Complications of Jejunoileal Bypass for Morbid Obesity William R. Jewell, MD; Arlo S. Hermreck, MD;
Creighton
A. Hardin, MD
Fifty-two patients had jejunoileal bypass surgery. End-to-end (Scott) or end-to-side (Payne) shunts were randomly selected for each patient; 31 standard length shunts and 21 shortened bypasses were performed. Only 22 patients had an acceptable result, whereas 30 patients had inadequate weight loss (less than 2.3 kg [5 lb] per month per year) or had gastrointestinal tract, metabolic, or surgical complications judged severe enough to render the outcome less than adequate. There was one death, and four patients required reanastomosis of the bypass. The primary determinant of success was age, ie, younger patients had clearly better results than older patients. In general, shorter shunts produced more weight loss than standard bypass procedures, but were associated with an increased complication rate. Three new complications of jejunoileal bypass are reported: acute colonic dilation with necrosis, beriberi, and lupus erythematosus.
importantly, morbid obesity alters the quality of life by reducing employability and impairing personal inter¬ relationships, which often leads to a poor body image and the all-too-frequent complaint of "helplessness" and "selfentrapment syndrome."3 Several large early reports have suggested that jejuno¬ ileal bypass leads to a suitable weight reduction without significant complications,46 whereas other more recent more
studies would suggest that serious and even life-threat¬ ening complications can and do occur with a high fre¬ quency following these procedures.79 It is the purpose of this report to attempt to balance the benefits of surgery against the complications observed in a sizable group of patients undergoing jejunoileal bypass for morbid obesity. PATIENTS AND METHODS
Operations larity
for morbid obesity are being performed in in increasing numbers. The popu¬ institutions many and demand for these procedures stem from two ba¬ sic observations: First, it is now well accepted that medi¬ cal therapy (diets, pills, and so on) and the group therapy approach (TOPS, Weight Watchers) almost always fail in long-term efforts to control weight in patients 45 kg (100 lb) or more over ideal weight. Second, it is generally agreed that morbid obesity is associated with serious health hazards, such as sudden death, hypertension, and a decreased life expectancy.1-2 In addition, and perhaps for publication April 3, 1975. From the University of Kansas Medical Center, Kansas City. Read before the 32nd annual meeting of the Central Surgical Association, Chicago, March 1, 1975. Reprint requests to Surgical Section of Oncology, University of Kansas Medical Center, Rainbow Boulevard at 39th Street, Kansas City, KS 66103
Accepted
(Dr. Jewell).
Fifty-four patients were selected for jejunoileal bypass using guidelines established by Payne et al," and Scott et al,5 ie, weight more than 56.5 kg (125 lb) in excess of ideal weight, rea¬ sonable motivation, no evidence of endogenous causes, and ade¬ the
quate health to withstand surgery.
Fifty-two patients were available for follow-up ranging from six months to 3Vè years. All patients were seen in an outpatient clinic at two- to four-week intervals immediately after bypass surgery, and at two- to three-month intervals thereafter. Patients underwent extensive preoperative evaluation to rule out causes for morbid obesity other than hyperphagia and increased caloric ingestion. The type of jejunoileal bypass performed (Scott or Payne) was determined at the time of operation by opening a sealed envelope containing a prerandomized card. Initially, the bypass procedures were performed precisely as described by Scott et al and Payne et al. Subsequently, however, because of inade¬ quate weight loss and patient dissatisfaction, individual surgeons were permitted to alter the length of the jejunal and ileal limbs of the shunt in order to obtain a more satisfactory operation. AU sur-
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/27/2015
Table 1.—Clinical Results of Jejunoileal
Bypass Results Inadequate Weight ,-»-
Mean
Procedure End-to-side End-to-side End-to-end End-to-end End-to-end End-to-end
End-to-end
Average Age, yr
Weight, kg (lb)
Jejunum, cm
cm
No.
33 33 38 46 21 29 55
132.0 (292) 134.7 (298) 144.6 (320) 127.9 (283) 137.0 (303) 131.1 (290) 159.6 (353)
35.6 25.4 30.5 30.5 25.4 25.4 10.2
10.2 10.2 30.5 15.2 30.5 25.4 30.5
22
Ileum,
major complication.
The criteria for a major complication were based solely on clini¬ cal observations and are outlined below. All operative complica¬ tions were considered major and listed as such. Severe diarrhea was considered a serious complication only if it persisted more than six months and could not be managed well with orally admin¬ istered narcotics. Perirectal disorders were considered serious when hemorrhoids prolapsed and bled chronically or failed to re¬ spond to conventional treatment and required hemorrhoidectomy. Vomiting and flatus were also considered as major complications when protracted in the former and excessive and foul in the latter. All metabolic complications (each required rehospitalization) were considered serious except for mild, transient electrolyte imbalance responding to orally administered supplements. A weight loss of less than 20% of the preoperative body weight was similarly con¬ sidered an unsatisfactory result. In general, these patients had a weight loss of less than 2.3 kg (5 lb) per month, and had clearly plateaued by the sixth month.
RESULTS A summary of the average age, preoperative weight, type of procedure performed, and result in 52 patients is shown in Table 1. Clearly 60% of patients had a poor re¬ sult, with the remaining 40% being evenly split between good and excellent results. There was no substantial dif¬ ference between the standard Payne (35.6 cm of jejunum and 10.2 cm of ileum) or Scott (30.5 cm of jejunum and 30.5 cm of ileum) shunt in terms of result. Shortening of the jejunum and ileum, respectively, did not improve results, and in patients undergoing an end-to-end 10.2x30.5-cm shunt clearly resulted in such serious problems that both patients were reoperated to restore jejunoileal lengths. Table 2 shows the effect of age on clinical results of jeju¬ noileal bypass. Over 70% of patients 30 years and younger
Excellent
Good
Poor 13
13
gical procedures
were performed by or under the direct super¬ vision of the authors. Postoperatively, most patients were main¬ tained on endotracheal intubation and a mechanical ventilator for 24 hours. Alimentation was begun on resumption of active bowel sounds, and all patients were allowed to take food and water ad libitum. Following the small bowel bypass, all patients were in¬ structed to take gluconate calcium, 1 gm four times daily, and multiple vitamins. The patients were evaluated postoperatively by a simple system comparing weight loss with complications. The patients clearly clustered into three groups as outlined as follows: excellent (E): sustained weight loss of 2.7 kg (6 lb) per month per year with no complications; good (G): sustained weight loss of 2.7 kg (6 lb) per month per year with one major complication; and poor (P): weight loss of less than 2.3 kg (5 lb) per month per year, or more than one
Loss
Table 2.—Effect of
Age on Clinical Results of Jejunoileal Bypass Results
Age, yr 18-30 30-40 40-65 Total
Table
Total 21 16
Excellent
Good
Poor
4
15 52
0 11
2 1 11
10 14 30
3.—Major Complications of Jejunoileal Bypass Complications
Total
Surgical
Wound infection Dehiscence Hernia Acute colon dilation Death (pulmonary insufficiency) Gastrointestinal tract Severe diarrhea (6 mo) Hemorrhoids (prolapsed, bleeding)
Hemorrhoidectomy Vomiting
Excess flatus Metabolic
Liver dysfunction
Electrolyte imbalance Renal calculi Arthritis
Systemic lupus erythematosus Vitaminosis
5 1 6 1
1 11 9 4 1 1 4 12 3 4 2 1 2
Integument changes Inadequate weight loss_15
had a good or excellent result, whereas only 27% of pa¬ tients in the 30 to 40 age group and 7% in the 40 to 65 age group had good or excellent results. Clearly, age is a major factor in attaining a satisfactory result. Table 3 outlines the myriad major complications occur¬ ring after jejunoileal bypass. These were divided into three major subgroups.
Surgical Complications There was one death that occurred postoperatively in a 41-year-old, 177.6-kg (393-lb) woman with severe chronic obstructive pulmonary disease and the Pickwickian syn¬ drome. She died of pulmonary insufficiency on the fourth postoperative day, and clearly, in retrospect, should not have undergone a bypass operation.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/27/2015
Wound infection, dehiscence, and ventral hernia were the other surgical complications. Considering the weight of the patients, this rate is thought to be acceptable. One major postoperative problem, however, occurred that has not previously been reported. A 43-year-old, 155.9-kg (345-lb) man underwent an end-to-side 25.4 x 10.2-cm jejunoileal bypass recommended by his internist be¬
of sustained diastolic hypertension and chemical evidence of diabetes. The operation was uneventful and his early postopera¬ tive course was unremarkable. Oral feeding was begun on the fourth postoperative day, at which time he was passing flatus freely. On the fifth postoperative day, the patient appeared "sep¬ tic" and his blood urea nitrogen (BUN) and creatinine levels rose from normal preoperative levels to 64 and 4.8 mg/100 ml, respec¬ tively. An x-ray film of the abdomen with the patient upright showed massive dilation of the ascending colon (Figure). A lap¬ arotomy was performed that revealed massive dilation and necro¬ sis of the ascending colon. There was no evidence of anastomotic obstruction or volvulus, and the jejunoileal bypass was intact. A right hemicolectomy was performed, the jejunoileal bypass was taken down, and intestinal tract continuity was reestablished. Postoperatively, wound dehiscence occurred which required clo¬ sure. The patient ran a septic course for some time, but eventually recovered. The pathology report showed ischemie necrosis of the colon wall. cause
Gastrointestinal Tract
Complications
Only complications that impaired the patient's wellbeing were considered. Moderate diarrhea was present in almost all patients, and whereas this usually ended by the third month, short recurrent episodes were exceedingly frequent. The sequels of diarrhea were usually easily man¬ aged with orally administered narcotics. Metabolic
Complications
Metabolic complications occurred in 28 instances. Tran¬ sient electrolyte imbalance was common, but 12 patients had prolonged, severe hypokalemia, hypocalcemia, and/or hypomagnesemia, requiring hospitalization. All of these patients were eventually managed by orally administered mineral supplements, but parenteral augmentation of electrolyte levels was frequently necessary. Severe liver dysfunction was uncommon. Several patients had tran¬ sient increase in alkaline phosphatase levels (5 to 10 units), but only four patients had evidence of moderate or severe liver dysfunction. One patient required restoration of the gastrointestinal tract to normal length because of jaundice, hypoalbuminemia, and ascites. She has made a
complete
recovery.
Renal calcium oxalate calculi were found in three pa¬ tients. One patient had postoperative 24-hour urinary oxa¬ late levels of 135, 263, and 181 mg/24 hours, (normal, 40 mg/24 hours). It appears that a marked alteration in oxa¬ late metabolism occurs and all patients with and without stones should be evaluated. Oxalate renal calculi have been reported in patients with small bowel disease, short bowel syndrome, and jejunoileal bypass.10 Two patients who were admitted with particularly wor¬ risome metabolic findings are reported separately. A
130.2-kg (288-lb), 37-year-old
man
underwent
an
end-to-end,
Acute colon dilation five days following jejunoileal bypass. No anatomic obstruction was present at surgery.
25.4 x 25.4-cm jejunoileal bypass. He had an excellent result with weight loss of 46.1 kg (102 lb) in one year and only occasional diarrhea. He developed a calcium oxalate renal calculus in the 12th postoperative month, which he passed spontaneously, and he was subsequently placed on a low oxalate diet. One month later, he de¬ veloped an erythematous rash with a facial butterfly distribution. A lupus erythematosus preparation was positive and he is being evaluated for systemic lupus erythematosus. A 212.4-kg (470-lb), 40-year-old woman underwent an end-toside, 25.4 x 10.2-cm shunt. Her weight decreased to 135.6 kg (300 lb) within one year, but she complained of occasional diarrhea. She developed severe peripheral polyneuropathy of motor and sensory nerves, severe enough to make walking impossible and the use of both hands was lost. A diagnosis of beriberi was made and she re¬ sponded promptly to parenteral complex vitamins. In retro¬ spect, inadequate dietary vitamin intake may have been a contrib¬ uting factor.
Inadequate Weight
Loss
Weight loss was judged inadequate in 15 patients. Most of these patients plateaued at 9 to 13.6 kg (20 to 30 lb) be¬ low preoperative weights within the first few months. Shortening of the jejunoileal limb lengths produced un¬ predictable results. Generally, patients with shorter shunts tended to lose more weight, but this effect was overshadowed by a higher complication rate. The one pa¬ tient undergoing a 30.5 x 15.2-cm shunt as now recom¬ mended by Scott et al,5 had an acceptable result. However, a second patient who had initially had a 30.5x30.5-cm end-to-end bypass was shortened to a 30.5 15.2-cm by¬ pass because of inadequate weight loss and again failed to lose more than a few kilograms. COMMENT
Any surgical procedure must be evaluated not only with respect
to the benefits derived but also in terms of the our experience, it appears that the
complications. From
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/27/2015
complications of jejunoileal bypass seriously detract from the resulting benefit of weight loss. Only 11 of our 52 pa¬ tients had weight loss enough to be worthwhile without complications. Another 11 had good weight loss, but had significant complications detracting from the goal of the operation. The remaining 30 patients had a poor result, with 15 patients failing to lose weight significantly, whereas those who did lose weight sustained multiple complications that overshadowed their loss of weight. Of 52 patients, three developed complications never before reported: beriberi, lupus erythematosus, and acute idio¬ pathic colon obstruction. The patient with beriberi may not have developed this complication if increased vitamin intake had been ef¬ fected. The development of lupus erythematosus may have been a chance occurrence. However, the suspicion of the same complication in a second patient and the devel¬ opment of significant arthritic complaints in other pa¬ tients suggest that the alterations of metabolism with je¬ junoileal bypass may be responsible for these findings. It would seem worthwhile to further explore these changes before proceeding with these procedures on a larger scale. Liver dysfunction remains a significant problem, as does the development of hyperoxaluria and calcium oxalate re¬ nal calculi. The liver problem appears most severe during the first year after bypass, with gradual improvement thereafter,7 but hyperoxaluria is probably persistent. Hair loss present in two patients may also reflect metabolic dysfunction.
It is difficult to assess the benefits of weight loss pro¬ duced by these procedures in terms of quality and quan¬ tity of life. It seems fairly clear that morbid obesity is as¬ sociated with increased risk of sudden death and overall poor survivability.12 However, whether or not patients undergoing bypass surgery will in fact survive longer than their still obese peers who did not undergo operation
remains to be seen. Quality of life seems to be obviously improved. Solow et al' have shown psychosocial benefit from this operation and all authors have reported positive patient response. Also, it would appear that not all meta¬ bolic changes are bad, as a clear fall of serum cholesterol and triglycéride levels has been a common observation in most
reports.5
Because of the above
findings, jejunoileal bypass is not currently being performed for morbid obesity at the Uni¬ versity of Kansas Medical Center. Suitable patients are now undergoing the gastric bypass procedure as described by Printen and Mason.11 In 18 patients operated on thus far, suitable weight loss with fewer complications has been observed, but this series is not far enough along to provide meaningful data. References 1. Gubner R: Overweight and health: Prognostic realities and therapeutic possibilities, in Lasagna L (ed): Obesity: Causes, Consequences and Treatment. New York, Medcom Press, 1974, pp 7-25. 2. Health implications, in Obesity and Health. Arlington, Va, US Public Health Service, National Center for Chronic Diseases Control, 1968, pp 23\x=req-\ 32. 3. Solow C, Silberfab PM, Swift K: Psychosocial effects of intestinal bypass surgery for severe obesity. N Engl J Med 290:300-303, 1974. 4. Payne JH, DeWind L, Schwab CE, et al: Surgical treatment of morbid obesity. Arch Surg 106:432-437, 1973. 5. Scott HW, Dean R, Shull HJ, et al: New considerations in use of jejunoileal bypass in patients with morbid obesity. Ann Surg 177:723-733,1973. 6. Salmon PA: The results of small bowel intestinal bypass operations for the treatment of obesity. Surg Gynecol Obstet 132:965-979, 1971. 7. Moxley RT, Pozefsky T, Lockwood DH: Protein nutrition and liver disease after jejunoileal bypass for morbid obesity. N Engl J Med 290:921-926, 1974. 8. McGill DB, Humphrey SR, Baggenstoss AH: Cirrhosis and death after jejunoileal bypass. Gastroenterology 63:872-877, 1972. 9. DeMuth WE Jr, Rottenstein HS: Death associated with hypocalcemia after small bowel bypass. N Engl J Med 270:1239-1240, 1964. 10. Williams HE: Nephrolithiasis. N Engl J Med 290:33-38, 1974. 11. Printen KJ, Mason EE: Gastric surgery for relief of morbid obesity. Arch Surg 106:428-431, 1973.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/27/2015
Creighton
A. Hardin, MD
Fifty-two patients had jejunoileal bypass surgery. End-to-end (Scott) or end-to-side (Payne) shunts were randomly selected for each patient; 31 standard length shunts and 21 shortened bypasses were performed. Only 22 patients had an acceptable result, whereas 30 patients had inadequate weight loss (less than 2.3 kg [5 lb] per month per year) or had gastrointestinal tract, metabolic, or surgical complications judged severe enough to render the outcome less than adequate. There was one death, and four patients required reanastomosis of the bypass. The primary determinant of success was age, ie, younger patients had clearly better results than older patients. In general, shorter shunts produced more weight loss than standard bypass procedures, but were associated with an increased complication rate. Three new complications of jejunoileal bypass are reported: acute colonic dilation with necrosis, beriberi, and lupus erythematosus.
importantly, morbid obesity alters the quality of life by reducing employability and impairing personal inter¬ relationships, which often leads to a poor body image and the all-too-frequent complaint of "helplessness" and "selfentrapment syndrome."3 Several large early reports have suggested that jejuno¬ ileal bypass leads to a suitable weight reduction without significant complications,46 whereas other more recent more
studies would suggest that serious and even life-threat¬ ening complications can and do occur with a high fre¬ quency following these procedures.79 It is the purpose of this report to attempt to balance the benefits of surgery against the complications observed in a sizable group of patients undergoing jejunoileal bypass for morbid obesity. PATIENTS AND METHODS
Operations larity
for morbid obesity are being performed in in increasing numbers. The popu¬ institutions many and demand for these procedures stem from two ba¬ sic observations: First, it is now well accepted that medi¬ cal therapy (diets, pills, and so on) and the group therapy approach (TOPS, Weight Watchers) almost always fail in long-term efforts to control weight in patients 45 kg (100 lb) or more over ideal weight. Second, it is generally agreed that morbid obesity is associated with serious health hazards, such as sudden death, hypertension, and a decreased life expectancy.1-2 In addition, and perhaps for publication April 3, 1975. From the University of Kansas Medical Center, Kansas City. Read before the 32nd annual meeting of the Central Surgical Association, Chicago, March 1, 1975. Reprint requests to Surgical Section of Oncology, University of Kansas Medical Center, Rainbow Boulevard at 39th Street, Kansas City, KS 66103
Accepted
(Dr. Jewell).
Fifty-four patients were selected for jejunoileal bypass using guidelines established by Payne et al," and Scott et al,5 ie, weight more than 56.5 kg (125 lb) in excess of ideal weight, rea¬ sonable motivation, no evidence of endogenous causes, and ade¬ the
quate health to withstand surgery.
Fifty-two patients were available for follow-up ranging from six months to 3Vè years. All patients were seen in an outpatient clinic at two- to four-week intervals immediately after bypass surgery, and at two- to three-month intervals thereafter. Patients underwent extensive preoperative evaluation to rule out causes for morbid obesity other than hyperphagia and increased caloric ingestion. The type of jejunoileal bypass performed (Scott or Payne) was determined at the time of operation by opening a sealed envelope containing a prerandomized card. Initially, the bypass procedures were performed precisely as described by Scott et al and Payne et al. Subsequently, however, because of inade¬ quate weight loss and patient dissatisfaction, individual surgeons were permitted to alter the length of the jejunal and ileal limbs of the shunt in order to obtain a more satisfactory operation. AU sur-
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/27/2015
Table 1.—Clinical Results of Jejunoileal
Bypass Results Inadequate Weight ,-»-
Mean
Procedure End-to-side End-to-side End-to-end End-to-end End-to-end End-to-end
End-to-end
Average Age, yr
Weight, kg (lb)
Jejunum, cm
cm
No.
33 33 38 46 21 29 55
132.0 (292) 134.7 (298) 144.6 (320) 127.9 (283) 137.0 (303) 131.1 (290) 159.6 (353)
35.6 25.4 30.5 30.5 25.4 25.4 10.2
10.2 10.2 30.5 15.2 30.5 25.4 30.5
22
Ileum,
major complication.
The criteria for a major complication were based solely on clini¬ cal observations and are outlined below. All operative complica¬ tions were considered major and listed as such. Severe diarrhea was considered a serious complication only if it persisted more than six months and could not be managed well with orally admin¬ istered narcotics. Perirectal disorders were considered serious when hemorrhoids prolapsed and bled chronically or failed to re¬ spond to conventional treatment and required hemorrhoidectomy. Vomiting and flatus were also considered as major complications when protracted in the former and excessive and foul in the latter. All metabolic complications (each required rehospitalization) were considered serious except for mild, transient electrolyte imbalance responding to orally administered supplements. A weight loss of less than 20% of the preoperative body weight was similarly con¬ sidered an unsatisfactory result. In general, these patients had a weight loss of less than 2.3 kg (5 lb) per month, and had clearly plateaued by the sixth month.
RESULTS A summary of the average age, preoperative weight, type of procedure performed, and result in 52 patients is shown in Table 1. Clearly 60% of patients had a poor re¬ sult, with the remaining 40% being evenly split between good and excellent results. There was no substantial dif¬ ference between the standard Payne (35.6 cm of jejunum and 10.2 cm of ileum) or Scott (30.5 cm of jejunum and 30.5 cm of ileum) shunt in terms of result. Shortening of the jejunum and ileum, respectively, did not improve results, and in patients undergoing an end-to-end 10.2x30.5-cm shunt clearly resulted in such serious problems that both patients were reoperated to restore jejunoileal lengths. Table 2 shows the effect of age on clinical results of jeju¬ noileal bypass. Over 70% of patients 30 years and younger
Excellent
Good
Poor 13
13
gical procedures
were performed by or under the direct super¬ vision of the authors. Postoperatively, most patients were main¬ tained on endotracheal intubation and a mechanical ventilator for 24 hours. Alimentation was begun on resumption of active bowel sounds, and all patients were allowed to take food and water ad libitum. Following the small bowel bypass, all patients were in¬ structed to take gluconate calcium, 1 gm four times daily, and multiple vitamins. The patients were evaluated postoperatively by a simple system comparing weight loss with complications. The patients clearly clustered into three groups as outlined as follows: excellent (E): sustained weight loss of 2.7 kg (6 lb) per month per year with no complications; good (G): sustained weight loss of 2.7 kg (6 lb) per month per year with one major complication; and poor (P): weight loss of less than 2.3 kg (5 lb) per month per year, or more than one
Loss
Table 2.—Effect of
Age on Clinical Results of Jejunoileal Bypass Results
Age, yr 18-30 30-40 40-65 Total
Table
Total 21 16
Excellent
Good
Poor
4
15 52
0 11
2 1 11
10 14 30
3.—Major Complications of Jejunoileal Bypass Complications
Total
Surgical
Wound infection Dehiscence Hernia Acute colon dilation Death (pulmonary insufficiency) Gastrointestinal tract Severe diarrhea (6 mo) Hemorrhoids (prolapsed, bleeding)
Hemorrhoidectomy Vomiting
Excess flatus Metabolic
Liver dysfunction
Electrolyte imbalance Renal calculi Arthritis
Systemic lupus erythematosus Vitaminosis
5 1 6 1
1 11 9 4 1 1 4 12 3 4 2 1 2
Integument changes Inadequate weight loss_15
had a good or excellent result, whereas only 27% of pa¬ tients in the 30 to 40 age group and 7% in the 40 to 65 age group had good or excellent results. Clearly, age is a major factor in attaining a satisfactory result. Table 3 outlines the myriad major complications occur¬ ring after jejunoileal bypass. These were divided into three major subgroups.
Surgical Complications There was one death that occurred postoperatively in a 41-year-old, 177.6-kg (393-lb) woman with severe chronic obstructive pulmonary disease and the Pickwickian syn¬ drome. She died of pulmonary insufficiency on the fourth postoperative day, and clearly, in retrospect, should not have undergone a bypass operation.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/27/2015
Wound infection, dehiscence, and ventral hernia were the other surgical complications. Considering the weight of the patients, this rate is thought to be acceptable. One major postoperative problem, however, occurred that has not previously been reported. A 43-year-old, 155.9-kg (345-lb) man underwent an end-to-side 25.4 x 10.2-cm jejunoileal bypass recommended by his internist be¬
of sustained diastolic hypertension and chemical evidence of diabetes. The operation was uneventful and his early postopera¬ tive course was unremarkable. Oral feeding was begun on the fourth postoperative day, at which time he was passing flatus freely. On the fifth postoperative day, the patient appeared "sep¬ tic" and his blood urea nitrogen (BUN) and creatinine levels rose from normal preoperative levels to 64 and 4.8 mg/100 ml, respec¬ tively. An x-ray film of the abdomen with the patient upright showed massive dilation of the ascending colon (Figure). A lap¬ arotomy was performed that revealed massive dilation and necro¬ sis of the ascending colon. There was no evidence of anastomotic obstruction or volvulus, and the jejunoileal bypass was intact. A right hemicolectomy was performed, the jejunoileal bypass was taken down, and intestinal tract continuity was reestablished. Postoperatively, wound dehiscence occurred which required clo¬ sure. The patient ran a septic course for some time, but eventually recovered. The pathology report showed ischemie necrosis of the colon wall. cause
Gastrointestinal Tract
Complications
Only complications that impaired the patient's wellbeing were considered. Moderate diarrhea was present in almost all patients, and whereas this usually ended by the third month, short recurrent episodes were exceedingly frequent. The sequels of diarrhea were usually easily man¬ aged with orally administered narcotics. Metabolic
Complications
Metabolic complications occurred in 28 instances. Tran¬ sient electrolyte imbalance was common, but 12 patients had prolonged, severe hypokalemia, hypocalcemia, and/or hypomagnesemia, requiring hospitalization. All of these patients were eventually managed by orally administered mineral supplements, but parenteral augmentation of electrolyte levels was frequently necessary. Severe liver dysfunction was uncommon. Several patients had tran¬ sient increase in alkaline phosphatase levels (5 to 10 units), but only four patients had evidence of moderate or severe liver dysfunction. One patient required restoration of the gastrointestinal tract to normal length because of jaundice, hypoalbuminemia, and ascites. She has made a
complete
recovery.
Renal calcium oxalate calculi were found in three pa¬ tients. One patient had postoperative 24-hour urinary oxa¬ late levels of 135, 263, and 181 mg/24 hours, (normal, 40 mg/24 hours). It appears that a marked alteration in oxa¬ late metabolism occurs and all patients with and without stones should be evaluated. Oxalate renal calculi have been reported in patients with small bowel disease, short bowel syndrome, and jejunoileal bypass.10 Two patients who were admitted with particularly wor¬ risome metabolic findings are reported separately. A
130.2-kg (288-lb), 37-year-old
man
underwent
an
end-to-end,
Acute colon dilation five days following jejunoileal bypass. No anatomic obstruction was present at surgery.
25.4 x 25.4-cm jejunoileal bypass. He had an excellent result with weight loss of 46.1 kg (102 lb) in one year and only occasional diarrhea. He developed a calcium oxalate renal calculus in the 12th postoperative month, which he passed spontaneously, and he was subsequently placed on a low oxalate diet. One month later, he de¬ veloped an erythematous rash with a facial butterfly distribution. A lupus erythematosus preparation was positive and he is being evaluated for systemic lupus erythematosus. A 212.4-kg (470-lb), 40-year-old woman underwent an end-toside, 25.4 x 10.2-cm shunt. Her weight decreased to 135.6 kg (300 lb) within one year, but she complained of occasional diarrhea. She developed severe peripheral polyneuropathy of motor and sensory nerves, severe enough to make walking impossible and the use of both hands was lost. A diagnosis of beriberi was made and she re¬ sponded promptly to parenteral complex vitamins. In retro¬ spect, inadequate dietary vitamin intake may have been a contrib¬ uting factor.
Inadequate Weight
Loss
Weight loss was judged inadequate in 15 patients. Most of these patients plateaued at 9 to 13.6 kg (20 to 30 lb) be¬ low preoperative weights within the first few months. Shortening of the jejunoileal limb lengths produced un¬ predictable results. Generally, patients with shorter shunts tended to lose more weight, but this effect was overshadowed by a higher complication rate. The one pa¬ tient undergoing a 30.5 x 15.2-cm shunt as now recom¬ mended by Scott et al,5 had an acceptable result. However, a second patient who had initially had a 30.5x30.5-cm end-to-end bypass was shortened to a 30.5 15.2-cm by¬ pass because of inadequate weight loss and again failed to lose more than a few kilograms. COMMENT
Any surgical procedure must be evaluated not only with respect
to the benefits derived but also in terms of the our experience, it appears that the
complications. From
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/27/2015
complications of jejunoileal bypass seriously detract from the resulting benefit of weight loss. Only 11 of our 52 pa¬ tients had weight loss enough to be worthwhile without complications. Another 11 had good weight loss, but had significant complications detracting from the goal of the operation. The remaining 30 patients had a poor result, with 15 patients failing to lose weight significantly, whereas those who did lose weight sustained multiple complications that overshadowed their loss of weight. Of 52 patients, three developed complications never before reported: beriberi, lupus erythematosus, and acute idio¬ pathic colon obstruction. The patient with beriberi may not have developed this complication if increased vitamin intake had been ef¬ fected. The development of lupus erythematosus may have been a chance occurrence. However, the suspicion of the same complication in a second patient and the devel¬ opment of significant arthritic complaints in other pa¬ tients suggest that the alterations of metabolism with je¬ junoileal bypass may be responsible for these findings. It would seem worthwhile to further explore these changes before proceeding with these procedures on a larger scale. Liver dysfunction remains a significant problem, as does the development of hyperoxaluria and calcium oxalate re¬ nal calculi. The liver problem appears most severe during the first year after bypass, with gradual improvement thereafter,7 but hyperoxaluria is probably persistent. Hair loss present in two patients may also reflect metabolic dysfunction.
It is difficult to assess the benefits of weight loss pro¬ duced by these procedures in terms of quality and quan¬ tity of life. It seems fairly clear that morbid obesity is as¬ sociated with increased risk of sudden death and overall poor survivability.12 However, whether or not patients undergoing bypass surgery will in fact survive longer than their still obese peers who did not undergo operation
remains to be seen. Quality of life seems to be obviously improved. Solow et al' have shown psychosocial benefit from this operation and all authors have reported positive patient response. Also, it would appear that not all meta¬ bolic changes are bad, as a clear fall of serum cholesterol and triglycéride levels has been a common observation in most
reports.5
Because of the above
findings, jejunoileal bypass is not currently being performed for morbid obesity at the Uni¬ versity of Kansas Medical Center. Suitable patients are now undergoing the gastric bypass procedure as described by Printen and Mason.11 In 18 patients operated on thus far, suitable weight loss with fewer complications has been observed, but this series is not far enough along to provide meaningful data. References 1. Gubner R: Overweight and health: Prognostic realities and therapeutic possibilities, in Lasagna L (ed): Obesity: Causes, Consequences and Treatment. New York, Medcom Press, 1974, pp 7-25. 2. Health implications, in Obesity and Health. Arlington, Va, US Public Health Service, National Center for Chronic Diseases Control, 1968, pp 23\x=req-\ 32. 3. Solow C, Silberfab PM, Swift K: Psychosocial effects of intestinal bypass surgery for severe obesity. N Engl J Med 290:300-303, 1974. 4. Payne JH, DeWind L, Schwab CE, et al: Surgical treatment of morbid obesity. Arch Surg 106:432-437, 1973. 5. Scott HW, Dean R, Shull HJ, et al: New considerations in use of jejunoileal bypass in patients with morbid obesity. Ann Surg 177:723-733,1973. 6. Salmon PA: The results of small bowel intestinal bypass operations for the treatment of obesity. Surg Gynecol Obstet 132:965-979, 1971. 7. Moxley RT, Pozefsky T, Lockwood DH: Protein nutrition and liver disease after jejunoileal bypass for morbid obesity. N Engl J Med 290:921-926, 1974. 8. McGill DB, Humphrey SR, Baggenstoss AH: Cirrhosis and death after jejunoileal bypass. Gastroenterology 63:872-877, 1972. 9. DeMuth WE Jr, Rottenstein HS: Death associated with hypocalcemia after small bowel bypass. N Engl J Med 270:1239-1240, 1964. 10. Williams HE: Nephrolithiasis. N Engl J Med 290:33-38, 1974. 11. Printen KJ, Mason EE: Gastric surgery for relief of morbid obesity. Arch Surg 106:428-431, 1973.
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