The Price of Weight Loss by Jejunoileal Shunt MARK M. RAVITCH, M.D., ROBERT E. BROLIN, M.D.
In the performance of end-to-end jejunoileal shunt, operative mortality can be nearly eliminated and late deaths largely prevented by assiduous care and follow-up. We attempted to prevent serious complications by regular outpatient visits. However, 703 outpatient visits costing $49.00 per visit failed to improve results. There were 170 readmissions among 64 patients lasting 4-57 days (average hospital stay -16 days per admission at $3,000.00). Twenty-four of those patients alive and followed 18 months or more (53%) sustained adequate weight loss and were free of major problems. Patient satisfaction nevertheless appears high, and when there has been a good weight loss, even severe problems tend to be glossed over by the patient. The ultimate outcome is still unknown, but it seems clear that many of the patients are in a state of controlled malnutrition, which may lead to progressive penalties. We have documented gross pathologic lesions in the bypass enteritis syndrome and draw attention to neurologic sequelae of the bypass, which probably represents deficiency manifestations. Despite brilliant results in some patients and satisfactory results in perhaps half, the cost in life, suffering, dollars, patient and physician time, the uncertain long-term effects, and the unpredictability of the weight loss, all place in question the appropriateness of jejunoileal shunt as the remedy for morbid obesity.
THE CONCEPT of controlled malabsorption by exclusion of measured segments of the bowel, from the alimentary stream in the effort to correct massive obesity, introduced by Kremen et al.6 and pioneered and intensively studied by Salmon and Reedyk,14,15 Payne et al ,11,12 Scott et al. ,16.17,18 Buchwald and Varco et al. ,2,3,4 and others and since put widely into clinical application around the world, has now had more than a decade of extensive experience. When we embarked on a series of these operations in 1972, after some reluctance, we understood that the initial hazards could be overcome by appropriate care and diligence and that in time the patients adjusted and compensated for the induced abnormality and their condition stabilized. This was an experimental program to be performed according to protocol by a single operator. All patients were informed that the operation was experimental, the ultimate results were unknown, the current mortality within a year of operation was expected to be about 5%, that Presented at the Annual Meeting of the American Surgical Association, Hot Springs, Virginia, April 26-28, 1979.
From the Departments of Surgery, Montefiore Hospital and the University of Pittsburgh, Pittsburgh, Pennsylvania
they would have to be permanently and closely followed, return to the hospital for admission on demand, whether for scheduled examinations or for therapeutic indications and that the extent and rapidity of weight loss were unpredictable, except that patients were unlikely to reach the sylph-like figure that they visualized. This was chiefly because in balancing a massive weight loss and, on the other hand, leaving a safe margin of functioning bowel to minimize the likelihood of disaster we would err on the latter side. Materials and Methods From 1972 to 1978, 12 male and 52 female patients, ranging in age from 20 to 59 years, underwent jejunoileal bypass at the Montefiore Hospital of Pittsburgh; all but three of them were followed by us for their entire postoperative course. The patients all weighed at least 100 pounds over ideal body weight and usually weighed over 300 pounds, except for a few women five feet tall (Table 1). There was no discovered evidence of endocrine abnormality in any. All had had numerous trials of non-operative weight reduction. Initially, we rejected a good many patients for what we considered to be unstable or pathological personalities, depressive tendencies or intelligence insufficient for reliable cooperation in the subsequent years. Remarkably enough, when a third of the way through the study, we were able to enlist the energetic cooperation of a psychologist and a psychiatrist, and essentially no more patients were rejected for those reasons (except two or three of whom we were so fearful that we did not send them for those studies). The psychiatric and psychological reports were usually that the patient was indeed disturbed or erratic or not very bright, but his/her life was hopeless unless a massive weight loss was achieved. Since there seemed no other way to achieve the weight loss, operation was advised, and the psychiatric-psychological studies after operation usually showed great satisfaction, improved self-image, etc.
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The operation, always a Scott-type end-to-end jejunoileal anastomosis, underwent some modifications. The incision was transverse, supraumbilical and originally crossed the whole right side and extended almost as far on the left; subsequently it was changed so that it usually went only to the midline, dividing the linea alba but not the left rectus. The end of the bypassed bowel originally was implanted in the sigmoid. This was found to be technically difficult, and we thought it resulted in troublesome reflux of gas into the bypassed bowel; therefore we employed the right transverse colon for a time and ultimately came to make the anastomosis to the ascending colon. Our original anastomoses united 12 inches of jejunum, measured on the antimesenteric border (a shorter length of bowel, therefore, than if it had been measured on the mesenteric border) to 8 inches of ileum. This failed to give optimal weight loss sufficiently often that we came to use 11 inches and 6 inches as our standard lengths. All bowel divisions, closures and anastomoses were made with the staplers, and there were no intraperitoneal infections and no anastomotic leaks or fecal fistulae. A single patient some months after operation vomited repeatedly and showed some intermittent filling defect at the anastomosis. The patient was found at operation (in the original operator's absence from the city) to have a flap ofredundant mucosa prolapsing through the anastomosis; the condition was relieved without complication by the excision of this mucosal flap. Results
This review was undertaken because we were impressed by the number of patients who several years after operation complained of lack of strength, still required medication for the control of diarrhea and continued to manifest or develop anew a variety of complications: sometimes one or another complication would develop late in a patient who had never before had any significant trouble. The depth of the prior unhappiness of these massively obese patients can perhaps best be measured by their ecstasy over their weight loss, ability to buy clothes off the shelf, bend down and tie their own shoes, go swimming with their children and create jealousy in their spouse and even more by their unwillingness to consider restoration of intestinal continuity. Even the sickest patients with the severest or most prolonged complications fight the idea of alimentary reconstitution, knowing the inevitability of weight gain after it. It is of some interest that in discussing the pros and cons of the original operation, the complications, mortality, etc., with patients who met the criteria of accept-
383
TABLE 1. Associated Preoperative Conditions
Condition
No. Patients
Family history of obesity Hypertension Dyspnea on exertion Previous cholecystectomy Hemorrhoids Venous insufficiency -lower extremity Degenerative arthritis Adult onset diabetes Pickwickian symptoms Preeclampsia Congestive heart failure
34* 15 20 10 9 5 5 5 3 3 1
* Another 16 patients had no statement concerning family history of obesity; only four patients in the series had negative family histories or other associated conditions.
ability for operation, we have several times been successful in dissuading men from the operation but not once a woman. By the same token, the only two patients to ask for a dismantling of the operation were men. One, a steel factory foreman who had no other postoperative problems, said he and his wife considered that the operation had transformed their lives but he feared the pain of renal colic. He had, in fact, had five documented attacks with stones, requiring a ureterolithotomy for one, and had other episodes of renal colic. The other, a man with a public position who had given innumerable exuberant testimonies of his new image and its effect, had had several bouts of metabolic derangement, probably brought on by drinking large amounts of fluid, and was one of those patients who often develop a sudden abdominal distention of astonishing degree. Our female patients have been reluctant to accept the dismantling procedure, even when it was discussed in terms of saving their lives. I do not think there is one who has not said, "I would do it all over again," although a psychiatrist might well take this as meaning, "I must at all costs deny that the risk, the suffering, the economic cost were not worthwhile." Many of the patients were patient-referred, although a sophisticated motivation analysis might offer a variety of explanations for that as well. The evaluation of "patient satisfaction" is particularly difficult after operations for morbid obesity, since the patients are guiltily aware that the obesity was self-induced, and they have more than the usual patient's vested interest in finding that the risks, expense and suffering were all justified. Discussion The problem which we have had in the present analysis is just this matter of the pleasure the patients take in their new lives, their repeated expressions of gratitude and our inability to determine how much risk,
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384
TABLE 2. Response of Obesity-related Diseases to Weight Loss bv Jejunoileal Shunt
Preop. Condition Adult onset diabetes mellitus Hypertension Degenerative arthritis (Disability) Venous insufficiency Respiratory insufficiency
No. Patients
Resolved
Improved
5 15
5 13
2
5
1 3 23
4 1
5
23
Unaffected
1
how much discomfort, how much expense is justified in terms of the results achieved and the still uncertain future for all of these patients. Will years of oxaluria result in the renal damage in some percentages of those who do not form stones? Will there be a certain incidence of late hepatic insufficiency? Will the neurologic lesions progress? What we are producing, after all, is a controlled malnutrition. The serum levels of the common electrolytes are easily measured, but their changes in the total body composition are much less readily so. Of the trace elements we know little. Protein deficiency is clinically obvious in many patients in the continuing brittleness and sparseness of their hair, change in character of their nails, weakness and decreased muscle mass. Osteoporosis and vertebral fracture in a woman who had never had tetany or low serum calcium was disconcerting. Almost all of the patients recognize some weakness, occasionally rather severe, particularly the women. The appearance of neurological symptoms in five patients, i.e., dizziness, ataxia, loss of consciousness, was particularly disturbing The patients were all discharged and maintained on oral vitamin supplements, calcium, magnesium and potassium and provided with codeine sulfate, Lomotilg or Loperamide® for diarrhea. One "macho" salesman originally took no medication of any kind, finally coming to take codeine occasionally, but never took electrolyte or vitamin supplements. In many others the degree of religiosity of compliance is unknown. All patients were talked to at length before operation, repeatedly in the hospital, again before and after operation and at the frequent postoperative visits concerning the severe thirst they might feel, the necessity for controlling their desire to drink large quantities of fluids, the inevitability of the resultant fluid and electrolyte loss, etc. Yet patient after patient who returned with overwhelming diarrhea or electrolyte imbalance-hypokalemia, hypocalcemia- admitted to having drunk large amounts of fluid and listened in wide-eyed innocence when given the explanation once again. Four of our patients died. Two died of liver failure at eight and six months after operation. Both were patients
Ann. Surg. * September 1979
who would not or could not eat, who vomited regardless, who lived in rural Pennsylvania and were difficult to bring to the hospital. Both came early in our experience, when we had not adopted our policy of immediately hospitalizing any patient with hepatic dysfunction and had not yet learned the effectiveness of amino acid infusion in 5% glucose for such patients. "I A third patient who at times had severe hypokalemia and hypocalcemia died suddenly at home, a few days after having been seen with a modest hypokelemia 10 months after operation. The medical examiner's postmorten study showed no cause for death. The fourth patient lost weight inadequately after her 12 in. to 12 in. shunt, had a reversion and lost massively and would eat and do well in hospital but vomited and starved at home and was brought in for reconstitution. She was placed on conventional hyperalimentation, with 25% glucose, went into coma and died-a risk of which we were not aware. We had two instances of postoperative ventral hernias, no eviscerations, a single severe subcutaneous infection and 11 lesser infections. One patient required overnight tracheal intubation, a woman of 467 pounds. All of our patients were operated upon with the head of the table depressed 15° to empty the leg veins and decrease the likelihood of pulmonary embolism.7 Episodes which seemed to represent pulmonary embolism occurred in three patients. In short, this is an operation which we are persuaded can be performed with a very low immediate risk, even in these large patients, and from which we are confident late mortality can be largely eliminated by appropriate care, with the occasional need for a timely reintervention. The determination of the value of the operation will have to be made on an estimation of the quality of life to be lived, the significance of the complications and the long-term results. We are accustomed to tell our patients that they are well aware that if they remain hugely obese, their life expectancy will be shortened and they will be more likely to develop hypertension and diabetes. Fifteen of 64 had hypertension before operation; it was relieved in 13 and improved in two. Five of 64 had diabetes before operation, and all were able to discontinue medication for the diabetes (Table 2). And, of course, after operation upon patients with progressive disability, dyspnea, alarming tachycardia on slight exertion or pickwickian picture before operation, one can say that whatever their present problems, they might not now be alive but for the beneficial effects ofthe massive weight loss. The record of complications in our hands is not dissimilar to that reported by others. 13.17,20 Early postoperative morbidity is summarized in Table 3. Five patients had prolongation of their hos-
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pital stay due to excessive diarrhea, which eventually responded to codeine or Lomotil. Nausea and vomiting prolonged the hospitalization of three patients. The nausea in patients with jejunoileal shunt deserves special comment. Many of them, in almost the same words, will say, "I get queasy when I wake up in the morning," and, for many, vomiting induced by tooth brushing is the chief vomiting problem. Others vomit alarmingly often, and in some the resultant starvation at a time when they should have a large food intake is dangerous; it was fatal in two patients who died with jaundice. The patient with a vomiting problem will often say, "I can't stand the smell offood." We thought the vomiting was usually not psychogenic. Occasional patients still vomit, at times years after operation, but they usually do not mention it unless specifically asked. We have mentioned the 12 infections in the subcutaneous fat, one of them major. Nine patients had urinary tract infections (all patients had indwelling urinary catheters for at least 48 hours). There was one patient with pneumonia, and we have mentioned the three presumed pulmonary emboli, none major. The total number of patients with early complications was thus 21 (32%). Forty-five of the 64 patients (70%) were readmitted to the hospital for late sequelae. In all, there were 170 such admissions ranging from four to 57 days, 16 days on the average, at a 1977 cost of $3,000.00 each admission, despite the fact that we tried to treat patients on an outpatient basis for diarrhea and mild electrolyte imbalance. We recognized electrolye imbalance as a problem in 31 patients (almost 50%), and 11 required hospitalization, presenting with weakness, muscle cramps, paresthesias and occasionally carpopedal spasm. All 31 had hypokalemia, 19 had hypocalcemia, and 13 had hypomagnesemia. The relative severity of the electrolyte disturbances is seen in Table 4. While excessive diarrhea-frequently in patients who admitted to massive fluid intake and then "forgot to take" codeine or Lomotil-preceded the episode of electrolyte imbalance, we saw several patients with severe hypocalcemia and hypomagnesemia who claimed to have only three or four formed stools daily. TABLE 3. Early Postoperative Complications No. Patients
Complications Wound infection Gastrointestinal distress* Urinary tract infection Pulmonary embolus Ventral hernia
12 9 8 3 2
* Includes nausea, vomiting, bloating and diarrhea which prolonged the patient's hospital course.
385 TABLE 4.
Electrolyte Imbalance No. Patients
Hypokalemia
K = 3.1-3.5 K s 3.0
16 15
Hypocalcemia
Ca = 7.1-8.8 Cac 7.0
11 8
Hypomagnesemia Mg = 1.1-1.8 Mg c 1.0
7 6
We have documented vitamin A deficiency by decreased vitamin A levels in two patients with pathognomonic skin and ocular lesions which disappeared with vitamin supplementations. In at least three patients a fiery red, smooth, painful tongue and rhagades indicated overt vitamin B insufficiency. Hospitalization was indicated for nausea, vomiting and diarrhea in 27 patients. One patient complained of stools "all day long' and claimed no relief from frequent doses of codeine, but in spite of this there was no evidence of electrolyte disturbances, and we felt forced to restore the normal alimentary pathway. On the other hand, in 13 patients there were nausea, vomiting and abdominal cramps without excessive numbers of daily stools (more than six). These patients frequently had a distended abdomen at such times and showed distended loops of (bypassed) bowel in the x-ray films. Nine patients were considered to have some degree of hepatocellular dysfunction. In five, the elevation of serum bilirubin was minor and the hepatocellular enzymes elevated to levels less than three times the upper limit of normal. All of these patients had nausea, vomiting and abdominal pain. We have described the two deaths from liver failure, and the patient who died unexpectedly at home had earlier mild evidence of impaired liver function. One patient was hospitalized twice with moderately severe symptoms, mild icterus and aberrations of hepatic function and responded to rest and intravenous fluids. On a third occasion, she was feeble and deeply jaundiced, with hepatic enzymes five times the normal, and unable to take nourishment by mouth. She responded dramatically to 2 weeks of intravenous amino acids and has had no further suggestion of hepatic dysfunction in over two years. An additional patient was operated upon for hepatic failure at a military hospital, and her functional segment of small intestine was lengthened, reversing her hepatic dysfunction at the expense of a 30 lb. weight gain in the first 3 months after operation. Eight patients have had renal calculi, all calcium oxalate; two of these have had multiple episodes. We
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RAVITCH AND BROLIN
have mentioned one patient, who in one episode required ureterolithotomy and whom we reconverted, and we plan reconversion in the other patient with multiple episodes. We agree with O'Leary et al.9 that urinary oxalate is so frequently elevated in the first months after jejunoileal shunt that the determination has no prognostic value. In at least one of our patients with an oxalate stone, the urinary oxalate determination performed some time earlier was within normal limits. Significant anemia was found in 23 patients, long after the operative event. (No patient required transfusion during the operative admission, except for the patient with an extensive wound infection.) Of the 14 with hemoglobin of 10-12 gm, the red blood cell indices were normochromic and normocytic in ten. In two patients, the anemia was megaloblastic and responded to folate and vitamin B12. In nine patients hemoglobin was less than 10 gm. Three of these were discovered to have blood in the stool more or less constantly; the other nine had no consistent red blood cell picture nor was the cause for the anemia found by extensive hematological investigation. In all, there were 12 patients with normochromic-normocytic indices suggesting iron deficiency. The occurrence of troublesome diarrhea was variable and not quite universal. Some patients took antidiarrheal drugs regularly, others only "for safety" or after episodes of diarrhea, some almost never. An occasional patient reported only one or two stools per day. Many patients preferred diarrhea to the bloating cramps and distention which accompany use of codeine or Lomotil. Anal burning, pruritus, hemorrhoidal protrusion and bleeding at stool were common. Five patients required minor anorectal operations, all with relief, usually for fissure. A number of patients were troubled at times by incontinence, especially at night. Most patients had their stools principally in the morning and evening, but some have never stopped having to get up at night. The unbearably foul odor of stools and flatus was a problem to all. Patients learned that even for the passage of flatus it was well to retreat to a bathroom and then to open the window. In some instances, marital problems resulted. The entity called bypass enteritis10 produces for the most part nonspecific symptoms of bloating, pain, abdominal distress and diarrhea. We had 12 patients repeatedly hospitalized for such symptoms, usually responding to a period of bed rest and intravenous alimentation. In three patients we had unequivocal evidence of such disease in the small bowel. One patient early in our experience was operated upon when x-rays disclosed pneumoperitoneum, although the clinical picture was not that of peritonitis. Pneumatosis intestinalis, but no perforation, was found, and she recovered,
Ann.
Surg. * September 1979
although she is one ofthe two who later died from hepatic insufficiency. A number of reports have mentioned pneumatosis cystoides intestinalis and pneumoperitoneum5 8"19 occurring in patients after jejunoileal bypass. A second patient, who had had troublesome diarrhea and many episodes of hypokalemia, came in with severe abdominal pain and a palpable mass. Exploration demonstrated several feet of the distal bypassed bowel had thickened, enlarged and became firm and an angry, dark reddish purple and was covered by numerous conspicuous, tortuous vessels. Nothing was done, and her symptoms subsided. This woman, who had had bilateral knee joint replacements for crippling osteoarthritis and had been in a wheel chair when we first saw her, a year later was walking well without any aids and was having less trouble with diarrhea and maintenance of electrolytes, which had been a recurrent problem; however, she had several massive hemorrhages from her intestine and underwent reconstitution. The bypassed bowel was thickened but no longer inflamed externally. Histologic examination of the amputated end showed evidences of mucosal and submucosal inflammation. She has not bled since. The third and most dramatic example occurred in a man whose weight had gone from 300 to 180 pounds in 18 months. He developed a severe secondary anemia but remained otherwise well, vigorous and enthusiastic. A vagotomy and pyloroplasty, done in his hometown, were unavailing. Our colonoscopy showed the ileum, which had been anastomosed to the transverse colon, to be the seat of large, discrete, sharply outlined ulcers, the mucosa between them appearing not inflamed. At operation at 2 1/2 years, the involved segment, found to be about 18 in. long, was resected. The patient continued as before without the slightest symptoms, eating ravenously and maintaining his new physique, but he resumed bleeding. After 4 1/2 months, we reoperated, resected another thickened, ulcerated distal segment and converted his Scott-type end-to-end operation to a Payne end-to-side operation. In the 36 months since then, he has gained 35 pounds, still 115 pounds less than his original weight, and has bled no more. It is of some interest that his sister, also with a superb weight loss but with polymyositis, had a severe chronic anemia and ultimately, after 5 years and 3 months, had a lengthening, elsewhere, of her functioning bowel because of hepatic dysfunction, with a substantial gain in weight of 30 pounds in 3 months. Three patients had severe, recurrent, migratory polyarthralgia, which ultimately cleared in two, but which in a third has been intermittently present and is at times disabling after 5 years. The puzzling neurological manifestations in five patients have consisted of attacks of dizziness, instability,
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387
TABLE 5. Pattern of Weight Loss
Average weight No. patients
Preop
I mo.
3 mo.
6 mo.
9 mo.
12 mo.
18 mo.
24 mo.
36 mo.
317.7 64
281.1 64
273.6 64
247.6 64
227.4 59
222.0 56
198.7 49
187.7 42
176.6 28
tilting to one side in walking, walking with a wide base and, in two cases, not personally observed by us, a comatose state of some hours' duration, with spontaneous recovery. Some of these patients with neurological problems have been patients otherwise difficult to handle. One, on the other hand, was a steel hauler who had gone back to work promptly, had a splendid weight loss and no problem with diarrhea or electrolytes. Repeated and extensive study of these patients yielded only the information that one patient was considered to have multiple sclerosis on the basis of spinal fluid studies. If so, she has had a remission for over 2 years now. Two patients required hospitalization for severe psychoses, one with alternating moods of euphoria and depression, delusions and hallucinations, the other with a severe reactive depression manifested by complete withdrawal. Both responded very satisfactorily to psychiatric treatment and have had no further difficulty. Both were among the patients who had difficulty in accepting their new slender selves as "me." Neither had presented any other major problems. One man, previously a "jolly fat man," coincident with a massive and relatively uncomplicated weight loss, became violent and abusive toward his family and required two admissions for episodes of severe disturbance; he ultimately adjusted. One patient developed seizures, had an abnormal EEG, and on anticonvulsants has had no further episodes. Table 5 shows the pattern of weight loss achieved, and Figure 1 shows the slope of the weight loss curve expressed as the cumalative percentage of initial weight reached per unit time. There was substantial variation in the rapidity and extent of weight loss. Of 49 patients followed more than 18 months, in 26 the weight had stabilized by 18 months, while 23 continued to lose weight. Five of these were stable by 24 months, the remainder leveled off in the 3rd year. Despite the known variation in the length of bowel from one individual to another, the imprecision of the actual measurement and the problem imposed by the varying appearance of Treitz's ligament and the occasional covering over of the ileocecal junction by fat, there was a remarkable difference in weight loss, with small changes in the length of residual functioning small bowel. Figure 1 compares the weight loss in 12 patients with 19 in. or more of functioning small bowel (all but one operated upon early in the series) with the 52 patients whose functioning small bowel measured 18 in. or less.
The weight loss curves for these two groups begin to separate at about 12 months postoperatively. By 18 months, the cumulative percentage of weight lost by the 19 in. or more group was 28%, as compared to the 37% in the 18 in. or less group. The patients with the longer segments flattened their weight loss curves at 18 months, and at 36 months all the patients with the shorter segments had lost at least one-third of their preoperative weight, whereas only three of 12 of the other group had lost that much. We were troubled by the fact that some patients lost inadequate amounts weight after what was a standardized operation-two in the 19 in. group and two with 11 inches of jejunum and 7 inches of terminal ileum. At reoperation, as Scott'6 and others have shown, the jejunal segment was longer, thicker and dilated, and the ileal segment was less so. Viewed quantitatively, the complications resulted in 170 hospital admissions of 4-57 days in these 64 patients, as of the time this analysis was done. The average length of hospitalization was 16 days at an estimated cost of $3,000.00 per 16 day admission (costs based on the rates in December 1977, no allowance for subsequent inflation). There had been 703 outpatient visits, 11 per patient (at a cost each time of $49 for laboratory determinations) and innumerable phone calls in addition. Two patients had more than ten admissions and 30 follow-up visits each. Given the assumed shortened life expectancy with
100 I
CD
w
IL ¢
0
-J
z PREOP I
3
6
9
12
18
24 36
MONTHS POST OP FIG. 1. Weight loss over a three year period. Group A (broken line) includes all patients whose combined jejunal and ileal lengths were 2 47.5 cm (19 in). Group B (solid line) includes all patients whose combined jejunal and ileal lengths were 45 cm (18 in). -
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RAVITCH AND BROLIN
massive obesity, the known increased risk of diabetes and hypertension and the poor quality of life for the monstrously obese and in the light of the almost universal failure of non-operative measures, it was hoped that jejunoileal bypass would be an effective and acceptable form of therapy. The operative mortality is or should be very low and the long-term mortality can be minimized, but we have come to the conclusion that even with close follow-up and prescription of multiple medications, the late postoperative sequelae have not been predictable or preventable. As of December 1977, 1 1% of our patients had undergone restitution; the number continues to grow. Only ten of 45 patients whose weight has stabilized have not required readmission to hospital, and two of those stabilized failed to lose 33% of their preoperative weight. Of the entire 45, only 24 (53%) lost more than one-third of their preoperative weight and were doing well with their bypass, somewhat less than the 66% good results quoted by Scott et al.17
6. 7.
8. 9. 10. 11.
12. 13. 14.
15.
References 1. Ames, F. C., Copeland, E. M., Leeb, D. C. et al.: Liver Dysfunction Following Small-bowel Bypass for Obesity. Nonoperative Treatment of Fatty Metamorphosis with Parenteral Hyperalimentation. JAMA, 235:1249, 1976. 2. Buchwald, H., Moore, R. B. and Varco, R. L.: Ten Years Clinical Experience with Partial Ileal Bypass in Management of the Hyperlipidemias. Ann. Surg., 180:384, 1974. 3. Buchwald, H. and Varco, R. L.: A Bypass Operation for Obese Hyperlipidemic Patients. Surgery, 70:62, 1971. 4. Buchwald, H., Varco, R. L., Moore, R. B. and Schwartz, M. Z.: Intestinal Bypass Procedures. Partial Ileal Bypass for Hyperlipidemia and Jejunoileal Bypass for Obesity. Curr. Probl. Surg., 1975. 5. Drenick, E. J., Ament, M. E., Finegold, S. M. et al.: Bypass
DISCUSSION
DR. J. HOWARD PAYNE, SR. (Los Angeles, California): A search of the literature showed innumerable publications on the various surgical approaches to the morbidly obese patient since 1965. Our first experience was in 1956, but our first publication was not until 1963. It took us seven years to arrive at the conclusion that the jejunocolic bypass was hazardous and should be abandoned. We now have 23 years of experience with the surgical approach to hyperobesity. We still see and follow our first patient to undergo surgical therapy for malnutrition morbid obesity. Every effort has been made to provide for the patient's long-term care, clinical observation and problems. With this background, we have periodically reported our results to provide a perspective for other investigators, with our approach, and to the adventuresome who are trying other surgical methods to reduce weight. The bypass with the end-to-end anastomosis, known as the Scott procedure, decompresses the bypassed bowel into the colon. There will be regurgitation of large bowel content into the bypassed bowel whether the ileocolic anastomosis is into the cecum, transverse
16.
17. 18. 19.
20.
Ann. Surg. * September 1979
Enteropathy. Intestinal and Systemic Manifestations Following Small-bowel Bypass. JAMA, 236:269, 1976. Kremen, H. J., Linner, J. H. and Nelson, C. H.: An Experimental Evaluation of Nutritional Importance of Proximal and Distal Small Intestine. Ann. Surg., 140:439, 1954. McLachlin, A. D., McLachlin, J. A., Jory, T. A. and Ramling, E. G.: Venous Stasis in the Lower Extremities. Trans. Am. Surg. Assoc., LXVIII, 1960. Menguy, R.: Pneumatosis Intestinalis After Jejunoileal Bypass. JAMA, 236: 1721, 1976. 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, 1974. Passaro, E., Jr., Drenick, E. J. and Wilson, S. E.: Bypass Enteritis. A New Complication of Jejunoileal Bypass for Obesity. Am. J. Surg., 131:169, 1976. Payne, J. H. and DeWind, L.: Surgical Treatment of Obesity. Am. J. Surg., 118: 141, 1969. Payne, J. H., DeWind, L., Schwab, G. E. and Kern, W. H.: Surgical Treatment of Morbid Obesity. Sixteen Years of Experience. Arch. Surg., 106:432, 1973. Phillips, R. B.: Small Intestinal Bypass for the Treatment of Morbid Obesity. Surg. Gynecol. Obstet., 146:455, 1978. Salmon, P. A.: The Results of Small Intestine Bypass Operations for the Treatment of Obesity. Surg. Gynecol. Obstet., 132:965, 1971. Salmon, P. A. and Reedyk, L.: Fatty Metamorphosis in Patients with Jejunoileal Bypass. Surg. Gynecol. Obstet., 141:75, 1975. Scott, H. W., Jr., Dean, R. H., Shull, H. J. et al.: Further Considerations in the Use of Jejunoileal Bypass in Patients with Morbid Obesity. Bull. Soc. Int. Chir., 33:378, 1974. Scott, H. W., Jr., Dean, R. H., Shull, H. J. and Gluck, R.: Results of Jejunoileal Bypass in Two Hundred Patients with Morbid Obesity. Surg. Gynecol. Obstet., 145:661, 1977. Scott, H. W., Jr., Sandstead, H. H., Brill, A. B. et al.: Experience with a New Technique of Intestinal Bypass in the Treatment of Morbid Obesity. Ann Surg., 174:560, 1971. Sicard, G. A., Vaugh, R. and Wise, L.: Pneumatosis Cystoides Intestinalis: An Unusual Complication of Jejunoileal Bypass. Surgery, 79:480, 1976. Starkloff, G. B., Donovan, J. F., Ramach, K. R. and Wolfe, B. M.: Metabolic Intestinal Surgery. Its Complications and Management. Arch. Surg., 110:652, 1975.
colon or sigmoid. In may opinion, this is the primary cause of one of the relatively new problems, namely, the so-called bypass enteritis syndrome. These problems are responsible for many revisions and takedown operations. One patient has described the syndrome as "the bloats and the blahs." The gastric bypass has been changed so many times that I cannot keep up with it. It is inappropriate to draw conclusions with only one year of follow-up study. We are now seeing failures and devastating complications. I have never done a gastric bypass but have consulted with patients and their doctors relative to the procedure and their problems. These data could supply enough information for a separate manuscript. The use of large stapling devices in the upper abdomen in a 400 pound patient is difficult and uncertain. The most skilled surgeons have problems maneuvering in the subdiaphragmatic area of the celomic cavity even in the patient who is not obese. With the foregoing in mind plus many happy alumni, we have continued to do the jejunoileal bypass using 35 cm of proximal jejunum anastomosed end-to-side to the distal 10 cm of the ileum with a minor modification designed to prevent reflux into the bypassed segment. This procedure has been named by others as the
In the performance of end-to-end jejunoileal shunt, operative mortality can be nearly eliminated and late deaths largely prevented by assiduous care and follow-up. We attempted to prevent serious complications by regular outpatient visits. However, 703 outpatient visits costing $49.00 per visit failed to improve results. There were 170 readmissions among 64 patients lasting 4-57 days (average hospital stay -16 days per admission at $3,000.00). Twenty-four of those patients alive and followed 18 months or more (53%) sustained adequate weight loss and were free of major problems. Patient satisfaction nevertheless appears high, and when there has been a good weight loss, even severe problems tend to be glossed over by the patient. The ultimate outcome is still unknown, but it seems clear that many of the patients are in a state of controlled malnutrition, which may lead to progressive penalties. We have documented gross pathologic lesions in the bypass enteritis syndrome and draw attention to neurologic sequelae of the bypass, which probably represents deficiency manifestations. Despite brilliant results in some patients and satisfactory results in perhaps half, the cost in life, suffering, dollars, patient and physician time, the uncertain long-term effects, and the unpredictability of the weight loss, all place in question the appropriateness of jejunoileal shunt as the remedy for morbid obesity.
THE CONCEPT of controlled malabsorption by exclusion of measured segments of the bowel, from the alimentary stream in the effort to correct massive obesity, introduced by Kremen et al.6 and pioneered and intensively studied by Salmon and Reedyk,14,15 Payne et al ,11,12 Scott et al. ,16.17,18 Buchwald and Varco et al. ,2,3,4 and others and since put widely into clinical application around the world, has now had more than a decade of extensive experience. When we embarked on a series of these operations in 1972, after some reluctance, we understood that the initial hazards could be overcome by appropriate care and diligence and that in time the patients adjusted and compensated for the induced abnormality and their condition stabilized. This was an experimental program to be performed according to protocol by a single operator. All patients were informed that the operation was experimental, the ultimate results were unknown, the current mortality within a year of operation was expected to be about 5%, that Presented at the Annual Meeting of the American Surgical Association, Hot Springs, Virginia, April 26-28, 1979.
From the Departments of Surgery, Montefiore Hospital and the University of Pittsburgh, Pittsburgh, Pennsylvania
they would have to be permanently and closely followed, return to the hospital for admission on demand, whether for scheduled examinations or for therapeutic indications and that the extent and rapidity of weight loss were unpredictable, except that patients were unlikely to reach the sylph-like figure that they visualized. This was chiefly because in balancing a massive weight loss and, on the other hand, leaving a safe margin of functioning bowel to minimize the likelihood of disaster we would err on the latter side. Materials and Methods From 1972 to 1978, 12 male and 52 female patients, ranging in age from 20 to 59 years, underwent jejunoileal bypass at the Montefiore Hospital of Pittsburgh; all but three of them were followed by us for their entire postoperative course. The patients all weighed at least 100 pounds over ideal body weight and usually weighed over 300 pounds, except for a few women five feet tall (Table 1). There was no discovered evidence of endocrine abnormality in any. All had had numerous trials of non-operative weight reduction. Initially, we rejected a good many patients for what we considered to be unstable or pathological personalities, depressive tendencies or intelligence insufficient for reliable cooperation in the subsequent years. Remarkably enough, when a third of the way through the study, we were able to enlist the energetic cooperation of a psychologist and a psychiatrist, and essentially no more patients were rejected for those reasons (except two or three of whom we were so fearful that we did not send them for those studies). The psychiatric and psychological reports were usually that the patient was indeed disturbed or erratic or not very bright, but his/her life was hopeless unless a massive weight loss was achieved. Since there seemed no other way to achieve the weight loss, operation was advised, and the psychiatric-psychological studies after operation usually showed great satisfaction, improved self-image, etc.
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The operation, always a Scott-type end-to-end jejunoileal anastomosis, underwent some modifications. The incision was transverse, supraumbilical and originally crossed the whole right side and extended almost as far on the left; subsequently it was changed so that it usually went only to the midline, dividing the linea alba but not the left rectus. The end of the bypassed bowel originally was implanted in the sigmoid. This was found to be technically difficult, and we thought it resulted in troublesome reflux of gas into the bypassed bowel; therefore we employed the right transverse colon for a time and ultimately came to make the anastomosis to the ascending colon. Our original anastomoses united 12 inches of jejunum, measured on the antimesenteric border (a shorter length of bowel, therefore, than if it had been measured on the mesenteric border) to 8 inches of ileum. This failed to give optimal weight loss sufficiently often that we came to use 11 inches and 6 inches as our standard lengths. All bowel divisions, closures and anastomoses were made with the staplers, and there were no intraperitoneal infections and no anastomotic leaks or fecal fistulae. A single patient some months after operation vomited repeatedly and showed some intermittent filling defect at the anastomosis. The patient was found at operation (in the original operator's absence from the city) to have a flap ofredundant mucosa prolapsing through the anastomosis; the condition was relieved without complication by the excision of this mucosal flap. Results
This review was undertaken because we were impressed by the number of patients who several years after operation complained of lack of strength, still required medication for the control of diarrhea and continued to manifest or develop anew a variety of complications: sometimes one or another complication would develop late in a patient who had never before had any significant trouble. The depth of the prior unhappiness of these massively obese patients can perhaps best be measured by their ecstasy over their weight loss, ability to buy clothes off the shelf, bend down and tie their own shoes, go swimming with their children and create jealousy in their spouse and even more by their unwillingness to consider restoration of intestinal continuity. Even the sickest patients with the severest or most prolonged complications fight the idea of alimentary reconstitution, knowing the inevitability of weight gain after it. It is of some interest that in discussing the pros and cons of the original operation, the complications, mortality, etc., with patients who met the criteria of accept-
383
TABLE 1. Associated Preoperative Conditions
Condition
No. Patients
Family history of obesity Hypertension Dyspnea on exertion Previous cholecystectomy Hemorrhoids Venous insufficiency -lower extremity Degenerative arthritis Adult onset diabetes Pickwickian symptoms Preeclampsia Congestive heart failure
34* 15 20 10 9 5 5 5 3 3 1
* Another 16 patients had no statement concerning family history of obesity; only four patients in the series had negative family histories or other associated conditions.
ability for operation, we have several times been successful in dissuading men from the operation but not once a woman. By the same token, the only two patients to ask for a dismantling of the operation were men. One, a steel factory foreman who had no other postoperative problems, said he and his wife considered that the operation had transformed their lives but he feared the pain of renal colic. He had, in fact, had five documented attacks with stones, requiring a ureterolithotomy for one, and had other episodes of renal colic. The other, a man with a public position who had given innumerable exuberant testimonies of his new image and its effect, had had several bouts of metabolic derangement, probably brought on by drinking large amounts of fluid, and was one of those patients who often develop a sudden abdominal distention of astonishing degree. Our female patients have been reluctant to accept the dismantling procedure, even when it was discussed in terms of saving their lives. I do not think there is one who has not said, "I would do it all over again," although a psychiatrist might well take this as meaning, "I must at all costs deny that the risk, the suffering, the economic cost were not worthwhile." Many of the patients were patient-referred, although a sophisticated motivation analysis might offer a variety of explanations for that as well. The evaluation of "patient satisfaction" is particularly difficult after operations for morbid obesity, since the patients are guiltily aware that the obesity was self-induced, and they have more than the usual patient's vested interest in finding that the risks, expense and suffering were all justified. Discussion The problem which we have had in the present analysis is just this matter of the pleasure the patients take in their new lives, their repeated expressions of gratitude and our inability to determine how much risk,
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TABLE 2. Response of Obesity-related Diseases to Weight Loss bv Jejunoileal Shunt
Preop. Condition Adult onset diabetes mellitus Hypertension Degenerative arthritis (Disability) Venous insufficiency Respiratory insufficiency
No. Patients
Resolved
Improved
5 15
5 13
2
5
1 3 23
4 1
5
23
Unaffected
1
how much discomfort, how much expense is justified in terms of the results achieved and the still uncertain future for all of these patients. Will years of oxaluria result in the renal damage in some percentages of those who do not form stones? Will there be a certain incidence of late hepatic insufficiency? Will the neurologic lesions progress? What we are producing, after all, is a controlled malnutrition. The serum levels of the common electrolytes are easily measured, but their changes in the total body composition are much less readily so. Of the trace elements we know little. Protein deficiency is clinically obvious in many patients in the continuing brittleness and sparseness of their hair, change in character of their nails, weakness and decreased muscle mass. Osteoporosis and vertebral fracture in a woman who had never had tetany or low serum calcium was disconcerting. Almost all of the patients recognize some weakness, occasionally rather severe, particularly the women. The appearance of neurological symptoms in five patients, i.e., dizziness, ataxia, loss of consciousness, was particularly disturbing The patients were all discharged and maintained on oral vitamin supplements, calcium, magnesium and potassium and provided with codeine sulfate, Lomotilg or Loperamide® for diarrhea. One "macho" salesman originally took no medication of any kind, finally coming to take codeine occasionally, but never took electrolyte or vitamin supplements. In many others the degree of religiosity of compliance is unknown. All patients were talked to at length before operation, repeatedly in the hospital, again before and after operation and at the frequent postoperative visits concerning the severe thirst they might feel, the necessity for controlling their desire to drink large quantities of fluids, the inevitability of the resultant fluid and electrolyte loss, etc. Yet patient after patient who returned with overwhelming diarrhea or electrolyte imbalance-hypokalemia, hypocalcemia- admitted to having drunk large amounts of fluid and listened in wide-eyed innocence when given the explanation once again. Four of our patients died. Two died of liver failure at eight and six months after operation. Both were patients
Ann. Surg. * September 1979
who would not or could not eat, who vomited regardless, who lived in rural Pennsylvania and were difficult to bring to the hospital. Both came early in our experience, when we had not adopted our policy of immediately hospitalizing any patient with hepatic dysfunction and had not yet learned the effectiveness of amino acid infusion in 5% glucose for such patients. "I A third patient who at times had severe hypokalemia and hypocalcemia died suddenly at home, a few days after having been seen with a modest hypokelemia 10 months after operation. The medical examiner's postmorten study showed no cause for death. The fourth patient lost weight inadequately after her 12 in. to 12 in. shunt, had a reversion and lost massively and would eat and do well in hospital but vomited and starved at home and was brought in for reconstitution. She was placed on conventional hyperalimentation, with 25% glucose, went into coma and died-a risk of which we were not aware. We had two instances of postoperative ventral hernias, no eviscerations, a single severe subcutaneous infection and 11 lesser infections. One patient required overnight tracheal intubation, a woman of 467 pounds. All of our patients were operated upon with the head of the table depressed 15° to empty the leg veins and decrease the likelihood of pulmonary embolism.7 Episodes which seemed to represent pulmonary embolism occurred in three patients. In short, this is an operation which we are persuaded can be performed with a very low immediate risk, even in these large patients, and from which we are confident late mortality can be largely eliminated by appropriate care, with the occasional need for a timely reintervention. The determination of the value of the operation will have to be made on an estimation of the quality of life to be lived, the significance of the complications and the long-term results. We are accustomed to tell our patients that they are well aware that if they remain hugely obese, their life expectancy will be shortened and they will be more likely to develop hypertension and diabetes. Fifteen of 64 had hypertension before operation; it was relieved in 13 and improved in two. Five of 64 had diabetes before operation, and all were able to discontinue medication for the diabetes (Table 2). And, of course, after operation upon patients with progressive disability, dyspnea, alarming tachycardia on slight exertion or pickwickian picture before operation, one can say that whatever their present problems, they might not now be alive but for the beneficial effects ofthe massive weight loss. The record of complications in our hands is not dissimilar to that reported by others. 13.17,20 Early postoperative morbidity is summarized in Table 3. Five patients had prolongation of their hos-
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pital stay due to excessive diarrhea, which eventually responded to codeine or Lomotil. Nausea and vomiting prolonged the hospitalization of three patients. The nausea in patients with jejunoileal shunt deserves special comment. Many of them, in almost the same words, will say, "I get queasy when I wake up in the morning," and, for many, vomiting induced by tooth brushing is the chief vomiting problem. Others vomit alarmingly often, and in some the resultant starvation at a time when they should have a large food intake is dangerous; it was fatal in two patients who died with jaundice. The patient with a vomiting problem will often say, "I can't stand the smell offood." We thought the vomiting was usually not psychogenic. Occasional patients still vomit, at times years after operation, but they usually do not mention it unless specifically asked. We have mentioned the 12 infections in the subcutaneous fat, one of them major. Nine patients had urinary tract infections (all patients had indwelling urinary catheters for at least 48 hours). There was one patient with pneumonia, and we have mentioned the three presumed pulmonary emboli, none major. The total number of patients with early complications was thus 21 (32%). Forty-five of the 64 patients (70%) were readmitted to the hospital for late sequelae. In all, there were 170 such admissions ranging from four to 57 days, 16 days on the average, at a 1977 cost of $3,000.00 each admission, despite the fact that we tried to treat patients on an outpatient basis for diarrhea and mild electrolyte imbalance. We recognized electrolye imbalance as a problem in 31 patients (almost 50%), and 11 required hospitalization, presenting with weakness, muscle cramps, paresthesias and occasionally carpopedal spasm. All 31 had hypokalemia, 19 had hypocalcemia, and 13 had hypomagnesemia. The relative severity of the electrolyte disturbances is seen in Table 4. While excessive diarrhea-frequently in patients who admitted to massive fluid intake and then "forgot to take" codeine or Lomotil-preceded the episode of electrolyte imbalance, we saw several patients with severe hypocalcemia and hypomagnesemia who claimed to have only three or four formed stools daily. TABLE 3. Early Postoperative Complications No. Patients
Complications Wound infection Gastrointestinal distress* Urinary tract infection Pulmonary embolus Ventral hernia
12 9 8 3 2
* Includes nausea, vomiting, bloating and diarrhea which prolonged the patient's hospital course.
385 TABLE 4.
Electrolyte Imbalance No. Patients
Hypokalemia
K = 3.1-3.5 K s 3.0
16 15
Hypocalcemia
Ca = 7.1-8.8 Cac 7.0
11 8
Hypomagnesemia Mg = 1.1-1.8 Mg c 1.0
7 6
We have documented vitamin A deficiency by decreased vitamin A levels in two patients with pathognomonic skin and ocular lesions which disappeared with vitamin supplementations. In at least three patients a fiery red, smooth, painful tongue and rhagades indicated overt vitamin B insufficiency. Hospitalization was indicated for nausea, vomiting and diarrhea in 27 patients. One patient complained of stools "all day long' and claimed no relief from frequent doses of codeine, but in spite of this there was no evidence of electrolyte disturbances, and we felt forced to restore the normal alimentary pathway. On the other hand, in 13 patients there were nausea, vomiting and abdominal cramps without excessive numbers of daily stools (more than six). These patients frequently had a distended abdomen at such times and showed distended loops of (bypassed) bowel in the x-ray films. Nine patients were considered to have some degree of hepatocellular dysfunction. In five, the elevation of serum bilirubin was minor and the hepatocellular enzymes elevated to levels less than three times the upper limit of normal. All of these patients had nausea, vomiting and abdominal pain. We have described the two deaths from liver failure, and the patient who died unexpectedly at home had earlier mild evidence of impaired liver function. One patient was hospitalized twice with moderately severe symptoms, mild icterus and aberrations of hepatic function and responded to rest and intravenous fluids. On a third occasion, she was feeble and deeply jaundiced, with hepatic enzymes five times the normal, and unable to take nourishment by mouth. She responded dramatically to 2 weeks of intravenous amino acids and has had no further suggestion of hepatic dysfunction in over two years. An additional patient was operated upon for hepatic failure at a military hospital, and her functional segment of small intestine was lengthened, reversing her hepatic dysfunction at the expense of a 30 lb. weight gain in the first 3 months after operation. Eight patients have had renal calculi, all calcium oxalate; two of these have had multiple episodes. We
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have mentioned one patient, who in one episode required ureterolithotomy and whom we reconverted, and we plan reconversion in the other patient with multiple episodes. We agree with O'Leary et al.9 that urinary oxalate is so frequently elevated in the first months after jejunoileal shunt that the determination has no prognostic value. In at least one of our patients with an oxalate stone, the urinary oxalate determination performed some time earlier was within normal limits. Significant anemia was found in 23 patients, long after the operative event. (No patient required transfusion during the operative admission, except for the patient with an extensive wound infection.) Of the 14 with hemoglobin of 10-12 gm, the red blood cell indices were normochromic and normocytic in ten. In two patients, the anemia was megaloblastic and responded to folate and vitamin B12. In nine patients hemoglobin was less than 10 gm. Three of these were discovered to have blood in the stool more or less constantly; the other nine had no consistent red blood cell picture nor was the cause for the anemia found by extensive hematological investigation. In all, there were 12 patients with normochromic-normocytic indices suggesting iron deficiency. The occurrence of troublesome diarrhea was variable and not quite universal. Some patients took antidiarrheal drugs regularly, others only "for safety" or after episodes of diarrhea, some almost never. An occasional patient reported only one or two stools per day. Many patients preferred diarrhea to the bloating cramps and distention which accompany use of codeine or Lomotil. Anal burning, pruritus, hemorrhoidal protrusion and bleeding at stool were common. Five patients required minor anorectal operations, all with relief, usually for fissure. A number of patients were troubled at times by incontinence, especially at night. Most patients had their stools principally in the morning and evening, but some have never stopped having to get up at night. The unbearably foul odor of stools and flatus was a problem to all. Patients learned that even for the passage of flatus it was well to retreat to a bathroom and then to open the window. In some instances, marital problems resulted. The entity called bypass enteritis10 produces for the most part nonspecific symptoms of bloating, pain, abdominal distress and diarrhea. We had 12 patients repeatedly hospitalized for such symptoms, usually responding to a period of bed rest and intravenous alimentation. In three patients we had unequivocal evidence of such disease in the small bowel. One patient early in our experience was operated upon when x-rays disclosed pneumoperitoneum, although the clinical picture was not that of peritonitis. Pneumatosis intestinalis, but no perforation, was found, and she recovered,
Ann.
Surg. * September 1979
although she is one ofthe two who later died from hepatic insufficiency. A number of reports have mentioned pneumatosis cystoides intestinalis and pneumoperitoneum5 8"19 occurring in patients after jejunoileal bypass. A second patient, who had had troublesome diarrhea and many episodes of hypokalemia, came in with severe abdominal pain and a palpable mass. Exploration demonstrated several feet of the distal bypassed bowel had thickened, enlarged and became firm and an angry, dark reddish purple and was covered by numerous conspicuous, tortuous vessels. Nothing was done, and her symptoms subsided. This woman, who had had bilateral knee joint replacements for crippling osteoarthritis and had been in a wheel chair when we first saw her, a year later was walking well without any aids and was having less trouble with diarrhea and maintenance of electrolytes, which had been a recurrent problem; however, she had several massive hemorrhages from her intestine and underwent reconstitution. The bypassed bowel was thickened but no longer inflamed externally. Histologic examination of the amputated end showed evidences of mucosal and submucosal inflammation. She has not bled since. The third and most dramatic example occurred in a man whose weight had gone from 300 to 180 pounds in 18 months. He developed a severe secondary anemia but remained otherwise well, vigorous and enthusiastic. A vagotomy and pyloroplasty, done in his hometown, were unavailing. Our colonoscopy showed the ileum, which had been anastomosed to the transverse colon, to be the seat of large, discrete, sharply outlined ulcers, the mucosa between them appearing not inflamed. At operation at 2 1/2 years, the involved segment, found to be about 18 in. long, was resected. The patient continued as before without the slightest symptoms, eating ravenously and maintaining his new physique, but he resumed bleeding. After 4 1/2 months, we reoperated, resected another thickened, ulcerated distal segment and converted his Scott-type end-to-end operation to a Payne end-to-side operation. In the 36 months since then, he has gained 35 pounds, still 115 pounds less than his original weight, and has bled no more. It is of some interest that his sister, also with a superb weight loss but with polymyositis, had a severe chronic anemia and ultimately, after 5 years and 3 months, had a lengthening, elsewhere, of her functioning bowel because of hepatic dysfunction, with a substantial gain in weight of 30 pounds in 3 months. Three patients had severe, recurrent, migratory polyarthralgia, which ultimately cleared in two, but which in a third has been intermittently present and is at times disabling after 5 years. The puzzling neurological manifestations in five patients have consisted of attacks of dizziness, instability,
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387
TABLE 5. Pattern of Weight Loss
Average weight No. patients
Preop
I mo.
3 mo.
6 mo.
9 mo.
12 mo.
18 mo.
24 mo.
36 mo.
317.7 64
281.1 64
273.6 64
247.6 64
227.4 59
222.0 56
198.7 49
187.7 42
176.6 28
tilting to one side in walking, walking with a wide base and, in two cases, not personally observed by us, a comatose state of some hours' duration, with spontaneous recovery. Some of these patients with neurological problems have been patients otherwise difficult to handle. One, on the other hand, was a steel hauler who had gone back to work promptly, had a splendid weight loss and no problem with diarrhea or electrolytes. Repeated and extensive study of these patients yielded only the information that one patient was considered to have multiple sclerosis on the basis of spinal fluid studies. If so, she has had a remission for over 2 years now. Two patients required hospitalization for severe psychoses, one with alternating moods of euphoria and depression, delusions and hallucinations, the other with a severe reactive depression manifested by complete withdrawal. Both responded very satisfactorily to psychiatric treatment and have had no further difficulty. Both were among the patients who had difficulty in accepting their new slender selves as "me." Neither had presented any other major problems. One man, previously a "jolly fat man," coincident with a massive and relatively uncomplicated weight loss, became violent and abusive toward his family and required two admissions for episodes of severe disturbance; he ultimately adjusted. One patient developed seizures, had an abnormal EEG, and on anticonvulsants has had no further episodes. Table 5 shows the pattern of weight loss achieved, and Figure 1 shows the slope of the weight loss curve expressed as the cumalative percentage of initial weight reached per unit time. There was substantial variation in the rapidity and extent of weight loss. Of 49 patients followed more than 18 months, in 26 the weight had stabilized by 18 months, while 23 continued to lose weight. Five of these were stable by 24 months, the remainder leveled off in the 3rd year. Despite the known variation in the length of bowel from one individual to another, the imprecision of the actual measurement and the problem imposed by the varying appearance of Treitz's ligament and the occasional covering over of the ileocecal junction by fat, there was a remarkable difference in weight loss, with small changes in the length of residual functioning small bowel. Figure 1 compares the weight loss in 12 patients with 19 in. or more of functioning small bowel (all but one operated upon early in the series) with the 52 patients whose functioning small bowel measured 18 in. or less.
The weight loss curves for these two groups begin to separate at about 12 months postoperatively. By 18 months, the cumulative percentage of weight lost by the 19 in. or more group was 28%, as compared to the 37% in the 18 in. or less group. The patients with the longer segments flattened their weight loss curves at 18 months, and at 36 months all the patients with the shorter segments had lost at least one-third of their preoperative weight, whereas only three of 12 of the other group had lost that much. We were troubled by the fact that some patients lost inadequate amounts weight after what was a standardized operation-two in the 19 in. group and two with 11 inches of jejunum and 7 inches of terminal ileum. At reoperation, as Scott'6 and others have shown, the jejunal segment was longer, thicker and dilated, and the ileal segment was less so. Viewed quantitatively, the complications resulted in 170 hospital admissions of 4-57 days in these 64 patients, as of the time this analysis was done. The average length of hospitalization was 16 days at an estimated cost of $3,000.00 per 16 day admission (costs based on the rates in December 1977, no allowance for subsequent inflation). There had been 703 outpatient visits, 11 per patient (at a cost each time of $49 for laboratory determinations) and innumerable phone calls in addition. Two patients had more than ten admissions and 30 follow-up visits each. Given the assumed shortened life expectancy with
100 I
CD
w
IL ¢
0
-J
z PREOP I
3
6
9
12
18
24 36
MONTHS POST OP FIG. 1. Weight loss over a three year period. Group A (broken line) includes all patients whose combined jejunal and ileal lengths were 2 47.5 cm (19 in). Group B (solid line) includes all patients whose combined jejunal and ileal lengths were 45 cm (18 in). -
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RAVITCH AND BROLIN
massive obesity, the known increased risk of diabetes and hypertension and the poor quality of life for the monstrously obese and in the light of the almost universal failure of non-operative measures, it was hoped that jejunoileal bypass would be an effective and acceptable form of therapy. The operative mortality is or should be very low and the long-term mortality can be minimized, but we have come to the conclusion that even with close follow-up and prescription of multiple medications, the late postoperative sequelae have not been predictable or preventable. As of December 1977, 1 1% of our patients had undergone restitution; the number continues to grow. Only ten of 45 patients whose weight has stabilized have not required readmission to hospital, and two of those stabilized failed to lose 33% of their preoperative weight. Of the entire 45, only 24 (53%) lost more than one-third of their preoperative weight and were doing well with their bypass, somewhat less than the 66% good results quoted by Scott et al.17
6. 7.
8. 9. 10. 11.
12. 13. 14.
15.
References 1. Ames, F. C., Copeland, E. M., Leeb, D. C. et al.: Liver Dysfunction Following Small-bowel Bypass for Obesity. Nonoperative Treatment of Fatty Metamorphosis with Parenteral Hyperalimentation. JAMA, 235:1249, 1976. 2. Buchwald, H., Moore, R. B. and Varco, R. L.: Ten Years Clinical Experience with Partial Ileal Bypass in Management of the Hyperlipidemias. Ann. Surg., 180:384, 1974. 3. Buchwald, H. and Varco, R. L.: A Bypass Operation for Obese Hyperlipidemic Patients. Surgery, 70:62, 1971. 4. Buchwald, H., Varco, R. L., Moore, R. B. and Schwartz, M. Z.: Intestinal Bypass Procedures. Partial Ileal Bypass for Hyperlipidemia and Jejunoileal Bypass for Obesity. Curr. Probl. Surg., 1975. 5. Drenick, E. J., Ament, M. E., Finegold, S. M. et al.: Bypass
DISCUSSION
DR. J. HOWARD PAYNE, SR. (Los Angeles, California): A search of the literature showed innumerable publications on the various surgical approaches to the morbidly obese patient since 1965. Our first experience was in 1956, but our first publication was not until 1963. It took us seven years to arrive at the conclusion that the jejunocolic bypass was hazardous and should be abandoned. We now have 23 years of experience with the surgical approach to hyperobesity. We still see and follow our first patient to undergo surgical therapy for malnutrition morbid obesity. Every effort has been made to provide for the patient's long-term care, clinical observation and problems. With this background, we have periodically reported our results to provide a perspective for other investigators, with our approach, and to the adventuresome who are trying other surgical methods to reduce weight. The bypass with the end-to-end anastomosis, known as the Scott procedure, decompresses the bypassed bowel into the colon. There will be regurgitation of large bowel content into the bypassed bowel whether the ileocolic anastomosis is into the cecum, transverse
16.
17. 18. 19.
20.
Ann. Surg. * September 1979
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colon or sigmoid. In may opinion, this is the primary cause of one of the relatively new problems, namely, the so-called bypass enteritis syndrome. These problems are responsible for many revisions and takedown operations. One patient has described the syndrome as "the bloats and the blahs." The gastric bypass has been changed so many times that I cannot keep up with it. It is inappropriate to draw conclusions with only one year of follow-up study. We are now seeing failures and devastating complications. I have never done a gastric bypass but have consulted with patients and their doctors relative to the procedure and their problems. These data could supply enough information for a separate manuscript. The use of large stapling devices in the upper abdomen in a 400 pound patient is difficult and uncertain. The most skilled surgeons have problems maneuvering in the subdiaphragmatic area of the celomic cavity even in the patient who is not obese. With the foregoing in mind plus many happy alumni, we have continued to do the jejunoileal bypass using 35 cm of proximal jejunum anastomosed end-to-side to the distal 10 cm of the ileum with a minor modification designed to prevent reflux into the bypassed segment. This procedure has been named by others as the
