Jejunoileal Bypass Surgery Research Articles

Differentiation status of rat enterocytes after intestinal adaptation to jejunoileal bypass.

The differentiation status of epithelial cells in intestinal adaptation remains unclear. To determine whether enterocytes reach optimum maturity following adaptation after 85% shortening of the rat gut by jejunoileal bypass surgery, activities of two brush border enzymatic markers of differentiation, alkaline phosphatase and sucrase, were examined in subpopulations of epithelial cells isolated sequentially from the villus/crypt axis of normal (sham operated) and hyperplastic mucosa. In jejunal villi, adaptational hyperplasia was associated with an increase in total epithelial alkaline phosphatase, but not total sucrase, activity; alkaline phosphatase activity increased most obviously in cells at the 11-50% position (from the tip) on villi. In hyperplastic ileal villi, total alkaline phosphatase activity fell, although sucrase activity did not change significantly. Specific activity (per mg protein) of sucrase on jejunal villus epithelium was reduced by the adaptational changes to bypass; alkaline phosphatase specific activity remained unchanged. In the ileum, despite adaptational changes to bypass, there was no increase in the normally low specific activities of sucrase and alkaline phosphatase. Bypass surgery did not change the major site of expression of either enzyme on jejunal or ileal villi. In conclusion, enzymatic markers of functional differentiation are not all equally affected by adaptational hyperplasia. Hypertrophy of villi and increased cell proliferation seen in jejunum remaining exposed to luminal contents resulted in an increase in the alkaline phosphatase but not the sucrase content. This is not, therefore, the result of a simple immaturity of villus cells. Morphological adaptation in the ileum, however, is not accompanied by adaptation of brush border enzyme markers of differentiation, confirming a functional immaturity of these cells. Strategies for increasing the expression of these markers may have clinical value.

A Jejuno-ileal Bypass Patient Presenting with Recurrent Renal Stones due to Primary Hyperparathyroidism.

In the past, jejuno-ileal (JI) bypass operations were performed for the treatment of massive intractable obesity. This procedure is known to be complicated by numerous malabsorptive syndromes, occasionally resulting in electrolyte abnormalities and oxalate renal calculi. Recurring renal stones and oxalate nephropathy are cause to reverse the JI bypass. However, investigation of recurring renal stones should be done to exclude causes that are not secondary to the bypass procedure itself. We present a patient 13 years post JI bypass with recurring renal calculi due to primary hyperparathyroidism.

Late Calcium Metabolic Consequences of Jejuno-ileal Bypass.

Seventeen patients with previous jejuno-ileal bypass operation (JIB) for obesity were included in a follow-up study 11 to 19 years after JIB. Evaluation of calcium-parathyroid hormone axis was performed by a highly sensitive two-site IRMA assay for serum intact parathyroid hormone and serum ionized calcium. Evidence of a varying degree of secondary hyperparathyroidism was found. The observed hyperparathyroidism was of clinical significance in a subpopulation characterized by increased bone turnover and reduced bone mineral content. As a consequence, the calcium metabolism with special attention to the parathyroid function must be carefully monitored in JIB patients. Serum ionized calcium alone and vitamin D metabolites do not identify patients at risk of bone loss.

Does Calcium Supplementation Reduce the Risk of Urinary Oxalate Calculi after Jejunoileal Bypass for Morbid Obesity?

Twelve patients having received an end-to-side jejunoileal bypass operation for morbid obesity 6-10 years previously were studied over three periods of 2 weeks each. The first period was used for baseline observations without any treatment. For the second period patients were randomly assigned to equimolar (75 mmol/day) oral calcium supplements administered either as a slow release or as a bolus calcium preparation. During the third period these treatments were crossed over. The calcium preparations used caused equal reductions in frequency of bowel movements. Both preparations increased serum calcium and serum phosphate, but significance (p < 0.05) was reached only during supplementation with the slow-release preparation. Despite the Intended raising of serum calcium levels, none of the preparations influenced the 24-hour urine oxalate to creatinine ratio or the urine stone index. There are several other reasons for supplying extra calcium after intestinal bypass procedures, but our data do not support the concept of preventing renal stone formation by means of calcium supplementation.

Renal Tubular Acidosis after Jejunoileal Bypass for Morbid Obesity: role of secondary hyperparathyroidism.

The effect of calcium infusion was studied in patients with renal tubular acidosis (RTA) and secondary hyperparathyroidism. Both developed after jejunoileal bypass operation (JIB) for morbid obesity. In three of four cases the acidification defect was abolished, probably due to a decrease of serum parathyroid hormone. As we found RTA in 9% (95% confidence limits 2-21%) of our patients, screening for acidosis is recommended in obesity patients after malabsorptive operations. RTA can be verified through an ammonium loading test. Before deciding on re-establishing bowel continuity due to RTA, we suggest that patients be evaluated for secondary hyperparathyroidism and vitamin D deficiency by measurement of serum calcium, parathyroid hormone and vitamin 1.25(OH)&inf2D&inf3;, and any calcium and vitamin D deficiency be corrected. An intravenous calcium loading test can predict the outcome of oral calcium and vitamin D supplementation. If RTA can be abolished through correction of calcium homeostasis, reoperation may be avoided. Before deciding on re-establishing bowel continuity in JIB patients with RTA, we therefore suggest that patients be evaluated for secondary hyperparathyroidism and any calcium deficiency be corrected.

Jejunoileal Bypass Operations With a Side-to-side Anastomosis in the Treatment of Morbid Obesity.

In order to avoid a stagnant loop syndrome in intestinal bypass operations for morbid obesity, we have tried a jejunoileal bypass with a side-to-side anastomosis in a pilot study. Seven patients were operated on with this method, which resulted in a very high incidence of liver damage. The study puts a question mark to the blind loop syndrome as an etiological factor in producing liver damage.

Fatty liver hepatitis (steatohepatitis) and obesity: An autopsy study with analysis of risk factors

Steatohepatitis (fatty liver hepatitis), histologically identical to alcoholic disease, occurs in some obese patients after jejunoileal bypass. A similar lesion occurs rarely in obese patients without bypass surgery, but the risk factors are poorly understood. Hepatic steatosis, steatohepatitis and fibrosis were sought in 351 apparently nonalcoholic patients at autopsy and various risk factors were evaluated. Incidence of steatosis and steatohepatitis correlated with the degree of obesity. Steatohepatitis was found in 18.5% of markedly obese patients and 2.7% of lean patients. Additional risk factors for steatohepatitis were type II diabetes, weight loss in the preterminal period shortly before death and intravenous glucose therapy in the last week of life. Severe fibrosis was found in 13.8% of markedly obese patients and in 6.6% of lean patients; this difference was largely explained by the higher prevalence of diabetes in obese groups. The risk factors defined in this study are known to be associated with abnormalities of free fatty acid metabolism. Obesity, type II diabetes and intravenous glucose therapy are associated with hyperinsulinemia, which may inhibit fatty acid oxidation. Obesity and weight loss increase the presentation of fatty acids to the liver. Similar metabolic changes may occur in obese patients after jejunoileal bypass surgery. Thus this study supports the hypothesis that fatty acids have a role in the hepatocellular necrosis found in some obese individuals.

Cure of arthritis-dermatitis syndrome due to intestinal bypass by resection of nonfunctional segment of blind loop

Many complications that followed jejunoileal bypass operations performed for the relief of morbid obesity were caused by bacterial overgrowth in the excluded blind loop. The arthritis-dermatitis syndrome was one of the common distressing disorders. The pathogenetic mechanism was thought to be an immune-complex-mediated process related to bypass enteritis. Antiarthritic medication was ineffective in most instances, and the skin lesions were refractory to treatment. A 45-year-old woman was suffering from the disorder as described above. She also had diarrhea, a low hematocrit, an elevated white blood cell count, and an increased sedimentation rate. Her nutritional status was satisfactory, presumably because of adaptive hypertrophy of the short functioning small intestinal segment. The patient adamantly refused dismantling of the bypass or any gastric restriction operations. Therefore, the blind loop, the source of her disease, was excised with immediate relief of all ill effects and restoration of normal laboratory findings. The patient has been entirely well since, and her weight has remained stable for one year.

Regression of Liver Steatosis following Gastroplasty or Gastric Bypass for Morbid Obesity

15 consecutive persons aged under 50 with an overweight exceeding 75% were examined clinically, biochemically and with liver biopsy after gastric bypass (7 patients) or gastroplasty (8 patients). After 1 year the occurrence of steatosis had fallen from 73 to 40% which, together with a marked decrease in individual gradings of fatty changes, represented a significant regression of the steatosis. Likewise, discrete inflammatory and granulomatous changes largely disappeared. In no case was fibrosis present. Serum alkaline phosphatases preoperatively increased above normal range in 20% but their mean level was significantly reduced after 12 months of weight loss. Other liver function tests remained normal and stable. In contrast to published experience with jejunoileal bypass operations liver steatosis associated with morbid obesity seems to be morphologically and biochemically reversed together with the weight reduction obtained by gastroplasty or gastric bypass.

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.

PERIOPERATIVE CHANGES IN FUNCTIONAL RESIDUAL CAPACITY IN MORBIDLY OBESE PATIENTS

Functional residual capacity (FRC) was measured before and after induction of anaesthesia for jejunoileal bypass surgery in 30 morbidly obese patients. The onset of anaesthesia was associated with a 51% reduction in FRC from 2.2 litre to 1.0 litre. Eighteen of the patients were investigated more extensively; in these subjects FRC was reduced below the control values of residual volume (RV) with the onset of anaesthesia, but recovered towards baseline after laparotomy incision. Reduction in FRC is related to baseline vital capacity (VC) and FRC and is much greater than that reported for patients of normal weight.

Prospective study of malabsorption induced risk of gall stone formation in relation to fall in plasma cholesterol.

The relationship between cholesterol in plasma and risk of gall stone formation was investigated in 210 obese patients who underwent jejunoileal bypass surgery and were free of gall stone disease at the time. Among 185, successfully reexamined on average 19 months after surgery, 26 (14%) developed gall stones. The fall in plasma cholesterol after surgery exhibited a U-shaped relation to risk of gall stone formation with a minimum risk around the average fall (2.6 mmol/l). This was confirmed by multivariate logistic regression analysis (p less than 0.01) taking into account other possible determinants. The relation was not significantly dependent on weight loss or ratio between jejunum and ileum left in function. The study suggests that malabsorption induced fall in plasma cholesterol is related to risk of gall stone formation by two oppositely working mechanisms, one enhancing and one reducing the risk.

Malabsorptive Procedures in Surgical Treatment of Morbid Obesity

There is no ideal operation for morbid obesity and there probably never will be one. The disease is multifaceted, with unknown polyfactorial etiology. The multitude of surgical methods attests to the frustrations in trying to palliate the morbidly obese. Gastric restriction on its own is proving inadequate for the heaviest patients ("super obese"), for patients with preferences for "sweets," and for patients who have had failure of previous surgery, whether it be jejunoileal bypass or gastroplasty. The current trend toward performing malabsorptive procedures is symptomatic. Experimentation with varying sizes and configurations of gastric remnants in combination with varying lengths of small intestine in continuity is reminiscent of the early experience with jejunoileal bypass. That era has been called by some respected and influential surgeons the "dark ages of surgery." Very few of the tens of thousands of patients would agree with this assessment. Nevertheless, Payne was convinced that the "malignant abuse of all of these operations. . . could result in the abandonment of the only practical method. . . for the treatment of the morbidly obese patient." Jejunoileal bypass operations can be "salvaged" by vigorous medical management. When that fails, there are several surgical options for dealing with the blind loop, short of reanastomosing the bowel. New malabsorptive operations have been developed and are being rigorously scrutinized by relatively few dedicated surgeon-scientists. The most important lesson learned from the many severe late complications of jejunoileal bypass is that operations for morbid obesity need to be studied intensely and for a sufficiently long period of time before they can be considered ready for routine use.

Pulmonary Function in Morbid Obesity

Morbid obesity is not infrequently associated with severe respiratory impairment. In our experience approximately 10 per cent of morbidly obese patients who underwent gastric surgery had severe respiratory impairment. Respiratory insufficiency of obesity can be divided into two primary breathing disorders: the obstructive sleep apnea syndrome (SAS) and the obesity hypoventilation syndrome (OHS). In its most severe form, when both SAS and OHS are present, it is called the Pickwickian syndrome. In our series 59 morbidly obese patients with respiratory insufficiency secondary to obesity underwent gastric surgery for weight reduction. Fourteen had OHS, 19 had SAS and 26 had both. Of these, two patients died of postoperative complications and one died at five weeks with an inconclusive autopsy, totalling an operative mortality rate of 3.4 per cent and a total mortality of 5.1 per cent. In our overall experience morbidly obese patients lost 67 per cent of excess weight after gastric procedures. In conclusion, surgically induced weight loss will markedly improve or correct respiratory insufficiency secondary to obesity. It will improve arterial oxygenation, minimize CO2 retention, expand lung volumes, correct polycythemia, and reduce apnea frequency. The magnitude of changes in these variables is clinically significant. Therefore, respiratory insufficiency of obesity should be considered a major indication for an aggressive approach to weight reduction. The jejunoileal bypass and unbanded gastroplasty operations have an unacceptable incidence of complications or failure, respectively. There is a high degree of recidivism following dietary programs. Sweets eaters will not do well with a gastroplasty procedure. Gastric bypass for individuals addicted to sweets or the vertical banded gastroplasty for "gorgers" are currently our procedures of choice and are associated with the average loss of two thirds of excess weight and correction of breathing problems associated with morbid obesity.

Alcohol-induced liver injury after jejunoileal bypass operation in rats

The objective of this study was to investigate whether alcohol administration exerts a synergistic effect on jejunoileal bypass-induced liver dysfunction in rats. Male Wistar rats were subjected to 90% jejunoileal bypass or sham operation. For 10 weeks, subgroups were pair-fed either an alcohol-containing (36% of total calories) liquid diet or a liquid diet where alcohol was replaced isocalorically by starch. Alcohol feeding in rats with jejunoileal bypass increased hepatic triglyceride content about 6-fold as compared with bypassed rats receiving control diet. Neither jejunoileal bypass nor alcohol feeding led to significant changes in hepatic DNA and protein contents. Alcohol feeding increased cytochrome P-450 levels both in operated and in sham-operated rats. The administration of alcohol-containing diet decreased the activity of succinic dehydrogenase, the decrease being distinctly more pronounced in rats with jejunoileal bypass than in the sham-operated controls. Light microscopy revealed no significant morphological alterations in liver sections of rats fed the control diet after jejunoileal bypass or of rats receiving either the alcohol-containing diet or the control diet after sham operation. Alcohol feeding in bypassed rats, however, produced marked diffuse accumulation of fat, and regularly led to other histological abnormalities in the liver. These abnormalities included ballooning of hepatocytes and disarray of the trabecular structure of the liver lobule, hyalin inclusions resembling megamitochondria, single-cell necrosis and focal clustering of necrosis, increased number of mitotic figures, and infiltrates with inflammatory cells. The histological lesions of the liver of bypassed rats receiving alcohol exhibited no obvious zonal distribution. The results demonstrate that alcohol feeding to rats subjected to jejunoileal bypass leads to marked liver injury which mimics, at least in part, that of alcohol-induced liver disease in man. Rats subjected to jejunoileal bypass may, therefore, provide a new model for the study of alcoholic liver disease.

Alcohol-induced liver injury following jejunoileal bypass operation (JIB) in rats: Effect on adenosinphosphates and phospholipids

Alcohol-induced liver injury following jejunoileal bypass operation (JIB) in rats: Effect on adenosinphosphates and phospholipids

Bowel-associated dermatosis-arthritis syndrome: Bowel bypass syndrome without bowel bypass

The bowel bypass syndrome is a well-recognized complication in patients who have had jejunoileal bypass for morbid obesity. It consists of an influenza-like illness with increased temperature, chills, polyarthralgia, myalgia, and inflammatory papules and pustules that are 2 to 4 mm in diameter and that usually appear on the extremities and the upper part of the trunk. A patient is reported who had an identical bowel-associated dermatosis-arthritis syndrome but who had not undergone a jejunoileal bypass operation. Seven previously reported similar cases are reviewed.

Oxalate Degradation by Gastrointestinal Bacteria from Humans

Anaerobic bacteria that metabolize oxalic acid have only recently been isolated from the rumen and from other gastrointestinal habitats. They constitute a new genus and species, Oxalobacter formigenes. This report presents the first comparison of cultural counts of these organisms from human feces and indicates that numbers as high as 107/g may be present in feces from normal humans. Rates of oxalate degradation by mixed bacterial populations in feces from seven normal humans ranged from 0.1 to 4.8 µmol/(g · h). With fecal samples from eight patients that had undergone jejunoileal bypass surgery, rates were much lower [0–0.006 µmol/(g · h)]. We propose that oxalic acid degradation by Oxalobacter formigenes may influence absorption of oxalate from the intestine and that lower rates or lack of oxalate degradation in the colons of jejunoileal bypass patients may contribute to the increased absorption of dietary oxalate and the hyperoxaluria commonly associated with such patients.

Aversive consequences of jejunoileal bypass in the rat: A conditioned taste aversion analysis

Jejunoileal bypass (JIB) surgery reduces food intake and body weight in obese humans and rats. Human bypass patients report visceral discomfort following surgery, and the present study assessed the aversive consequences of JIB in rats using a conditioned taste aversion paradigm. In Experiment 1 rats given a cherry-flavored solution immediately after JIB surgery subsequently displayed a strong aversion to the cherry flavor compared to Bypass and Sham-Bypass control groups. Rats in Experiment 2 were familiarized with cherry solution prior to surgery and they did not display an aversion to the solution after receiving a JIB. In Experiment 3, Bypass rats who developed a cherry flavor aversion after JIB subsequently lost this aversion following reconnection of their intestinal tract. The rats in Experiment 4 displayed an aversion to a saccharin-flavored chow that was eaten shortly after JIB surgery, although the aversion was not as pronounced as that obtained with the cherry solution. The results suggest that JIB produces a persisting malaise in rats that may contribute to the feeding and weight inhibitory effects of the operation.