Intestinal Bypass Surgery Research Articles

Long-term outcome of reversal of small intestinal bypass operations

Between 1976 and 1987, 43 patients underwent reversal of jejunoileal bypass operations because of metabolic complications of the operation. Electrolyte imbalance, malnutrition, and diarrhea (16 patients); cirrhosis (9); nephrolithiasis (9); arthritis (7); and pathologic fractures (1) were the primary indications for reconstruction. Many patients had multiple complications of the jejunoileal bypass operation. Twenty-nine patients underwent gastroplasty at the time of reversal and 14 did not. Seventy three +/- 5 months after reversal, patients with a gastroplasty weighed significantly less than patients without a gastroplasty. Patients with electrolyte imbalance, malnutrition, and diarrhea were all improved after reconstruction. Two patients with cirrhosis died of liver failure after reconstruction; the distinguishing preoperative characteristic was ascites. Postoperative interval liver biopsies indicated improvement in histologic appearance in four patients and no change in three. Nephrolithiasis improved or disappeared in all patients after reconstruction, whereas arthritis improved in 5 of 7 patients. Gastroplasty produced no benefit in alleviation of metabolic complications of jejunoileal bypass operations. Although the survival rate in these patients at last follow-up was 95 percent, 28 percent were incapacitated. Simultaneous gastroplasty performed at the time of reversal significantly decreases body weight when compared with patients undergoing reversal without a gastroplasty.

Night Blindness and Vitamin A Deficiency following Jejunoilieal Bypass Surgery

A 42-year-old man who developed severe night blindness 15 years following jejunoileal bypass surgery for morbid obesity is described. Ophthamological testing, including dark adaptation, electroretinography and serum vitamin A levels, confirmed a diagnosis of vitamin A deficiency. Oral vitamin A 25,000 iu/day for two months resulted in a full recovery of visual deficits. Nutritional vitamin A deficiency is discussed in the context of intestinal bypass surgery.

Radiology of Obesity Surgery

Modern imaging modalities are the key to prompt evaluation of the efficacy and complications of obesity surgery. These are divided into the early and late complications of gastric restrictive surgery and intestinal bypass surgery.

Enteropathic Arthropathies

Musculoskeletal disease occurs in association with inflammatory bowel disorders including Crohn's disease and ulcerative colitis, as well as with Whipple's disease; with enteritis caused by Salmonella, Shigella, and Yersinia; and also following intestinal bypass surgery. Extraintestinal causes of musculoskeletal alterations include Laennec's and biliary cirrhosis and pancreatitis. Three types of musculoskeletal abnormalities are recognized in patients with inflammatory bowel diseases: peripheral joint arthritis, sacroiliitis and spondylitis identical to ankylosing spondylitis, and rarely, miscellaneous changes such as digital clubbing and hypertrophic osteoarthropathy.

PROGNOSIS AFTER RECONSTRUCTION IN EIGHT PATIENTS WITH COMPLICATIONS OF INTESTINAL BYPASS SURGERY

Eight patients suffered from complications at various after intestinal bypass surgery. Complications include bacterial overgrowth syndrome and chronic pseudo-obstruction. They underwent reconstructive opeartions with end-to-end anastomoses, with or without resection of the bowel loops. After surgical correction of the bowel, six patients developed ileus and five had severe motor disturbances of the intestine for a mean duration of 37 days. However, no anatomical obstruction was detected by subsequent X-ray examination. These patients, without additional surgery, healed completely through careful management of electrolyte balance and nutrition.

Intestinal bypass operation and pregnancy outcome

With the aid of the national Medical Birth Registries and Discharge Registries in Denmark and Sweden it was possible to identify and study delivery outcome in 77 women who, prior to pregnancy, had undergone an intestinal bypass operation for obesity. Analysis of birth weight and pregnancy length distribution showed that infants borne by these women had an increased rate of low birth weight, short gestation, and also growth retardation. There were no distinct differences between those infants that were conceived less than 24 months or more than 24 months after operation. Only two infants had congenital malformations, none died perinatally.

Metabolic bone disease with and without osteomalacia after intestinal bypass surgery: A bone histomorphometric study

We performed iliac bone histomorphometry after in vivo double tetracycline labeling 3–14 years after intestinal bypass surgery for obesity in 21 patients, selected because of clinical suspicion of metabolic bone disease, and compared the results with those of 40 age-matched normal control subjects. Osteomalacia defined by rigorous kinetic criteria was found in six cases, histologic features of secondary hyperparathyroidism without significantly impaired mineralization in one case, and possible Osteomalacia masked by impaired matrix synthesis in one case. In the patients with definite Osteomalacia, nonfracture bone pain was more frequent, corrected plasma calcium lower, plasma alkaline phosphatase and magnesium higher, and secondary hyperparathyroidism more severe than in the other patients. In the patients without Osteomalacia there was a 24.5% reduction in trabecular bone volume compared to the controls; in contrast to age-related bone loss and post-menopausal osteoporosis, this was due mainly to reduction in the thickness rather than the density of trabecular plates. About two-thirds of the reduction in trabecular thickness was due to reduction in interstitial bone thickness, representing the cumulative effect of increased depth of osteoclastic resorption cavities, probably due in part to secondary hyperparathyroidism. About one-third of the reduction in trabecular thickness was the result of reduced mean wall thickness, representing insufficient osteoblastic matrix synthesis, probably due in part to malabsorption of an unidentified nutrient necessary for normal bone health. Resorption indices were not increased at the time of the biopsy, but there were persistent defects in the recruitment and activity of osteoblasts. Clinically significant bone loss after intestinal shunt surgery, as in several other clinical situations, results from the combined effects of an unsustained increase in bone resorption and a sustained decrease in bone formation.

Impairment of Vitamin D Metabolism and Bone Mineral Content after Intestinal Bypass for Obesity

Ten obese subjects who had undergone intestinal bypass operation (end-to-side jejunoileostomy) were studied longitudinally with respect to vitamin D and other indices of calcium metabolism. Investigations were carried out before operation (t0) and after 6 months (t1), 12 months (t2), and a mean of 54 months (range, 49-58 months) (t3) postoperatively. Serum 25-hydroxyvitamin D (25OHD) was subnormal at t0 but after operation values declined gradually to an extremely low level at t3, possibly because of a loss through malabsorption. Serum 24,25-dihydroxyvitamin D remained normal at t1 and t2 but fell to about half the normal level at t3, probably owing to lack of its precursor, 25OHD. In contrast, serum 1,25-dihydroxyvitamin D (1,25(OH)2D) remained normal throughout the study, indicating a marked stimulation of kidney 1 alpha-hydroxylase activity. Serum calcium fell rapidly to a constant subnormal level, and it is concluded that the serum calcium malabsorption is due to factors other than impaired 1,25(OH)2D activity. Bone mineral content (BMC) was unchanged between t0 and t2, but thereafter (between t2 and t3) the mean BMC fell rapidly to about 90% of preoperative value, possibly due to a defective bone mineralization in the late postoperative period. The findings indicate a high risk of bone disease developing after intestinal bypass operation. Substitution with calcium and vitamin D should be given to these patients, but the optimal vitamin D metabolite (or combination of metabolites) for such treatment is still unknown.

D-Lactic acidosis and selected cerebellar ataxias.

D-Lactic acidosis and selected cerebellar ataxias.

D-Lactic Acidosis and Other Complications of Intestinal Bypass Surgery

Cathy Lazarus, MD, Resident in Medicine, Jewish Hospital of St Louis: An obese, 54-year-old woman had an intestinal bypass procedure in 1975. An appendectomy and cholecystectomy were also performed at that time. Preoperatively, her weight stabilized to 155 kg. During the next four years she passed two to four diarrheal stools per day and lost 45 kg. In 1979 she noticed monthly episodes of euphoria and drunkenness during intervals when neither alcohol nor drugs were taken. Although the spells were disconcerting, they were short lived, and she failed to notify her physician. She was hospitalized at another institution in April 1980 because of an episode of ataxia and slurred speech. At that time, the blood pH was 7.34; Pco 2 , 27 mm Hg; Po 2 , 102 mm Hg; and bicarbonate ion levels, 14 mEq/L. Blood vitamin B 12 levels were also low. She was subsequently treated with monthly vitamin B

D-lactic acidosis and other complications of intestinal bypass surgery

D-lactic acidosis and other complications of intestinal bypass surgery

Bowel bypass arthritis dermatitis syndrome: a histological and electron microscopical study

A case of dermal vasculitis with arthralgia after intestinal bypass surgery is reported. A 36-year-old woman developed arthralgia and skin rash, 1 year after an ileo-jejunal bypass operation was performed for overweight (130 kg). Skin biopsy showed leucocytoclastic vasculitis in the dermis. E.M. study showed clumps of platelets around small dermis blood vessels, and polymorphous perivascular infiltration. The symptoms subsided after tetracycline treatment.

Energy balance and regulation of body weight after intestinal bypass surgery in rats.

This study evaluated the possibility that intestinal bypass surgery alters energy balance and regulation of body weight. In two sets of experiments, male Sprague-Dawley rats underwent bypass or sham bypass surgery. In experiment 1, half of each group was overfed and half was underfed. Bypass reduced net calorie intake (intake - fecal loss) at 2 wk but not at 6 wk. Body weights were maintained at a much lower level in the bypass rats, yet apparent energy expenditure was greater. In experiment 2, bypass rats were compared with sham bypass and sham bypass who were food restricted for paired-weight-loss to bypass (PWL sham). Net calorie intake and body weights of bypass and sham bypass followed a similar pattern as in experiment 1. At similar levels of body weight postoperatively, bypass rats required more calories per kilogram than did the PWL shams, suggesting that bypass resets downward the level at which body weight is regulated. Calorie requirements correlated with food intake better than with absolute body weight. Further studies to determine the mechanism of altered energy expenditure may provide methods for weight loss without extensive surgery.

Pediatric Rheumatology for the Practitioner

There has been an explosion of textbooks on pediatric rheumatology in the past few years: one from England (by Ansell) and four from the United States (by Miller, Brewer, Cassidy, and Jacobs), with one more yet to come (by Gershwin). This single-author textbook written by Jacobs is derived from his long experience as a pediatric rheumatologist at the Columbia University College of Physicians and Surgeons, New York. Some of the strengths of this volume come from the uniformity of style and avoidance of overlapping topics that come with a single author. It is well written in an easy, readable style; individual case reports are interspersed at good intervals. There is a complete section on differential diagnosis; however, unfortunately, some syndromes are listed, eg, the arthritis and rash seen after intestinal bypass surgery, Whipple's disease, and arthritis with type IV hyperlipoproteinemia, that have not been reported to appear in children and

Vitamin D and bone mineral content after intestinal bypass operation for obesity.

Twenty-three obese subjects who had undergone intestinal bypass operation (end-to-side jejunostomy) were studied with respect to vitamin D and other indices of calcium metabolism. Group 1 (11 patients) was examined before and one year after operation. Group 2 (12 patients, bypass operated two to seven years earlier was investigated twice with an interval of one year. The two groups were comparable. Bone mineral content and alkaline phosphatases were unchanged during the study in both groups. Bone phosphorus/hydroxyproline ratio was high postoperatively indicating a high degree of bone mineralisation. Serum calcium declined rapidly in group 1 to a constant level, which was maintained in group 2. The serum levels of iPTH and 1,25(OH)2D did not change within each group, but combining the two groups demonstrated an increase/decrease in iPTH/1,25(OH)2D over the years. The findings suggest that factors other than 1,25(OH)2D and iPTH are involved in calcium metabolism in such patients. The findings do not justify routine administration to such patients of high potency vitamin D derivatives, f.ex. 1 alpha-OH-D3.

Episodic arthritis, skin manifestations and immune complexes following intestinal by-pass operations for morbid obesity.

A systematic search for immune complexes (IC) in blood and skin revealed no correlation to IC-related disorders in 35 patients who had undergone jejunoileal bypass for obesity. Tests for cryoprecipitates and endotoxins proved negative.

Appetite suppressant activity in plasma of rats after intestinal bypass surgery.

Male Sprague-Dawley rats with a jejunoileal bypass ate 32% less in the 1st h of refeeding after an overnight fast than did sham-bypass rats. Fasted recipients injected intraperitoneally with 6-7 ml of bypass plasma also ate 32% less (P less than 0.001) during the 1st h of refeeding than did recipients of sham-bypass plasma, but subsequent intake was not significantly different. Rectal temperature, hematocrit, white blood cell count, and percent polymorphonuclear leukocytes were not different between bypass and sham-bypass rats. A test for aversive conditioning suggested that the effect of bypass plasma was not due to illness or discomfort. These data suggest that intestinal bypass produces a transferable humoral factor that suppresses food intake and that the effect is not due to illness or discomfort. If the decreased food intake in humans after intestinal bypass is due to a similar mechanism, the possibility exists that this humoral appetite-suppressant factor may be clinically useful in the treatment of morbid obesity.

Jejuno-ileal Bypass Surgery in Obesity

Changes in the quality of life were demonstrated in 38 young women who had undergone intestinal bypass surgery for obesity. After the operation about half the women complained of decreased libido or sexual activity, apparently due to psychological problems related to the development of asthenia secondary to metabolic disturbances. Bypass surgery resulted in a more regular pattern of menstruation but oral contraception was ineffective because of impaired intestinal absorption, perhaps due to a rapid transit time. No absolute contraindication to pregnancy was found but there are many risk-factors for both mother and fetus because of electrolyte disturbances, malnutrition and vitamin deficiency. Infants born to women after bypass surgery were found to have lower birth weights, were shorter, and the placental weight was low. It is necessary for these patients to have close medical supervision. The results of our study show that intestinal bypass surgery in young women has side effects which should not be ignored.

Depressive syndromes in grossly obese women.

Seventy-three consecutive female candidates for intestinal bypass surgery because of gross obesity, were evaluated for the presence or history of affective disorder. Fourteen patients gave a history of depressive disorder fulfilling Feighner et al. (1) criteria, giving treated expectancy (age 15-60) of about 28%, much higher than that found in the general population. A second syndrome of depressed moods of short duration, carbohydrate craving and weight gain was found in fifty-seven (78%) of the patients. This syndrome is similar to the carbohydrate craving and weight gain found in patients suffering from depressed mood and premenstrual fluid retention.

Hepatic Steatosis After Intestinal Bypass—Prevention and Reversal by Metronidazole, Irrespective of Protein-Calorie Malnutrition

Thirty-three patients were studied after intestinal bypass operations to determine if the postoperative hepatic steatosis could be related to bacterial overgrowth in the excluded segment, rather than to protein-calorie malnutrition. Metronidazole, a drug known to suppress anaerobic intestinal organisms, brought about improvement in the intestinal and systemic manifestations of the bypass enteropathy. When metronidazole was given at random intervals after surgery, the clinical improvement was associated with a reduction in hepatic steatosis in 12 of 12 patients. In 8 patients of this group, morphology reverted to normal within the first year. In contrast, without metronidazole treatment, steatosis increased in 12 of 17 patients during the postoperative period, only 1 reverted to normal in the first year, and in 9 of 12 patients the steatosis was still worse than at baseline during the second year after surgery. Additionally, in 9 patients, 3- or 4-mo periods with metronidazole were alternated repeatedly with drug-free intervals. Without metronidazole, steatosis increased in this group during 12 of 12 intervals, while in 12 of 13 periods with metronidazole, the steatosis diminished or disappeared. This improvement was evident despite concurrent progressive decreases in serum albumin levels during 5 of these 13 intervals. Overall, changes in hepatic fat content in the sequential liver biopsy specimens were found unrelated to weight loss rates or to plasma amino acid levels, and they inconsistently correlated to changes in serum albumin as indices of protein calorie nutrition. The data of this study suggest.that hepatic steatosis after an intestinal bypass operation is the result of a process related to the organisms colonizing the excluded intestinal segment, and that it is independent of protein-calorie malnutrition.