Symposium on Morbid Obesity
Surgical Experience with Jejunoileal Bypass for Morbid Obesity H. William Scott, Jr., M.D., F.A.C.S. *
A surgical approach to massive, exogenous (morbid) obesity is based on the dual concept that it is a serious, life-shortening disorder and that medical treatment is usually unsuccessful. 6• 7 Various operative procedures have been suggested, but extensive jejunoileal bypass has been used most widely. In the last 12 years we have made a clinical, psychologic, and metabolic study of morbid obesity and the effects of jejunoileal bypass in management of225 patients. Patients were selected for operation from a much larger group after appraisal of their clinical and metabolic status. Criteria for selection included: obesity of at least two to three times ideal weight of 10 to 15 years' duration; evidence from both history and attending physician of failure of dietary management over a period of years; absence of correctable endocrinopathy (hypothyroidism, Cushing's syndrome); absence of unrelated significant disease which might increase operative risk; presence of complications such as Pickwickian syndrome, hyperlipidemia, and adult onset of diabetes or hypertension which might be alleviated by obligatory weight loss; and assurance of the patient's cooperation in prolonged follow-up. 10• 12
CLINICAL APPRAISAL The end-to-side jejunoileal shunt described by Payne 6• 7 was used in 11 early patients, but inadequate weight reduction in these led us to the use of end-to-end jejunoileal shunt with drainage of the bypassed small bowel into the colon in 214 patients (Fig. 1). There were 135 women and 90 men in the group, whose ages ranged from 16 to 63 years, with an average of36years. Weights ranged from 110 to 186 kg in women, with an average of 137 kg; in men, weights ranged from 123 to 255 kg, with an average of 174 kg. *Professor and Chairman, Department of Surgery, and Director, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville; Surgeon-in-Chief, Vanderbilt University Hospital, Nashville, Tennessee
Surgical Clinics of North America-Vol. 59, No. 6, December 1979
1033
1034
H.
WILLIAM SCOTT, JR.
Figure 1. The technique of end-to-end jejunoileostomy with extensive jejunoileal bypass. The closed end of the bypassed jejunum is sutured securely to the mesentery to prevent intussusception. The end of the bypassed ileum is drained by end-toside anastomosis with the transverse colon (A) or sigmoid (B).
Table 1. Additional Findings in 225 Patients with Morbid Obesity Hyperlipidemia Gallstones Diabetes Hypertension Incisional or umbilical hernia Gout Ovarian cyst Pickwickian syndrome Hiatal hernia with reflux Fibroids of uterus Carcinoma of uterus Carcinoid of intestine Peptic ulcer (inactive) Carcinoma of cervix Carcinoma (male) breast Abdominal aortic aneurysm Angina pectoris Myocardial infarction (old) Osteomyelitis of tibia (old)
112
62 49 31 19 13 9
8 4 3 3 2 2 1 1 1 1 1
1
SURGICAL EXPERIENCE WITH ]EJUNOILEAL BYPASS FOR MORBID OBESITY
1035
Table 1 summarizes the additional findings prior to operation in these obese patients. One hundred and twelve (50 per cent) of the group had hyperlipidemia, most frequently type IV hyperlipoproteinemia, and less frequently familial hypercholesterolemia (types Ila and b). Gallstones (27 per cent), adult onset diabetes (22 per cent), and hypertension (14 per cent) were other rather frequent findings. Aside from diabetes, no endocrinopathy was identified in these patients. Except as in Table 1, preoperative absorptive status, gastrointestinal radiography, vitamin levels, and hematologic studies were normal.
OPERATION A three to five day cleansing bowel preparation was used in each patient with oral neomycin and tetracycline for 36 hours prior to operation. Early in our experience halothane was used for anesthesia but in recent years "balanced anesthesia" has been used. A transverse epigastric incision which transected both recti was used in most patients. Figure 2 shows diagrams of the four modifications of jejunoileal bypass used in this study. The dimensions are in centimeters. All patients survived the operation, but five patients died from postoperative complications (Table 2). The operative mortality rate was 2.2 per cent. Most patients had an uneventful recovery from the operation, although nonfatal postoperative complications developed in 49 (22 per cent). These included wound seroma (14 patients) and superficial wound infection (15 patients). One ofthe latter also developed stomal obstruction which required revision and venous thrombosis with pulmonary emboli.
Treitz
Treitz
lig.
Payne's Operation
Figure 2. The four modifications of jejunoileal bypass used in this study (measurements are in centimeters).
lig.
(Group 2)
(Group I)
Treitz
Treitz
Lig.
(Group 3)
lig.
(Group4)
1036
H.
WILLIAM SCOTT, JR.
Table 2. Operative Mortality in 225 Patients with Morbid Obesity Pulmonary embolism Thrombophlebitis, sepsis, hemorrhagic pneumonitis Infarction of ileum after resection of carcinoid
3
TOTAL
5 (2.2 per cent)
1
Twelve other patients had thromboembolic complications. There were five urinary tract infections and one evisceration. All of these patients recovered with appropriate treatment. Before discharge from the hospital (usually eight to ten days after operation) each patient was instructed in the importance of control of dia:iThea to no more than three to four liquid stools per day by adhering to a high protein low fat diet and the use of antidiarrheal drugs. In recent years instruction in a low oxalate diet has been added to reduce the potential of urinary stones.
FOLLOW-UP STUDIES AND RESULTS Although early precipitant weight loss occurred in each group, those with end-to-side jejunoileal shunt (Group 1) and those with 30 em to 30 em end-to-end jejunoileal shunt (Group 2) began to regain weight after 12 to 18 months. Weights were most effectively reduced and the reductions best sustained in Groups 3 and 4 which had the shortest lengths of incontinuity small intestine (45 em) (Fig. 3). More than 70 per cent of patients in Groups 3 and 4 followed for one or more years achieved weight reduction to the "ideal" range.
100
--GROUP I ----GROUP 2 ··••••••• GROUP 3 -··-··GROUP 4
~
~
g
80
Figure 3. Body weight after jejunoileal bypass as a percentage of preoperative weight.
~ 75
il' ~
...z
~
70
65 60
55
2 4
6
8
10 12 14 16 18 20 22 24 30 32 34 36 MONTHS AFTER OPERATION
SURGICAL EXPERIENCE WITH JEJUNOILEAL BYPASS FOR MORBID OBESITY
1037
Metabolic parameters which were assessed prior to operation have been restudied during follow-up. 10 A reduction in carbohydrate absorption was measured by impairment of d-xylose tolerance and flattening of oral glucose tolerance curves. This is reflected clinically by the fact that no diabetic patient has required insulin or tolbutainide since operation. Malabsorption of fat and interference with enterohepatic cycles of cholesterol and bile acids have been accompanied by an impressive and sustained fall in serum cholesterol and triglycerides in all groups (Fig. 4). After jejunoileal bypass the reduction in serum cholesterol and triglyceride does not tend to rise during follow-up (Fig. 5). 9
ALL PREOPERATIVE PHENOTYPE
-~~~~~~~ op 6 12 18 24 30 36
Figure 4. Alterations in mean serum cholesterol and triglyceride concentrations in morbidly obese patients after jejunoileal bypass.
:n b
-~~~~~~op 6 12 18 24 30 :56
MONTHS POST-OPERATIVE
ALL PREOPERATIVE PHENOTYPE lll: mold I
-~~~~~~op 5 12 IB 24 30 36
-~~~~~~~ op 6 12 18 24 30 ae
MONTHS POST-OPERATIVE
H.
1038
WILLIAM SCOTT, JR.
mg%
350
TOTAL SERUM CHOLESTEROL 300
24
30
36
42
48
60
MONTHS
Figure 5. After jejunoileal bypass, the reduction in serum cholesterol and triglyceride does not tend to rise during follow-up.
Results of studies of body composition after jejunoileal bypass indicate that both body fat and lean tissue are lost in the early months after operation. In all groups potassium homeostasis was usually achieved after four to six months and subsequently fat was lost in preference to lean tissue. 8 Metabolic complications after jejunoileal bypass have included hyperoxaluria with urinary stones, the enterohepatic syndrome of hepatocellular injury secondary to heavy bacterial growth in the bypassed bowel, electrolyte and acid-base alterations secondary to persistent diarrhea, hyperuricemia and gouty arthritis, vitamin deficiencies, and manifestations of various other malabsorptive syndromes. In approximately 15 per cent of patients, clinical and laboratory evidence was found of the enterohepatic syndrome, and a similar frequency of one or more oxalate urinary stones has been observed. During the follow-up period from 1966 to 1979 in the 220 patients who survived operation, 11 deaths have occurred, five of which were unrelated to jejunoileal bypass. In five patients, however, fatal hepatic failure occurred, and one patient died from renal failure and stress gastric bleeding secondary to uncontrolled diarrhea. Follow-up results have been appraised critically in all surviving patients in each group who have been observed for one year or longer after operation. These are summarized in Table 3. In Groups 1 and 2 good results were achieved in only four of 21 patients. Except for one patient who died from alcoholic cirrhosis, fair and poor results in Groups 1 and 2 can be credited to inadequate weight loss. In groups 3 and 4 good results were achieved in 130 of 175 patients (75 per cent). Fair and poor results in these groups, as well as the six related deaths which have been listed,
SURGICAL EXPERIENCE WITH JEJUNOILEAL BYPASS FOR MORl!ID OBESITY
1039
Table 3. Results of Follow-Up of 196 Patients Who Underwent ]ejunoileal Bypass for Obesity from 1966 to 1978 at Vanderbilt University END-TO-SIDE
NUMBER OF
JEJUNOILEAL SHUNT
PATIENTS
Group 1: Payne Procedure, 35 to 10 em Group 2: 30 to 30 em Group 3: 30 to 15 em Group 4: 30 to 20 em and 25 to 20 em
RESULTS YEARS
Good
Fair
Poor
11
8 to 11
0
1
10
10 19 156
7to8 6 to 7 1to6
4 13 117
2 4 23
5 2 16
were usually a result of metabolic complications rather than of poor weight control.
COMMENT The degree of rehabilitation in the patients who have had good results from jejunoileal bypass and in most of those who have had fair results is difficult to measure objectively. Return to full preoperative work capacity or assumption of new work has been accomplished by all but 15 patients in the good and fair categories. In the latter small group retirement programs or wealth which precluded the need to work are important influences. The new body image developed by those who have achieved reductions to a normal or near normal weight range has been impressive to our surgical group and in particular to our clinical psychologists and psychiatric consultants. Psychologic studies have been reported separately. 1 ' 13 In recent years we have used the 12 to 18 inch (30 to 20 em) end-to-end jejunoileal shunt in most obese patients whose weights are in the range of 350 pounds (160 kg) or less, and have reserved the 12 to 6 inch (30 to 15 em) or 10 to 8 inch (25 to 15 em) end-to-end jejunoileal shunt for massively obese patients whose weights are in excess of 350 pounds (160 kg). The metabolic complications of greatest frequency (15 per cent) and importance after jejunoileal bypass for obesity are "bypass enteritis" or, as we prefer to call it, the "enterohepatic syndrome" of hepatocellular injury from heavy bacterial growth in the bypassed small bowel, and hyperoxaluria and oxalate urinary stones. 2 • 3 • 5 The enhanced fatty metamorphosis of the liver coupled with proteincalorie malnutrition which occurs after jejunoileal bypass resembles an adult form of the tropical protein deficiency disorder known as kwashiorkor. Our clinical metabolic and body compositional data support the concept that the majority of massively obese patients treated by jejunoileal bypass will recover from this phase of protein depletion and hepatic fatty metamorphosis in an entirely satisfactory manner if no added hepatotoxic factors are imposed. Excessive alcohol intake after jejunoileal bypass
1040
H.
WILLIAM SCOTT,
]R.
clearly led to alcoholic hepatosis, necessitating revision of the shunt in two patients, and cirrhosis, variceal hemorrhage, and death from hepatic failure in two others. We believe alcohol abuse was contributory to the similar death from hepatic failure in one other patient. We advise all patients to abstain from alcohol after a jejunoileal bypass. Another possible cause of hepatic injury after jejunoileal bypass is the potential of bacterial colonization and overgrowth in the bypassed jejunoileum with toxic absorption of bacterial metabolites, deconjugates such as lithocholic acid, or bacterial endotoxin. The experimental work of Woodward et al. 2 • 5 and our own studies 4 • 11 support this possibility and suggest the use of broad spectrum antibiotic therapy. Close clinical observation of all patients who undergo jejunoileal bypass is mandated by the uncommon but hazardous potential for development of toxic damage to the liver, especially during the transient phase of protein-calorie malnutrition. The clinical symptoms are those of a flulike syndrome of malaise, myalgia, weakness, and easy fatigue coupled with anorexia and nausea. Elevation of serum alkaline phosphatase, lactic dehydrogenases, and serum glutamic-oxalacetic transaminase values usually precede a rise in the bilirubin level or clinical jaundice. Australia antigen is usually negative. In most patients in the present series in whom these clinical manifestations developed within a few weeks to 18 months after jejunoileal bypass, treatment for three to four weeks with Flagyl (metronidazole), tetracyclines, or doxycycline, coupled with elemental dietary supplements, has resulted in a subsidence of symptoms, a reversal of the serum enzyme alterations, and a return of biopsies to normal. Failure of prompt response to such treatment is an indication for revision of the intestinal bypass and the restoration of continuity of the alimentary tract. 3 • 11 Hyperoxaluria and one or more oxalate urinary stones have occurred in 15 per cent of patients in this series. The problem seems to be most closely related to the shortened bowel and the preferential binding of available calcium in the colon by free bile acids, thus permitting unbound oxalic acid to be absorbed in excess and excreted in urine. Excess oxalate and fat in the diet exaggerate the problem by further binding calcium to fatty acids. Hyperoxaluria is then the basis for formation of calcium oxalate stones. In recent years all patients in this series have been instructed to follow a high protein, low fat, low oxalate diet. This has reduced but by no means eliminated this complication of the short bowel syndrome. 3 • 14 The large reduction in serum lipid concentrations as well as the large reduction in body fat that results from jejunoileal bypass should be of value in slowing the progress of atherogenesis and its catastrophic manifestations in these obese patients. 3 • 9 Long-range clinical, metabolic and nutritional follow-up study is mandatory and is best conducted by the operating surgeon.
SUMMARY Jejunoileal bypass for morbid obesity with our current bowel length
SURGICAL EXPERIENCE WITH JEJUNOILEAL BYPASS FOR MORBID OBESITY
1041
dimensional considerations has achieved good results in 74 per cent of patients. Morbidity and mortality are significant and must limit wide application of the procedure.
REFERENCES 1. Abram, H. S., Meixel, S. A., Webb, W. W., et al.: Psychologic adaptation to jejunoileal bypass fur morbid obesity. J. Nerv. Ment. Dis., 162:151, 1976. 2. Brown, R. G., O'Leary, J.P., and Woodward, E. R.: Hepatic effects ofjejunoileal bypass for morbid obesity. Am. J. Surg., 127:53, 1974. 3. Buchwald, H., Varco, R. L., Moore, R. B., et al.: Intestinal Bypass Procedures. Chicago, Year Book Medical Publishers, 1975. 4. Edmiston, C. E., Jr., Hulsey, T. K., Scott, H. W., Jr., et al.: Microbial colonization and hepatic abnormalities in jejunoileal bypass. J. Infect. Dis., 1979, in press. 5. O'Leary, J.P., Maher, J. W., Hollenbeck, J. 1., et al.: Pathogenesis of hepatic failure after jejunoileal bypass. Surg. Forum, 25:356, 1974. 6. Payne, J. H., and DeWind, L. T.: Surgical treatment of obesity. Am. J. Surg., 118:141, 1969. 7. Payne, J. H., DeWind, L. T., Schwab, C. E., et al.: Surgical treatment of morbid obesity. Arch. Surg., 106:432, 1973. 8. Scott, H. W., Jr., Brill, A. B., and Price, R. R.: Body composition inmorbidlyobesepatients befure and after jejunoileal bypass. Ann. Surg., 182:395, 1975. 9. Scott, H. W., Jr., Dean, R. H., LeQuire, V., et al.: Alterations in plasma lipid concentrations in normal and hyperlipidemic patients with morbid obesity befure and after jejunoileal bypass. Am. J. Surg., 135:341, 1978. 10. Scott, H. W., Jr., Dean, R., Shull, H. J., et al.: New considerations in use ofjejunoileal bypass in patients with morbid obesity. Ann. Surg., 177:723, 1973. 11. Scott, H. W., Jr., Dean, R. H., Shull, H. J., et al.: The results ofjejunoileal bypassin200patients with morbid obesity. Surg. Gynecol. Obstet., 145:661, 1977. 12. Scott, H. W., Jr., Law, D. H., IV, Sandstead, H. H., et al.: Jejunoileal shunt in surgical treatment ofmorbid obesity. Ann. Surg., 171:770, 1970. 13. Webb, W. W., Phares, R., Abram, H. S., et al.: Jejunoileal bypass procedures in morbid obesity: Preoperative psychological findings. J. Clin. Psycho!., 32:82, 1976. 14. Wright, H. K., and Tilson, M.D.: The Short Gut Syndrome: Pathophysiology and Treatment. Chicago, Year Book Medical Publishers, 1971. Department of Surgery Section of Surgical Sciences Vanderbilt University Medical Center Nashville, Tennessee, 37232
Surgical Experience with Jejunoileal Bypass for Morbid Obesity H. William Scott, Jr., M.D., F.A.C.S. *
A surgical approach to massive, exogenous (morbid) obesity is based on the dual concept that it is a serious, life-shortening disorder and that medical treatment is usually unsuccessful. 6• 7 Various operative procedures have been suggested, but extensive jejunoileal bypass has been used most widely. In the last 12 years we have made a clinical, psychologic, and metabolic study of morbid obesity and the effects of jejunoileal bypass in management of225 patients. Patients were selected for operation from a much larger group after appraisal of their clinical and metabolic status. Criteria for selection included: obesity of at least two to three times ideal weight of 10 to 15 years' duration; evidence from both history and attending physician of failure of dietary management over a period of years; absence of correctable endocrinopathy (hypothyroidism, Cushing's syndrome); absence of unrelated significant disease which might increase operative risk; presence of complications such as Pickwickian syndrome, hyperlipidemia, and adult onset of diabetes or hypertension which might be alleviated by obligatory weight loss; and assurance of the patient's cooperation in prolonged follow-up. 10• 12
CLINICAL APPRAISAL The end-to-side jejunoileal shunt described by Payne 6• 7 was used in 11 early patients, but inadequate weight reduction in these led us to the use of end-to-end jejunoileal shunt with drainage of the bypassed small bowel into the colon in 214 patients (Fig. 1). There were 135 women and 90 men in the group, whose ages ranged from 16 to 63 years, with an average of36years. Weights ranged from 110 to 186 kg in women, with an average of 137 kg; in men, weights ranged from 123 to 255 kg, with an average of 174 kg. *Professor and Chairman, Department of Surgery, and Director, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville; Surgeon-in-Chief, Vanderbilt University Hospital, Nashville, Tennessee
Surgical Clinics of North America-Vol. 59, No. 6, December 1979
1033
1034
H.
WILLIAM SCOTT, JR.
Figure 1. The technique of end-to-end jejunoileostomy with extensive jejunoileal bypass. The closed end of the bypassed jejunum is sutured securely to the mesentery to prevent intussusception. The end of the bypassed ileum is drained by end-toside anastomosis with the transverse colon (A) or sigmoid (B).
Table 1. Additional Findings in 225 Patients with Morbid Obesity Hyperlipidemia Gallstones Diabetes Hypertension Incisional or umbilical hernia Gout Ovarian cyst Pickwickian syndrome Hiatal hernia with reflux Fibroids of uterus Carcinoma of uterus Carcinoid of intestine Peptic ulcer (inactive) Carcinoma of cervix Carcinoma (male) breast Abdominal aortic aneurysm Angina pectoris Myocardial infarction (old) Osteomyelitis of tibia (old)
112
62 49 31 19 13 9
8 4 3 3 2 2 1 1 1 1 1
1
SURGICAL EXPERIENCE WITH ]EJUNOILEAL BYPASS FOR MORBID OBESITY
1035
Table 1 summarizes the additional findings prior to operation in these obese patients. One hundred and twelve (50 per cent) of the group had hyperlipidemia, most frequently type IV hyperlipoproteinemia, and less frequently familial hypercholesterolemia (types Ila and b). Gallstones (27 per cent), adult onset diabetes (22 per cent), and hypertension (14 per cent) were other rather frequent findings. Aside from diabetes, no endocrinopathy was identified in these patients. Except as in Table 1, preoperative absorptive status, gastrointestinal radiography, vitamin levels, and hematologic studies were normal.
OPERATION A three to five day cleansing bowel preparation was used in each patient with oral neomycin and tetracycline for 36 hours prior to operation. Early in our experience halothane was used for anesthesia but in recent years "balanced anesthesia" has been used. A transverse epigastric incision which transected both recti was used in most patients. Figure 2 shows diagrams of the four modifications of jejunoileal bypass used in this study. The dimensions are in centimeters. All patients survived the operation, but five patients died from postoperative complications (Table 2). The operative mortality rate was 2.2 per cent. Most patients had an uneventful recovery from the operation, although nonfatal postoperative complications developed in 49 (22 per cent). These included wound seroma (14 patients) and superficial wound infection (15 patients). One ofthe latter also developed stomal obstruction which required revision and venous thrombosis with pulmonary emboli.
Treitz
Treitz
lig.
Payne's Operation
Figure 2. The four modifications of jejunoileal bypass used in this study (measurements are in centimeters).
lig.
(Group 2)
(Group I)
Treitz
Treitz
Lig.
(Group 3)
lig.
(Group4)
1036
H.
WILLIAM SCOTT, JR.
Table 2. Operative Mortality in 225 Patients with Morbid Obesity Pulmonary embolism Thrombophlebitis, sepsis, hemorrhagic pneumonitis Infarction of ileum after resection of carcinoid
3
TOTAL
5 (2.2 per cent)
1
Twelve other patients had thromboembolic complications. There were five urinary tract infections and one evisceration. All of these patients recovered with appropriate treatment. Before discharge from the hospital (usually eight to ten days after operation) each patient was instructed in the importance of control of dia:iThea to no more than three to four liquid stools per day by adhering to a high protein low fat diet and the use of antidiarrheal drugs. In recent years instruction in a low oxalate diet has been added to reduce the potential of urinary stones.
FOLLOW-UP STUDIES AND RESULTS Although early precipitant weight loss occurred in each group, those with end-to-side jejunoileal shunt (Group 1) and those with 30 em to 30 em end-to-end jejunoileal shunt (Group 2) began to regain weight after 12 to 18 months. Weights were most effectively reduced and the reductions best sustained in Groups 3 and 4 which had the shortest lengths of incontinuity small intestine (45 em) (Fig. 3). More than 70 per cent of patients in Groups 3 and 4 followed for one or more years achieved weight reduction to the "ideal" range.
100
--GROUP I ----GROUP 2 ··••••••• GROUP 3 -··-··GROUP 4
~
~
g
80
Figure 3. Body weight after jejunoileal bypass as a percentage of preoperative weight.
~ 75
il' ~
...z
~
70
65 60
55
2 4
6
8
10 12 14 16 18 20 22 24 30 32 34 36 MONTHS AFTER OPERATION
SURGICAL EXPERIENCE WITH JEJUNOILEAL BYPASS FOR MORBID OBESITY
1037
Metabolic parameters which were assessed prior to operation have been restudied during follow-up. 10 A reduction in carbohydrate absorption was measured by impairment of d-xylose tolerance and flattening of oral glucose tolerance curves. This is reflected clinically by the fact that no diabetic patient has required insulin or tolbutainide since operation. Malabsorption of fat and interference with enterohepatic cycles of cholesterol and bile acids have been accompanied by an impressive and sustained fall in serum cholesterol and triglycerides in all groups (Fig. 4). After jejunoileal bypass the reduction in serum cholesterol and triglyceride does not tend to rise during follow-up (Fig. 5). 9
ALL PREOPERATIVE PHENOTYPE
-~~~~~~~ op 6 12 18 24 30 36
Figure 4. Alterations in mean serum cholesterol and triglyceride concentrations in morbidly obese patients after jejunoileal bypass.
:n b
-~~~~~~op 6 12 18 24 30 :56
MONTHS POST-OPERATIVE
ALL PREOPERATIVE PHENOTYPE lll: mold I
-~~~~~~op 5 12 IB 24 30 36
-~~~~~~~ op 6 12 18 24 30 ae
MONTHS POST-OPERATIVE
H.
1038
WILLIAM SCOTT, JR.
mg%
350
TOTAL SERUM CHOLESTEROL 300
24
30
36
42
48
60
MONTHS
Figure 5. After jejunoileal bypass, the reduction in serum cholesterol and triglyceride does not tend to rise during follow-up.
Results of studies of body composition after jejunoileal bypass indicate that both body fat and lean tissue are lost in the early months after operation. In all groups potassium homeostasis was usually achieved after four to six months and subsequently fat was lost in preference to lean tissue. 8 Metabolic complications after jejunoileal bypass have included hyperoxaluria with urinary stones, the enterohepatic syndrome of hepatocellular injury secondary to heavy bacterial growth in the bypassed bowel, electrolyte and acid-base alterations secondary to persistent diarrhea, hyperuricemia and gouty arthritis, vitamin deficiencies, and manifestations of various other malabsorptive syndromes. In approximately 15 per cent of patients, clinical and laboratory evidence was found of the enterohepatic syndrome, and a similar frequency of one or more oxalate urinary stones has been observed. During the follow-up period from 1966 to 1979 in the 220 patients who survived operation, 11 deaths have occurred, five of which were unrelated to jejunoileal bypass. In five patients, however, fatal hepatic failure occurred, and one patient died from renal failure and stress gastric bleeding secondary to uncontrolled diarrhea. Follow-up results have been appraised critically in all surviving patients in each group who have been observed for one year or longer after operation. These are summarized in Table 3. In Groups 1 and 2 good results were achieved in only four of 21 patients. Except for one patient who died from alcoholic cirrhosis, fair and poor results in Groups 1 and 2 can be credited to inadequate weight loss. In groups 3 and 4 good results were achieved in 130 of 175 patients (75 per cent). Fair and poor results in these groups, as well as the six related deaths which have been listed,
SURGICAL EXPERIENCE WITH JEJUNOILEAL BYPASS FOR MORl!ID OBESITY
1039
Table 3. Results of Follow-Up of 196 Patients Who Underwent ]ejunoileal Bypass for Obesity from 1966 to 1978 at Vanderbilt University END-TO-SIDE
NUMBER OF
JEJUNOILEAL SHUNT
PATIENTS
Group 1: Payne Procedure, 35 to 10 em Group 2: 30 to 30 em Group 3: 30 to 15 em Group 4: 30 to 20 em and 25 to 20 em
RESULTS YEARS
Good
Fair
Poor
11
8 to 11
0
1
10
10 19 156
7to8 6 to 7 1to6
4 13 117
2 4 23
5 2 16
were usually a result of metabolic complications rather than of poor weight control.
COMMENT The degree of rehabilitation in the patients who have had good results from jejunoileal bypass and in most of those who have had fair results is difficult to measure objectively. Return to full preoperative work capacity or assumption of new work has been accomplished by all but 15 patients in the good and fair categories. In the latter small group retirement programs or wealth which precluded the need to work are important influences. The new body image developed by those who have achieved reductions to a normal or near normal weight range has been impressive to our surgical group and in particular to our clinical psychologists and psychiatric consultants. Psychologic studies have been reported separately. 1 ' 13 In recent years we have used the 12 to 18 inch (30 to 20 em) end-to-end jejunoileal shunt in most obese patients whose weights are in the range of 350 pounds (160 kg) or less, and have reserved the 12 to 6 inch (30 to 15 em) or 10 to 8 inch (25 to 15 em) end-to-end jejunoileal shunt for massively obese patients whose weights are in excess of 350 pounds (160 kg). The metabolic complications of greatest frequency (15 per cent) and importance after jejunoileal bypass for obesity are "bypass enteritis" or, as we prefer to call it, the "enterohepatic syndrome" of hepatocellular injury from heavy bacterial growth in the bypassed small bowel, and hyperoxaluria and oxalate urinary stones. 2 • 3 • 5 The enhanced fatty metamorphosis of the liver coupled with proteincalorie malnutrition which occurs after jejunoileal bypass resembles an adult form of the tropical protein deficiency disorder known as kwashiorkor. Our clinical metabolic and body compositional data support the concept that the majority of massively obese patients treated by jejunoileal bypass will recover from this phase of protein depletion and hepatic fatty metamorphosis in an entirely satisfactory manner if no added hepatotoxic factors are imposed. Excessive alcohol intake after jejunoileal bypass
1040
H.
WILLIAM SCOTT,
]R.
clearly led to alcoholic hepatosis, necessitating revision of the shunt in two patients, and cirrhosis, variceal hemorrhage, and death from hepatic failure in two others. We believe alcohol abuse was contributory to the similar death from hepatic failure in one other patient. We advise all patients to abstain from alcohol after a jejunoileal bypass. Another possible cause of hepatic injury after jejunoileal bypass is the potential of bacterial colonization and overgrowth in the bypassed jejunoileum with toxic absorption of bacterial metabolites, deconjugates such as lithocholic acid, or bacterial endotoxin. The experimental work of Woodward et al. 2 • 5 and our own studies 4 • 11 support this possibility and suggest the use of broad spectrum antibiotic therapy. Close clinical observation of all patients who undergo jejunoileal bypass is mandated by the uncommon but hazardous potential for development of toxic damage to the liver, especially during the transient phase of protein-calorie malnutrition. The clinical symptoms are those of a flulike syndrome of malaise, myalgia, weakness, and easy fatigue coupled with anorexia and nausea. Elevation of serum alkaline phosphatase, lactic dehydrogenases, and serum glutamic-oxalacetic transaminase values usually precede a rise in the bilirubin level or clinical jaundice. Australia antigen is usually negative. In most patients in the present series in whom these clinical manifestations developed within a few weeks to 18 months after jejunoileal bypass, treatment for three to four weeks with Flagyl (metronidazole), tetracyclines, or doxycycline, coupled with elemental dietary supplements, has resulted in a subsidence of symptoms, a reversal of the serum enzyme alterations, and a return of biopsies to normal. Failure of prompt response to such treatment is an indication for revision of the intestinal bypass and the restoration of continuity of the alimentary tract. 3 • 11 Hyperoxaluria and one or more oxalate urinary stones have occurred in 15 per cent of patients in this series. The problem seems to be most closely related to the shortened bowel and the preferential binding of available calcium in the colon by free bile acids, thus permitting unbound oxalic acid to be absorbed in excess and excreted in urine. Excess oxalate and fat in the diet exaggerate the problem by further binding calcium to fatty acids. Hyperoxaluria is then the basis for formation of calcium oxalate stones. In recent years all patients in this series have been instructed to follow a high protein, low fat, low oxalate diet. This has reduced but by no means eliminated this complication of the short bowel syndrome. 3 • 14 The large reduction in serum lipid concentrations as well as the large reduction in body fat that results from jejunoileal bypass should be of value in slowing the progress of atherogenesis and its catastrophic manifestations in these obese patients. 3 • 9 Long-range clinical, metabolic and nutritional follow-up study is mandatory and is best conducted by the operating surgeon.
SUMMARY Jejunoileal bypass for morbid obesity with our current bowel length
SURGICAL EXPERIENCE WITH JEJUNOILEAL BYPASS FOR MORBID OBESITY
1041
dimensional considerations has achieved good results in 74 per cent of patients. Morbidity and mortality are significant and must limit wide application of the procedure.
REFERENCES 1. Abram, H. S., Meixel, S. A., Webb, W. W., et al.: Psychologic adaptation to jejunoileal bypass fur morbid obesity. J. Nerv. Ment. Dis., 162:151, 1976. 2. Brown, R. G., O'Leary, J.P., and Woodward, E. R.: Hepatic effects ofjejunoileal bypass for morbid obesity. Am. J. Surg., 127:53, 1974. 3. Buchwald, H., Varco, R. L., Moore, R. B., et al.: Intestinal Bypass Procedures. Chicago, Year Book Medical Publishers, 1975. 4. Edmiston, C. E., Jr., Hulsey, T. K., Scott, H. W., Jr., et al.: Microbial colonization and hepatic abnormalities in jejunoileal bypass. J. Infect. Dis., 1979, in press. 5. O'Leary, J.P., Maher, J. W., Hollenbeck, J. 1., et al.: Pathogenesis of hepatic failure after jejunoileal bypass. Surg. Forum, 25:356, 1974. 6. Payne, J. H., and DeWind, L. T.: Surgical treatment of obesity. Am. J. Surg., 118:141, 1969. 7. Payne, J. H., DeWind, L. T., Schwab, C. E., et al.: Surgical treatment of morbid obesity. Arch. Surg., 106:432, 1973. 8. Scott, H. W., Jr., Brill, A. B., and Price, R. R.: Body composition inmorbidlyobesepatients befure and after jejunoileal bypass. Ann. Surg., 182:395, 1975. 9. Scott, H. W., Jr., Dean, R. H., LeQuire, V., et al.: Alterations in plasma lipid concentrations in normal and hyperlipidemic patients with morbid obesity befure and after jejunoileal bypass. Am. J. Surg., 135:341, 1978. 10. Scott, H. W., Jr., Dean, R., Shull, H. J., et al.: New considerations in use ofjejunoileal bypass in patients with morbid obesity. Ann. Surg., 177:723, 1973. 11. Scott, H. W., Jr., Dean, R. H., Shull, H. J., et al.: The results ofjejunoileal bypassin200patients with morbid obesity. Surg. Gynecol. Obstet., 145:661, 1977. 12. Scott, H. W., Jr., Law, D. H., IV, Sandstead, H. H., et al.: Jejunoileal shunt in surgical treatment ofmorbid obesity. Ann. Surg., 171:770, 1970. 13. Webb, W. W., Phares, R., Abram, H. S., et al.: Jejunoileal bypass procedures in morbid obesity: Preoperative psychological findings. J. Clin. Psycho!., 32:82, 1976. 14. Wright, H. K., and Tilson, M.D.: The Short Gut Syndrome: Pathophysiology and Treatment. Chicago, Year Book Medical Publishers, 1971. Department of Surgery Section of Surgical Sciences Vanderbilt University Medical Center Nashville, Tennessee, 37232
