Complications of gastric bypass for morbid obesity

This report details the complications observed in 154 morbidly obese patients who had a gastric bypass performed in the period from April 1975 through March 1979. Thirteen intraoperative complications occurred. In the first 30 days after operation, one or more complications developed in 29 or 17.9 percent of the patients. One patient died from pulmonary embolism. The most serious complication unique to gastric bypass was a leak from the stomach or the anastomosis. The factors responsible are discussed and suggestions are made concerning the prevention of this complication. Sixteen late complications occurred in 13 patients. The 62 operative procedures performed incidental to gastric bypass and the 50 performed subsequently as a result of it are enumerated and discussed. The findings of this investigation document the serious complications that may occur with gastric bypass. The late complications of this operation are few and trivial compared with those that occur with jejunoileal bypass [1,2,4,5,9].     

A prospective comparison of gastric and jejunoileal bypass procedures for morbid obesity.

A randomized prospective evaluation of the gastric and jejunoileal bypass procedures for morbid obesity was performed. The gastric bypass was performed predominantly as a 90% gastric exclusion with a Roux-en-Y reconstitution. The jejunoileal bypass was an end-to-end anastomosis between 30 cm of jejunum and 25 cm of terminal ileum, the bypassed segment of small bowel being decompressed by an end-to-side ileocolostomy. There were 32 patients in the gastric group and 27 in the jejunoileal group. The two groups were comparable in age, preoperative weight and height. There were no postoperative deaths, but the gastric bypass operation was associated with a slightly higher early complication rate indicating it is a more technically demanding procedure. Late sequellae were more prominent in the jejunoileal bypass group and included significant diarrhea in 56% and need for medication in 74%. Kidney stones and cholelithiasis also complicated the jejunoileal group and were not seen after gastric bypass. All patients showed fatty metamorphosis on the original liver biopsy. This had worsened in 75% of the jejunoileal group at one year whereas it had improved or was stable in all of the patients in the gastric group.     

Complications of jejunoileal bypass for morbid obesity.

Fifty-two patients had jejunoileal bypass surgery. End-to-end (Scott) or end-to-side (Payne) shunts were randomly selected for each patient; 31 standard length shunts and 21 shortened bypasses were performed. Only 22 patients had an acceptable result, whereas 30 patients had inadequate weight loss (less than 2.3 kg [5 lb] per month per year) or had gastrointestinal tract, metabolic, or surgical complications judged severe enough to render the outcome less than adequate. There was one death, and four patients required reanastomosis of the bypass. The primary deteriminant of success was age, ie, younger patients had clearly better results than older patients. In general, shorter shunts produced more weight loss than standard bypass procedures, but were associated with an increased complication rate. Three new complications of jejunolieal bypass are reported: acute comonic dilation with necrosis, beriberi, and lupus erythematosus.     

Brown Bowel Syndrome Secondary to Jejunoileal Bypass: The First Case Report

A 58-year-old woman with a surgical history of jejunoileal bypass in 1980 for weight reduction sought medical attention with multiple complaints. The patient had not been taking any nutritional supplements since her bypass surgery, 26 years previously. She was found to have osteomalacia, chronic diarrhea, secondary hyperparathyroidism, and hyperoxaluria with a frequent history of nephrolithiasis. Because of her severe osteodystrophy and metabolic complications, reversal of her jejunoileal bypass was recommended. Reversal of the jejunoileal bypass with a sleeve gastrectomy was performed. Laparotomy revealed brown discoloration of the entire alimentary limb with atrophy of the bypassed intestinal limb. Histologic examination of the resected small bowel demonstrated brown pigment deposits within smooth muscle cells of the bowel wall. The pigment stained positive with Fontana-Masson most likely representing lipofuscin. We report a case of brown bowel syndrome complicating jejunoileal bypass, the first case reported in the literature to the best of our knowledge.     

Interval jejunoileal bypass reduces the morbidity and mortality of Roux-en-Y gastric bypass in the super-obese

Among Roux-en-Y gastric bypass (RYGB) patients, large male patients carry the greatest risk for severe, life-threatening complications. The higher complication rate is partly related to large amounts of intra-abdominal fat that increases the technical difficulty of the RYGB. In order to minimize the risk for complications, we established a staged approach for weight loss surgery for high-risk, super-obese patients. Patients with intra-abdominal fat at exploration which precluded the performance of RYGB underwent jejunoileal bypass (JIB). Following an initial period of weight loss (6-24 months), they were converted to a RYGB during a second operation. Twenty-four patients underwent initial JIB that was associated with a major complication rate of 8.3 per cent (2/24) and no mortality. Eight patients lost 53.4 +/- 6.3 kg prior to their conversion to RYGB (mean, 14.1 months). There was one major complication (12%) and no deaths (0%). Following RYGB, an additional period of weight loss resulted in overall excess weight loss (EWL) totaling 62 per cent. A two-step procedure is a safe and effective approach for minimizing complications for high-risk patients undergoing RYGB. The initial JIB was associated with low morbidity and no mortality, and the follow-up RYGB procedure was a technically simple operation that could be performed with few complications.     

Critical analysis of jejunoileal bypass

This study analyzed a group of morbidly obese patients who underwent jejunoileal bypass over a 10 year period. Patients underwent either a Payne or Scott procedure. Weight loss was reported in terms of percent of excessive weight loss. Results showed that patients who had a Payne bypass had an average excess weight loss of 75 percent, whereas those with the Scott bypass had an average excess weight loss of 61 percent. All patients lost weight. Complications in this series were lower than what has been traditionally reported. The problem that occurred most often was kidney stones (8 percent of the patients). There has been only one death to date. The low incidence of complications can be attributed to the fact that the patients were evaluated, operated on, supervised, and followed by one doctor and his associated nurses. Thus, it is proposed that jejunoileal bypass, compounded with good patient care and careful patient selection, can produce positive results with a minimum number of problems.     

Impact of technological advances on complications of revisional bariatric operations

BACKGROUND: Revisional bariatric operations are technically challenging and are associated with a high perioperative complication rate. Several parameters were analyzed to determine whether experience, coupled with technical innovation, reduced complications after these high-risk procedures. STUDY DESIGN: Outcomes of 215 consecutive revisional bariatric operations performed by 1 surgeon during the past 22 years were assessed before and after routine use of 6-row endostaplers and harmonic scalpel, which began in 2001. RESULTS: All but 3 operations were performed open, including 151 for weight loss failure (14 jejunoileal bypass, 71 gastroplasty or banding, 66 gastric bypass) and 64 for complications of the primary procedure (12 jejunoileal bypass, 11 gastroplasty or banding, 41 gastric bypass). Major perioperative complications occurred in 45 patients (21%): there were 15 leaks, 11 wound infections, 3 pulmonary embolisms, and 16 miscellaneous, including 3 deaths (1.4%). Morbidity after January 2001 was 6 of 73 (8.2%) versus 39 of 138 (28%) before 2001 (p < 0.0005). All deaths occurred before 2001. Complications occurred in 10 of 97 patients (10.3%) who had primary gastric restrictive operations (excluding banding) by the author versus 24 of 65 patients (36.9%) who had similar primary operations by other surgeons (p < 0.0001). Morbidity after second revisions was 70% versus 14.4% after first revisions (p < 0.0001). The 32 most recent patients were discharged in a mean of 3.0 days without complications. CONCLUSIONS: Incorporating the endostaplers and harmonic scalpel into open revisional operations significantly reduced postoperative complications. Because these 2 devices were introduced during the last 5 years of this study, it seems likely that cumulative experience also contributed to improved outcomes. Our results also suggest that surgeons perform their initial revisions on their own patients rather than on patients who had primary procedures elsewhere. Patients presenting as candidates for a second revision should be cautiously evaluated, anticipating a high morbidity rate.     

Reoperative bariatric surgery. Lessons learned to improve patient selection and results.

OBJECTIVE: The purpose of this study was to determine the spectrum of presentation, safety, and efficacy of operative bariatric surgery. SUMMARY BACKGROUND DATA: The only lasting therapy for medically complicated clinically severe obesity is bariatric surgery. Several operative approaches have resulted in disappointing long-term weight loss or an unacceptable incidence of complications that require revisionary surgery. METHODS: Sixty-one consecutive patients who underwent reoperative bariatric surgery from 1985 to 1990 were observed prospectively. One, two, or three previous bariatric procedures had been performed in 77%, 18%, and 5% of patients, respectively. Reoperation was required for unsatisfactory weight loss after gastroplasty or gastric bypass (61%), metabolic complications of jejunoileal bypass (23%), or other complications (16%), including stomal obstruction, alkaline- or acid-reflux esophagitis, and anastomotic ulcer. Revisionary procedures included conversion to vertical banded gastroplasty (33% of operations) and vertical Roux-en-Y gastric bypass (52% of operations); partial pancreato-biliary bypass was used selectively in four patients with severe, medically complicated obesity. RESULTS: A single patient died postoperatively of a pulmonary embolus; serious morbidity occurred in 11%. Weight loss (mean +/- SEM) after reoperation for unsuccessful weight loss was greater with gastric bypass than with vertical banded gastroplasty (54 +/- 6% versus 24 +/- 6% of excess body weight). Metabolic complications of jejunoileal bypass were corrected, but 67% of the patients were dissatisfied with their postoperative lifestyle because of changes in eating habits or weight gain (64% of patients). Stomal complications and esophageal reflux symptoms were reversed in all patients. CONCLUSIONS: Reoperative bariatric surgery in selected patients is safe and effective for unsatisfactory weight loss or for complications of previous bariatric procedures. Conversion to gastric bypass provides more effective weight loss than vertical banded gastroplasty.     

A 13-year review of jejunoileal bypass

One hundred and eighty patients had a jejunoileal bypass performed during the years 1971-1982. By leaving only 14 in. (35 cm) of intestine in continuity a mean weight loss of 34.4 per cent (s.d. = 8.5) was achieved over 2 years and, unless the operation had to be reversed for complications, this weight loss was maintained. The improvement in quality of life for a majority of patients should not be undervalued. Two-thirds of patients required admission for complications and eight patients died (4 per cent). Many of these problems were provoked by an inability to control eating. There have been no hospital deaths since 1976 which we attribute to better management of complications and a policy of early reversal for patients with excessive weight loss and signs of metabolic failure. Despite performing jejunoileal bypass less often in recent years we are still frequently reversing patients with electrolyte disturbances, metabolic failure, urinary calculi or arthritis. Thirty patients (16.7 per cent) have been reversed, half more than 5 years after bypass. Metabolic failure may occur even after many years of stable weight reduction. Because this is not well known the insidious onset of new weight loss and malaise may not be recognized, or not associated with the bypass many years before. Indefinite outpatient surveillance is mandatory. Changes in the operation have not significantly affected results. There has been no serious liver dysfunction in the 7:7:CJ group but this may reflect better management of lesser metabolic disturbances. Jejunoileal bypass remains the most effective operation for gross obesity and, with experience, can be performed safely. However, the complication rate and difficulty maintaining satisfactory follow-up on large numbers of young patients makes it an unacceptable procedure on any major scale.     

Surgical management of the failed jejunoileal bypass

The jejunoileal bypass is an efficient surgical treatment for morbid obesity, but it has a high complication rate that necessitates reversal in about 25 percent of patients. Conversion to Roux-Y gastric bypass was associated with acceptable morbidity and provided excellent control of weight. On the other hand, conversion to gastric partition resulted in weight gain almost equal to that seen with simple reversal alone. Conversion to Roux-Y gastric bypass is an acceptable procedure in the surgical treatment of the unsuccessful jejunoileal bypass.     

Hyperoxaluria in kidney stone formers treated with modern bariatric surgery

PURPOSE: Nephrolithiasis and renal failure secondary to severe hyperoxaluria were complications of jejunoileal bypass for obesity, leading to the discontinuation of this procedure in the United States in 1980. Bariatric procedures currently in use have not been adequately evaluated for this complication. MATERIALS AND METHODS: We compared 24-hour urine chemistry studies of 132 patients with nephrolithiasis who had undergone bariatric surgery with the urine chemistry studies of patients who had undergone jejunoileal bypass, those with routine kidney stones and normal subjects. The primary aim was to determine if hyperoxaluria developed in patients who underwent bariatric surgery and had kidney stones as had been seen with jejunoileal bypass. RESULTS: Patients who have undergone modern bariatric surgery had an adjusted mean urine oxalate excretion of 83 mg per day compared to 39 mg per day for routine kidney stone formers and 34 mg per day for normal subjects (p <0.001 for both comparisons), but not quite as high as that found in patients treated with jejunoileal bypass (102 mg per day, p <0.001). Urine supersaturation of calcium oxalate, the main driving force for calcium oxalate stone formation, was higher in patients treated with bariatric surgery compared to routine kidney stone formers and normal subjects (p <0.001 for both comparisons). CONCLUSIONS: Hyperoxaluria is the most significant abnormality of urine chemistry studies in patients with kidney stones who have undergone bariatric surgery. Many of these patients have a degree of hyperoxaluria that could lead to kidney failure. Further studies are required to determine the prevalence of this problem in patients who have undergone bariatric surgery.     

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.     

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.     

The prevention of bypass enteritis after jejunoileal bypass for morbid obesity.

The symptoms of bypass enteritis are disabling sequelae in many patients after jejunoileal bypass. This is a preliminary report of efforts to devise a valve to prevent reflux into the bypassed intestine after jejunoileal bypass. Valve I (42 cases) was formed by dividing the ileum, everting the proximal end as one matures an ileostomy, and inserting this into the distal ileum. Only 12 of these valves were competent. Valve II (six cases) was formed by dividing the ileum and merely inserting the proximal bowel into the distal, allowing it to evert spontaneously as with an unmatured ileostomy. In two cases the valve was competent, but four cases became obstructed and this valve is mentioned only to be condemned. Valve III (19 cases) is similar to an isoperistaltic Kock valve, except that the intussuscepted ileum is first divested of its mesentery. All such valves have been competent. All 33 patients with a competent valve have been free of the stigmata of bypass enteritis, whereas 54% of 156 patients showed the symptoms of enteritis after conventional jejunoileal bypass.     

Reanastomosis after jejunoileal bypass

One hundred and one patients underwent jejunoileal bypass after careful preoperative evaluation. These patients were re-evaluated after operation on a frequent basis, and 23% have required restoration of intestinal continuity (reanastomosis) by a mean postoperative time of 44 months. The most frequent reasons for reanastomosis were liver dysfunction (5% of the entire series), severe malnutrition or weakness (5%), and late electrolyte imbalance (4%). Two patients did not survive reanastomosis, both having liver failure. Of the patients who did survive, weight gain (approaching prebypass weight) and improvement in liver function tests, electrolyte balance, serum vitamin levels, and diarrhea have been the rule. Of the entire series of 101 patients who underwent bypass, 58% either had life-threatening complications, had to be reanastomosed, or died. These morbidity and mortality rates raise the important question of whether jejunoileal bypass is an appropriate procedure for the treatment of morbid obesity.     

Long-term outcome of surgical management for diffuse jejunoileal Crohn's disease

BACKGROUND: In diffuse jejunoileal Crohn's disease, resectional surgery may lead to short-bowel syndrome. Since 1980 strictureplasty has been used for jejunoileal strictures. This study reviews the long-term outcome of surgical treatment for diffuse jejunoileal Crohn's disease. METHODS: The cases of 46 patients who required surgery for diffuse jejunoileal Crohn's disease between 1980 and 1997 were reviewed. RESULTS: Strictureplasty was used for short strictures without perforating disease (perforation, abscess, fistula). Long strictures (<20 cm) or perforating disease was treated with resection. During an initial operation, strictureplasty was used on 63 strictures in 18 patients (39%). After a median follow-up of 15 years, there were 3 deaths: 1 from postoperative sepsis, 1 from small-bowel carcinoma, and 1 from bronchogenic carcinoma. Thirty-nine patients required 113 reoperations for jejunoileal recurrence. During 75 of the 113 reoperations (66%), strictureplasty was used on 315 strictures. Only 2 patients experienced the development of short-bowel syndrome and required home parenteral nutrition. At present, 4 patients are symptomatic and require medical treatment. All other patients are asymptomatic and require neither medical treatment nor nutritional support. CONCLUSIONS: Most patients with diffuse jejunoileal Crohn's disease can be restored to good health with minimal symptoms by surgical treatment that includes strictureplasty.     

Long-term Outcome in a Series of Jejunoileal Bypass Patients

In 65 jejunoileal (JI) bypasses done from 1973-1979, there were nine Scott and 56 Payne (with Y-shaped anastomosis). Preoperative excess body weight (EBW) translated to the 1983 Metropolitan Tables was 112 ± 30%. Eight patients are lost to follow-up. We reversed seven patients for renal stones (12%) accompanied by a vertical banded gastroplasty (VBG) and one because she demanded a VBG. Five patients were reversed by surgeons elsewhere for minor problems (three with an accompanying gastric reduction operation), and all five regained and requested a JI bypass again, which we now refused to undertake. This leaves 44 JI bypass patients being followed: loss of EBW is 71 ± 22% at 12-18 years. The eight reversed by us accompanied by a VBG regained some weight (loss of EBW from initial weight is 56 ± 18%). Liver biopsies were done for 5 years in 31 patients, and showed improvement by 36 months. Patients took predigested collagen capsules plus high protein and multivitamins. Injections of B₁₂ are indicated in 18 patients, given every 3 months. Liver dysfunction has not occurred in the long-term. Low serum carotene levels persist. Migratory arthralglas were controlled by oral metronidazole and did not occur after the fifth year. Oxalate crystals remain on urinalysis. Potassium and magnesium replacement is not required now, and a mean of 2.5 stools per day is not a problem, with infrequent diarrhea after greasy foods. Metronidazole is continued in 33 patients to prevent foul flatus. One patient developed a brain tumor, one myxedema, and one primary hyperparathyroidism, thought to be complications of the bypass until diagnosed. Most patients appear to be doing well.     

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

BACKGROUND AND AIMS: Bariatric 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. METHODS: Consecutive 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. RESULTS: Forty-three patients were enrolled. The mean value of weight and body mass index (BMI) fell from 128 kg and 46 kg/m(2) before operation to 85 kg and 31 kg/m(2) 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. CONCLUSION: The 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.     

Gastric bypass in the operative revision of the failed jejunoileal bypass.

Fifty-five patients with failed jejunoileal bypasses underwent reanastomosis and gastric bypass at the same operation. One patient died of undetermined cause three months postoperatively. The 54 surviving patients were all relieved of their preoperative symptoms, and 40 patients achieved satisfactory weight control. Technical complications prevented weight loss in 13 patients: four were given pouches too large to be effective, and nine had late disruption of the staple line. Two patients gained weight despite the fact that their pouches were of appropriate size. Reanastomosis will reverse the side effects of jejunoileal bypass, and a properly performed gastric bypass at the same operation will afford protection against subsequent weight gain.