Jejunoileal Bypass For Morbid Obesity Research Articles

Bariatric surgery for curing NASH in the morbidly obese?

Guillaume Lassailly1,3, Robert Caiazzo2,4, Francois Pattou2,4, Philippe Mathurin1,3,* 1Hepatology Service, CHRU Lille, Universite Lille 2, Lille, France; 2Department of General and Endocrine Surgery, CHRU Lille, Universite Lille 2, Lille, France; 3U995 INSERM, Universite Lille 2, Lille, France; 4U859 INSERM, Universite Lille 2, Lille, France *Corresponding author. Address: 1, rue Michel Polonovski Hopital Claude Huriez (CHRU Lille), 59037 Lille CEDEX, France. *E-mail address: philippe.mathurin@chru-lille.fr Bariatric surgery for curing NASH in the morbidly obese?

Refractory Diffuse Bony Pain 20 Years After Jejunoileal Bypass

Osteomalacia can be a late but unrecognized complication following jejunoileal bypass. We describe a 53-year-old man who underwent jejunoileal bypass for morbid obesity twenty years earlier who suffered from progressive diffuse bony pain refractory to nonsteroidal anti-inflammatory drugs. He was initially diagnosed with a malignancy with bone metastasis. However, pertinent laboratory data were notable for hypocalcemia (7.5 mg/dL, albumin 4.1 mg/dL) with low urinary calcium excretion (14 mg/day), hypophosphatemia (2.0 mg/dL) with low urinary phosphate excretion (53 mg/day), hypomagnesemia (1.5 mg/dL) with low urine magnesium excretion (23 mg/day), low 1, 25 (OH)2 vitamin D3, and elevated serum alkaline phosphatase and intact parathyroid hormone (iPTH). These laboratory findings pointed to a defect in calcium, phosphate, and magnesium handling in the gastrointestinal tract. Bone biopsy of the iliac crest clearly demonstrated typical changes of osteomalacia with excessive osteoid accumulation and reduced mineralization. His clinical symptoms were refractory to oral 1, 25 (OH)2 vitamin D3 and calcium supplementation but significantly improved with the addition of intermittent intravenous active 1, 25 (OH)2 vitamin D3, calcium, phosphate, and magnesium supplementation. Osteomalacia is an easily misdiagnosed late complication of jejunoileal bypass. Early recognition can avoid circuitous diagnosis and inappropriate management.

An Extremely Late Complication of a Roux-en-Y Jejuno-ileal Bypass

We report the case of a patient who underwent an open Roux-en-Y jejuno-ileal bypass for morbid obesity in February 1976. Having enjoyed a normal and stable body mass index for 30years, she presented acutely with an intussusception of the blind limb.

Use of Sevelamer Hydrochloride as an Oxalate Binder

We tested the hypothesis that the cationic phosphate binder sevelamer hydrochloride could reduce hyperoxaluria and calcium oxalate supersaturation in patients with enteric hyperoxaluria by binding fatty acids, binding phosphate and rendering calcium free to bind oxalate, and/or directly binding oxalate. A secondary objective was to assess changes in the urinary excretion of other substances associated with nephrolithiasis. Ten patients with enteric hyperoxaluria were enrolled in a nonrandomized, open label trial of sevelamer hydrochloride (3,200 mg 3 times daily for 7 days). With treatment mean urinary oxalate decreased 17% (0.84 to 0.70 mmol per day) and the urinary oxalate-to-creatinine ratio decreased 11% (0.055 to 0.049 mmol/mmol, p not significant for both). Urinary calcium increased 25% (p not significant). Urinary citrate decreased 23% (p = 0.01) and urinary phosphorus decreased 44% (p = 0.0001). Mean supersaturation of calcium oxalate, brushite, hydroxyapatite, uric acid and sodium urate did not change significantly. However, the decrease in brushite supersaturation approached statistical significance (p = 0.07). Mean serum phosphorus was 3.6 mg/dl at baseline and 3.3 mg/dl with therapy (p not significant). Hypophosphatemia did not develop in any patients. One patient dropped out of study due to abdominal pain. Sevelamer hydrochloride dramatically decreased urinary phosphorus excretion with a lesser effect on urinary oxalate. Supersaturation of calcium oxalate did not decrease due to countervailing effects on other constituents including an increase in urinary calcium and a decrease in urinary citrate. Although sevelamer hydrochloride may not be an ideal agent for correcting hyperoxaluria, its potential to reduce calcium phosphate supersaturation merits further investigation.

Intestinal failure

The small bowel is a marvellous organ. First, it absorbs nutrients on behalf of all the other organs of the body. This function is not entirely ‘altruistic’: enteric (small-bowel) epithelium is itself nourished by luminal nutrients, which explains its disproportionately severe atrophy in starvation or total parenteral nutrition. Second, it has an enormous functional reserve. In the era of jejunoileal bypass for morbid obesity, most patients with 85–90% of the small bowel taken out of circuit could still maintain a body weight above normal. Third, the fact that diarrhoea after a major enterectomy diminishes with time indicates the adaptive power of the remnant small intestine. The lining of the jejunum and ileum is normally shed every few days as cells migrate from crypt base to villus tip, yet the process can be further accelerated to compensate for loss of tissue mass.

Intestinal adaptation after jejunoileal bypass for morbid obesity: a possible explanation for inadequate weight loss.

Thirty-two patients required further abdominal operations 6-77 months after jejunoileal bypass for morbid obesity. Twenty operations were needed because of inadequate weight loss, while the remaining 12 patients had lost sufficient weight but had developed complications. In all 32 patients the lengths of functioning jejunum and ileum were measured and compared with those recorded during the original operation; elongation had occurred in 29. There was a striking difference between the median increase in jejunoileal length of 44 per cent when weight loss was inadequate and 7 per cent when weight loss was adequate (P less than 0.01). Similarly, intestinal circumference and mural thickness were greater in the first group. There appears to be a relationship between intestinal adaptation and the extent of weight loss after jejunoileal bypass.

Long term follow up of patients who underwent jejunoileal bypass for morbid obesity.

To describe our long term results after jejunoileal (JI) bypass for morbid obesity. Retrospective study. Teaching hospital, Denmark All 57 patients who underwent JI bypass for morbid obesity between January 1973 and December 1988. Type A and type B JI bypass. Weight loss, operative morbidity and mortality, and subjective evaluation of the results. Mean duration of follow up was 15.9 years (range 8-22). There were no operative or early postoperative deaths, but there were 7 late deaths (12%). 5 patients developed postoperative complications (9%), and 11 patients (19%) required reoperation for side effects or complications. The mean body mass index (BMI, kg/m2) was reduced from 47.5 (range 40-60) to 32 (range 22-49) during the follow up period which corresponded to a weight loss of about 42 kg. Of the 39 patients who still had a JI bypass in 1994, nearly two thirds said that they were satisfied with the operation, though they nearly all had some side effects such as diarrhoea or intermittent abdominal pain. As complications of JI bypass can develop at any time, we suggest that all patients who have had the operation should be regularly followed up at special clinics so that complications can be diagnosed and treated as soon as possible.

Jejuno-ileal bypass, enteric hyperoxaluria, and oxalate nephrosis: a role for polarised light in the renal biopsy.

Enteric hyperoxaluria, a complication of jejuno-ileal bypass, is associated with renal failure owing to oxalate nephrosis or tubulo-interstitial nephritis. A 54 year old woman developed renal failure 17 months after...

Long-term consequences after jejunoileal bypass for morbid obesity.

This study assesses the long-term results of jejunoileal bypass (JIB) in 43 prospectively followed patients whose surgical bypass remained intact. Follow-up was 12.6+/-0.25 years from JIB. Weight loss and improved lipid levels, glucose tolerance, cardiac function, and pulmonary function were maintained. Adverse effects such as hypokalemia, cholelithiasis, and B12 or folate deficiency decreased over time. The incidence of diarrhea remained constant (63% vs 64% at five years), while the occurrence of hypomagnesemia increased (67% vs 43% at five years, P < 0.05). Nephrolithiasis occurred in 33% of patients. Hepatic fibrosis developed in 38% of patients and was progressive. Overall, after more than 10 years, 35% of patients appeared to benefit from JIB as defined by alleviation of preoperative symptoms and the development of only mild complications (vs 47% at five years). On the other hand, irreversible complications appeared to outweigh any benefit derived from the JIB in 19% (vs no patients at five years; P < 0.01). In summary, patients with JIB remain at risk for complications, particularly hepatic fibrosis, even into the late postoperative period.

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

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.

Utility of Hydrogen and Methane Breath Tests in Combination with X-Ray Examination after a Barium Meal in the Diagnosis of Small Bowel Bacterial Overgrowth after Jejuno-Ileal Bypass for Morbid Obesity.

To study why the symptoms of abdominal bloating occurring in a number of patients after jejuno-ileal bypass for morbid obesity become resistant to antibiotics, we used a method which combined a hydrogen breath test after lactulose with an X-ray examination of the abdomen after barium. Ten operated patients with bloating symptoms resistant to antibiotics, ten operated patients without symptoms or with pre-existing symptoms, that had remitted after antibiotic treatment and ten nonoperated obese controls were investigated. There was a significant correlation between post-surgical symptoms persisting after antibiotics and the exhalation of large amounts of hydrogen of colonic origin (> 100 parts per million) after lactulose. Furthermore, symptomatic patients had high prevalence of colonic motility disorders (slow transit). In these patients, treatment with a prokinetic (cisapride 40 mg/kg/day for 10 days) reduced colonic transit time, colonic hydrogen production and bloating symptoms. Abdominal symptoms in these patients may therefore have other causes than small bowel bacterial overgrowth alone. All operated patients with persistent abdominal bloating should therefore be investigated before starting empirical treatment with antibiotics.

Intestinal Microflora Settlement in Patients with Jejunoileal Bypass for Morbid Obesity.

Intestinal microflora settlement was evaluated in this retrospective study of 49 patients with jejunoileal bypass who required reoperation. Colonic microflora was observed in the samples of the contents of the functioning jejunum and ileum but not in 55% of the samples from the middle of the excluded loop. Colonization of the excluded loop was not detected in patients without clinical signs of bacterial overgrowth but was significantly frequent (p < 0.01) in those with clinical signs (bloating, migratory arthralgias, rashes, skin lesions). However, positive excluded loop cultures were not always associated with clinical manifestations. No significant correlation was observed between bacteriology of the contents of the excluded loop and bypass results. The success of an intestinal bypass may depend not only on anatomic and functional adaptation to the new, surgically created conditions, but also to the attainment of microbiological equilibrium in the intestinal ecosystem.

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.

Abdominal reduction following jejunoileal bypass for morbid obesity

We present six patients who underwent abdominal reduction after successfully losing weight following jejunoileal bypass. Three patients needed more than one operation to achieve a good cosmetic result. There were no serious complications. After reviewing these patients and the few previously reported cases we make the following suggestions: 2 years should elapse after a stable weight is attained before surgery. Preoperative metabolic screening is essential. Preoperative marking of the lines of excision, prophylactic antibiotics and drainage of the wounds are strongly recommended. Lower abdominal aprons may be safely removed by a low transverse incision extended laterally up to the iliac crests and superiorly as far as the umbilicus. The umbilicus can be resited without risk of necrosis. High abdominal aprons should be excised as a transverse or vertical “melon-slice” ellipse without undermining.

Use of histological examination to assess ultrastructure of liver in patients with long standing jejuno-ileal bypass for morbid obesity.

To assess the pattern and severity of liver disease in patients who had undergone jejuno-ileal bypass for the treatment of morbid obesity, 23 patients were biopsied, all of whom had had intact bypasses for more than 10 years. These were examined by light and electron microscopy. Previous biopsy specimens from each patient, including specimens taken before bypass, were reviewed. Similar biopsy specimens were obtained from six obese patients undergoing gastroplasty. There was no evidence of cirrhosis, and mild or moderate degrees of fibrosis were found in only a few patients. Steatosis tended to persist after bypass, albeit to a lesser degree. Giant mitochondria and intramitochondrial filamentous inclusions were present in four of six specimens taken before gastroplasty and in 15 of 23 specimens taken after jejuno-ileal bypass, being especially numerous in those specimens showing little or no steatosis. It is suggested that such features reflect ultrastructural evidence of adaptation to an abnormal metabolic environment both in the morbidly obese and even many years after jejuno-ileal bypass. Their prognostic importance is unclear.

Rectal hyperplasia after jejunoileal bypass for morbid obesity.

Jejunoileal bypass (JIB) has been widely used to treat patients with morbid obesity for the past 20 years. In rats JIB causes adaptive colonic hyperplasia and enhances colorectal neoplasia. In this study crypt cell production rate (CCPR) was measured stathmokinetically in cultured rectal biopsies from nine patients with JIB and seven controls without intestinal operations or disease. Crypt cell production rate in the group with JIB was more than double that of controls (12.80 (2.67) v 6.23 (1.49) cells/crypt/h: p less than 0.001). There were no significant differences in crypt morphometry and histological examination of rectal biopsies was normal. Patients with JIB have a marked and persistent increase in cell proliferation in the large intestine and may be at increased risk of developing colonic cancer.

Pattern of progression in liver injury following jejunoileal bypass for morbid obesity.

Liver biopsies from 34 patients with morbid obesity, performed before and 5-9 months after jejunoileal bypass, were studied. The patients were divided into four groups according to preoperative findings: A: no or slight steatosis (15 patients), B: moderate-severe steatosis (6), C: steatohepatitis (steatosis + lobular lymphocytic inflammation) (8), D: steatofibrosis (steatosis + pericellular fibrosis) (5). In Group A, 12 patients showed postoperative progression to either moderate/severe steatosis, steatohepatitis, or steatofibrosis. In Group B, all patients progressed to steatohepatitis or steatofibrosis, and one developed septate fibrosis. All patients in Group C progressed to steatofibrosis, and 5 developed septate fibrosis or cirrhosis. In Group D, 3 developed bridging fibrosis. Mallory bodies appeared postoperatively in 11 patients (32%), all of whom preoperatively had either severe steatosis, steatohepatitis, or steatofibrosis. Only patients with postoperative pericellular fibrosis and Mallory bodies developed deranged architecture: 6 septate/bridging fibrosis, and 3 cirrhosis. Five patients, all with deranged architecture, developed reversible liver insufficiency. Progressive liver injury after jejunoileal bypass appears to reflect aggravation of a pre-existing liver lesion. The sequence of events: increasing steatosis, lobular lymphocytic inflammation, pericellular fibrosis, Mallory bodies, and deranged architecture is similar to that of the alcoholic liver lesion, indicating common pathogenetic mechanisms.

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.

Renal tubular acidosis secondary to jejunoileal bypass for morbid obesity.

Renal handling of acid and base was studied in patients with persistent metabolic acidosis 3-9 years after jejunoileal bypass for morbid obesity. Excretion of acid was studied before and after intravenous infusion of NH4Cl and excretion of bicarbonate after infusion of NaHCO3. Bypass patients showed impaired capacity for acidification of urine. The lowest urinary pH was 5.53 +/- 0.10 in 10 bypass patients and 4.76 +/- 0.06 in 6 controls. The corresponding values for standard bicarbonate in plasma were 15.0 +/- 0.3 mM and 15.8 +/- 0.3 mM. Glomerular filtration rate was identical in the two groups. Fractional loss of bicarbonate in urine was higher in controls than in bypass patients. The renal impairment is classified as distal renal tubular acidosis.