Surgical palliation of massive and severe obesity

Abstract

Experience with planned small intestinal bypass for palliation in either massive or severe obesity in 123 patients is reported. The patients underwent careful preoperative evaluation which attempted to select those patients who were likely to have a marked improvement in their prognosis and who could be restored to a productive socioeconomic status. All patients had had multiple attempts at conservative therapy without effective control of the obesity. In addition, a number of patients had had other surgical conditions of the abdomen or disabling orthopedic or medical problems whose treatment, in the absence of obesity, would have been successful. A few had had life-threatening cardiorespiratory disorders, and control of obesity by aggressive surgical treatment was successfully applied. Jejunoileostomy with the end to side technic described by Payne was performed in all but two patients. The Salmon procedure was used successfully in two patients. Panniculectomy was a concomitant procedure in eighty patients. There were two deaths during the early postoperative period and one death from hepatic failure occurred six months postoperatively. Pulmonary embolism was the most serious postoperative complication but subcutaneous wound infection was a slightly more frequent postoperative complication in our series. Diarrhea occurred for varying periods postoperatively in almost all patients, but the electrolyte depletion did not cause any significant morbidity. Only four patients required supplemental therapy for hypokalemia. Results measured by an acceptable degree of weight loss in a twelve to eighteen month postoperative period were excellent in over 90 per cent of the patients followed up for one year or longer. Two patients underwent reversal of the bypass because of secondary problems. To date, it has not been necessary to reverse the procedure because of excessive weight loss in any patient in this series. Our studies and observations thus far suggest only a small risk of acute hepatic failure as a serious late complication. Almost all patients adapted well to the severe malabsorption and do not have evidence of a significant deficiency state. Vitamin B 12 absorption was markedly impaired postoperatively and parenteral vitamin B 12 must be given indefinitely. Weight loss ceased about twelve to fifteen months postoperatively in all patients and usually stabilized thereafter at a level somewhat above the ideal weight. Serum carotene determinations have proved to be a reliable test to assess the effectiveness of the intestinal bypass and have correlated quite well with the level of weight eventually attained. Secondary operations to increase malabsorption were performed in seven patients who had an inadequate response to initial jejunoileostomy. These reoperations produced less satisfactory weight reductions than did a properly performed primary procedure but appeared to be worthwhile in all but one patient. No late sequelae occurred in those patients who had additional shortening or revision of the bypass. Proper selection of patients for operation and frequent and thorough postoperative care are essential to obtain a good palliation.