Emotional responses to weight reduction by three methods: gastric bypass, jejunoileal bypass, diet.
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Adolescent↗
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Hypothalamic hyperphagia and obesity in rats with jejunoileal bypass.
Jejunoileal bypass or sham surgery was performed in adult female rats followed 35 days later by ventromedial hypothalamic (VMH) knife cut or sham surgery (forming groups Bypass-VMH, Bypass-Sham, Sham-VMH, and Sham-Sham). Bypassed rats receiving VMH cuts (Bypass-VMH group) ate more food and gained more weight than did either Bypass-Sham or Sham-Sham groups. The hyperphagia and obesity of the Bypass-VMH rats was, however, substantially less than that of the sham bypass VMH cut rats (Sham-VMH group). Bypass-VMH rats that had their intestinal tract reconnected increased their food intake and ultimately became as obese as the Sham-VMH rats. Two additional groups received VMH knife cut or sham surgery followed 50 days later by jejunoileal bypass surgery (VMH-Bypass and Sham-Bypass groups). At the time of the bypass the VMH-Bypass group was hyperphagic and obese, but after surgery they underate and lost weight until they eventually stabilized their body weight at a level below that of the Sham-Bypass group. The body weight of the VMH-Bypass group was also 167 g less than that of the Bypass-VMH group. Thus, the order of surgery significantly influences the food intake and body weight level of rats with VMH knife cuts and jejunoileal bypass.
Animals↗
Skeletal abnormalities after jejunoileal bypass.
Jejunoileal bypass surgery is fraught with many longterm complications, among which is hypovitaminosis D. The relationship, if any, of hypovitaminosis D to the skeletal disease which may occur following this operation is, however, unknown. Consequently, we studied eight patients with low circulating levels of 25-hydroxyvitamin D who had undergone jejunoileal bypass at least two and one-half years previously. Despite the absence of skeletal symptoms, the bone biopsies of six of these patients were abnormal. The volume of trabecular bone was diminished in the group as a whole, and half the patients had an excess of unmineralized skeletal matrix. However, no noninvasive diagnostic technique identified those patients with skeletal disease. We therefore conclude that recognition of those jejunoileal bypass patients potentially at risk to develop clinically significant bone disease requires biopsy of the skeleton.
Adult↗
Influence of bile acid replacement on cyclosporine absorption in a patient with jejunoileal bypass.
Jejunoileal bypass reportedly inhibits the absorption of cyclosporine. In patients with malabsorption syndromes, bile acid replacement has been given to enhance the absorption of cyclosporine. A candidate for heart transplantation with New York Heart Association class IV heart failure and a jejunoileal bypass received cyclosporine alone and with concomitant ursodiol administration to determine whether therapeutic cyclosporine plasma concentrations would be attainable after heart transplantation. There were no differences in peak concentration, time to peak, area under the serum concentration versus time curve, or bioavailability of oral cyclosporine when administered alone or with ursodiol. Plasma cyclosporine concentrations were consistent with those in the general population.
Cyclosporine↗
Intestinal absorption of oxalate and calcium in patients with jejunoileal bypass.
Jejunoileal bypass (JIB) has been widely performed for treatment of excessive obesity. Formation of calcium oxalate stones is a common side effect. Since, under physiological conditions, the intestinal absorption of calcium and that of oxalate are interrelated, intestinal oxalate and calcium absorption were measured in the present study by isotope techniques in 19 JIB patients and 20 healthy controls. The JIB patients showed pronounced hyperoxaluria and markedly increased absorption of oxalate, with a urinary excretion of 14C-oxalate of 29 +/- 19% (controls 6.2 +/- 3.7%; p less than 0.001). There was a strong correlation between the intestinal absorption and urinary excretion of oxalate in the JIB patients (r = 0.72; p less than 0.001). Furthermore, their oxalate kinetics was altered, with continued urinary excretion of 14C-oxalate for up to 48 hours. The JIB patients also had reduced calcium absorption (36 +/- 9.1% vs. 47 +/- 9.0%; p less than 0.001) and patients with malabsorption of calcium and low urinary calcium had the highest intestinal absorption and urinary excretion of oxalate. It is concluded that hyperoxaluria in JIB patients is due to a significant extent to hyperabsorption of oxalate.
Adult↗
Reversibility of hepatic failure following jejunoileal bypass.
Jejunoileal bypass was performed in 50 morbidly obeses patients. The morbidity encountered compared favorably with that of other series. All patients manifesting hepatic failure demonstrated hyperbilirubinemia within the first three months postoperatively. Hyperbilirubinemia, if uncorrected, resulted in a mortality of 75%. Augmentation jejunal interposition was performed in three patients who demonstrated hepatic decompensation or severe electrolyte imbalance or both. This resulted in rapid correction of electrolyte disturbances, liver function measurements, and patient symptoms without significant postoperative weight gain. Persistent hyperbilirubinemia or recalcitrant electrolyte problems or both are indications for augmentation jejunal interposition.
Body Weight↗
Certain metabolic consequences of jejunoileal bypass.
Jejunoileal bypass for obesity has been shown to be associated with increased hepatic triglycerides during the period of brisk weight loss. The current report describes certain metabolic changes observed in 29 patients 21 months after bypass. Significant decreases in serum cholesterol, serum triglycerides, blood sugar after a glucose load, and fasting plasma insulin levels were noted. Increased oxalate excretion and occasional episodes of hypomagnesemia occurred. Repeated clinical and laboratory observations by a medical-surgical team offer the best opportunity to evaluate this procedure.
Adolescent↗
Complications of jejunoileal bypass.
Jejunoileal bypass for morbid obesity is accompanied by excessive morbidity and significant mortality. Weight loss is achieved at the expense of major nutritional changes which in and of themselves produce complications. The operation should be considered investigational and be limited to those centers with special interest in the problem and where longterm follow-up and management can be carried out.
Adult↗
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.
Enteritis↗
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.
Adult↗
Amino acid and peptide absorption in bypassed jejunum following jejunoileal bypass in rats.
The intestinal digestive and absorptive function of the excluded jejunum was evaluated 6 and 12 weeks after jejunoileal bypass in rats. Brush border and cytosol aminopeptidase activities as well as mucosal sucrase activity were measured in self-emptying excluded jejunal segments following bypass surgery. In addition, following in vivo perfusion of equimolar amounts of amino acid (L-leucine) and dipeptide (L-leucyl-L-leucine) solutions through bypassed jejunal segments, the uptake of L-leucine was determined. Mucosal weight, protein, and DNA content were reduced in the bypass segment reflecting jejunal mucosal cell hypoplasia. Hydrolytic activities for all enzymes (including the subcellular fractions of the aminopeptidase activities) and absorption rates from both the free amino acid and peptide solutions were reduced in bypassed jejunal segments. When expressed on the basis of mucosal DNA content, however, no changes were observed. This study indicates that the functional alterations in the excluded jejunum after bypass are due to the reduced mucosal cell content of this segment.
Amino Acids↗
Sudden reversal of renal failure after take-down of a jejunoileal bypass. Report of a case involving hemorrhagic proctocolitis, and renal and hepatic failure late after jejunoileal bypass for obesity.
Hepatic and renal failure developed in association with severe enteritis and hemorrhagic proctocolitis in a patient who had had a jejunoileal bypass 8 yr previously for morbid obesity. Parenteral antibiotic treatment abolished the systemic manifestations of the enteritis, but did not change the course of the hepatic and renal failure, and prolonged hemodialysis was necessary. Liver function improved in response to hyperalimentation. Take-down of the jejunoileal bypass resulted in immediate improvement of renal function, and hemodialysis could be discontinued. Although there is no direct evidence supporting this theory, the course of this patient suggested that the renal failure was functional in origin, and was caused by a toxin generated as a result of the intestinal bypass. We suspect that the toxin originated from bacteria within the blind bowel loop. Its delivery to the renal circulation was probably facilitated by increased absorption from the ulcerated large intestine and by impaired clearance by the diseased liver. When the bacterial flora were returned toward normal by take-down of the bypassed intestine, the quantity of circulating toxins probably decreased, which allowed renal function to improve.
Acute Kidney Injury↗
Metabolic consequences from conversion of jejunoileal bypass to gastric bypass.
Conversion of jejunoileal bypass to gastric bypass was performed in 11 patients because of metabolic problems and physical discomforts, and in three patients because of insufficient weight loss. There was no mortality and little morbidity after operation. An additional mean weight loss of 6% occurred, and weight stabilized satisfactorily in most patients. Two patients regained significant weight. Serum cholesterol levels rose within a month in most patients, with a mean increase of 61%. However, levels remained within normal limits. Serum triglyceride levels did not change significantly, especially in patients whose weight remained stabilized. Plasma glucose levels remained normal in all patients, including four patients who had been clinically diabetic before jejunoileal bypass. These patients had become normoglycemic immediately after jejunoileal bypass, and remained normal after conversion to gastric bypass.
Blood Glucose↗
Fasting and meal-stimulated plasma levels of neurotensin in obese patients after jejunoileal bypass with 3:1 or 1:3 jejunoileal ratio.
The functional role of the jejunum and ileum with regard to peripheral plasma levels of intact neurotensin and NH2-terminal immunoreactivity of neurotensin was studied by using jejunoileal bypass as a model. Plasma levels were measured by radioimmunoassay before and after jejunoileal bypass randomized to different jejunoileal ratios. Seven patients were studied before bypass surgery and 28 were examined after end-to-side jejunoileal bypass with 50 cm intestine in continuity and a 3:1 or 1:3 ratio between the length of the jejunal and ileal segments. Fasting levels of intact neurotensin were unchanged by surgery, whereas levels of NH2-terminal immunoreactivity were higher in bypass patients with a long ileal segment (37.5 cm) than in unoperated patients and in those with a short ileal segment (12.5 cm). Meal-stimulated levels of intact neurotensin were higher after 1:3 than 3:1 jejunoileal bypass. The levels of NH2-terminal immunoreactivity in patients with a short ileal segment and in controls were lower than in patients with a long ileal segment. The results show that postprandial levels of both intact neurotensin and NH2-terminal immunoreactivity are related to the length of the functioning ileum and that even a difference in length of 25 cm is reflected in the circulating levels of neurotensin.
Adult↗
Adaptation of intestinal muscle in bypassed loops after jejunoileal bypass in rat.
The function and structure of intestinal smooth muscle in the bypassed intestine of rats with 70% intestinal bypass were compared with the function and structure of muscle from equivalent areas of intestine from transected and nontransected controls. Muscle function was assessed by evaluating changes in intestinal transit. At all times studied after operation, transit in transected controls was identical to that seen in nontransected controls. In the bypassed intestine at 3 days after operation, transit in fasted animals was significantly slower than intestinal transit in either control group. Over a period of 14-35 days, transit in the bypassed intestine of fasted animals returned toward control values. In fed animals, on the other hand, transit was delayed when measured at both 3 and 35 days after bypass operation. These findings demonstrate a persistent change in muscle function in bypassed intestine in response to the ingestion of a meal. No changes in intestinal structure were found when bypassed intestine was compared with tissue from transected controls. Thus there were no indications of mucosal or muscular atrophy in the bypassed intestine. The weights of the combined submucosal, muscular, and serosal layers in the study segments were increased at 35 days after either bypass or transection compared with tissue from nontransected controls. These changes appear to be a nonspecific result of operation.
Animals↗
The manifestations of bypass enteritis following jejunoileal bypass.
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Adult↗
Ileostomy of the distal end of the bypassed intestine in a patient with jejunoileal bypass for obesity.
Ileostomy of the distal end of the bypassed segment of small intestine was done twenty-three months after a 28 to 20 cm (12 to 8 inch) end-to-end jejunoileal bypass for obesity (Scott operation) in a forty-eight year old white female, thus creating a Thiry fistula. Weight prior to jejunoileal bypass was 130 kg (287 pounds). Before ileostomy it had stabilized at 80.3 kg (177 pounds). Indications for ileostomy were three episodes of blind loop syndrome and three episodes of severe bleeding from the ileotransverse colostomy anastomotic site. Culture of the bypassed segment at laparotomy revealed bacteroides, clostridia, and other anaerobes as well as the usual aerobic large bowel flora. After ileostomy the bypassed segment contained no anaerobic bacteria. Daily fluid output from the ileostomy has decreased with time, averaging 436 ml per day for the first postileostomy month and 50 ml per day for the ninth month. Beneficial effects of the ileostomy include: (1) better sense of well being; (2) no further episodes of blind loop syndrome or intestinal bleeding; and (3) cessation of anal itching. Nine months after ileostomy, hyperoxaluria and acquired megacolon were present. Weight was 5.9 kg (13 pounds) greater than before ileostomy.
Bacteroides Infections↗
An approach to the treatment of recurring polyarthralgia after jejunoileal bypass.
Polyarthralgia after jejunoileal bypass (JI) is a well-documented complication. In the past, this was treated by antibiotic therapy, but definitive therapy uncommonly necessitated surgical reversal of the JI bypass. This case report discusses the etiology of arthralgias and presents a technique for its treatment without bypass reversal.
Adult↗