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Fatal outcome after jejunoileal bypass for obesity
Fatal Outcome After Jejunoileal Bypass for Obesity
Teis Andersen, MD, Copenhagen, Denmark Erik Juhl, MD, Copenhagen, Denmark Flemming Quaade, MD, Copenhagen, Denmark
Jejunoileal bypass operation for obesity was first performed by Payne in 1959, and the first fatal case was reported in 1964 [I]. Since then, there have been a great number of reports of fatal outcome after the operation, and reports on patient groups large enough to allow an estimate give a mortality rate of 1 to 11 percent after Payne’s and Scott’s operation [2,3]. In most such reports observation time is either less than 2 years or unspecified. In a review of the status in the spring of 1977, the average mortality, early and late, was found to be 4.3 percent in reports including at least 50 patients and explicitly mentioning the number of deaths [4]. The aim of the present report is to analyze the causes of death and other features of possible relevance. Material
and Methods
The material consists of 538 reports on jejunoileal bypass operations on humans. The main part of the references is the result of a comprehensive survey of the Medical Literature Analysis and Retrieval System (MEDLARS) for the years 1967 through the first third of 1979. The key words of the search program were chosen to identify reports fulfilling the following two conditions: (1) primarily dealing with obesity in combination with either surgery or therapy, and (2) dealing with surgery and jejunum or surgery and ileum or surgery and small intestine. For the years 1963 to 1966, a comparable search was made in the Index Medicus. A bibliographic recheck based on Phillips’s extensive survey [5] revealed 13 (2 percent) missed references. These were included in the present survey. A total of 538 reports were found and read, if necessary, after translation. Three hundred eighty-two references
From the Department of Medicine, Sections of Endocrinology and Hepatology, Hvidovre Hospital, University of Copenhagen, Denmark. This work was supported by a grant from C. C. Klestrup and Wife’s Memorial Fund, Copenhagen, Denmark. Requests for reprints should be addressed to Teis Andersen, MD. Department of Medicine 233, Hvidovre Hospital, DK-2650, Hvidovre, Denmark.
Volume 142, November 1981
were excluded for being surveys with no original data (131), duplicate reports (86) or reports without stated mortality (165). Subsequently, 156 reports dealing with 6,722 patients fulfilled the criteria of originality and stated mortality. In the case of duplicate reports, only the latest was included. Where possible, all data on the number of deaths, the cause of death, postoperative duration, and type of operation were registered, in addition to sex, age, total number of patients, and country and year of publication. Results Of the 156 reports, 100 originated in the United States, dealing with 4,949 patients; 218 of these patients died (4.4 percent). The remaining 56 reports from the rest of the world dealt with 1,773 patients, 64 of whom died (3.6 percent) These two mortality rates do not differ significantly from one another. Of the total number of patients who died, sex was not specified in 57 percent. Of those remaining, two thirds were women. The type of operation was not stated in 35 percent of the fatal cases, but specified as Scott’s operation in 47 percent and Payne’s operation in 53 percent of the remaining cases. Table I shows the trend in mortality over the years. Unproportionately high mortality was reported in the small number of patients in the 1960s; in the last decade the mortality rate has been stable at about 4 percent. In Table II the causes of death are specified under 39 headings divided into 16 main groups. Liver disease was the most common cause of death, culminating 5 to 9 months postoperatively (Figure l), but cases were reported throughout the observation period. Cirrhosis of the liver occurred early as well as late, but its incidence increased with the length of observation time. It is impossible to characterize in detail the 91 patients who died from liver disease; explicit mention of the presence or absence of a relevant factor was lacking in most cases. Alcoholism had been present
619
Andersen et al
TABLE
Year 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979
I
Mortality in Relation to Year of Publication Cumulative Patients Operated on (n)
13 16 158 161 686 1,622 1,988 2,983 5.071 61712 6,722
Cause of Death in 282 Patients Deaths
Cumulative Deaths n %
0
0 1 1 1 1 1 1 1 6 7
50.0 50.0 50.0 25.0 20.0 7.7 6.3 3.8 4.3
$: 71 131 217 282 282
3’:: 3.6 4.4 4.3 4.2 4.2
95% Confidence Limits O-100 O-100 O-100 O-100 O-67.4 O-55.1 o-22.2 O-18.1 0.8-8.8 1.2-7.5 1.5-3.6 2.7-4.5 2.8-4.4 3.7-5.1 3.7-4.8 3.7-4.7 3.7-4.7
in five patients before operation and was noted after operation in six. In 16 cases the usual symptoms of hepatic insufficiency were noted before death. Lack of patient cooperation or other reasons for inadequate follow-up were mentioned in nine cases. A liver biopsy before or during the operation was performed in about one fourth (22 patients). In 15 patients the shunt was taken down before death, while 19 patients were not reoperated on. Autopsy was performed in only 16 cases. The second main cause of death, pulmonary embolism, was common not only in immediate connection with the operation but during the entire first postoperative month. No death from pulmonary embolism was reported after the first postoperative year. Comments In this review of mortality after jejunoileal bypass, which covers all available literature, we had hoped to be able to analyze a number of clinical variables in detail. Among other things, it would have been of great interest to identify certain patient characteristics or clinical events that correlated with mortality. As it turned out, a great deal of relevant information was either lacking or insufficient. This applies, for example, to criteria for entry, age, sex, initial weight and general state of health, alcoholism, obesity complications present before surgery, and description of clinical events leading up to death. Even the cause of death was not always mentioned, and autopsy was mentioned in only a minority of patients who died from liver disease. Nevertheless, some important features stand out: The overall mortality after jejunoileal bypass, about 4.0 percent, has not diminished over the last 8 years,
620
TABLE II
n Liver failure, unspecified Cirrhosis Fatty liver Acute hepatitis, toxic Acute hepatitis, viral Acute hepatitis, unspecified Liver deaths, total
63 15 5 2 1 5 91
Pulmonary embolism
51
Insufficiency of anastomosis Wound complications Pancreatitis Gut perforation Peritonitis Ulcerative colitis Necrotizing enterocolitis Mesenteric vein thrombosis Cholecystitis Erosive gastritis Gastrointestinal complications, total
10 9 4 3 2 2 ,l 1 1 1 34
Myocardial infarction Cardiac arrhythmia Other cardiac disorder Cardiac disease, total
10 3 9 22
Pneumonia Aspiration Hypoxia Respiratory insufficiency Respiratory disorder, total
6 3 1 1 11
Hypokalemia Hypocalcemia Electrolyte disorder, unspecified Electrolyte disorders, total
6 1 2 9
Septicemia
8
Glomerulonephritis F’yelonephritis Renal failure, unspecified Renal complications, total
1 1 5 7
Acute lntracerebral disorder
5
Neoplasm
3
Trauma
3
Suicide
2
Tuberculosis
1
Influenza
1
Others
4
Not mentioned or unknown
30
% of Total
11
and there seems to be no reason to anticipate any improvement in this respect. In fact, a higher mortality might be expected if observation times had been longer. Another important point is that the number of postoperational sequelae and the corresponding causes of death are very high, representing a wide range of disease groups. It proved impossible to obtain a detailed description of the patients who died from liver disease. The risk of this cause of death was
The American Journal of Surgery
Fatal Outcome After Jejunoileal Bypass
POne death from cirrhosis
OOnc death from pirlmonary embolus USame, time not exact
lone death from other or unknown bver disease BOSame, time not exact
131211109 8 7 6 5 f. 3 2 1
i
123456789lO111213
3 years
3years
2years
2 years
.
1 year
necessary in the future to take this risk into account in the surgical treatment of obese patients. In view of the fact that jejunoileal bypass has been in use for more than 20 years, the public and the medical profession have long been entitled to a verdict on the advisability of this method of treating severe obesity. It is, however, difficult to give a clear-cut answer to this question. Among many others, the following three important factors complicate the issue: First, we do not know enough about mortality, morbidity and quality of life in conservatively treated, massively obese patients of comparable age. Still, it seems to us unlikely that this condition would carry a mortality of 4 percent over 2 years. Second, most formerly obese patients treated with jejunoileal bypass seem to prefer the postoperational hazards and troubles of somatic illnes to the psychological burden and somatic hazards of being obese [6]. On this point there is often a discrepancy between what the patient is ready to accept for himself and what the physician finds advisable on behalf of the patient. Finally, the judgment on jejunoileal bypass should be passed solely on the basis of the operation’s own merits; still, it is difficult to close one’s eyes to the promising alternatives offered recently by gastric surgery. With due consideration to the abovementioned uncertainties, on the basis of this review of mortality from jejunoileal bypass we have formed the opinion that this operation should no longer be endorsed by the medical profession.
Summary
1312111098765.4
32
Deaths from pulmonary embolus (n-39 )
1
12345678910111213 Deaths from liver disease ( n.60 )
Figure 1. Deaths from pulmonary embolism ( /eft) and from liver disease ( rfght). Note the change in the t/me scale after 1 year of observation.
A review of all literature on jejunoileal bypass for obesity disclosed 282 deaths, corresponding to a mortality rate of 4.2 percent. This rate has been fairly constant through the last 8 years. The causes of death and the postoperative duration are quantified. Pulmonary embolism, mostly early, and liver disease, sometimes late, dominate among the numerous causes of death. Details are too scarcely reported to allow guidance to better results.
References not confined to the period of weight loss. Alcoholism could be shown to be a possible etiologic factor in only a small proportion of cases. Reoperation was often unsuccessful, possibly because it was performed too late. Considering that we are dealing with elective surgery in relatively young patients, the perioperational mortality is considerable and has remained so, even in the latest reports. By far the most important of the early lethal complications is pulmonary embolism. It occurs throughout the first postoperative month, not only in the days immediately after surgery. It will be
Volume 142, November 1991
1. DeMuth WE, Rottenstein HS. Death associated with hypocalcemia after small-bowel short circuiting. N Engl J Med 1964;270:1239-40. 2. Wade DH, Richards V. Burhenne l-U. Radiographic changes after small bowel bypass for morbid obesity. Radio1Clin North Am 1976;14:493-8. 3. Brown GR, O’Leary JP, Woodward ER. Hepatic effects of jejunoileal bypass for morbid obesity. Am J Surg 1974;127: 53-8. 4. Andersen T, Juhl E, Quaade F. Jejunoileal bypass for obesity-what can we learn from a literature study? Am J Clin Nutr 1980;33:440-5. 5. Phillips BR. Small intestinal bypass for the treatment of morbid obesity. Surg Gynecol Obstet 1978;146:455-68. 6. The Danish Obesity Project. Randomised trial of jejunoileal bypass versus medical treatment in morbid obesity. Lancet 1979:2: 1255-8.
621
Teis Andersen, MD, Copenhagen, Denmark Erik Juhl, MD, Copenhagen, Denmark Flemming Quaade, MD, Copenhagen, Denmark
Jejunoileal bypass operation for obesity was first performed by Payne in 1959, and the first fatal case was reported in 1964 [I]. Since then, there have been a great number of reports of fatal outcome after the operation, and reports on patient groups large enough to allow an estimate give a mortality rate of 1 to 11 percent after Payne’s and Scott’s operation [2,3]. In most such reports observation time is either less than 2 years or unspecified. In a review of the status in the spring of 1977, the average mortality, early and late, was found to be 4.3 percent in reports including at least 50 patients and explicitly mentioning the number of deaths [4]. The aim of the present report is to analyze the causes of death and other features of possible relevance. Material
and Methods
The material consists of 538 reports on jejunoileal bypass operations on humans. The main part of the references is the result of a comprehensive survey of the Medical Literature Analysis and Retrieval System (MEDLARS) for the years 1967 through the first third of 1979. The key words of the search program were chosen to identify reports fulfilling the following two conditions: (1) primarily dealing with obesity in combination with either surgery or therapy, and (2) dealing with surgery and jejunum or surgery and ileum or surgery and small intestine. For the years 1963 to 1966, a comparable search was made in the Index Medicus. A bibliographic recheck based on Phillips’s extensive survey [5] revealed 13 (2 percent) missed references. These were included in the present survey. A total of 538 reports were found and read, if necessary, after translation. Three hundred eighty-two references
From the Department of Medicine, Sections of Endocrinology and Hepatology, Hvidovre Hospital, University of Copenhagen, Denmark. This work was supported by a grant from C. C. Klestrup and Wife’s Memorial Fund, Copenhagen, Denmark. Requests for reprints should be addressed to Teis Andersen, MD. Department of Medicine 233, Hvidovre Hospital, DK-2650, Hvidovre, Denmark.
Volume 142, November 1981
were excluded for being surveys with no original data (131), duplicate reports (86) or reports without stated mortality (165). Subsequently, 156 reports dealing with 6,722 patients fulfilled the criteria of originality and stated mortality. In the case of duplicate reports, only the latest was included. Where possible, all data on the number of deaths, the cause of death, postoperative duration, and type of operation were registered, in addition to sex, age, total number of patients, and country and year of publication. Results Of the 156 reports, 100 originated in the United States, dealing with 4,949 patients; 218 of these patients died (4.4 percent). The remaining 56 reports from the rest of the world dealt with 1,773 patients, 64 of whom died (3.6 percent) These two mortality rates do not differ significantly from one another. Of the total number of patients who died, sex was not specified in 57 percent. Of those remaining, two thirds were women. The type of operation was not stated in 35 percent of the fatal cases, but specified as Scott’s operation in 47 percent and Payne’s operation in 53 percent of the remaining cases. Table I shows the trend in mortality over the years. Unproportionately high mortality was reported in the small number of patients in the 1960s; in the last decade the mortality rate has been stable at about 4 percent. In Table II the causes of death are specified under 39 headings divided into 16 main groups. Liver disease was the most common cause of death, culminating 5 to 9 months postoperatively (Figure l), but cases were reported throughout the observation period. Cirrhosis of the liver occurred early as well as late, but its incidence increased with the length of observation time. It is impossible to characterize in detail the 91 patients who died from liver disease; explicit mention of the presence or absence of a relevant factor was lacking in most cases. Alcoholism had been present
619
Andersen et al
TABLE
Year 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979
I
Mortality in Relation to Year of Publication Cumulative Patients Operated on (n)
13 16 158 161 686 1,622 1,988 2,983 5.071 61712 6,722
Cause of Death in 282 Patients Deaths
Cumulative Deaths n %
0
0 1 1 1 1 1 1 1 6 7
50.0 50.0 50.0 25.0 20.0 7.7 6.3 3.8 4.3
$: 71 131 217 282 282
3’:: 3.6 4.4 4.3 4.2 4.2
95% Confidence Limits O-100 O-100 O-100 O-100 O-67.4 O-55.1 o-22.2 O-18.1 0.8-8.8 1.2-7.5 1.5-3.6 2.7-4.5 2.8-4.4 3.7-5.1 3.7-4.8 3.7-4.7 3.7-4.7
in five patients before operation and was noted after operation in six. In 16 cases the usual symptoms of hepatic insufficiency were noted before death. Lack of patient cooperation or other reasons for inadequate follow-up were mentioned in nine cases. A liver biopsy before or during the operation was performed in about one fourth (22 patients). In 15 patients the shunt was taken down before death, while 19 patients were not reoperated on. Autopsy was performed in only 16 cases. The second main cause of death, pulmonary embolism, was common not only in immediate connection with the operation but during the entire first postoperative month. No death from pulmonary embolism was reported after the first postoperative year. Comments In this review of mortality after jejunoileal bypass, which covers all available literature, we had hoped to be able to analyze a number of clinical variables in detail. Among other things, it would have been of great interest to identify certain patient characteristics or clinical events that correlated with mortality. As it turned out, a great deal of relevant information was either lacking or insufficient. This applies, for example, to criteria for entry, age, sex, initial weight and general state of health, alcoholism, obesity complications present before surgery, and description of clinical events leading up to death. Even the cause of death was not always mentioned, and autopsy was mentioned in only a minority of patients who died from liver disease. Nevertheless, some important features stand out: The overall mortality after jejunoileal bypass, about 4.0 percent, has not diminished over the last 8 years,
620
TABLE II
n Liver failure, unspecified Cirrhosis Fatty liver Acute hepatitis, toxic Acute hepatitis, viral Acute hepatitis, unspecified Liver deaths, total
63 15 5 2 1 5 91
Pulmonary embolism
51
Insufficiency of anastomosis Wound complications Pancreatitis Gut perforation Peritonitis Ulcerative colitis Necrotizing enterocolitis Mesenteric vein thrombosis Cholecystitis Erosive gastritis Gastrointestinal complications, total
10 9 4 3 2 2 ,l 1 1 1 34
Myocardial infarction Cardiac arrhythmia Other cardiac disorder Cardiac disease, total
10 3 9 22
Pneumonia Aspiration Hypoxia Respiratory insufficiency Respiratory disorder, total
6 3 1 1 11
Hypokalemia Hypocalcemia Electrolyte disorder, unspecified Electrolyte disorders, total
6 1 2 9
Septicemia
8
Glomerulonephritis F’yelonephritis Renal failure, unspecified Renal complications, total
1 1 5 7
Acute lntracerebral disorder
5
Neoplasm
3
Trauma
3
Suicide
2
Tuberculosis
1
Influenza
1
Others
4
Not mentioned or unknown
30
% of Total
11
and there seems to be no reason to anticipate any improvement in this respect. In fact, a higher mortality might be expected if observation times had been longer. Another important point is that the number of postoperational sequelae and the corresponding causes of death are very high, representing a wide range of disease groups. It proved impossible to obtain a detailed description of the patients who died from liver disease. The risk of this cause of death was
The American Journal of Surgery
Fatal Outcome After Jejunoileal Bypass
POne death from cirrhosis
OOnc death from pirlmonary embolus USame, time not exact
lone death from other or unknown bver disease BOSame, time not exact
131211109 8 7 6 5 f. 3 2 1
i
123456789lO111213
3 years
3years
2years
2 years
.
1 year
necessary in the future to take this risk into account in the surgical treatment of obese patients. In view of the fact that jejunoileal bypass has been in use for more than 20 years, the public and the medical profession have long been entitled to a verdict on the advisability of this method of treating severe obesity. It is, however, difficult to give a clear-cut answer to this question. Among many others, the following three important factors complicate the issue: First, we do not know enough about mortality, morbidity and quality of life in conservatively treated, massively obese patients of comparable age. Still, it seems to us unlikely that this condition would carry a mortality of 4 percent over 2 years. Second, most formerly obese patients treated with jejunoileal bypass seem to prefer the postoperational hazards and troubles of somatic illnes to the psychological burden and somatic hazards of being obese [6]. On this point there is often a discrepancy between what the patient is ready to accept for himself and what the physician finds advisable on behalf of the patient. Finally, the judgment on jejunoileal bypass should be passed solely on the basis of the operation’s own merits; still, it is difficult to close one’s eyes to the promising alternatives offered recently by gastric surgery. With due consideration to the abovementioned uncertainties, on the basis of this review of mortality from jejunoileal bypass we have formed the opinion that this operation should no longer be endorsed by the medical profession.
Summary
1312111098765.4
32
Deaths from pulmonary embolus (n-39 )
1
12345678910111213 Deaths from liver disease ( n.60 )
Figure 1. Deaths from pulmonary embolism ( /eft) and from liver disease ( rfght). Note the change in the t/me scale after 1 year of observation.
A review of all literature on jejunoileal bypass for obesity disclosed 282 deaths, corresponding to a mortality rate of 4.2 percent. This rate has been fairly constant through the last 8 years. The causes of death and the postoperative duration are quantified. Pulmonary embolism, mostly early, and liver disease, sometimes late, dominate among the numerous causes of death. Details are too scarcely reported to allow guidance to better results.
References not confined to the period of weight loss. Alcoholism could be shown to be a possible etiologic factor in only a small proportion of cases. Reoperation was often unsuccessful, possibly because it was performed too late. Considering that we are dealing with elective surgery in relatively young patients, the perioperational mortality is considerable and has remained so, even in the latest reports. By far the most important of the early lethal complications is pulmonary embolism. It occurs throughout the first postoperative month, not only in the days immediately after surgery. It will be
Volume 142, November 1991
1. DeMuth WE, Rottenstein HS. Death associated with hypocalcemia after small-bowel short circuiting. N Engl J Med 1964;270:1239-40. 2. Wade DH, Richards V. Burhenne l-U. Radiographic changes after small bowel bypass for morbid obesity. Radio1Clin North Am 1976;14:493-8. 3. Brown GR, O’Leary JP, Woodward ER. Hepatic effects of jejunoileal bypass for morbid obesity. Am J Surg 1974;127: 53-8. 4. Andersen T, Juhl E, Quaade F. Jejunoileal bypass for obesity-what can we learn from a literature study? Am J Clin Nutr 1980;33:440-5. 5. Phillips BR. Small intestinal bypass for the treatment of morbid obesity. Surg Gynecol Obstet 1978;146:455-68. 6. The Danish Obesity Project. Randomised trial of jejunoileal bypass versus medical treatment in morbid obesity. Lancet 1979:2: 1255-8.
621