28
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
JANUARY, 1976
Recurrent Obstruction of Bypassed Intestine in Obesity Surgery: A Challenging Late Complication NORMAN ROGERS, M.D., PAUL CARTER, M.D. and BURKE SYPHAX, M.D., Department of Surgery Howard University College of Medicine, Washington, D.C.
OVER the past two decades, surgery has been used in the treatment of what may be considered an increasing side effect of inadequate nutritional education, psychic stresses and above-world-average affluence.Y16 This side effect, morbid obesity, is now being treated by a rather radical method, the success of which depends on the marked metabolic derangements it produces.1,7-9 This invasive method of treating massive obesity is becoming popular because of the immediate and often lasting results in the face of continued gluttony, unobtainable from the non-invasive medical means. The complications from jejuno-ileal bypass may range from multiple episodes of diarrhea to death. 1'3'48'10 However, the reported surgical complications following bypass surgery for obesity have been uncommon. Some of the reported surgical complications have included wound infection,1-3'7 perforated stress ulcer of the descending colon,9 intussusception,3'11 bowel obstruction 3,5,7,12,13 upper GI hemorrhage,13 and acute cholecystitis.4'14 This paper will suggest an inherent tendency toward herniation beneath the proximal edge of the ileal mesentery causing obstruction of the ileum near or at its anastomosis to the sigmoid when this method is used to drain the bypassed small bowel after making the jejuno-ileal anastomosis beneath the root of the mesentery. The following is such a case. CASE REPORT This 27-year-old black female, L.W. 357227, was admitted to another local hospital in 1971 complaining of uncontrolled obesity most of her life, which rapidly increased since mar-
riage six years prior to admission. She weighed 310 lbs., and was five feet seven inches tall. She had tried numerous weight-losing diets, and diet pills which only made her nervous, but did not cause her to lose weight. After a negative investigation for any organic etiology of her obesity, an intestinal bypass operation was performed on 12-10-71. In this operation, the proximal jejunum was divided 12 inches from the ligament of Treitz and the terminal ileum was divided 12 inches proximal to the ileocecal valve. A two-layer end-to-end anastomosis was performed beneath the root of the mesentery between the proximal jejunum and distal ileum. An end to side two layer anastomosis was then constructed between the proximal end of the divided ileum and the sigmoid colon. Therefore, the proximal end of the divided ileum of necessity was brought over the jejuno-ileal anastomosis to construct the ileosigmoidostomy as drainage for the bypassed small bowel. The closed distal end of the divided jejunum was sutured to the transverse mesocolon with nonabsorbable suture. The mesenteric defects were reportedly closed with chromic catgut. A liver biopsy indicated moderate midzonal fatty infiltration. Her post-operative course was uncomplicated until approximately 15 months later when she was admitted to another hospital, complaining of abdominal pain for two days that was associated with intermittent vomiting of food and liquid. She did not notice any increase in abdominal girth and she continued to have bowel movements of normal consistency. The abdomen was obese, soft, with moderate tenderness in the peri-umbilical region and left lower quadrant, but was without splinting or other signs of peritoneal irritation. Upper gastrointestinal x-ray series showed the bypass to be functioning well and a barium enema examination revealed a normal colon. She continued for the next two weeks to have dull, aching abdominal pain with intermittent nausea and vomiting. Nasogastric suction relieved the nausea and vomiting but not the pain and tenderness. During this period she was suspected of having partial intestinal obstruction. She was ambulatory, tolerating oral feedings, passing flatus and feces spontaneously, but the intermittent vomiting continued and analgesics could not be discontinued for any substantial number of hours. Repeated examination of the abdomen and repeated x-ray studies of the abdomen indicated mechanical obstruction of the bypassed small bowel (Fig. 1). Abdominal exploration revealed obstruction of the bypassed ileum at the ileosigmoid anastomosis resulting from herniation of the bypassed bowel through a defect beneath the edge of the ileal mesentery. This hemiation caused "volvulus like" twisting of the ileum at the
Vol. 68, No. I
Obesity Surgery
29
pletely closed to the transverse mesocolon with non-absorbable suture. On 3-3-74, when she was discharged, she still was able to detect fetal movements. However, she had a still birth one month later which will be the subject of another report. After 22 months, she has had no recurrence of her obstruction. COMMENT -
s.~~~~~~
~
~
~~~~~~~~~~~~~~~~~~~~~~~..H '
............~~~~~~~~~~~~~~~~~~~~~~:..
Fig. 1. Small bowel distention with air fluid levels and the haze of fluid filled loops suggesting mechanical small bowel obstruction.
site of the anastomosis. The ileosigmoid anastomosis was taken down and the ileum untwisted. A new ileosigmoid anastomosis was performed with the mesenteric defect being closed with non-absorbable interrupted suture. A liver biopsy again revealed mild fatty metamorphosis. Her post-operative course was uncomplicated. On 2-21-74, she, now seven months pregnant and weighing 230 pounds, was admitted to the obstetrics ward of this hospital complaining of generalized colicky abdominal pain present for two days and increasing in intensity. She continued to have bowel movements of normal consistency on the day of admission. She also had abdominal distention and hypoactive bowel sounds, but no splinting or rebound tenderness. The uterus was the approximate size of a 22 weeks gestation. There were occasional peristaltic rushes associated with pain. The cervix was long and closed. All laboratory data were normal. Surgical consultation was obtained from the surgeon who managed the first episode of obstruction. X-ray findings were similar to the figure. Again a diagnosis of mechanical obstruction of the bypassed small bowel was made and laparotomy was performed eleven hours after admission, but only a few hours after consultation. This delay being incident to hydration, volume replacement and bowel preparation. Operative findings included closed loop obstruction secondary to hemiation of bypassed small bowel through the mesenteric defect of the ileosigmoid anastomosis causing twisting of the ileum identical to the previous operative findings. The silk sutures previously placed had pulled out of the mesentery. It is doubted that the gravid uterus had any significant relationship to this second episode of obstruction since the uterine enlargement was anterior and did not disturb, displace or distort either anastomosis. The ileosigmoid anastomosis was dismantled and converted to an ileotransverse colostomy, with the ileal mesentery being easily and com-
This case demonstrates the challenge of diagnosing obstruction of the small bowel in an obese patient. Obesity in any patient makes the abdominal evaluation of distention, tension and muscle tone difficult. This patient, unknown to the examiners on admission, and weighing 260 pounds, was most difficult to evaluate on abdominal examination. Repeated abdominal examination and x-ray studies did, however, prove gradually increasing abdominal distention. The diagnosis was further clouded because of subdued symptoms and signs which were probably due to the gradual distention of the obstructed bypassed bowel. Also the patient continued oral intake and the passage of flatus and feces up until the time of exploration. This patient had little anorexia and only intermittent nausea and vomiting. It is our impression that the vomiting was possibly reflex in nature. Consideration was given to the possibility of intermittent obstruction of the jejuno-ileostomy by the large distended loops of obstructed bypassed bowel. This was decided not to be the case because the vomitus was always only gastric content and never feculent. In the second episode, the abdominal symptoms and signs were much more pronounced. She had abdominal distention, severe crampy abdominal pain which bore to the back, anorexia, nausea and vomiting which are noted in closed loop intestinal obstruction of the bypassed bowel must be. Because of this and especially of the previous episode, the proper diagnosis was made promptly and surgical intervention was not unduly delayed. A most significant finding in both episodes was seen on the x-ray films of the abdomen (Fig. 1). These showed the typical step ladder pattern of air fluid levels. This finding with the absence of identifiable colon is diagnostic of small intestinal obstruction. In a
30
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
patient with approximately 24 inches of in continuity small bowel, after allowing for hypertrophy, dilatation and elongation, the number of loops alone suggests that the out of continuity intestine is obstructed. Even though the surgical technique may be considered straight-forward and uncomplicated, attention to detail is fundamentally necessary. When the jejuno-ileostomy is performed beneath the root of the small bowel mesentery for accurate and complete closure of the mesentery defect, the distal end of the bypassed small bowel must be anastomosed to the cecum, ascending or transverse colon. However, when the jejuno-ileostomy is performed above the root of the small bowel mesentery, the distal end of the bypassed small bowel must be anastomosed to the sigmoid colon.6 This patient's jejuno-ileal anastomosis was beneath the root of the mesentery making absolute closure of mesenteric defects after ileosigmoidostomy difficult because the jejuno-ileostomy and its mesentery were crossed over by the proximal ileum and its mesentery. All defects must then be closed to prevent internal herniation. If, however, in the above situation the transverse colon is used for drainage of the bypassed small bowel, easy, complete closure of the free edge of the ileal mesentery to the transverse mesocolon, with no other interposing structures, can be accomplished. Intestinal bypass surgery is now being performed by many surgeons, therefore the chance of any practicing surgeon seeing a patient who is having a complication of this procedure is increasing. This case illustrates another complication which may be gradual in onset and difficult to diagnose which to our knowledge has not been previously reported. Without critical observation such a patient could progress to strangulation obstruction with its increased morbidity and mortality. SUMMARY
A case of recurrent obstruction of the bypassed small bowel following jejuno-ileal bypass to control morbid obesity is presented. The initial obstruction, approxi-
JANUARY, 1976
mately 15 months after original bypass, was caused by herniation of the bypassed small bowel through the mesenteric defect at the ileosigmoidostomy with '"volvulus-like" twisting of the ileum near this anastomosis. The second episode occurred 10 months after the first in the presence of a gravid uterus. The recurrence has been apparently terminated by converting the ileosigmoidostomy to an ileotransverse colostomy. Continued follow-up, however, is important. LITERATURE CITED
1. PAYNE, J. H. and L. T. DE WIND, and R. R. COMMONS. Metabolic Observations in Patients with Jejunocolic Shunts. Am. J. Surg., 106:273, 1963. 2. SCOTT, H. W. and D. H. LAW, IV. Clinical Appraisal of Jejuno-ileal Shunt in Patients with Morbid Obesity. Am. J. Surg., 117:246, 1969. 3. PAYNE, J. H. and L. T. DE WIND. Surgical Treatment of Obesity. Am. J. Surg., 118:141, 1969. 4. SALMON, P. A. The results of Small Intestine Bypass Operations for the Treatment of Obesity. Surg. Gynec. Obstet., 132:965, 1971. 5. SCOTT, H. W. et al. Jejunoileal Bypass for Morbid Obesity: Appraisal of Results in 100 Patients. J. Tenn. Med. Assoc., 1974, p. 203. 6. SCOTT, et al. Experience with a New Technique of Intestinal Bypass in the Treatment of Morbid Obesity. Ann. Surg., 174:560, 1971. 7. DANO, P. and S. JARNUM, and V. NIELSEN. Intestinal Shunt-Operation in Obesity. A Comparison of Three Types of Operation. Scand. J. Gastroent., 8:457, 1973. 8. BONDAR, G. F. and W. PISESKY. Complications of Small Intestinal Short-Circuiting for Obesity. Arch. Surg., 94:707, 1967. 9. SCHWARTZ, M. Z. and R. L. VARCO and H. BUCHWALD. Preoperative Preparation, Operative Technique and Postoperative Care of Patients Undergoing Jejunoileal Bypass for Massive Exogenous Obesity. J. Surg. Res., 14:147, 1973. 10. DE MUTH, W. E. and H. S. ROTTENSTEIN. Death Associated with Hypocalcemia After Small Bowel Short Circuiting. New Eng. J. Med., 270:1239-1240, 1964. 11. KAUFMANN, H. J., and H. W. WELDON. Intussusception - A Late Complication of SmallBowel Bypass for Obesity. J.A.M.A., 202:87-88, 1967. 12. SCOTT, H. W. et al. New Considerations in Use of Jejunoileal Bypass in Patients with Morbid Obesity. Ann. Surg., 173:723, 1973. (Concluded on page 13)
Vol. 68, No. 1
Perifolliculitis Capitis
At the same time lymphatic dilatation also occurs which promotes drainage from the area. Even though the early use of X-rays to control various infectious diseases had been discontinued with the discovery of antibiotics, in perifolliculitis capitis abscedens et suffodiens where there is extensive scarring which impairs the effectiveness of the antibiotics, X-rays, whatever the mechanism, may be still used as an effective therapeutic measure. LITERATURE CITED
1. HOFFMAN, E. Perifolliculitis Capitis Abscedens et Suffodiens: Case Presentation. Derm. Z., 15:122-123, 1908. 2. SPITZER. Dermat. Ztschr., 1903 p. 109. 3. NOBEL. Case Presentation. Arch. Dermat. M. Syph., 74:80, 1905. 4. RUETE, A. Ein Fall von Perifolliculitis Capitis Abscedens et Suffodiens. Dermat. Ztschr., 20:901, 1913. 5. FREDWIRE, F. and H. J. PARKHURST; A Rare Form of Suffurating and Cicatrizing Disease of the Scalp. Arch. Derm. Syph., 4:750-768, 1921. 6. GROSS. Perifolliculitis Capitis Abscedens et Suffodiens: Case Presentation. Arch. Dermat. & Syph., 19:840-841, 1929. 7. BARNEY, R. F. Dissecting Cellulitis of the
8.
9. 10. 11.
12. 13. 14. 15. 16. 17.
13
Scalp (Perifolliculitis Capitis Abscedens et Suffodiens). Arch. Dermat. Syph., 23:503-518, 1931. ASBECK, F. Perfolliculitis Capitis Abscedens et Suffodiens. Genes and Behandlung, Dermat. Wchnschr., 105:1605-1612, 1937. CANNON, A. B. Perifolliculitis Abscedens et Suffodiens: Case Presentation. Arch. Dermat. & Syph., 49:67-68, 1944. ESTRIN, M. M. Perifolliculitis Capitis Abscedens et Suffodiens. A.M.A. Arch. Derm., 73:256-263 (March) 1956. McMULLAN, F. H. and I. ZELIGMAN; Perifolliculitis Capitis Abscedens et Suffodiens, A.M.A. Arch. Derm., 73:256-263, 1956. MOYER, D. G. and R. M. WILLIAMS. Perifolliculitis Capitis Abscedens et Suffodiens. A.M.A. Arch. Derm., 85:378-384, 1962. CUENI, S. Zur Kenntris der Pathogerse der Perifolliculitis Capitis Abscedens et Suffodiens. Dermat. Ztrchr., 51:94, 1928. BRUNSTING, H. A. Hidradenitis and Other Variants of Acne. A.M.A. Arch. Dermat. & Syph., 65:303-315, 1952. CIPOLLARO, A. C. and P. M. CROSSLAND. X-rays and Radium in the Treatment of Diseases of the Skin. Lea & Febiger. 1967. pp. 564-565. DESJARDINS, A. U. The Action of Roentgen Rays on Inflammatory Conditions. Radiology, 38:274-280, 1942. PENDERGRASS, E. P. and P. J. HODES Roentgen Irradiation in the Treatment of Inflam mations. Am. J. Roentgenol., 45:74-106, 1941.
(Gullattee, from page 54) 4. ALEXANDER, F. Psychosom. Med. W. W. bottom and let all things hang out, but rather Norton & Co., Inc., N.Y., 1950. that one's level of perception be sharpened so 5. BARBER, J. B. Personal communication. that the full circle of referrals for the good of 6. FINNESON, B. E. Diagnosis and Management the patient may be achieved. A final caution, of Pain Syidrome. W. B. Saunders Co., Phila. all pain in the female is not psychosomatic. 1969. 7. GURDJIAN, E. W. and L. M. THOMAS. Neckache and Backache. Charles C Thomas, Springfield, 1970. LITERATURE CITED 8. BURROUGHS W. Pain: Current Concepts on Pain and Analgeisa, v. 2, no. 1. 1. BAKER, J. W. and H. MERSKEY. Pain in 9. RABINOVITCH, R. Diseases of the InterverteGeneral Practice. J. Psychosom. Res., 10:383-387, 1967. bral Disc and its Surrounding Tissues. Charles C Thomas, Springfield. 2. PFEIFFER, E. Treating the Patient with Con10. SEMMES, R. E. Ruptures of the Lumbar Interfirmed Functional Pain. Hosp. Physic., 6:71. vertebral Disc. Charles C Thomas, Springfield, 3. ERICKSON, D. I. The Making of a Low-Back 1964. Loser. Med. Opin., pp. 14-17, Aug., 1974. (Rogers et al. from page 30) 14. PAYNE, J. H. et al. Surgical Treatment of 13. CORSO, P. J. and W. J. JOSEPH. Intestinal Morbid Obesity. Arch. Surg., 106:432, 1973. Bypass in Morbid Obesity. Surg. Gynec. Obstet., 138:1, 1974.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
JANUARY, 1976
Recurrent Obstruction of Bypassed Intestine in Obesity Surgery: A Challenging Late Complication NORMAN ROGERS, M.D., PAUL CARTER, M.D. and BURKE SYPHAX, M.D., Department of Surgery Howard University College of Medicine, Washington, D.C.
OVER the past two decades, surgery has been used in the treatment of what may be considered an increasing side effect of inadequate nutritional education, psychic stresses and above-world-average affluence.Y16 This side effect, morbid obesity, is now being treated by a rather radical method, the success of which depends on the marked metabolic derangements it produces.1,7-9 This invasive method of treating massive obesity is becoming popular because of the immediate and often lasting results in the face of continued gluttony, unobtainable from the non-invasive medical means. The complications from jejuno-ileal bypass may range from multiple episodes of diarrhea to death. 1'3'48'10 However, the reported surgical complications following bypass surgery for obesity have been uncommon. Some of the reported surgical complications have included wound infection,1-3'7 perforated stress ulcer of the descending colon,9 intussusception,3'11 bowel obstruction 3,5,7,12,13 upper GI hemorrhage,13 and acute cholecystitis.4'14 This paper will suggest an inherent tendency toward herniation beneath the proximal edge of the ileal mesentery causing obstruction of the ileum near or at its anastomosis to the sigmoid when this method is used to drain the bypassed small bowel after making the jejuno-ileal anastomosis beneath the root of the mesentery. The following is such a case. CASE REPORT This 27-year-old black female, L.W. 357227, was admitted to another local hospital in 1971 complaining of uncontrolled obesity most of her life, which rapidly increased since mar-
riage six years prior to admission. She weighed 310 lbs., and was five feet seven inches tall. She had tried numerous weight-losing diets, and diet pills which only made her nervous, but did not cause her to lose weight. After a negative investigation for any organic etiology of her obesity, an intestinal bypass operation was performed on 12-10-71. In this operation, the proximal jejunum was divided 12 inches from the ligament of Treitz and the terminal ileum was divided 12 inches proximal to the ileocecal valve. A two-layer end-to-end anastomosis was performed beneath the root of the mesentery between the proximal jejunum and distal ileum. An end to side two layer anastomosis was then constructed between the proximal end of the divided ileum and the sigmoid colon. Therefore, the proximal end of the divided ileum of necessity was brought over the jejuno-ileal anastomosis to construct the ileosigmoidostomy as drainage for the bypassed small bowel. The closed distal end of the divided jejunum was sutured to the transverse mesocolon with nonabsorbable suture. The mesenteric defects were reportedly closed with chromic catgut. A liver biopsy indicated moderate midzonal fatty infiltration. Her post-operative course was uncomplicated until approximately 15 months later when she was admitted to another hospital, complaining of abdominal pain for two days that was associated with intermittent vomiting of food and liquid. She did not notice any increase in abdominal girth and she continued to have bowel movements of normal consistency. The abdomen was obese, soft, with moderate tenderness in the peri-umbilical region and left lower quadrant, but was without splinting or other signs of peritoneal irritation. Upper gastrointestinal x-ray series showed the bypass to be functioning well and a barium enema examination revealed a normal colon. She continued for the next two weeks to have dull, aching abdominal pain with intermittent nausea and vomiting. Nasogastric suction relieved the nausea and vomiting but not the pain and tenderness. During this period she was suspected of having partial intestinal obstruction. She was ambulatory, tolerating oral feedings, passing flatus and feces spontaneously, but the intermittent vomiting continued and analgesics could not be discontinued for any substantial number of hours. Repeated examination of the abdomen and repeated x-ray studies of the abdomen indicated mechanical obstruction of the bypassed small bowel (Fig. 1). Abdominal exploration revealed obstruction of the bypassed ileum at the ileosigmoid anastomosis resulting from herniation of the bypassed bowel through a defect beneath the edge of the ileal mesentery. This hemiation caused "volvulus like" twisting of the ileum at the
Vol. 68, No. I
Obesity Surgery
29
pletely closed to the transverse mesocolon with non-absorbable suture. On 3-3-74, when she was discharged, she still was able to detect fetal movements. However, she had a still birth one month later which will be the subject of another report. After 22 months, she has had no recurrence of her obstruction. COMMENT -
s.~~~~~~
~
~
~~~~~~~~~~~~~~~~~~~~~~~..H '
............~~~~~~~~~~~~~~~~~~~~~~:..
Fig. 1. Small bowel distention with air fluid levels and the haze of fluid filled loops suggesting mechanical small bowel obstruction.
site of the anastomosis. The ileosigmoid anastomosis was taken down and the ileum untwisted. A new ileosigmoid anastomosis was performed with the mesenteric defect being closed with non-absorbable interrupted suture. A liver biopsy again revealed mild fatty metamorphosis. Her post-operative course was uncomplicated. On 2-21-74, she, now seven months pregnant and weighing 230 pounds, was admitted to the obstetrics ward of this hospital complaining of generalized colicky abdominal pain present for two days and increasing in intensity. She continued to have bowel movements of normal consistency on the day of admission. She also had abdominal distention and hypoactive bowel sounds, but no splinting or rebound tenderness. The uterus was the approximate size of a 22 weeks gestation. There were occasional peristaltic rushes associated with pain. The cervix was long and closed. All laboratory data were normal. Surgical consultation was obtained from the surgeon who managed the first episode of obstruction. X-ray findings were similar to the figure. Again a diagnosis of mechanical obstruction of the bypassed small bowel was made and laparotomy was performed eleven hours after admission, but only a few hours after consultation. This delay being incident to hydration, volume replacement and bowel preparation. Operative findings included closed loop obstruction secondary to hemiation of bypassed small bowel through the mesenteric defect of the ileosigmoid anastomosis causing twisting of the ileum identical to the previous operative findings. The silk sutures previously placed had pulled out of the mesentery. It is doubted that the gravid uterus had any significant relationship to this second episode of obstruction since the uterine enlargement was anterior and did not disturb, displace or distort either anastomosis. The ileosigmoid anastomosis was dismantled and converted to an ileotransverse colostomy, with the ileal mesentery being easily and com-
This case demonstrates the challenge of diagnosing obstruction of the small bowel in an obese patient. Obesity in any patient makes the abdominal evaluation of distention, tension and muscle tone difficult. This patient, unknown to the examiners on admission, and weighing 260 pounds, was most difficult to evaluate on abdominal examination. Repeated abdominal examination and x-ray studies did, however, prove gradually increasing abdominal distention. The diagnosis was further clouded because of subdued symptoms and signs which were probably due to the gradual distention of the obstructed bypassed bowel. Also the patient continued oral intake and the passage of flatus and feces up until the time of exploration. This patient had little anorexia and only intermittent nausea and vomiting. It is our impression that the vomiting was possibly reflex in nature. Consideration was given to the possibility of intermittent obstruction of the jejuno-ileostomy by the large distended loops of obstructed bypassed bowel. This was decided not to be the case because the vomitus was always only gastric content and never feculent. In the second episode, the abdominal symptoms and signs were much more pronounced. She had abdominal distention, severe crampy abdominal pain which bore to the back, anorexia, nausea and vomiting which are noted in closed loop intestinal obstruction of the bypassed bowel must be. Because of this and especially of the previous episode, the proper diagnosis was made promptly and surgical intervention was not unduly delayed. A most significant finding in both episodes was seen on the x-ray films of the abdomen (Fig. 1). These showed the typical step ladder pattern of air fluid levels. This finding with the absence of identifiable colon is diagnostic of small intestinal obstruction. In a
30
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
patient with approximately 24 inches of in continuity small bowel, after allowing for hypertrophy, dilatation and elongation, the number of loops alone suggests that the out of continuity intestine is obstructed. Even though the surgical technique may be considered straight-forward and uncomplicated, attention to detail is fundamentally necessary. When the jejuno-ileostomy is performed beneath the root of the small bowel mesentery for accurate and complete closure of the mesentery defect, the distal end of the bypassed small bowel must be anastomosed to the cecum, ascending or transverse colon. However, when the jejuno-ileostomy is performed above the root of the small bowel mesentery, the distal end of the bypassed small bowel must be anastomosed to the sigmoid colon.6 This patient's jejuno-ileal anastomosis was beneath the root of the mesentery making absolute closure of mesenteric defects after ileosigmoidostomy difficult because the jejuno-ileostomy and its mesentery were crossed over by the proximal ileum and its mesentery. All defects must then be closed to prevent internal herniation. If, however, in the above situation the transverse colon is used for drainage of the bypassed small bowel, easy, complete closure of the free edge of the ileal mesentery to the transverse mesocolon, with no other interposing structures, can be accomplished. Intestinal bypass surgery is now being performed by many surgeons, therefore the chance of any practicing surgeon seeing a patient who is having a complication of this procedure is increasing. This case illustrates another complication which may be gradual in onset and difficult to diagnose which to our knowledge has not been previously reported. Without critical observation such a patient could progress to strangulation obstruction with its increased morbidity and mortality. SUMMARY
A case of recurrent obstruction of the bypassed small bowel following jejuno-ileal bypass to control morbid obesity is presented. The initial obstruction, approxi-
JANUARY, 1976
mately 15 months after original bypass, was caused by herniation of the bypassed small bowel through the mesenteric defect at the ileosigmoidostomy with '"volvulus-like" twisting of the ileum near this anastomosis. The second episode occurred 10 months after the first in the presence of a gravid uterus. The recurrence has been apparently terminated by converting the ileosigmoidostomy to an ileotransverse colostomy. Continued follow-up, however, is important. LITERATURE CITED
1. PAYNE, J. H. and L. T. DE WIND, and R. R. COMMONS. Metabolic Observations in Patients with Jejunocolic Shunts. Am. J. Surg., 106:273, 1963. 2. SCOTT, H. W. and D. H. LAW, IV. Clinical Appraisal of Jejuno-ileal Shunt in Patients with Morbid Obesity. Am. J. Surg., 117:246, 1969. 3. PAYNE, J. H. and L. T. DE WIND. Surgical Treatment of Obesity. Am. J. Surg., 118:141, 1969. 4. SALMON, P. A. The results of Small Intestine Bypass Operations for the Treatment of Obesity. Surg. Gynec. Obstet., 132:965, 1971. 5. SCOTT, H. W. et al. Jejunoileal Bypass for Morbid Obesity: Appraisal of Results in 100 Patients. J. Tenn. Med. Assoc., 1974, p. 203. 6. SCOTT, et al. Experience with a New Technique of Intestinal Bypass in the Treatment of Morbid Obesity. Ann. Surg., 174:560, 1971. 7. DANO, P. and S. JARNUM, and V. NIELSEN. Intestinal Shunt-Operation in Obesity. A Comparison of Three Types of Operation. Scand. J. Gastroent., 8:457, 1973. 8. BONDAR, G. F. and W. PISESKY. Complications of Small Intestinal Short-Circuiting for Obesity. Arch. Surg., 94:707, 1967. 9. SCHWARTZ, M. Z. and R. L. VARCO and H. BUCHWALD. Preoperative Preparation, Operative Technique and Postoperative Care of Patients Undergoing Jejunoileal Bypass for Massive Exogenous Obesity. J. Surg. Res., 14:147, 1973. 10. DE MUTH, W. E. and H. S. ROTTENSTEIN. Death Associated with Hypocalcemia After Small Bowel Short Circuiting. New Eng. J. Med., 270:1239-1240, 1964. 11. KAUFMANN, H. J., and H. W. WELDON. Intussusception - A Late Complication of SmallBowel Bypass for Obesity. J.A.M.A., 202:87-88, 1967. 12. SCOTT, H. W. et al. New Considerations in Use of Jejunoileal Bypass in Patients with Morbid Obesity. Ann. Surg., 173:723, 1973. (Concluded on page 13)
Vol. 68, No. 1
Perifolliculitis Capitis
At the same time lymphatic dilatation also occurs which promotes drainage from the area. Even though the early use of X-rays to control various infectious diseases had been discontinued with the discovery of antibiotics, in perifolliculitis capitis abscedens et suffodiens where there is extensive scarring which impairs the effectiveness of the antibiotics, X-rays, whatever the mechanism, may be still used as an effective therapeutic measure. LITERATURE CITED
1. HOFFMAN, E. Perifolliculitis Capitis Abscedens et Suffodiens: Case Presentation. Derm. Z., 15:122-123, 1908. 2. SPITZER. Dermat. Ztschr., 1903 p. 109. 3. NOBEL. Case Presentation. Arch. Dermat. M. Syph., 74:80, 1905. 4. RUETE, A. Ein Fall von Perifolliculitis Capitis Abscedens et Suffodiens. Dermat. Ztschr., 20:901, 1913. 5. FREDWIRE, F. and H. J. PARKHURST; A Rare Form of Suffurating and Cicatrizing Disease of the Scalp. Arch. Derm. Syph., 4:750-768, 1921. 6. GROSS. Perifolliculitis Capitis Abscedens et Suffodiens: Case Presentation. Arch. Dermat. & Syph., 19:840-841, 1929. 7. BARNEY, R. F. Dissecting Cellulitis of the
8.
9. 10. 11.
12. 13. 14. 15. 16. 17.
13
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