Jejunoileal Bypass Surgery Research Articles

Transplantation: platform to study recurrence of disease.

Beyond the direct benefit that a transplanted organ provides to an individual recipient, the study of the transplant process has the potential to create a better understanding of the pathogenesis, etiology, progression and possible therapy for recurrence of disease after transplantation while at the same time providing insight into the original disease. Specific examples of this include: 1) recurrence of focal segmental glomerulosclerosis (FSGS) after kidney transplantation, 2) recurrent autoimmunity after pancreas transplantation, and 3) recurrence of disease after orthotopic liver transplantation (OLT) for cirrhosis related to progressive steatosis secondary to jejuno-ileal bypass (JIB) surgery. Our team has been studying these phenomena and their immunologic underpinnings, and we suggest that expanding the concept to other pathologic processes and/or transplanted organs that harbor the risk for recurrent disease may provide novel insight into the pathogenesis of a host of other disease processes that lead to organ failure.

Effect of modified jejunoileal bypass surgery on the colon microflora: A case study

Effect of modified jejunoileal bypass surgery on the colon microflora: A case study

Colonic Lipomatosis

A 57-year-old woman with a remote history of jejunoileal bypass surgery, 37 years prior, presented with worsening abdominal bloating and increasing bowel frequency over the past several years. A computed tomography scan of the abdomen was performed, which revealed innumerable fat-containing lesions throughout the colon, consistent with colonic lipomatosis (Figures A and B). Findings suggestive of a nonobstructing intussusception were appreciated in the distal transverse colon (Figure C). A barium enema fluoroscopy study was performed, demonstrating multiple filling defects throughout the colon without evidence of intussusception or obstruction.

Oxalate Nephropathy Causing Irreversible Renal Failure After Roux-en-Y Gastric Bypass Surgery

Introduction: Oxalate nephropathy after RYGB, albeit rare, has a poor prognosis with a rapid progression to kidney failure. Oxalate nephropathy has many etiologies and is one of the rare causes of renal failure. Case Presentation: A 39-year-old diabetic woman came to our nephrology clinic because of a progressive increase in serum creatinine from 1 to 4.2. She had a history of Roux-en-Y gastric bypass (RYGB) surgery six months earlier. In view of the unexplained progressive increase in creatinine, a kidney biopsy was done. The histological diagnosis of oxalate nephropathy with diabetic nephropathy class 2b was made. Conclusions: Oxalate nephropathy is a rare and most severe renal complication after bariatric surgery that is reported in some patients after jejunoileal bypass and RYGB surgery. Oxalate nephropathy is progressive in nature and has a poor prognosis. In our case, oxalate nephropathy and kidney failure occurred six months after RYGB surgery. Since the histological finding in our patient revealed oxalate nephropathy with diabetic nephropathy class 2b, it seems diabetic nephropathy can probably facilitate calcium oxalate crystals formation. This important point should be considered that oxalate nephropathy could rapidly progress to renal failure; so, patients who undergo Roux-en-Y gastric bypass surgery should have regular follow-ups.

Small-bowel obstruction after modified jejunoileal bypass surgery due to gallstone ileus

Small-bowel obstruction after modified jejunoileal bypass surgery due to gallstone ileus

Diagnosis and Assessment of NAFLD: Definitions and Histopathological Classification.

Nonalcoholic fatty liver disease (NAFLD) comprises a spectrum of clinical and histopathological changes including "simple" steatosis, steatosis with inflammation, steatohepatitis, cirrhosis, and hepatocellular carcinoma. It was initially described in the context of drug-induced liver injury and acute liver disease following jejunoileal bypass surgery, but since the early 1980s it has been widely acknowledged as the hepatic manifestation of metabolic syndrome. It now represents a burgeoning public health crisis and is fast becoming the main indication for liver transplantation in some parts of the world. Its true incidence and prevalence are unknown, although estimates have been made from large imaging studies. Liver biopsy interpretation is still regarded as the gold standard for making accurate diagnoses in NAFLD, but sampling limitations are recognized. Furthermore, clear definitions for key histopathological components have been lacking, resulting in significant interobserver variations in making a diagnosis of steatohepatitis. In this review the authors consider some aspects of classification and variant forms of NAFLD such as that occurring in children. They provide an update on grading and staging systems and histopathological prognostic factors, and address the role of liver biopsy in contemporary clinical care of patients with NAFLD.

PWE-233 An organic marine hydrocolloid acts as a stool thickener in patients with diarrhoea and enteric hyperoxaluria due to short bowel syndrome

Introduction Calcium oxalate is the predominant component of most renal stones; they occur in 10% of patients with bile salt and/or fatty acid malabsorption due to enteric hyperoxaluria1. Patients who have undergone extensive ileal resection, jejuno-ileal bypass surgery or a Roux-en-Y gastric bypass, whose colon remains in continuity, are at a greater risk of developing enteric hyperoxaluria. It is managed by dietary restriction of oxalate and fat, a high calcium intake, and increasing water intake to ensure a daily urine volume of more than 3 litres. The latter is difficult to achieve in patients with short bowel syndrome. Ox-Absorb® is an organic marine hydrocolloid derived from plants and seaweed and was first described in the 1980’s as a promising new treatment for enteric hyperoxaluria. It was also noted that it thickened stools and reduced stool frequency. Ox-Absorb®is unlicensed in the UK and imported on a named patient basis from the USA. When it was used by the renal physicians at North Bristol NHS Trust to reduce oxalate stone formation, patients reported beneficial effect on stool frequency and consistency. Method We conducted a retrospective case note review of all patients prescribed Ox-Absorb® in North Bristol NHS Trust. Drug history, weight, change in stool consistency and urinary oxalate levels were documented. Net reduction in tablet burden and a cost analysis of the use of Ox-Absorb®were calculated. Results 8 patients were prescribed Ox-Absorb®. 7/8 patients reported thicker stools and reduced stool frequency and there was a reduction in tablet burden (mean 8.6 tablets; range 2 to 22; median 7). Mean net reduction of tablets was 22% (median 29%). There was a cost reduction in 3/8 patients, all of whom were taking higher doses of loperamide, codeine phosphate and Creon®(£1.09, £0.57 and £0.15 per day). 3/8 patients had to stop the drug due to supply problems and all noted worsening in diarrhoea symptoms which improved on restarting the drug. Urinary oxalate was reduced in only 2/8 patients. Conclusion In this small cohort, patients who were prescribed Ox-Absorb® reported thicker stools and were able to reduce their net anti-diarrhoeal tablet burden. This was cost effective in patients taking higher doses of loperamide, codeine and Creon®. We believe a larger study of this drug relative to standard treatments is justified. Disclosure of interest None Declared.

Oxalate nephropathy after Jejuno-Ileal bypass surgery

Oxalate nephropathy after Jejuno-Ileal bypass surgery

On the surgical treatment of the metabolic syndrome

We present he results of surgical treatment of 136 patients with metabolic syndrome at long-term period of evaluation (up to 15 years). All patients had jejunoileal bypass surgery in modification prof. Y.I. Sedletsky. We show the effect of surgery on overweight, hypertension, dyslipidemia, and hyperglycemia. We've traced above changes depending on the period elapsed since the time of the operation. The results prove the efficiency and stability of effects of jejunoileal bypass surgery on components of the metabolic syndrome. Evaluation of the complications rate of this method is also presented in the article.

Gastric bypass after liver transplantation

Few data are available for assessing the outcomes of bariatric surgery for patients who have undergone orthotopic liver transplantation (OLT). The University of Minnesota bariatric surgery database and transplant registry were retrospectively reviewed to identify patients who had undergone OLT and then open Roux-en-Y gastric bypass (RYGB) surgery between 2001 and 2009. Comorbidity-appropriate laboratory values, body mass indices (BMIs), histopathology reports, and immunosuppressive regimens were collected. Seven patients were identified with a mean age of 55.4 ± 8.64 years and a mean follow-up of 59.14 ± 41.49 months from the time of RYGB. The mean time between OLT and RYGB was 26.57 ± 8.12 months. The liver disease etiologies were hepatitis C (n = 4), jejunoileal bypass surgery (n = 1), hemangioendothelioma (n = 1), and alcoholic cirrhosis (n = 1). There were 2 deaths for patients with hepatitis C 6 and 9 months after bariatric surgery due to multiple-organ dysfunction syndrome and metastatic esophageal squamous carcinoma, respectively. One patient with hepatitis C required a reversal of the RYGB because of malnutrition and an inability to tolerate oral intake. Four of the 7 patients had type 2 diabetes mellitus (T2DM), 4 had hypertension, and 6 patients had dyslipidemia. All patients were on immunosuppressive medications, but only 4 were on corticosteroids. Glycemic control was improved in all surviving patients with T2DM. The mean BMI was 34.27 ± 5.51 kg/m(2) before OLT and 44.34 ± 6.08 kg/m(2) before RYGB; it declined to 26.47 ± 5.53 kg/m(2) after RYGB. In conclusion, in this case series of patients undergoing RYGB after OLT, we observed therapeutic weight loss, improved glycemic control, and improved high-density lipoprotein levels in the presence of continued dyslipidemia. RYGB may have contributed to the death of 1 patient due to multiple-organ dysfunction syndrome.

A Case of Nonalcoholic Steatohepatitis and Small Intestinal Bacterial Overgrowth with Peripheral Edema Caused by Intestinal Bypass Surgery and Relieved by Repair

Intestinal bypass surgery, particularly jejuno-ileal bypass surgery, performed for the purpose of weight reduction may cause an unexpected exacerbation of nonalcoholic steatohepatitis (NASH). Here, we report a case of NASH caused by small intestinal bacterial overgrowth, which developed after jejuno-colic bypass surgery and resolved dramatically after surgical correction.

The jejunoileal bypass provokes morphological changes in the large intestine? An experimental study in rats

PURPOSE: To analyse histopathological alterations characterized by the mitotic index in the mucosa of the large intestine in Wistar rats submitted to jejunoileal bypass operation after continued administration of sodium nitrite and vitamin C to different groups. METHODS: Eighty male Wistar rats were employed and separated into 12 groups. In the control group (20 rats): five animals ingested only water; five animals received vitamin C; five animals received sodium nitrite and five received sodium nitrite + vitamin C. In the sham group (20 rats), the animals were anesthetized and underwent midline laparotomy and only intestinal manipulation was performed: five animals ingested only water; five animals received vitamin C; five animals received sodium nitrite and five received sodium nitrite + vitamin C. In the operated group 40 rats underwent a jejunoileal bypass surgery: ten animals ingested only water; ten animals received vitamin C; ten animals received sodium nitrite and ten received sodium nitrite + vitamin C. The mean weight of the animals was measured weekly. The large intestine was subdivided into cecum (S1), ascending colon (S2), transverse colon (S3), descending colon (S4) and rectum (S5) for histopathological analysis and mitotic counts. The statistical analysis was used to compare the mitotic indices. The level of significance was 5%. RESULTS: The mean of all the segments indicates that the sodium nitrite+vitamin C group obtained the lowest mitotic index compared to the other treatments in the control group. The segments S1 and S2 showed a statistical difference with the vitamin C treatment: a higher mitotic index and better preservation of the mucosa in the operated group. In the sham group the main statistical difference occurred only in the sodium nitrite+vitamin C group between the means of the segments. CONCLUSIONS: The comparison of all the colonic segments of the various groups revealed a lower mitotic index in the animals treated with sodium nitrite+vitamin C. In addition, it was found that vitamin C did not present a statistically significant inhibiting effect on the preservation of the mucosa and the mitotic index.

D-Lactic Acidosis Presenting in Crohnʼs Disease with Short Bowel Syndrome

Purpose: D-lactic acidosis is a rare form of lactic acidosis that can occur in individuals following jejuno-ileal bypass surgery or short bowel syndrome. Symptoms typically occur after ingestion of a high-carbohydrate meal due to glucose and starch being metabolized by the colon into D-lactic acid-with subsequent absorption into circulation and systemic acidemia. D-lactate accumulates as L-lactate dehydrogenase is unable to convert this type of lactate into pyruvate. Methods: N/A Results: 48-year-old female with Crohn's disease s/p subtotal small bowel resection 3 years ago, with resultant short bowel syndrome presented with persistent weight loss, abdominal pain, postprandial nausea, headache, confusion, blurred vision, dizziness with ataxia, intermittently ongoing for several months. She complained of feeling as if she was intoxicated, although she denied any alcohol ingestion. She had a history of intestinal intussusception and CT enterography ordered 9 days prior showed dilated loops of distal small bowel consistent with partial small bowel obstruction. Lab work revealed normal CBC, LFTs, but also metabolic acidosis with serum bicarbonate at 16mmol/L, with anion gap of 12; VBG showed pH 7.15, pCO2 44mm Hg, pO2 17mmHg, bicarb 15mmol/L. However, serum lactic acid level was normal at lmmol/L. Serum D-lactate was drawn showing elevation to 6.15mmol/L — thus confirming the diagnosis of D-lactic acidosis. She was given fluids, bicarbonate and placed on Flagyl and Levaquin for bacterial overgrowth. Her acidosis along with her neurological symptoms shortly thereafter resolved. PEG tube was placed and she was started on enteral feeding for malnutrition. Her partial SBO also resolved with supportive care. Conclusion: In individuals with intact small intestine, few carbohydrates and starch reach the colon. In patients with short bowel syndrome, glucose reaches the colon, and when in combination with bacterial overgrowth (usually gram-positive anaerobes)—D-lactic acid is formed. Episodic metabolic acidosis can occur after meals with neurological symptoms including altered mental status, dysarthria, ataxia, and concentration/memory difficulties. Patients often appear drunk in the absence of ethanol consumption. D-lactic acidosis should be considered in short bowel patients with an anion gap metabolic acidosis, a normal serum lactate; characteristic neurological findings and acidosis following food intake. Diagnosis is confirmed with special enzymatic assay measuring serum D-lactate. Treatment involves sodium bicarbonate, low carbohydrate diet and antimicrobial agents to decrease bacteria overgrowth.

Adult Jejunojejunal Intussusception After Jejunoileal Bypass Bariatric Surgery

The jejunoileal bypass is one of the bariatric surgical options which have been abandoned for two reasons: first, it leads to severe malnutrition and liver failure and, second, the bypassed jejunum-being a blind loop-is susceptible to bacterial accumulation which might become a source of sepsis due to bacterial translocation. We hereby report a case of a 27-year-old lady who presented with jejunojejunal intussusception of the blind jejunal loop 2 years after jejunoileal bypass surgery. This complication could have led to serious consequences if it was not managed in the appropriate time.

Atypical histopathology in bowel-associated dermatosis-arthritis syndrome: A case report

Bowel-associated dermatosis-arthritis syndrome (BADAS) is characterized by a prodrome of fever, chills, and flu-like symptoms with subsequent skin eruptions, myalgias, and polyarthralgias. The syndrome was initially described following jejunoileal bypass surgery for weight loss. Histopathology of the skin lesions present in BADAS is described in the literature as identical to that of Sweet syndrome. We present a patient whose clinical history and physical exam were consistent with the diagnosis of BADAS. Dermatopathology in this case demonstrated a large subcorneal pustule without a significant dermal neutrophilic infiltrate. The histologic differential included subcorneal pustular dermatosis, bullous impetigo, or IgA pemphigus. The histology in BADAS may not necessarily be identical to Sweet syndrome, and the clinical picture alone plays an important role in diagnosis. The correct diagnosis of BADAS prevents a myriad of laboratory tests and allows for more effective symptom management in this chronic condition.

AA amyloidosis due to chronic oxalate arthritis and vasculitis in a patient with secondary oxalosis after jejunoileal bypass surgery

We report a case of a woman with secondary oxalosis after jejunoileal bypass surgery for obesity, who presented with oxalate stone disease and renal insufficiency requiring dialysis. Thirty years after surgery, longstanding osteoarticular symptoms were recognized as oxalate arthritis. Eventually, she also developed oxalate vasculitis, which improved with corticoid treatment and intensification of dialysis. Work-up for kidney transplantation revealed AA amyloidosis on gastric and colonic biopsies. Since no other cause of chronic inflammation could be identified, it was concluded that the amyloidosis was secondary to oxalate arthritis and vasculitis. To our knowledge, this is the first report on this association.

Obesity-Induced Lymphocyte Hyperresponsiveness to Chemokines: A New Mechanism of Fatty Liver Inflammation in Obese Mice

Hepatic lipid retention (steatosis) predisposes hepatitis. We investigated the mechanisms of lymphocyte homing to fatty liver and the role of lipopolysaccharide (LPS) in the onset of inflammation in ob/ob mice. We decreased intestinal bacterial compounds by oral antibiotic treatment to test the role of endogenous LPS in liver inflammation. Adoptive transfer of lymphocytes was used to study the respective contributions of steatosis and lymphocytes to liver inflammation. We tested lymphocyte response to chemokines by in vitro chemotaxis assays in ob/ob, their lean controls, and "non-obese ob/ob" mice, generated by controlling caloric intake to distinguish between the effects of obesity and leptin deficiency. Antibiotic treatment decreased liver infiltration with CD4(+) T, CD8(+) T, natural killer (NK)T, B, and NK cells. Adoptive transfer of lymphocytes from ob/ob or control mice showed that (1) steatosis increased lymphocyte recruitment to the liver; (2) CD4(+) T, CD8(+) T, and B cells from ob/ob mice had a greater propensity to migrate specifically to the liver. This migration was enhanced by LPS. These results were also observed in a model of high-fat diet-induced obesity. CD4(+) T and B cells were hyperresponsive to CXCL12 and CXCL13, respectively. Weight normalization in "non-obese ob/ob" mice decreased liver inflammation, lymphocyte response to chemokines, and homing to the liver. Our study provides the first evidence that liver inflammation in mice with genetic or diet-induced obesity results from both steatosis and lymphocyte hyperresponsiveness to chemokines expressed in the liver. These abnormalities are reversible with weight normalization.

Steatohepatitis und Leberzirrhose: Erstmanifestation 23 Jahre nach ejunoilealem Bypass

Intestinal shunting procedures followed by gastrointestinal bypass surgery have been used as therapeutic modalities in the treatment of morbid obesity since the mid 1950s. Enthusiasm reached its peak in the early 1960s with the introduction of the jejunoileal bypass, however began to wane as various complications were identified in the remote postoperative period and later. Finally, the jejunoileal bypass was abandoned in the 1980s. Apart from renal disorders, it frequently resulted in abnormal liver function and liver failure which are attributed to fatty infiltration. We report a 56-year-old woman, who underwent jejunoileal bypass surgery 23 years ago. She was admitted to our ICU because of hepatic encephalopathy IV, caused by upper gastrointestinal bleeding. Beside hepatic encephalopathy there were signs of severe liver failure (INR 2.8, cholesterol 32 mg/dl, ICG PDR 5%). Liver biopsy showed fatty infiltration and cirrhosis. Excluding other causes of liver disease, severe fatty liver disease following jejunoileal bypass surgery was diagnosed. The very late onset of severe liver disease emphasizes the importance of lifelong follow-up of these patients.

Modified Jejunoileal Bypass Surgery with Biliary Diversion for Morbid Obesity and Changes in Liver Histology During Follow-up

Background and aimsBariatric surgery is the most effective treatment for morbid obesity. The classic procedure, jejunoileal bypass, has many complications including rapid progress of liver disease. The senior author (I.F.) has developed a modification of jejunoileal bypass, which we believe overcomes many of the shortcomings of the classic procedure. MethodsConsecutive patients referring for bariatric surgery were included. A modified jejunoileal bypass in which the defunctionalized limb is eliminated by anastomosing its ends to the gall bladder and cecum was performed. Liver biopsies were taken during operation and at a mean of 16 months later. The patients were followed for 5 years. ResultsForty-three patients were enrolled. The mean value of weight and body mass index (BMI) fell from 128 kg and 46 kg/m2 before operation to 85 kg and 31 kg/m2 at 5 years, respectively (p < 0.001). There was no significant change in the degree of liver steatosis and necroinflammation. The mean liver fibrosis score increased from 0.1 to 0.9 (p = 0.015). No sign of advanced liver disease was observed during the 5-year follow-up. ConclusionThe modified jejunoileal bypass is very effective in inducing and maintaining weight loss for 5 years and does not lead to hepatic failure or rapid progression of liver disease.

D-Lactic Acidosis

To present 2 cases of D-Lactic Acidosis with different presentation. Chart review after informed consent. Case 1: 47 year old male with history of vertigo and jejunoileal bypass surgery in 1975 presented with mental status changes, vertigo – unresponsive to meclizine, irritability, gait ataxia, and slurred speech. Physical exam was unremarkable. Laboratory values showed: anion gap 22, bicarbonate 11, ABG showing pH 7.15, pCO2 19, and O2 saturation 93%. Lactic acid, salicylate levels, urine and serum toxicology screen, urine and serum ketones, methanol, and ethylene glycol were all normal. Serum creatinine 1.3, and serum ammonia level 65 and normal LFTs while D-lactic acid level of 2.46 mmol/L. Metronidazole, vancomycin, sodium bicarbonate infusion and a low carbohydrate diet improved patient's condition. D-lactic acid levels of 1.09 mmol/L at discharge. Case 2: 35 year old male had orchiectomy in 1997 for testicular teratoma treated with chemotherapy. In 2003, he presented with symptoms of small bowel obstruction secondary to retroperitoneal recurrence of teratoma, leading to surgical resection. On post-operative day 21, obstipation lead to re-exploration and gastrojejunostomy with enterosomy. His subsequent hospital course was uneventful and he was discharged on regular diet. In 2006, he presented with early satiety and abdominal discomfort. He was started on ciprofloxacin by his surgeon with some improvement. This raised the possibility of D-lactic acidosis, confirmed by an anion gap of 13.5, serum bicarbonate 14.5 and D-lactic acid level of 1.31 mm/L. He improved with low carbohydrate diet and flagyl. D-Lactic acidosis, is a rare entity associated with short bowel syndrome, short bowel surgery, or jejuno-ileal bypass. Mechanisms include overgrowth of gram-positive anaerobes that produce D-lactate, and malabsorption in the proximal small bowel leading to carbohydrate fermentation. Symptoms are mainly neurological, but may be insidious. Diagnosis is by history, anion gap acidosis, normal lactate levels but increased D-lactate levels, and sometimes an elevated urine anion gap. Acute treatment is a low carbohydrate diet, antibiotics, sodium bicarbonate, and rehydration. Extreme cases may require hemodialysis or surgical intervention such as reversal of jejuno-ileal bypass, intestinal lengthening, or colon resection. Any patient with a history of short bowel surgery or bypass presenting with neurological symptoms or unexplained anion gap acidosis should be a candidate for workup of D-lactic acidosis.