Biliary-intestinal bypass in the treatment of obesity: long term follow up

OBJECTIVE

To evaluate the long term outcome after biliary-intestinal bypass for morbid obesity.

DESIGN

Retrospective study.

SETTING

County hospital, Sweden.

SUBJECTS

120 consecutive patients operated on between 1977 and 1990.

INTERVENTIONS

A variation of jejunoileal bypass in which the excluded bowel was anastomosed to the gallbladder.

MAIN OUTCOME MEASURES

Weight, concentrations of blood lipids and glucose in blood, results of liver function tests, reversal rates, and complications.

RESULTS

The mean body mass index was reduced by 39% (from 42 kg/m2 to 26 kg/m2), serum cholesterol and triglyceride concentrations by more than 30%, and fasting blood glucose concentrations by 1 1%. There were no cases of irreversible hepatic failure, diabetes, deaths related to the operation, or progressive renal failure. The incidence of renal calculi increased by a ratio 2.3. The reversal rate/year was 2% (n = 20).

CONCLUSION

We conclude that biliary-intestinal bypass may be used to treat cases of obesity associated with seriously high blood lipid concentrations and where gastric restrictive operations are less suitable.

[Surgery of morbid obesity: intestinal bypass to adjustable gastric banding]

The authors present their experience at the Centre for the surgical treatment of morbid obesity at Milano University where since 1974, 603 obese patients underwent surgery: 312 jejuno-ileal bypass (JIB), 70 bilio-intestinal bypass (BIB), 102 horizontal gastroplasties (HGP), 44 silastic ring vertical gastroplasties (SRVGP) and 75 adjustable silastic gastric banding (ASGB). Average follow-up for these procedures is 16, 6, 11, 4 years and 24 months respectively. Weight loss is satisfactory in all cases even though the percentages vary in the different procedures. The most serious complications (severe hepatic failure, oxalic interstitial nephritis, persisting malabsorption) occurred in patients submitted to JIB. The best clinical outcome with the lowest complications rate was obtained with BIB compared to other intestinal bypasses. The most frequent complication observed in patients submitted to gastroplasties was incoercible vomiting while the most severe complications were diffuse peritonitis, secondary to gastric perforation, and peripheric neuropathy. Our experience confirms that surgical treatment of morbid obesity refractory to medical therapy is today a safe and effective treatment. BIB has still a role in super-obese young patients (BMI over 50) refusing dietary restriction lifetime. The gastric procedures, especially laparoscopic ASGB, seem to be the best option. The excellent outcome of bariatric surgery can be obtained only in specialized centers where various specialists work together.

Jejunoileal bypass-induced liver dysfunction and bacterial translocation: effect of intraluminal glutamine-infusion

We tested the effect of long-term intraluminal administration of glutamine on jejunoileal bypass (JIB) induced abnormalities in the plasma-liver profile in rats. Male Sprague Dawley rats (200-250 g) were subjected to an end to side JIB followed by daily intraluminal infusions of either 8 ml saline (n = 5), infused over a 4-hour period, or 8 ml saline containing 1g/Kg body weight glutamine (n = 7) for 3 weeks. Thirteen unoperated rats and four JIB rats without infusions served as controls. At the conclusion of the experiment, a cardiac blood sample was removed and analyzed for plasma cholesterol, albumin, total protein, gamma glutaril transferase, lactic dehydrogenase, glutamic-oxaloacetic transaminase, glutamic pyruvic transaminase, alkaline phosphatase, and bilirubin. Tissue samples from various segments of bowel, liver, mesenteric lymph nodes, and spleen underwent histopathologic examination. Bacteriological cultures were prepared from jejunum, ileum, mesenteric lymph nodes, liver, and spleen. Bacterial translocation occurred in both JIB-saline and JIB-glutamine infused rats. Glutamine-infused rats developed a significant decrease in the plasma cholesterol levels. However, glutamine did not prevent the JIB-induced alterations in the plasma-liver profile and bowel histopathology. It is suggested that experimental JIB procedure can be used as a model of bacterial translocation consequent to mucosal permeability and intestinal inflammatory diseases.

The antiobstruction stitch in stapled Roux-en-Y enteroenterostomy

During the past 9 years, 393 Roux-en-Y gastric bypass operations for morbid obesity were performed by one surgeon at a university hospital. Twelve of the 393 patients subsequently developed mechanical small-bowel obstruction, and 7 of these 12 cases developed in the initial 38 patients in this series. There were 2 cases of small-bowel volvulus and 10 cases of postoperative adhesions. Three cases of adhesive obstruction occurred at the jejunojejunostomy. Two of the patients with anastomotic obstruction required operative treatment, whereas the remaining patient was successfully treated by nasogastric tube decompression. A simple technique is described that has successfully prevented this type of anastomotic obstruction in 355 subsequent Roux-en-Y gastric bypass operations. This technique should be useful in preventing anastomotic obstruction after any stapled end-to-side enteroenterostomy.

[Current world experience in the surgical treatment of gross obesity]

Since 1954 the aim of surgical treatment of severe obesity has been to perfect a specific treatment capable of obtaining a massive, long-lasting and well tolerated loss of weight in severely obese subjects in which different and repeated attempts using conservative medicine have proved inefficacious or non-resolutive. During the course of almost 40 years, bariatric surgery has gradually evolved in the search for the "ideal" surgical treatment: for this purpose, operative methodologies and techniques have been proposed and experimented using differing physiopathological concepts and means of application. After a brief analysis of the history of bariatric surgery, there is a short summary of the most internationally widespread surgical methods and the most recent techniques now used for the surgical treatment of severe obesity based on the Authors' ten year experience of 321 intestinal bypasses (jejuno-ileal and biliointestinal), 110 horizontal gastroplasties and 23 vertical gastroplasties with a silastic ring. Intestinal bypass almost always allows sufficient weight loss to be achieved (85% of operated patients lose 80% of excess body weight) and the various postoperative problems of differing degrees of severity can be prevented by adequate replacement therapy and regular outpatient monitoring. Gastroplasties lead to a slightly smaller loss of weight (73% of excess body weight) within a shorter period of time, with fewer postoperative problems, but at the expense of a drastic and continual reduction in food intake. All patients operated require intense and long-term postoperative follow-up carried out by experts in order to achieve the desired results.

Ileal transposition surgery attenuates the increased efficiency of weight gain on a high-fat diet

High-fat diets enhance weight gain in rats and humans. Ileal transposition surgery (IT) causes long-term weight loss on ad libitum food intake. This study was designed to study the effect of high-fat diets on weight loss following ileal transposition surgery. We weight matched 40 rats, performed IT or sham IT, and fed defined high-carbohydrate (12 percent kcal as fat) or high-fat (45 percent kcal as fat) diets for 15 weeks postsurgery (N = 10/group, data are means +/- s.e.m.). Overall, IT rats ate less than sham IT rats, 9587 +/- 304 v. 10,615 +/- 356 kcal (39.6 +/- 1.2 v. 43.8 +/- 1.5 MJ) (P less than 0.01), and gained less weight (-14 +/- 7.8 v. 46 +/- 13.7 g) (P less than 0.01). Sham IT rats had similar food intakes on the two diets, but body weights were increased on the high-fat diet. However, the IT rats on the high-fat diet did not gain more weight or have higher efficiency of weight gain than did the IT rats on the high-carbohydrate diet. We conclude that ileal transposition attenuates the increased efficiency of weight gain usually associated with consumption of a high-fat diet. The mechanisms of this decreased metabolic efficiency are unclear.

[Comparison of the treatment of obesity by surgical methods and gastric balloon]

The paper is a review of the reports on the treatment of simple obesity, comparing the methods of surgical therapy used as yet with the new method of intragastric balloon. This method is simple, repeatable, connected with a low number of complications making possible a mean weight loss of 16 kg during one course of treatment.

[Value and limits of bypassing the distal ileum in the treatment of hypercholesterolemia]

Partial ileal bypass (PIB) was performed in 8 young adults (5 males and 3 females, mean age 37 +/- 5 years) with a history of vascular surgery (aorto-coronary bypass, ACB, n = 6; stroke, n = 2), presenting with hyperlipidemia (II B: n = 7; IIA: n = 1). None of the patients had diabetes, 2 had mild hypertension, and all were cigarette smokers. Hypolipidemic drugs were discontinued prior to PIB. Following bypass surgery, patients received vitamin B12 injections twice monthly. Total plasma cholesterol (TPC) and total plasma triglycerides (TPT) were assayed at 3 months and 1 year after surgery. The mean follow-up period was 84 months. Mean TPC level was significantly lower (3.96 +/- 0.57 preoperatively vs 2.19 +/- 0.79 (p less than 0.001) and 2.54 +/- 0.76 (p less than 0.01) 3 months and 1 year postsurgery, respectively. Mean TPT level was significantly lower 3 months after the intervention (4.85 +/- 2.37 vs 2.33 +/- 0.62, p. less than 0.02), but not after one year. Similar trends were observed throughout the follow-up period. One of the ACB patients died of drowing, while three others had recurring angina pectoris symptoms. Coronary angiography showed that, despite low TPC levels, coronary artery disease had extended either to other vessels not included in the former bypass, or beyond the anastomoses. Patients with a history of stroke were asymptomatic. PIB is effective in normalizing TPC. Nonetheless, this isolated procedure is insufficient to prevent the evolution of multifactorial atherosclerosis.

Dissociation of changes in plasma cholesterol and hepatic cholesterol synthesis, assessed by precursors in bile, after jejunoileal bypass with 3:1 and 1:3 jejunoileal ratio

Hepatic cholesterol synthesis, assessed by the biliary content of post-squalene cholesterol precursors relative to cholesterol, was related to fasting plasma cholesterol fractions in obese patients before (n = 7) and after jejunoileal bypass surgery with either a 3:1 ratio (n = 15) or a 1:3 ratio (n = 14) between jejunum and ileum left in function. The content of precursors increased after bypass surgery, and more so with a 3:1 than with a 1:3 jejunoileal ratio. However, the two types of bypass resulted in similar reductions in plasma concentrations of total cholesterol and low-density lipoprotein cholesterol. Within the unoperated group and the 3:1 bypass group the precursor content and plasma cholesterol levels were, as expected, inversely correlated, but within the 1:3 bypass group there were either weaker or even positive correlations. These findings suggest that the link between stimulation of hepatic cholesterol synthesis and reduction in plasma cholesterol may depend on the length of jejunum and ileum left in function.

[Changes induced by simple jejuno-ileal by-pass models in the distribution of D-cells producing intestinal somatostatin. Experimental study]

Cells that produce somatostatin are widely distributed throughout the digestive tube. They are found in the stomach, small bowel, large bowel and pancreas. The authors used 54 Wistar rats, with an approximate weight of 300 gr, to evaluate the possible variations of the D cell population in isolated and functional intestinal segments, using jejuno-ileal bypass as a model. Rats were divided into three groups, a control group and two groups in which simple derivation techniques were performed following the techniques of Payne and DeWind, and Scott. Rats were sacrificed after 7, 30 and 90 days in subgroups of six animals. Macroscopic, microscopic and ultrastructural studies were carried out. Cells were specifically stained using immunocytochemical techniques (PAP). The corresponding values of the mucous areas were obtained using a computerized image analyzer (Quantimet 800) and then the number of D cells per mm2 mucosa was calculated. The results show a decrease in the number of D cells per mm2 of mucosa in the functional intestinal segments and degranulation of these cells, coinciding with the existence of large areas of rough endoplasmic reticulum (sign of cellular hyperactivity).

Jejunoileal bypass arthritis

Although intestinal bypass procedures are no longer performed, important lessons have been learned concerning clinical arthritides resulting from bacterial overgrowth and immune complex deposition. This information is of considerable value in patients who present with the clinical picture of intestinal bypass arthritis on the basis of other bowel abnormalities. Furthermore, the pathogenetic mechanisms involving bacterial overgrowth, release of bacterial antigens, and immune complex deposition may be pertinent to many types of inflammatory arthritis.

Cholesterol synthesis in bypassed segments of the small intestine in hyperphagic rats

Previous studies have demonstrated that a variety of conditions that result in an increase in food intake lead to an increase in small-intestinal cholesterol synthesis. In the present study, it was determined whether hyperphagia induces an increase in cholesterol synthesis in segments of the small intestine excluded from contact with the food stream and whether this increase would occur in bypassed segments of the proximal or mid-small intestine. In hyperphagic diabetic rats, cholesterol synthesis is increased 91% in the proximal portion of the small intestine excluded from contact with nutrients. In lactating rats, another model of hyperphagia, cholesterol synthesis is increased 2.4-fold in midintestinal segments excluded from contact with the food stream and 2.9-fold in segments of the proximal intestine that have been bypassed. These observations demonstrate that the hyperphagia-induced increase in small-intestinal cholesterol synthesis will occur in portions of the small intestine, even if contact with the food stream is prevented. In addition, this data demonstrated that the mass of the bypassed portion of the small intestine is increased in hyperphagic animals. In diabetic animals, the weight of the bypassed proximal intestine is increased 2.1-fold, whereas in lactating animals the mass is increased 50% in the bypassed midintestine and 74% in the bypassed proximal small intestine. In conclusion, the present study suggests that circulating or neurologic factors, or both, play a role in stimulating intestinal cholesterol synthesis in hyperphagic animals. These findings also suggest that indirect factors play a role in the increase in intestinal mass associated with hyperphagia.

Surgical treatment of obesity

Surgical treatment of obesity by methods that have withstood over 5 years of clinical evaluation is effective in ameliorating and even curing manifest serious co-morbid diseases such as diabetes, hypertension, and respiratory distress in the majority of patients. Despite numerous shortcomings and limitations, surgical methods are the only viable alternative for achieving and maintaining substantial weight loss in dangerously obese patients and, therefore, represent a legitimate, often life-saving, intervention. Nevertheless, the magnitude of weight loss varies widely, as does the number of patients lost to follow-up or requiring multiple operations. Safety of performing the surgery and recognition and successful treatment of side effects in cooperating patients has improved greatly over the past 10 years. More effort needs to be put into improving patient selection to allocate patients to specific types of operations and to identify those patients who may not require surgery.

Oral contraceptive absorption and sex hormone binding globulins in obese women: effects of jejunoileal bypass

Plasma levels of two oral contraceptive gestagens were studied during 24 hour oral challenges in seven morbidly obese women after jejunoileal bypass comparing the results to unoperated normal controls. To study binding and transport of the gestagens, sex hormone binding globulin levels were determined in these patients, in normal-weight controls, and in unoperated morbidly obese patients. The unoperated morbidly obese patients had significantly decreased levels of sex hormone binding globulin, compared to normal-weight controls and to the jejunoileal bypass patients, whose levels were similar to the controls. The jejunoileal bypass patients had a reduced capacity to absorb oral contraceptive gestagens, although the plasma levels were of the same magnitude found in normal subjects using lower doses of gestagens. However, the gestagen to sex hormone binding globulin ratio was lower in jejunoileal bypass patients, implying reduced biologic activity and thus reduced contraceptive efficiency of the gestagen. There were no enzymatic or morphologic signs of liver dysfunction. No correlations were found between plasma gestagen levels and number or volume of stools, fecal fat excretion, or intravenous C-cholic acid load. It is concluded that caution must be exercised in prescribing oral contraceptives to jejunoileal bypass patients.

Microbial flora in the bypassed jejunum of patients with biliopancreatic bypass for obesity

The microbial flora in the bypassed biliopancreatic intestinal segment was studied after obesity surgery. This procedure causes less diarrhea than jejunoileal bypass and appears to avoid extraintestinal complications. This report concerns type and quantity of bacteria colonizing the biliopancreatic segment and changes occurring after oral metronidazole treatment. Twelve specimens were aspirated in 10 patients via catheter inserted percutaneously during surgery. The specimens were plated immediately on selective and nonselective media under aerobic and anaerobic conditions. Essentially equal numbers of aerobes and anaerobes were recovered from the biliopancreatic segment with average counts of 10(4) cfu/mL and median counts of 10(5) cfu/mL. Four patients had counts of 10(7) cfu/mL. The most common aerobes were E. coli, Klebsiella, Gram-positive cocci, and Candida; among anaerobes, Clostridium and the Bacteroides fragilis group were most common. In three patients treated with metronidazole because of diarrhea, anaerobes were eliminated and diarrhea cleared.

Bypass arthritis and the blind intestinal loop

Arthritis and other inflammatory processes are well established complications of intestinal bypass operations, and recently have been reported after other gastrointestinal procedures. Bacterial overgrowth in blind intestinal loops, actual or functional, appears to be the underlying pathophysiologic mechanism responsible for these systemic inflammatory disorders. In the case we have reported, arthritis was the primary manifestation of blind loop remaining after incomplete reversal of a jejunoileal bypass. Surgical elimination of the blind loop was curative.

[Surgical treatment of obesity]

Morbid obesity is a disease of modern society. Surgery is indicated when there is no endocrinopathy, medical treatment failed and Body Mass index (W/H2) is more than 40 (III degree obesity of Garrow). Many different methods were suggested in connection with the type of obesity, the associated diseases and the psychical state of the patient. Jejuno-ileal by-pass intend to produce a generic malabsorption syndrome. Personal experience is however good, possibly due to the blind loop jejunostomy that we always prepare as a conclusion of the operation and which gives an excellent support for the early post-operative time.