A Shunt Operation for Obesity'*

JAMES BARP, ON, M,D.,]" BoY FRAX*E, M.D.,+ + JOHN R, BOZALIS, M.D. +

From the Henry Ford Hospital, Detroit, Michigan

TODAY, obesity is one of the most com- mon nutr i t ional problems in the United States. For a long time, medical manage- ment has consisted of low-calorie diets, ex- ercise, anorectic agents and psychotherapy. T h e well-known medical and psychologic dangers of severe obesity have been respon- sible for continued at tempts to solve this serious p r o b l e m . . H o w e v e r , long-term re- sults in medical management of intractable obesity have not been good. On this ac- count, we have employed a surgical pro- cedure that consists of bypassing varying lengths of the small bowel and creates an artificial condition of malabsorpt ion which leads to a lessened degree of intestinal absorption.

This report is based on the records of 30 patients who underwent this type of operation. Admittedly, a bypass surgical procedure may appear to be a radical and potentially dangerous operat ion to solve a problem which would appear to have a relatively simple dietary solution.

A review of the medical l i terature reveals that the first detailed description of long- term beneficial effects resulting from surgi- cal operations was presented by Lewis and associates 3 in 1962. Kremen and associates 2 and Payne and associates 4 also reported a series of elective short-circuiting operations on the small intestine to relieve obesity.

T h e etiology of obesi,:y is complex. ~t is

Read at the meeting of the American Procto- logic Society, Denver, Colorado, June 10 to 13, 1968.

t Department of Surgery. ++ Department of Medicine.

characterized by abnormal eating habits which often are aggravated by anxiety and tension. Obese patients endure psychologic and physical burdens. T w o theories have made small intestinal bypass operations worthy of consideration in the t reatment of intractable obesity by lessening the degree of intestinal absorption. First, numerous clinical and exper imental factors have shown that patients can smwive, in a rela- tively good nutr i t ional state, after surgical removal or bypass of as much as 80 per cent of the small intestine. Second, knowledge of how to manage malabsorpt ion states has improved to a degree that expected min- eral and vi tamin deficiencies can, in most cases, be prevented or corrected by treat- n l e n t .

Since 1963, 30 patients have undergone small intestinal bypass operations at the Henry Ford Hospital , for t reatment of in- tractable obesity; they have been followed u p f o r periods varying from one to five and a half years.

Twenty-nine women and one man have undergone intestinal bypass operations in the treatment of severe intractable obesity. Preoperative weights ranged from 295 to 360 pounds, the average being 262 pounds. Ages ranged from t7 to 50 years, and the duration of obesity varied from five to 20 years. In the majori ty of cases, obesity be- gan during childhood. Wi~h few- excep- tions, these patients had many medical problems, such as arthritis, chronic back pain, toxemia dur ing pregnancy, hyperten- sion, infertility, guilt reaction, deep-seated

115

116 BARRON, ET AL.

lVic. 1. Jejunocolostomy. Proximal portion of jejunum is divided about 45 to 50 cm distal to the ligament of Treitz. Arrow points to opening bounded by transverse mesoco|on above, base of mesentery below, and upper end of jejunum in front. This is a common site for internal hernia- tion to occur when great amounts of fat are lost and intestines become mobile. Every attempt should be made to close this space at time o[ operation.

depression, and so forth. All had tried many dietary programs, inc lud ing heal th clubs, adminis t ra t ion of various anorectic agents, s tarvation diets (many unde r physicians ' supervis ion) , and most had unde rgone psychiatric treatment. All of ou r pat ients underwent careful medical and psychiatric examinat ions pr ior to surgery. A real effort was made to avoid opera t ing on persons who were severely d is turbed mentally. At times, many had lost a great deal of weight, but usually it was regained p rompt ly wi th in a period of several months after discontinu- ance o[ t reatment .

Prior to surgery, the potent ia l risk and the need for p ro longed medical manage- ment were explained carefu!!y to every patient. A psychiatric consul ta t ion and ex- amina t ion was ob ta ined for every patient , and all had been encouraged previously to utilize convent iona l methods for weight

control and self-discipline be[ore under- going surgeo' .

Surgical P rocedure

T h r e e types of short-circui t ing opera t ions were ut i l ized-- je junocolostomy, 21 pat ients (Fig. I ) ; je junocecostomy, two pat ients (Fig. 2), and je juno-i leostomy, seven pa-

tients (Fig. 3). In 21 patients, j e junoco los tomy was per-

formed. In most instances, a transverse in- cision was made and spinal anesthesia was used. Usually, the j e j u n u m -was divided about 45 to 50 cm distal to the l igament o[ Treitz, and the distal end of the p roxhna l segment was anastomosed to the transverse colon. Experience has p roved that the length of small bowel removed to produce satisfactory loss of weight is a critical fea- ture of the procedure. Usual ly abou t 20 inches or slightly less mus t be used. I n evmw case, an a t t empt was made to suture the base of the mesentery to the transverse mesocolon securely to prevent in ternal

hern ia t ion after weight had been lost. In every patient, the p rox imal end of the closed distal por t ion of the j e j u n u m was sutured carefully to the base of the mesen- tery to prevent intussuscept ion later (Fig. 4).

In seven patients, je juno- i leos tomy was performed~ T h e j e j u n u m was anas tomosed to the terminal por t ion of the i leum, about 8 to 10 cm proximal to the ileocecal valve. This usually did not require mobi l iza t ion o[ the cecum.

Dur ing the immedia te pos topera t ive pe- riod, one problem enconn te red was severe hiccups, and general ly poor coopera t ion characterized the postoperat ive behavior of the only man in the series. His postopera- tive course was complicated by a ventral hernia. No other pa t ien t su~ered this com- plication. Problems relat ing to ea t ing were encountered in a few patients, and feeding with a gastric tube was uti l ized unt i l they could cooperate and eat a reasonable diet.

A SHUNT OPERATION FOR OBESITY 117

Subcu taneous d ra ins were used in all cases

to assure w o u n d hea l ing .

D e l a y e d C o m p l i c a t i o n s

i n four pa t ien ts , i n t e rna l hern ias devel-

oped in which loops of the dis ta l p o r t i o n of the j e j u n u m a n d i l e u m passed t h rou gh the space be tween the t ransverse mesocolon

and the base o1~ the mesentery . Al l of these occur red in the j e j u n o c o l o s t o m y pat ients . In two, there was an in tussuscep t ion of the p r o x i m a l end of the closed dis ta l l )or t ion o~ the j e j u n u m in to the j e j u n u m . K a u l m a n n

and ~Veldon 1 descr ibed a s imi la r compl ica- tion. I n ou r series, this occur red desp i te p recau t ions , in every pa t i en t , to su tu re the

p r o x i m a l end o[ the j e j t m u m to the base of the mesentery . T h e r e was no evidence of i n t e rna l h e r n i a t i o n or in tussuscep t ion unt i l the pa t i en t h a d lost a grea t dea l of weight . These compl i ca t ions occur red be- cause the loss of fat increased the m o b i l i t y of the smal l intestine°

5

Fro. 3. Jejuno-ileostomy. Distal end of proximal portion of jejunum is sutured to terminal portion of ileum about 8 to 10 em from the ileocecal valve. Defect between mesentery of upper and lower small bowel should be closed. Total length of small bowel removed is critical for satisfactory weight loss, and usually should be 20 inches (50 era) or less. Cecum usuall,, does not require mohilization.

Fro. 2. [ejunocecostomy. Mobilization of cecum may be difticult in very obese patients, especially when previous surgery has been performed.

R e s u l t s

W e i g h t Loss: Signif icant Ioss of weight

occurred in al l pa t ien ts . I n the je junocolos - tomy pat ien ts , there was an average loss of 100 pounds d u r i n g the first year. T h i s was an average of a b o u t two p o u n d s per week. In those wi th the grea tes t loss, we encoun- tered the h ighes t inc idence of compl i ca t ed

pos tope ra t ive courses. J e j u n o - i l e o s t o m y pa- t ients averaged a we igh t loss of a b o u t 86

p o u n d s d u r i n g the first year. In genera l ,

there was a g r a d u a l l eve l ing off of weight loss d u r i n g 12 to !8 m o n t h s and, indeed, most or the we igh t lost usua l ly was lost d u r i n g tha t per iod . T h e a m o u n t o~ weight iost lessened def in i te ly af te r a lapse o~' '_2 to t8 months . T h e least a m o u n t of weight

lost by any p a t i e n t was 50 p o u n d s d u r i n g I2 months , and this o c c u r r e d in a p a t i e n t who u n d e r w e n t j e juno- i l eos tomy . T h e r e has

I18 BARRON, ET AL.

Fro. 4. Intussusception. In every patient, an effort was made to suture the proximal end of the lower segment of the jejunum to the base of the mesen- tery. As weight is lost, there is a definite tendency toward intussusception as bowel mobility increases.

been development of loose, flabby skin, but it has not presented a' serious problem.

Fluctuation in BSP (bromsulphalein) re- tention has been quite interesting in these patients. Significant elevation was observed in most patients tested during the first one to 12 months. In many, it went as high as 38 per cent. T h e peak of this elevation usually was noted within four to eight months. By 16 months, in most patients, there had been a re tnrn to less than 5 per cent retention of the dye. T w o patients died six and ten months after surgery as a result of hepatic failure. In each, the liver had been severely damaged prior to sur- gery and there was serious replacement by fatty tissue. Each had undergone a jejuno- colostomy shunt and both refused to have the intestinal continuity restored.

We believe that food intake is extremely impor tan t to protect the liver, and this is especially true for protein. In our experi- ence, seriously impai red food intake is an ominous sign and calls for immediate cor- rection. T u b e feeding has been of great help ~n these patients.

Prophylact ic T h e r a p y

Within one mon th of the initial surgical procedure, replacement therapy was insti-

tuted in all patients. This consisted of ad- ministration of vi tamin B complex and vi tamin C, plus trace elements, v i tamin B~2, folic acid (5 mg daily), v i tamin D, iron, cal- cium, magnesium, potassium when needed, and bulk producers to slow down bowel movements. In general, as long as patients adhered to the program outlined, relatively few complications were encountered. T h e two most frequent complications encoun- tered when patients discontinued therapy -were anemia and hypocalcemia. Several ]ejunocolostomy patients experienced rather severe water and electrolyte deficiencies, especially during the early postoperat ive course. These were more prone to occur in jejunocolostomy patients. However, when patients cooperated and carried out medi- cal treatment, the majori ty did very well.

Nonsurgical Complicat ions

This group has represented a rather iZas- cinating aspect of treatment. Some have complained of mild arthritislike disability. However, most of them had some symptoms prior to surgery. Gastric ulcers were found in two patients; they responded to medical treatment. Orthostatic hypotension was noted in seven patients, but this responded to medical management and applicat ion of elastic supports. T w o patients had tetany which responded satisfactorily to treatment. Dehydration and electrolyte imbalance were noted in five patients; this occurred invariably in the je junocolostomy group. They improved with medical management .

All patients were asked if they would undergo the operat ion again under similar circumstances. All answered the question affirmatively. Sixteen claim that they eat more than they did before surgery. Eight eat less and four eat about the same amount o~ £ood. ~n !3 patients, the number of stools per day varies f rom one to four; in ten, f rom four to eight; in three f rom eight to 12, and two have 12 to 15 stools daily. Twenty-seven patients say they are satisfied

A SHUNT OPERATION FOR OBESITY 119

with the weight reduction and improved body image. All believe they enjoy much better social adjustment.

Three patients have undergone success- ful pregnancy without complications. Be- cause of tetany, bruising and impaired liver function, one pat ient underwent a revision of the bypass two years after the initial operation. In this case, the jejunocolostomy was converted to a jejuno-ileostomy. T o establish a more satisfactory weight loss, two patients have had about 12 to 14 cm more of the proximal j e junum removed. One of these operations @as performed when a ventral hernia was repaired one year after the initial operation. T h e other was done when an internal hernia was cor- rected. Because of lack of energy, one pat ient had intestinal contimtity restored. She prompt ly gained weight markedly and now is anxious to have the bypass re- established.

Conclusion

"The shunt procedure can be performed with reasonable safety in properly selected, well-motivated and relatively young pa- tients. Improvements in appearance, emo-

tional outlook and family relations of the patients have been remarkable. T h e pro- cedure has been accepted well by the pa- tients and they have recommended it to others who are obese. Jejuno-ileostomy (about 20 inches) has caused fewer compli-

cations than jejunocolostomy. Every at- tempt should be made to prevent internal herniation and intussusception as weight is lost. Adequate nutr i t ion for hepatic protec- tion is most important . A careful follow-up medical program is extremely important ; the procedure should not be performed unless this is provided.

References 1. Kaufmann, H. J., and H. W. Weldon: Intus-

susception: A late complication of small- bowel bypass for obesity. J.A.M.A. 202: 1147, 1967.

2. Kremen, A. J., j . H. Linner, and C. H. Nelson: An experimental evaluation of nutri t ional importance of proximal and distal small in- testine. Ann. Surg. 140: 439, 1954.

3. Lewis, L. A., R. B. Turnbul l , Jr., and I. H. Page: "Short-circuiting" of the small intes- tine: Effect on concentration of serum cholesterol and lipoproteins. J.A.M.A. 182: 77, 196').

't. Payne, J. H., L. T. De , r ind , and R. R. Com- mons: Metabolic observations in patients with jejunocolic shunts. Am. J. Surg. 105: 273, 1963.

M e m o i r

MaaaE,',, MuaaaY, Brooklyn, New York; bo rn July 19, 19l l , New York City;

Univers i ty of Arkansas Medical School 1938; i n t e rnsh ip Israel Zion Hospi ta l ,

Brooklyn.

Dr. M a r r e n was elected to m e m b e r s h i p in the Amer i can Proctologic Society

in 1948 a n d became an Associate Fellow in 1955. He was a Fellow, I n t e r n a t i o n a l

College of Surgeons, and a m e m b e r of the Amer ican Medical Associat ion, New

York State Medical Society, Kings County Medical Society, Kings Coun ty

Surgical Society, Amer i can Ger ia t r ic Society, and New York Societ-y of Colon

and Recta1 Surgeons; on the staff at Maimonides Hospital. He died January 14, 1968.