Long-term morbidity following jejunoileal bypass: the continuing potential need for surgical reversal.

Abstract

Jejunoileal bypass (JIB) was a widely employed modality in the treatment of morbid obesity beginning in the late sixties. A significant number of patients had complications within a short time after the procedure.1,2 The most severe of these was acute liver failure occurring in up to 7% of patients, occasionally irreversible leading to death. Fluid and electrolyte imbalances and renal disease accounted for other indications for early failure. The initial impression was that if patients survived the early complications following jejunoileal bypass, then they tended to have a more benign, long‐term course.Requarth et al at the Dartmouth Hitchcock Medical Center followed 453 patients who had undergone JIB for up to 23 years postoperatively. They quantified weight loss, morbidities, and the need for reversal of the bypass, even many years after the initial procedure.Between 1965 and 1977, 453 patients underwent jejunoileal bypass for morbid obesity at the Center. Most of these cases involved an end‐to‐side jejunoileostomy with approximately 14 in. of jejunum anastomosed to 5 in. of terminal ileum. The patients were followed closely for the first year after surgery and then at increasing intervals thereafter. Beginning in 1988, patients or their survivors were contacted to obtain long‐term outcome.As expected, patients lost a significant amount of weight, which was greatest in the first 2 years after surgery. Mean body mass index (BMI)—(weight in kilograms per square of the height in meters) decreased from 49.3 ± 8.1 to a low of 31.1 ± 0.8. As the patients were followed beyond 15 years, weight gradually increased, with BMI rising to 35.4 ± 3.1. Early complications included a 30‐day operative mortality of 1%, primarily because of pulmonary embolus or peritonitis. Thirty‐one percent of patients followed long‐term required reversal of their bypass. This occurred at an average of 6.3 4.2 years after the initial surgery. Several patients required reversal within the first 2 years, most commonly because of diarrhea or acute liver failure. When causes for reversal were broken down, diarrhea with electrolyte imbalances was the primary indicator in 29%. This was followed by renal failure or stones in 20% and liver failure or cirrhosis in 13%. Many of these complications, especially renal disease, developed 10 to 15 years after the initial procedure. Five percent of patients being reversed died in the perioperative period, primarily from liver failure.To determine whether complications leveled off over time, the percent of patients with liver disease was followed for 17 years. There was a linear increase over this period, peaking at 11%. Patients developing renal disease similarly rose to a level of 35%. There was no plateau effect in either group. In the patients with liver disease, six of seven patients who died of acute liver disease did so within 16 months of the jejunoileal bypass, including two who had undergone bypass revision. Further, 28 patients developed cirrhosis prior to reversal and this risk for cirrhosis continued through the 15 years. A small percentage of the total patients with renal disease went on to require either permanent dialysis (2%) or transplantation (1%). In most cases, patients were reversed before permanent renal damage had occurred.