long run [13]. The so-called Pickwick syndrome is a condition with hypoventilation, carbon dioxide retention and an abnormal sleepiness seen occasionally among obese subjects [1, 37, 116]. Elevated hematocrit is often seen in this group. (3) Α number of joint disorders are found in obesity [85], an expression of the increased load on the body. This further increases the inactivity and the difficulty to achieve weight reduction by conservative means. (4) Many obese individuals have problems with their skin hygiene, and therefore, cutaneous infections are common. Other skin disorders, such as psoriasis and pustulosis palmaris and plantaris are also seen [71]. (5) Dysmenorrhea or amenorrhea is common in obese women, which may influence the fertility. Difficulties in performing the sexual act is a common male complaint.

HALLBERG/BACKMAN/ESPMARK

54

them, 13 women had attempted suicide [62]. In 18 out of 29 subjects examined by SoLow et al. [130] the primary motivation for surgical treatment of their obesity was of a psychosocial nature. Two thirds of the patients were characterized by deficient self-esteem, strong fears of rejection with associated compulsions to please others, and difficulties with self-assertion, distortion of body image, and vocational impairment. A severe distortion of body image has also been noted by others [30, 65, 78]. In summary, the situation of the massively obese persons has many negative trails. There are few other clinical conditions in which the patient so eagerly seeks surgical help.

ΡAυνΕ and DEWIND [107] and Sco.. and LAw [119] proposed the following indications for surgical treatment of obesity : (1) body weight of more than 150 ο/ο of normal ; (2) massive overweight of more than 5 years duration, with proven trials of conservative treatment ; (3) somatic complications of obesity, such as hypertension, diabetes mellitus, joint trouble, and hypercholesterolemía increase the indications for surgery ; (4) absence of complicating serious endocrine or other somatic disorders, such as Cushing's disease, coronary insufficiency and severe liver disease ; (5) willingness to take part in all examinations suggested by the treating doctor before and after surgery ; (6) absence of psychiatric aberrations thought to complicate the postoperative course. With a few variations, items 1-5 have been followed by most surgeons when making intestinal shunt operations. The sixth item has, however, become a matter of divergent opinions. In the first place, some authors [121] claim that massively obese subjects are routinely not even moderately psychiatrically disturbed, but at most, somewhat emotionally immature and unhappy, whereas others [18] have found in the majority guilt reactions and depressions, intense enough to have brought about psychiatric contacts. As regards the screening out of patients on psychiatric grounds, several surgeons recommend the exclusion from these operations of mentally unstable persons [18, 50, 107, 121] without, however, giving any definite criteria of this instability. On the other hand, some authors exclude few, if any patients for psychiatric reasons [117, 130, 145]. SoLow et al. [130], for instance, consider `active, current psychosis'

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Indications and Contraindications for Surgery

Surgical Treatment of Obesity

55

to be the only definite psychiatric contraindication. According to our experience, certain types of neurosis or even some kinds of psychosis related to obesity may even strengthen the indication for surgery, provided that this is performed in close collaboration with an experienced psychiatrist, with facilities also of treating the patient in a psychiatric ward for some period afterwards, if needed. Mental retardation and alcoholism are relative contraindications. In the former condition the patient may be unable to attend the necessary postoperative follow-up examinations and to carry out any dieting or medication, in the latter the patient risks severe liver injury after the operation. We want to add age as another factor of importance in selecting patients. In the first place, it seems important to treat massive obesity as early as possible, in order to prevent a maladaptive personality development. An indication of such a development is the fact that a great number of obese women live or have lived together with an alcoholic partner [62]. Besides this, subjects older than 50-55 years are more prone to develop serious somatic complications. Before operation the subjects should be evaluated with regard to cardiac or respiratory diseases. Abnormal electrolyte concentration in serum should raise suspicion of some endocrine disorder, in which case cortisol in serum or 17-ketosteroíds in urine should be examined. Thyroid function tests are indicated in certain cases. Signs of impaired liver function are found in a high percentage of the massively obese [15]. Frank steatosis was found in 80-90 0 /o of the cases examined by KERN and PAYNE [80] and BucHWALD et al. [35]. In most cases these abnormalities are no contraindications to surgery. However, if cirrhosis is suspected, surgery should not be performed.

Preoperative intestinal sterilization is done according to the principles of PITH [112] and Coκκ [43]. The anesthesia is induced by short-acting barbiturates and maintained with halothane. A mechanical respirator and muscle relaxants should be used. In rare cases it may be necessary to create a preoperative tracheostomy as a safeguard because of difficulties in maintaining free airway and prevention of postoperative respiratory complications.

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The Operation

56

Two types of abdominal incisions are used, transverse or paramedían. The latter is preferable if cholecystectomy or liver biopsy is also to be performed [117]. The exposure is usually adequate using either type of abdominal incision. In view of the risks of wound infections, paØCUlectomy is generally not done at the same time. Umbilical hernia is a common finding in the obese and should be repaired. Adipose tissue is sensitive to pressure, which easily may result in necrosis [3], and therefore we advise against the use of self-retaiØg abdominal hooks. This means that two assistants are required during the operation. Massively obese subjects, weighing 200 kg or less, can be operated upon placed on ordinary operating tables. When the patient is still heavier, improvisations are necessary ; a good solution is then a delivery table. Immediately after laparotomy, the length of the small intestine is measured. We think that this is an essential part of the operation, making it possible to `tailor' the procedure to suit individual patients. The intestinal length can be measured by means of an umbilical cotton tape, placed along the intestine. The technique for measuring the intestinal length is hampered by the same errors as measuring a rubber band. Therefore it is important to standardize the method carefully [14]. The measurement should be the first step in the operation, because simple handling of the intestine will cause a shortening of about 10-20 /o, which will give an error in later measurements and may explain poor results. There are considerable individual variations in length of the small intestine. We have observed a range of 5-10 m between Treitz' ligament and the ileocecal valve. The obese subjects had a longer intestine than subjects of normal body weight, in a study performed on 88 subjects [14]. The length of the jejunum and ileum, intended to function in the shunt, is then marked with clamps and the anastomosis is performed. The length of the individual segments in function should not be fixed but rather vary according to individual measurements of body weight and small intestinal length [9, 10]. Our experience is that when the length of the jejunum in function is about 40-60 cm, the distal ileum in function should be about 2 0/ο of the total small intestinal length. If the distal ileum is shorter in this situation, the patient is more prone to develop postoperative complications. Reflux of various degrees seems to occur after all types of surgery now in use [33, 114]. As long as the possibility of reflux in the blind loop exists, the optimal length of the distal ileum must be uncertain. This is a source of error in the present surgical method. Therefore, the desirable formula for determining the length of the intestinal segment in function is hard to

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HALLBERG/BACKMAN/ESPMARB

Surgical Treatment of Obesity

57

Fig. 6. Recommended end-to-side method for a standardized fixation of the end of the

establish. The reflux may be avoided by some kind of valve mechanism or limited to a known magnitude by variations in the surgical procedure (fig. 3). Body weight kinetics in clinical series with reflux prevention methods have not yet been published. Another essential part of the procedure is to secure the blind loop in order to avoid intussusception. In series where this has not been done routinely the incidence of intussusception is high [107, 142, 145]. This complication is difficult to diagnose, as typical physical signs or findings at X-ray examinations are usually absent because of the altered anatomy. Many patients have periods of diffuse abdominal pain after the bypass operation because of gas and diarrhea, which adds to the uncertainty in settling an obstruction diagnosis. We have in our series practised the method for fixation of the blind loop shown in figure 6. This seems to be effective as no patient has developed intussusception. With this fixation to the jejunum in function this part could be drawn into the blind loop and become obstructed and a typical intestinal obstruction should be produced, the diagnosis of which is easy to establish. A sometimes difficult part of the operation is the obliteration of the opening in the mesentery between the intestinal anastomosis and the dorsal parietal peritoneum. In spite of the fact that in a few cases it was impossible to close this space properly, we have not encountered any internal herniations. Appendectomy should be performed at the bypass operation, because appendicitis-like symptoms may occur after the operation. Some obese

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blind loop.

58

subjects have gallstone disease at the time of shunt operation and others develop gallstones after surgery. Wheter or not cholecystectomy should be performed at the same time as the bypass operation is a matter of discussion. Some authors routinely perform cholecystectomies [117]. We think this extension of the operation adds to the operative risk. Therefore we prefer to make it as a secondary operation after weight loss. This gives an opportunity for a second look at the earlier operative field and also, if indications are present, possibilities for revision of the shunt. In two cases, however, we had to make acute operations on the gallbladder or biliary tree during the phase of maximal rate of weight loss. In most cases the shunt operation is not technically difficult. However, when the patient is massively obese, the procedure might be complicated because the small intestine is often very long and the mesentery short. From the literature and from personal experience we know that it is easy to close the proximal jejunum and to anastomose the blind loop to the distal ileum [15, 56, 122]. The intestinal anatomy should therefore be checked before closing the abdomen. Some authors recommend assisted ventilation during a period of up to 24 h after the shunt operation [45, 118, 123, 142]. We have seen only two cases of respiratory distress postoperatively, in patients with bronchial asthma; not even in these cases was active assistance with the respirator necessary. Gastric drainage and intravenous administration of fluid and electrolytes should be used for the first few postoperative days until bowel movements start within 2-4 days of the operation. Mean length of hospitalization after operation in our series of 100 cases was 9 days. Multivitamin preparations orally and vitamin Β12 injections are prescribed to the patients on discharge but no extra potassium or calcium. In periods they may need antidiarrheic medication, such as codeine phosphate or diphenoxylate. The patients are checked for malnutrition when necessary, or at least every 2 months, during the 1st postoperative year. After this it is still necessary to follow these patients for an unlimited time, both for psychological and physical reasons. After weight loss, redundant skin will be a problem to many patients. Skin reconstruction has been performed in four areas : the lower abdomen, medial aspects of the thighs, upper arms and breasts. Our experience is that reconstructions will be best done as multiple operations at intervals of 2-3 months [17]. The skin reconstruction of the abdomen has been performed by the technique described by CALLIA [39] and modified by

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Hnιτ.aεκα/Bnεxaτnκ/Esrnτnκg

59

Surgical Treatment of Obesity

and VANDENBUSCHE [83], namely by transposition of the umbilicus cranially and removal of redundant skin from the lower abdomen. The thigh plasties are performed as excision of triangular areas of skin. Arm plastles are done as simple oval excisions of redundant skin [133, 137]. LAGACRE

Kinetics of Weight Loss after Operation The weight loss kinetics after jejunoileal bypass operations were analyzed by HALLBERG and Βλcκµλx [69]. In these analyses the postoperative time was divided into five periods (fig. 7). The body weight changed in a typical pattern during each period. Period Ι. Rapid weight loss during 3 weeks following the operation. The weight loss during this period often amounted to 10-15 kg. Period 1I. The rate of weight loss during this period was constant, in general of 40-80 weeks duration. During this period the main weight loss occurred. The rate of weight loss varied between 0.22 and 1.81 kg/week. Period III. The rate of weight loss slowed down and body weight reached its lowest value at the end of this period. Period IV. The weight increased slightly. Period V. The weight stabilized but fluctuated about 4-5 kg. The rapid weight loss during period I is due to several factors, one of which is the loss of body water, which the obese subject has in excess [28]. Another factor is the postoperative catabolism, to some degree potentiated



100

150

200 waaks

Fig.7. Α typical body weight curve after jejunoileostomy for treatment of obesity. The periods I—V are defined in text. The patient was 179 cm tall.

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0

HALLBERG/BACKMAN/ESPMARK

60

in many cases by decreased food intake. Much of the water is lost in the frequent diarrheas which are the rule during the first postoperative months. This water loss has in some cases necessitated intravenous fluid therapy in order to avoid hypovolemia during the first weeks. Period II is the most interesting and in some cases the most critical stage in the postoperative course. During this period the rate of weight loss is constant but shows great individual variations. In a series of 85 subjects operated on, the rate of weight loss (b value) varied between 0.22 and 1.81 kg/week or 0.003 and 0.023 body-weight index units (table V). The body weight index was used in order to allow comparisons between individuals of different heights. Body weight index was calculated according to Broca's formula: The rate of weight loss was significantly correlated to the incidence of the typical complications: electrolyte disturbances and laboratory signs of liver injury [15]. The incidence of such complications was higher when the rate of weight loss was high (table III). Other complications did not show the same relations to the rate of weight loss. The rate of weight loss during period II was positively correlated to preoperative body weight, or body weight index, and negatively correlated to the total small intestinal length or to the length of distal ileum as a fraction of total small intestine length [9]. Such correlations were not found to the length of the proximal jejunum in function. This would mean that subjects with long small intestines will lose weight at a higher rate than subjects with identical body weights but with shorter total small intestine lengths, provided the operation is performed in an identical way. These correlations also tend to indicate that in this type of operation the length of the distal ileum in function is of greater importance to the weight loss than is the length of the proximal jejunum in function. As a consequence of these correlations, it might be possible in the future to `tailor' intestinal shunt operations so as to fit each patient. However, reflux of varying degree into the blind loop is still an important source of error in predicting the optimal results. During period III the rate of weight loss slows down. Several factors seem to be implicated in this change in rate. Firstly, it is known that the small intestine adapts itself to the higher needs by hyperplasia, which involves both the height of the villi and the length of the intestinal segment [12]. Secondly, as the body weight decreases, basal metabolism diminishes. The intestinal adaptation starts in period II, probably continues in

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body weight (kg) body height (cm) — 100

Surgical Treatment of Obesity

61

period IV, and is cοlmpleted in period V. The changing absorption capacity, a result of this adaptation, is probably of great importance to the shape of the postoperative body weight curve (fig. 7). After the operation it is important for the patient to take a diet containing all essential nutrients, otherwise the instituted malabsorption may be too severe. A few cases with high rates of weight loss were treated with good results by parenteral nutrition with amino acids, carbohydrate solutions, and fat emulsions, as well as oral nutrition and antídiarrheic preparations. Among these cases, a few had a kind of anorexia because of psychological obstacles, and intense psychotherapy was necessary. The causes of the weight fluctuations after stabilization in period V are not known. One plausible cause is a sensitivity to various foods, especially fat, which may induce periods of diarrhea when the fluid loss may be considerable. The patients are also sensitive to gastrointestinal infections or influenza. It may be necessary to hospitalize patients for fluid therapy after simple gastroenteritis.

The immediate postoperative complications in a collected material are evident from table II. The most serious of these are wound dehiscence [3] and pulmonary embolism. Most obese subjects have well-trained and strong abdominal muscles and the íntraabdominal pressure when coughing is certainly higher than normal. In spite of a careful suturing technique, we have encountered wound dehiscence in 5 cases out of 100 operated on. In one case anastomotic insufficiency followed wound rupture and the patient later died in peritonitis. Wound dehiscence is easily understood by observing the technique which these subjects develop to make it possible to get out of bed. By training them preoperatively not to strain the abdomen, this complication can be diminished. Pulmonary embolism is the cause of about 50 Ο /ο of the reported deaths after jejunoileal bypass operations (table II). This is a higher incidence than after abdominal surgery in the nonobese [5, 57]. According to Mλsoν et al. [95], the high incidence of thromboembolism after gastric bypass operations in the massively obese is due to the thrombosis-inducing effect of fatty acids liberated during and after surgery. In their series the thrombus formation was significantly decreased when the subjects were treated postoperatively

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In-Hospital Morbidity and Mortality

62

HALLBERG/BACKMAN/ESPMARK

Table ΙΙ. Literature survey of early ín-hospital mortality following jejuno-ileostomy for treatment of massive obesity Author

Year n

Diagnosis

SALMON [117] Wnis[145] BABER etal.[8] BucηwαΡw et al. [34] DANÖ et al. [50] ΡλvνΕ et al. [108]1 Scorn et al. [121] Waιsµλνν [142] BLEICHER etal. [25] Como and οsaPn [45] FØ and CASSELLA [64] BACKMAN and HALLBERG [15]

Total

1971 1972 1973 1973 1973 1973 1973 1973 1974 1974 1974 1975



Ε ~.~+y ^

N

b

~

~

3

~

pancreatitis

cardiac death

a~

Mortality

0 0 0 1 0 0 0 0 0 0 0 0

0 2 0 0 0 1 0 0 0 0 0 0

0 2 0 0 0 0 0 0 0 0 0 0

1

3

2

~

~

120 259 86 94 36 165 62 123 50 34 52 103

0 1 0 0 0 3 0 0 0 0 0 0

4 0 0 0 0 0 0 0 0 0 0 1

1 4 0 0 0 2 1 2 0 0 1 0

1,184

4

5

11

5 9 0 1 0 6 1 2 0 0 1 1 26

4.1 3.5 0 1 0 3.6 1.6 1.6 0 0 1.9 1 2.2

with parenteral glucose and insulin, or glucose and amino acids, which stimulate insulin production. Postoperative wound infections seem to be a frequent complication of bypass surgery. In spite of preoperative intestinal sterilization, the incidence has been as high as 30-35 Ο/ο [15, 45, 121, 145]. As after any surgical procedure which involves handling of the intestine, early obstruction is occasionally seen after jejunoileal bypass operations. These obstructions are caused by bands, adhesions, or fibrous narrowing of the gut. An unusual type of relative obstruction has been noted by Wττrs [145] and Bλcκµλx et al. [15]. In these cases the intestinal continuity was initially patent. After a few days, however, there were signs of intestinal obstruction with abdominal cramps and vomiting. 1n these cases the proximal intestine in function was dilated, as seen in abdominal

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1 Including 16 subjects after jejunocolostomy. n=number of subjects.

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barium series, in spite of contrast passing to the colon. In most cases the passage was normal after a few days. Swelling in the anastomotic area or disturbance of the function of the intestinal propulsion might be the cause of this functional obstruction [60, 126].

The malabsorption after the intestinal bypass is caused by defective digestion, decreased absorption, and increased fecal losses. The primary changes after the intestinal shunt operation give rise to secondary metabolic effects. It is difficult to give a rigid classification of these secondary metabolic effects because of the intricate interplay between different metabolic pathways. In some aspects these changes are similar to starvation and in others, because of intestinal losses, different. Some symptoms and features of the malabsorption will be discussed below. (1) Diarrhea is the most characteristic feature after all types of shunt operations. In the first few weeks the frequency of liquid stools is high, often 15-20 times daily. Thereafter the frequency decreases. Analysis made by Stu ff:1x [117] showed that 39 ο/ο had more than three liquid stools per day at 6 months and 25 ο/ο at 12 months. After 1 year, only a few patients complain of diarrhea. The cause of the diarrhea is a combination of several factors. One factor is increased load of non-absorbed intestinal contents in the colon. The load of hyperosmolal fluid will induce contractions in the colon. Transit time through the intestine has been shown to be significantly reduced after the operation. The time between swallowing of a barium meal and its appearance in the cecal pole is 3-5 min. The maximum transit time, however, is prolonged [114]. The enterohepatic circulation of bile salts is disturbed after the bypass operation [32]. They are spilled over into the colon [146] where they induce secretion of water and electrolytes or inhibition of water absorption. Another consequence is an increased bile salt turnover and a lowering of plasma cholesterol, which is a desirable phenomenon in cases of hypercholesterolemia [32, 36]. The bile salt concentration in the duodenum and proximal intestine is decreased after the bypass [52]. This makes the fat-bile salt micelle concentration too low to guarantee adequate fat absorption. Another effect of the increased intestinal content of fatty acids is also evident after the bypass. The fatty acids will form soaps with calcium

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Complications and Signs of Metabolic Aberrations and their Management

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Patient 1. A 25-year-old woman with one child, body weight 164.5 kg, body height 182 cm. Onset of frequent vomiting, anxiety and depression 4.5 months after operation. At

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present in the intestinal lumen; these soaps will increase the diarrhea, and hypocalcemía may occur. The fat is partly hydroxylated by the colonic bacterias and will have a strong purgative effect, comparable with that of castor oil [110]. The diarrhoea frequency will decrease with time after the operation. One reason is the adaptation of the intestine, which will increase the absorptive intestinal surface area. Another reason is the effect seen of simple dietary measures, which some patients will soon find out. If they avoid drinking with the meals and taking too much fat in the food, the diarrhea frequency will be limited to 3-6 stools daily. In fact, diarrhea is a necessary consequence of the shunt operation and a sine qua non for the weight loss [125]. During periods with frequent diarrheas, codeine preparations or diphenoxylate have been used and with good results. After taking diphenoxylate, which is a morphine analogue, some patients, who before the operation had been drug addicts, experienced similar sensations as after drug intake. Therefore, the prescription of diphenoxylate should be carefully controlled and registered. (2) Electrolyte disturbances are common and in most cases presumably due to fecal losses. About 25-30 Ο /ο of the subjects will have subnormal serum concentrations of calcium, magnesium, or potassium for at least shorter periods [15]. Those who develop prolonged electrolyte disturbances (ED) belong to a group of individuals with the highest rate of weight loss during period II (table III). In a series of 80 subjects, 13 developed ED in periods after the operation. The deficiencies were in all cases amenable to treatment. In a few cases, longer periods of ED necessitated hospitalization and intravenous fluid and electrolyte therapy. One interesting and important finding is that low serum-calcium concentration in a few cases further decreased after oral calcium therapy, presumably because of increased soap formation with fatty acids and diarrhea with secondary losses. However, these states of serum-calcium deficiency were effectively treated with parenteral calcium or magnesium, 20-40 mEq MgSO4 intramusculary or 300 mg Mg Cl2 orally per day. Another interesting finding is that subjects with preoperatively low serum calcium had a significantly higher incidence of postoperative hypocalcemía and other electrolyte disturbances. These preoperative abnormalities were noted in the heaviest weight groups. In rare cases ED may be caused by psychogenic vomiting, triggered by psychic crises.

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Table III. Frequency of some complications within groups of different rate of weight loss (weight index units/week) during period II after jejunoileostomy in 80 cases Rate of weight loss

n

Type of complication ED

LI

UTC

IM

0 0 0 0 3 5 1 0

1 1 5 4 3 1 0 0

1 0 6 4 3 5 0 0

0-0.0030 0.0031-0.0060 0.0061-0.0090 0.0091-0.0120 0.0121-0.0150 0.0151-0.0180 0.0181-0.0210 0.0211-0.0240

1 8 19 16 20 13 2 1

0 0 0 2 3 5 2 1

Total χz for goodness of fit

80

13 15.998**

9 15 19 15.181** 2.4421S 2.3141S

** 0.01 >p >0.001 ; NS = not sigØcant. ED=Electrolyte deficiency; LI=signs of liver injury; UTC=urinary tract calculi; IM =immunopathy.

(3) Signs of disturbed liver function are often found in varying degree, especially during the 1st year after the operation. The preoperative liver histology showed increased fat content in 60-80 o/o of the massively obese subjects [35, 80, 89]. The implication of this finding as a contraindication for surgery is difficult to evaluate. We have tried to evaluate various aspects of liver function by a combination of tests on blood serum, each representative of excretory and metabolic functions or signs of cellular damage. This combination consists of bilirubin, alkaline phosphate, albumin, normotest, ASAT, ALAT, and LD. A pathological result of any one of these tests does not always signify a liver function disturbance, but

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hospitalization 2 months later signs of hepatic failure, which did not improve essentially in spite of intense therapy. During psychotherapy a strong fear of death since childhood was revealed, intensified at the time of operation. Following the surgery she had felt on the safe side until shortly before the onset of the vomiting, when she happened to hear about the death of a fellow-patient in late complications, which were presented to her as a `shrivelling of the stomach' by other patients. She then got fantasies of having to eat in order not to `shrink' inside, and opposing imaginations that eating might cause a supposedly unhealed inner operation wound to burst and thus cause her death. This conflict caused her to long for food, and at the same time to react with anxiety, distaste and vomiting as soon as the food appeared. Having been able to verbalize this conflict, she stopped vomiting within a few days. After that her somatic condition improved.

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Patient 2. A 40-year-οld woman with five children, body weight 120 kg, body height 164 cm. She was an alcoholic addict and a prostitute, submitted to surgery as there was reason to believe that weight reduction would improve her mental and social situation. Preoperative examinations were essentially normal, except for high serum triglyceride concentration (2.61 mmol/l). She had no signs of liver disease before the intestinal bypass. She was operated on by end-to-end jejunoileostomy with 40 cm of the jejunum and 15 cm of the distal ileum in function. The total small intestine length was 7.3 r. Besides short periods of easily treated electrolyte disturbances, mostly after alcoholic debauches, she managed primarily well, with no signs of severe liver injury. The rate of weight loss during period II was 0.0134 weight index units/week, or 0.87 kg/week. The body weight stabilized at about 70 kg after 60 weeks. However, 3 years after surgery she was hospitalized with signs of liver insufficiency after a long period of excessive alcoholic intake. The patient died in hepatic coma. Autopsy showed pronounced liver cirrhosis and acute gastrointestinal hemorrhage. Patient 3. A 27-year-old woman with one child, body weight 153 kg, body height 169 cm. All preoperative examinations were normal, exept for elevation of ALAT. No signs of liver affection were evident before admission for intestinal surgery. An end-to-end jejunoileostomy was performed with 50 cm of the jejunum and 15 cm of the ileum in function. The small intestine length was 8.0 m. Postoperatively she lost weight at the rate of 0.0162 weight index units/week, or 1.11 kg/week during period II. Signs of hepatic failure appeared 2 months after operation, and in spite of intense therapy she died 8 months after surgery in hepatic coma. Autopsy showed liver cirrhosis and stensis of the blind loop at the ileocecal anastomosis.

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the combination of various results will argue for or against a normal function [136]. For evaluation of the liver function after the operation we have used a point system, where one point represents one pathological value in each test/patient/time period examined. By adding together all the points during that period an estimation of liver function in general was found. The results in 80 jejunoileostomy cases observed for more than 1.5 years and examined during 10-week periods following the operation are as follows: The number of points increased during the first few months; thereafter it decreased and the `liver function' was thought to improve. About 1 year after the operation the number of points was lower than preoperatively, which may indicate a positive effect of the weight reduction on liver function. In most cases, only two or three of these parameters were pathological, mostly ASAT, ALAT, and LD. In some cases, however, more parameters were pathological simultaneously. Signs of liver injury were defined as a prolonged period of simultaneous pathological serum tests making at least five points in the test battery [15]. With this definition, nine subjects out of 80 developed liver injury. Three cases succumbed from various causes. The clinical features of these three cases were as follows.

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Our studies indicate that only subjects with the highest rate of weight loss during period II are exposed to the risk of liver injury (table III). Hence, this rate is probably a common denominator for factors said to cause liver injury. Therefore it is essential to `tailor' the shunt operation for each patient in order to achieve an optimal rate of weight loss. Progress of liver failure after intestinal shunt operations is the main cause of death (table IV) and may be arrested by restoration of the intestinal continuity [29, 108]. Indications for reanastomosis are, according to ΡΑΥΝΕ et al. [108], a high rate of weight loss combined with anorexia, impaired liver function, and hypoproteinemia. These subjects gain weight again after reanastomosis. However, our experiences indicate that reanastomosis is not necessary in all such cases. In some patients, as in patient 1, psychological factors are important. A clinical condition resembling anorexia nervosa may develop. In these cases intense psychotherapy must be instituted parallel to medical treatment with oral intake and concomitant intravenous infusions of carbohydrates, amino acids, fat emulsions, electrolytes, and vitamins. Supplementary feeding through a feeding jejunostomy in the blind loop has also been practised [34, 87]. This situation arose in 4 out of 100 cases operated on. It was possible in these cases to stop the rapid weight loss, to improve the liver function and electrolyte balance, and to get the patients into a mentally and physically better state. When the body weight stabilized, all these subjects reached periods IV and V (fig. 7). Thus the malabsorption was overcome. (4) Protein balance: an important aspect of the induced malnutrition is the possibility to maintain protein balance. An adequate protein balance is important, among many things, both to a normal liver function and to

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Patient 4. A 52-year-old woman with three children, body weight 157 kg, body height 174 cm. Preoperative examination showed elevation of amínotransferases and increased bromosulfophthalein retention (17.2%); all other tests were within normal limits. She was operated on by end-to-end jejunoileostomy with 40 cm of the jejunum and 15 cm of the ileum in function. The total small intestine length was 8.3 m. Primarily, she managed well. The rate of weight loss during period II was 0.0131 weight index units/week, or 0.97 kg/week. However, from 5 months after the shunt operation and onward she had abdominal discomfort and signs of electrolyte disturbances and liver injury and was repeatedly hospitalized. Because of increasing marasmus, the shunt was taken down in an attempt to stop the process. However, the patient died 18 months after the shunt operation, after a massive gastrointestinal bleeding from a duodenal ulcer. Autopsy showed severe chronic peritonitis, liver cirrhosis, pleuritis, and tuberculous lymph glands in the lung hilus. Direct microscopy and culture for mycobacterium tuberculosis from the pleura and abdominal cavity were positive.

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Table IV. Literature study of late mortality after jejunoileostomy for treatment of massive obesity n

Year

Author

Mortality

ED LI

total %

TB other

120 259 86 94 36 165 62 123 50 34 52 85

0 0 0 0 0 1 0 0 0 0 1 0

0 3 2 0 0 5 0 1 0 0 1 1

0 2 0 0 0 1 0 0 0 0 0 0

0 3 0 0 0 3 0 0 0 0 0 2

0 8 2 0 0 10 0 1 0 0 2 3

0 3.1 2.3 0 0 6.1 0 0.8 0 0 3.8 4.0

1,165

2

13

3

8

26

2.2

1971 1972 1973 BABERetaI. [8] 1973 BucsiwALD efaI. [34] 1973 Dακöetal. [50] 1973 Ρανκε et α1. [108]1 1973 Scorr etal. [121] 1973 WεlsΜακκ [142] 1974 BLmcHERetaL [25] 1974 CoRsoandJosEPH [45] 1974 Ø and CASSELLA [64] ΒαΡcκτ.ταΡκαηd ΗnτταεκG[15] 1975 SΑLΜΟΝ [117]

Wnxs [145]

Total

Causes to death

ED=Electrolyte disturbances; LI=signs of liver injury; TB= thromboembolísm. 1 Including 16 subjects operated with jejunocolostomy.

µ mοι /ι 400 -

Reference (n=26)

ES Aο Ref.-Ao

l°n Reference

Obese preop(n- s)

C O Obese postop (n = s )

ρ< O.os

Ref.-C Αρ< O ο

300 -

200 -

100 —

'
i~ u

~ú 4 =

* * **

J< ι- á

* *

CJa~ Σ *

α J~FJU Q Ú>α *

*

**\

1.0 (n =17) t test' between groups

I-II II-III I-III

Preoperative body parameters

mean highest lowest mean highest lowest mean highest lowest

Postoperative body parameters

height cm

weight kg

index units

∆ index b value, ∆ index weight units units kg per week

172.4 185 159 170.0 184 155 168.7 182 151

130.0 151.8 109.0 137.3 175.5 93.7 157.9 180.0 116.0

1.82 2.27 1.50 1.96 2.78 1.49 2.30 2.80 1.98

NS NS NS

NS *** ***

NS *** ***

0.0058 0.0098 0.0030 0.0110 0.0165 0.0043 0.0148 0.0230 0.0090 *** *** ***

31.3 42.0 20.3 51.6 78.0 27.0 80.9 105.2 54.0 *** *** ***

0.42 0.49 0.25 0.73 1.00 0.51 1.19 1.59 1.01 *** *** ***

electrolyte disturbances seemed instead to be secondary to psychological stress which had induced vomiting or increased diarrhea. Four patients made serious suicidal attempts during the follow-up period, and 17 others reported thoughts of suicide or weariness of life for some period. Those patients who had been treated earlier in a psychiatric clinic (13/66), all showed more or less intense psychological disturbances following operation. On the other hand, crisis reactions of even pronounced degrees were seen also in some patients with no previous psychiatric history. There was a significant relationship between the pronounced forms of postoperative psychiatric disturbances and the variables `incomplete couple of parents during preschool years', `rate of weight loss', and `female sex'. No correlation was found between postoperative psychological maladjustment and the variables `age at onset of obesity', `preoperative body weight index', or `age at operation'.

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* * * p < 0.001. NS = not significant. 1 t test for independent means. For definition of the parameters, see text.

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Fig.9. One patient before (left, 175 kg) and 18 months after (right, 75 kg) jejunoileostomy.

When comparing Rorschach tests before and 1-2 years after operation (24 subjects), a change was found in a positive direction of the comprehensive variable `mental health' as well as in a number of subvariables [47]. This change was most pronounced in those patients who had the most negative scoring before operation; it should be noticed, however, that some of these patients had undergone psychotherapy in the meantime.

The intestinal shunt operation, performed by adequate methods for intestinal length measurement, is an effective method to reduce body weight

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Results

Surgical Treatment of Obesity

75

Fig.10. The face of one patient photographed before and at intervals after jejuno-

without dietary restrictions (fig. 7). Table V epitomizes the results from 85 consecutive operations between 2 and 6 years after the procedure. The subjects were divided into three groups with regard to maximal change in body weight index (Broca's index). It can be seen, e. g., that 14 subjects with a mean preoperative body weight index of 1.82 or 130 kg lost 0.42 index units which correspondes to 31 kg. The postoperative mean body dimensions thus became 1.40 index units or 99 kg in this group. The results in the other two groups were still better. However, most complications, such as electrolyte imbalance or signs of liver injury occurred in 14 subjects among 17 subjects with the highest rate of index change (see also table III). The magnitude of weight reduction still has a wide range.

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ileostomy.

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Besides the body weight reduction, the results with respect to the mentioned social, somatic, and psychic disturbances of the obese individuals, are most impressive (fig. 5, 9, 10). The surgical procedure is still followed by many somatic and psychic complications, which may be mitigated when more experience has been gained. It is possible to treat most of the somatic complications. It is also important to support the patients psychologically, as severe depressions, anxiety states, anorexia, or even attempts at suicide may occur. According to PAYNE et al. [108] and our own experiences also, about 10 ο/ο of the operated patients may show an inadequate weight loss. In several of these cases reoperation with shortening of the shunt has been performed. The criteria for such a reoperation must be individual. One of our reoperated subjects with a height of 160 cm and a preoperative weight of 175 kg lost approximately 50 kg after the first operation before the body weight stabilized. But with a weight of 125 kg, she was not satisfied with the result. She had managed period II without complications, so we shortened the ileal segment at a second operation and with primarily good effect on weight loss.

Surgery for treatment of obesity results in permanent and adequate weight loss in most patients. The most common methods are various types of jejunoileoanastomosis. Experiences indicate that the method is preferable in young people with considerable overweight. Following the operation, somatic complications may occur in 10 Ο /ο of the subjects. The most serious of these are signs of liver injury and electrolyte disturbances, which occur mainly in the group of subjects with the highest rate of weight loss. Other, less serious complications show no such relations. The finding that the total length of the small intestine and its functional segments are correlated to the rate of weight loss indicates that it should be possible to `tailor' a bypass operation to fit the individual. Further studies concerning the operative procedure are necessary in order to reach this goal. This type of operation may radically improve the psychosocial situation for the patient. However, psychological crises following operation and weight reduction are common and this surgery should therefore be performed in close collaboration with an experienced psychiatrist.

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Summary

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77

I ALEXANDER, J.K.; AMAD, K. H., and CoLE, V.W. : Observations on some clinical features of extreme obesity, with particular reference to cardiorespiratory effects. Am. J. Med. 32: 512-524 (1962). 2 ÁLTHÁUSFN, T. L. ; UυΕυλµλ, K., and SιµPsοκ, R. G. : Digestion and absorption after massive resection of the small intestine. Gastroenterology 12: 795-807 (1949). 3 ALTMETER, W. A. and BERKICH, E.: Wound sepsis and dehiscence; in HARDY Critical surgical ilness, chap. 8 (Saunders, Philadelphia 1971). 4 ANDERSSON, H. and JAGENBURG, R. : Fat-reduced diet in the treatment of hyperoxaluria in patients with ileopathy. Gut 15: 360-366 (1974). 5 ANDREASEN, C. and LASSEN, H. K. : Fatal pulmonary embolism in a surgical department during a period of 15 years. Acta chic. scand., suppl. 343, pp. 42-47 (1965). 6 ANDREEN, Μ. ; ODENSJÖ, G. ; HALLBERG, D., and SODA, Μ.: Cardiac output and regional blood flow during intravenous infusion of an aminoacid mixture in dogs. IV. Acta chir. scand. 140: 441 (1974). 7 AVERS, Μ.: Obstetric and gynecologic effects of the ileal shunt. Ohio St. med. J. 69: 834-837 (1973). 8 BABER, J. C. ; HAYDEN, W. F., and TκοMrsοN, Β. W. : Intestinal bypass operations for obesity. Am. J. Surg. 126: 769-772 (1973). 9 BACKMAN, L. : The rate of weight loss after intestinal bypass operation in obesity : an analysis of factors of significance. Acta chir. scand. (in press). 10 BACKMAN, L.: Small intestinal bypass operations for treatment of obesity. Some methodological aspects ; thesis, Karolinska Institute, Stockholm (1975). 11 BACKMAN, L. ; BERGSTROM, K., and HALLBERG, D.: Urinary tract calculi - a complication caused by small intestinal bypass operation for treatment of obesity. Lak. Tidn. 72: 462-466 (1975). 12 BACKMAN, L.; FENVO, G., and HALLBERG, D. : Morphological changes of the small intestine following jejuno-ileal shunt in obese subjects. Acta chir. scand. (submitted). 13 BACKMAN, L. ; FREYSCHUSS, U. ; HALLBERG, D., and MELCHER, A. : Cardiovascular function in extreme obesity. Acta med. scand. 193: 437-446 (1973). 14 BACKMAN, L. and HALLBERG, D.: Small-intestinal length. An intraoperative study in obesity. Acta chic. scand. 140: 57-63 (1974). 15 BACKMAN, L. and HALLBERG, D. : Some somatic complications after small intestinal bypass operations in obesity. Possible factors of significance for the incidence. Acta chir. scand. (in press, 1975). 16 BACKMAN, L. ; HALLBERG, D., and KALLNER, A • Aminoacid pattern in plasma before and after jejuno-ileal shunt operation for obesity. Scand. J. Gastroent. (submitted, 1975). 17 BACKMAN, L. ; HALLBERG, D., and PALMER, Β.: Skin reconstruction following intestinal shunt operations for treatment of obesity. Scand. J. plast. reconstr. Surgery. (in press, 1975). 18 BARROl, J. ; FRAME, Β., and BAYELIS, J. R. : A shunt operation for obesity. Dis. Colon Rectum 12: 115-119 (1969). 19 BEECHER, H. K. : Placebos and the evaluation of subjective response ; in WIFE and SHAPΙRo The clinical evaluation of new drugs, pp. 61-75 (Hoeber-Harper, New York 1959).

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References

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20 BINDER, H.J.: Intestinal oxalate absorption. Gastroenterology 67: 441-445 (1974). 21 BJÖRNTORP, P. and SJUSTRUM, L.: The number and size of adipose tissue fat cells in relation to metabolism in human obesity. Metabolism 20: 703-713 (1971). 22 BJÖRNTORP, P. and SJbSTRbM, L.: Fat cell size and number in adipose tissue in relation to metabolism. Israel J. med. Sci. 8: 320-324 (1972). 23 BJÖRNTORP, Ρ. Effects of age, sex and clinical conditions on adipose tissue cellularity in man. Metabolism 23: 1091-1102 (1974). 24 BLANKENHoRN, D. H.: Disorders of lipid metabolism; in BRAV and BETHUNE Treatment and management of obesity, pp. 77-90 (Harper & Row, Hagerstown 1974). 25 BLEICHER, J. E. ; CEGIELSKI, M., and SAPORTA, J. A.: Intestinal bypass operation for massive obesity. Postgrad. Med. 55: 65-70 (1974). 26 BLOOM, W. L. : Fasting as an introduction to the treatment of obesity. Metabolism 8: 214-220 (1959). 27 BRAυ, G.: Pharmacological approach to the treatment of obesity; in BRAY and BETHuiE Treatment and management of obesity, pp. 117-131 (Harper & Row, Hagerstown 1974). 28 BRILL, A. B. ; SANDSTEAD, H. H. ; PRICE, R. ; JOHNSTON, R. E. ; LAW, D. H., and ScorT, H. W. : Changes in body composition after jejunoileal bypass in morbidly obese patients. Am. J. Surg. 123: 49-56 (1972). 29 BRowi, R. G. ; O'LEARY, J. P., and WοοηΡwλan, E. R. : Hepatic effects of jejuno-ileal bypass for morbid obesity. Am. J. Surg. 127: 53-58 (1974). 30 BRUCH, H. Eating disorders (Basic Book, New York 1973). 31 BUCnANAN, R. F. and WILLKENS, R. F. : Arthritis after jejuno-ileostomy. Arthritis Rheum. 15: 644-645 (1972). 32 BUCHWALD, H.: Lowering of cholesterol absorption and blood levels by ileal exclusion. Circulation 29: 713-720 (1964). 33 BUCHWALD, H. and VARLO, R. L. : A bypass operation for obese hyperlipidemic patients. Surgery, St. Louis 70: 62-70 (1971). 34 BUCHWALD, H. ; ScκwARrz, M. Z., and VARCο, R. L. : Surgical treatment of obesity. Adv. Surg. 7: 235-255 (1973). 35 BUCHWALD, H. ; LOBER, P. H., and VARCO, R. L. : Liver biopsy findings in seventyseven consecutive patients undergoing jejuno-ileal bypass for morbid obesity. Am. J. Surg. 127: 48-52 (1974). 36 BUCHWALD, H. ; MοοRΕ, R. B., and VARCO, R. L. : Surgical treatment of hyperlipidemia. Circulation 49: 1-37 (1974). 37 Βυ waLL, C. S. ; Roaji, E. D. ; WHALEY, R. D., and BICKELMAN, A. G. : Extreme obesity associated with alveolar hypoventilation - a Pickwickian syndrome. Am. J. Med. 21: 811 (1956). 38 CAMEL, J. M. : Respiratory problems in surgical patients. Am. J. Surg. 116: 362-368 (1968). 39 CALLIA, S.E.P.: Una plastica para o cirurgiao geral. Med. Hosp., S. Paolo 1: 40-41 (1967). 40 CASTANARES, S. and GOETHEL, J. : Abdominal lipectomy: a modification in technique. Plastic reconstr. Surg. 40: 378-383 (1967). 41 CATENACCI, Α.J. ; ANDERSON, J. D., and BoERSMA, D.: Anesthetic hazards of obesity. J. Am. med. Ass. 175: 666-671 (1961).

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65 GAZET, J. C. ; PILKINGTON, T. R. E. ; KALYCY, R. S. ; CRISP, Α. Η., and DAY, S.: Treatment of gross obesity by jejunal bypass. Br. med. J. ii: 311-314 (1974). 66 GERSHoFF, S. Ν. and PRIEN, E. L. : Effect of daily Mg0 and vitamin Bs administration to patients with recurring calcium oxalate kidney stones. Am. J. clin. Nutr. 20: 393-399 (1967). 67 GIER, R. L. ; NELSON, A.W., and Luam, W.V. : Experimental sphincter for shortbowel syndrome. Archs Surg., Chicago 102: 203-208 (1971). 68 GROSSMAN, Μ. S. and NUGENr, F. W. : Urolithiasis as a complication of chronic diarrheal disease. Am. J. dig. Dis. 12: 491-498 (1967). 69 HALLBERG, D. and BACKMAN, L.: Kinetics of the body weight after intestinal bypass operation in obesity. Acta chir. scand. 139: 557-562 (1973). 70 HALLBERG, D. and SODA, Μ.: Hepatic blood flow changes following infusion of different single amino acids in dogs. III. Acta chir. scand. 140: 338 (1974). 71 HALLBERG, D. and MOLLI, L. : Remission of pustolosis palmaris et plaritaris after intestinal shunt operation. Report on three cases. Acta derm.-vener., Stockh. 54: 155 (1974). 71a HALLBERG, D. : Valvel reconstruction at íleo-colic anastomosis. Svensk kirurg. För. Förh. 1973: 28. 72 ΗλυµονD, Η. B.: Massive resection of the small intestine. An analysis of 257 collected cases. Surgery Gynec. Obstet. 61: 693-705 (1935). 73 HENrnKssoN, V.: Kan tunntarmsresektion försvaras som terapi mot fettsot. Nord. Med. 47: 744 (1952). 74 HESS, R. J. : Polyarthritis after small bowel bypass. Okla. St. med. Ass. J. 67: 283-285 (1974). 75 HIRSCH, J. and KΝrrrτΡΕ, J. L. : Cellularity of obese and nonobese human adipose tissue. Fed. Proc. Fed. Am. Socs exp. Biol. 29: 1516-1521 (1970). 76 JORDAN, P. Η. ; STUART, J. R., and BRIGGS, J. D. : Radical small bowel resection : report of two cases. Am. J. dig. Dis. 3: 823-843 (1958). 77 JUHL, E. ; BRUNSGAARD, A. ; HΙΡPΕ, E. ; KORNER, B. ; QUAADE, F., and BADEN, Η. : Vitamin Β12 depletion in obese patients treated with jejuno-ileal shunt. Scand. J. Gastroent. 9: 543-547 (1974). 78 KALUCY, R. ; Soiow, C. ; HARTMANN, M., and Cmsρ, A. Η.: Self reports of estimated body widths in female obese subjects with major fat loss following ileo jejunal bypass surgery. 1st Int. Congr. Obesity, London 1974. 79 KANNEL, W. B. : Relations of body weight to development of coronary heart disease the Framingham study. Circulation 35: 735-744 (1967). 80 KERN, W. Η. and PAYNE, J. Η.: Fatty metamorphosis of the liver in morbid obesity. Archs Path. 96: 342-346 (1973). 81 ΚΙΝG, J. S. : Currents in renal stone research. Clin. Chem. 17: 971-982 (1971). 82 KREMEN, A.J. ; LINIER, J. Η., and NELSON, C. Η.: An experimental evaluation of the nutritional importance of proximal and distal small intestine. Ann. Surg. 140: 439-448 (1954). 83 LAGACRE, G. and VANDENBUSCHE, F. : Indications, contre-indications et résultats de la technique de callia dans le traitement des ptoses cutanées abdominales avec ou sans surcharge graisseuse. Lille chir. 26: 177 (1971). 84 LAw, D. K.; DUDRICK, S.J., and ABDOU, N.J.: The effects of protein calorie mal-

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nutrition on immune competence of the surgical patient. Surgery Gynec. Obstet. 139: 257-266 (1974). 85 LEACH, R. Ε. ; BAUMGARD, S., and BROOM, J.: Obesity : its relationship to osteoarthritis of the knee. Clin. Orthop. 93: 271-273 (1973). 86 MCCARTHY, P. J. : Pregnancy following jejuno-ileal bypass. Obst. Gynec., Ν. Y. 43: 455-457 (1974). 87 MCCLELLAND, R. Ν.: Prevention of hepatic injury after jejuno-ileal bypass by supplemental jejunostomy feedings. Surg. Forum 21: 368-370 (1970). 88 MCDONALD, I. : Trends in the treatment of obesity. Guy's Hosp. Rep. 119: 329-336 (1970). 89 MANES, J. L. ; TAYLOR, Η. and STARKLOFF, G. B. : Relationship between hepatic morphology and clinical and biochemical findings in morbidly obese patients. J. clin. Path. 26: 776-783 (1973). 90 MANN, G.V.: The influence of obesity on health. I. New Engl. J. Med. 291: 178-185 (1974). 91 MANN, G. V.: The influence of obesity on health. IL New Engl. J. Med. 291: 226-232 (1974). 92 MARArKA, Z. and NEDBAL, J.: Urolithiasis as a complication of the surgical treatment of ulcerative colitis. Gut 5: 214-217 (1964). 93 MARKS, Η.: Influence of obesity on morbidity and mortality. Bull. Ν. Y. Acad. Med. 36: 296-312 (1960). 94 MAsoν, E. E. and 1ro, C. : Gastric bypass in obesity. Surg. Clins Ν. Am. 47: 1345-1351 (1967). 95 Μλsoν, E. E. ; GORDY, D. D. ; CI-JERNIGOY, F. A., and PRINTEN, K. J.: Fatty acid toxicity. Surgery Gynec. Obstet. 133: 992-998 (1971). 96 MEYER, Η. W. : Acute superis mesenteric artery thrombosis. Archs Surg., Chicago 53: 298-303 (1946). 97 MEYER, Η. W. : Sixteen years survival following extensive resection of small and large intestine for thrombosis of the superior mesenteric artery. Surgery, St. Louis 51: 755-759 (1962). 98 MoxLEY, R. T. ; ΡΟΖΕΕSΚΥ, T., and LOCKWOOD, D. Η.: Protein nutrition and liver disease after small bowel bypass for obesity. Clin. Res. 21: 520 (1973). 99 MoxLEY, R. T. ; POZEFSKY, T., and LOCKWOOD, D. Η.: Protein nutrition and liver disease after jejuno-ileal bypass for morbid obesity. New Engl. J. Med. 290: 921-926 (1974). 100 MÜLLER, F. ; PAUL, I. ; BRASCH, C. ; KAPELL, R. ; KUORRE, Y. vol; GRIMMBERGER, E. ; GRIMIBERGER, M. und WITTIG, J. : Zur Verbreitung der Fettsucht in der DDR. Z. ges. inn. Med. 25: 1001-1009 (1970). 101 NASSET, E. S. : Role of the digestive system in protein metabolism. Fed. Proc. Fed. Am. Socs exp. Biol. 24: 953 (1965). 102 NILSSON, B. ; BACKIAN, L., and HALLBERG, D. : Immunological function in patients operated on for morbid obesity. Scand. J. Gastroent. (submitted, 1975). 103 O'LEARY, J.P. ; THOMAS, W.C., and WOODWARD, E. R.: Urinary tract stone after small bowel bypass for morbid obesity. Am. J. Surg. 127: 142-147 (1974). 104 ÖSTMAN, J. ; BACKMAN, L., and HALLBERG, D. : Cell size and lipolysis by human subcutaneous adipose tissue. Acta med. scand. 193: 469-475 (1973). 105 Ösrµλν, J. ; BACKIAN, L., and HALLBERG, D. : Cell size and the antilipolytic effect of insulin in human subcutaneous adipose tissue. Diabetologia 11: 1-6 (1975).

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D. HALLBERG, MD, Department of Surgery, Karolinska Sjukhuset, S-104 01 Stockholm-60 (Sweden)

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Surgical treatment of obesity.

Prog. Surg., νο1.14, pp. 46-83 (Karger, Basel 1975) Surgical Treatment of Obesity D. HALLBERG, L. BACKMAN and S. ESPMARK Departments of Surgery and P...
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