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Clinical appraisal of jejunoileal shunt in patients with morbid obesity
Clinical Appraisal of Jejunoileal Shunt in Patients with Morbid Obesity H. WILLIAM DAVID
The cause of morbid obesity remains obscure. No specific endocrinopathy has been implicated and although various explanations have been advanced, no uniformly practical medical or psychiatric program of effective treatment has evolved. The basic factor of gluttony with enormous caloric intake, coupled with indolent or absent exercise activity, appears to be the common denominator in most massively obese patients. Although no precise definition for this syndrome is generally accepted, we identify morbid obesity as existing in any person whose weight has reached a level two to three or more times his ideal weight and who has maintained this level of obesity for five years or more despite efforts by himself, family, friends, and physicians to bring about effective and sustained reduction of weight to medically acceptable standards. In the last fifteen years several groups of investigators have attempted to cope with the problem of massive intractable obesity by surgical operation. The basis for a surgical approach to the problem is the dual concept that massive obesity of the “fat man in the circus” variety is a serious disease of life-shortening severity and that long-term dietary control is usually unsatisfactory. The record of accomplishment in medical treatment of such persons by dietary restriction, including rigid inhospital dietary programs of 800 to 0 calories per day for periods up to 300 days, has been marred by the extremely high rate of recurrence of obesity once rigid conditions of dietary control are relinquished. From the Departments of Surgery and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee. This work was supported by U.S.P.H.S. Grant FR-95. Clinical Research Center, Vanderbilt University Hospital and the Irvin Strasburger Memorial Fund. Presented at the Ninth Annual Meeting of the Society for Surgery of the Alimentary Tract, San Francisco, California, June 15 and 16, 1968.
246
SCOTT,
JR.,
H. LAW, IV, M.D.,
M.D., Nashville,
Nashville,
Tennessee
Tennessee
Varco [I] at the University of Minnesota was among the first to suggest the use of surgical bypass of the distal small intestine to reduce the absorptive capacity of patients with morbid obesity. It was his concept that such an operation would combine the advantages of technical simplicity, low risk, reversibility if necessary, and hopefully minimal functional impairment coupled with obligatory reduction in weight, despite an anticipated continued large caloric intake. In the last three years Payne, DeWind, and Commons [2] of Los Angeles and Lewis, Turnbull, and Page [3] of Cleveland have described their respective experience with extensive small bowel bypass and jejunocolic anastomosis in massively obese patients. Although significant weight loss occurred in their patients when only about 30 inches of small bowel or less were maintained in alimentary continuity, many of their patients had serious water, electrolyte, and other nutritional problems coupled with severe diarrhea. Parenteral alimentation and extensive and prolonged nutritional supplementation were required in a number of these persons. In the last year DeWind and Payne [4] have described their experience with a modification of the intestinal bypass operation in which the integrity of the ileocecal valve is maintained. Payne’s procedure consists of dividing the jejunum 14 inches from the ligament of Treitz and anastomosing this proximal jejunal segment to the side of the terminal ileum 4 inches from the ileocecal junction. Satisfactory reduction in weight has resulted in over thirty patients treated in this way with minimal morbidity. Fluid, electrolyte, and vitamin supplementations have not been necessary after this procedure according to DeWind and Payne, and diarrhea has occurred only when the patient has overindulged in fats and/or liquids. We have begun a study of morbid obesity and in the last two years have applied Payne’s The
American
Journal
of Surgery
Jejunoileal
procedure in five carefully selected massiveiy obese patients. A clinical and metabolic appraisal of these patients has prompted this report. Criteria
for Selection
of Patients
We have used essentially the same criteria as DeWind and Payne [4] in selecting patients as candidates for jejunoileal shunt. These can be summarized as follows : 1. Obesity of massive degree (weights two or three times ideal levels) of at least five years’ duration. 2. Evidence from attending physician indicating failure of dietary efforts to correct obesity over a period of years. 3. Evidence from patients’ history and evaluation indicating patients’ apparent incapability to adhere to prescribed dietary regimens and/or exercise programs. 4. Absence of any correctible endocrinopathy (such as hypothyroidism and Cushing’s syndrome) which might be the cause of obesity. 5. Absence of any other unrelated significant disease which might increase operative risk. 6. Presence of certain complications such as Pickwickian syndrome, adult onset of diabetes, and hypertension, which might be alleviated by significant weight reduction. 7. Assurance of patients’ cooperation in conduct of pre- and postoperative metabolic and body compositional studies and prolonged fallow-up study. Study
of Patients
Five patients who have met these criteria have thus far been admitted to our study. These are three women and two men ranging in age from twenty-three to forty-seven years. After preliminary appraisal, each of these has been accepted for study and submitted to operation. Figure 1 shows the habitus of each patient immediately prior to operation. There was a long history (ten years or more) of massive obesity in each instance. In two persons maximal weights were in the 350 pound range whereas in the other three maximal weights were 475 to 618 pounds. In each instance there was firm assurance by the referring physician of failure of various dietary and drug programs designed to effect weight reduction and control of obesity. Each patient was admitted to a metabolic ward prior to operation for base-line studies with special attention directed toward possible endocrine causes of obesity, evaluation of carVol. 117,
February
1969
Shunt
in Morbid
Obesity
diopulmonary status, base-line absorptive and metabolic studies, psychiatric evaluation, and body composition studies. The endocrine studies included evaluation of thyroid function by determination of serum protein bound iodine and basal metabolic rate. Studies of adrenal function included plasma F determinations and twenty-four hour urine collections for measurement of 1’7-hydroxycorticosteroid and 1’7-ketosteroids. Films of the skull and long bones were taken in each instance. Pulmonary studies included measurement of arterial pOZ, pCO,, and pH in addition to spirometry for determination of respiratory rate, tidal volume, inspiratory capacity, inspiratory reserve volume, forced vital capacity, and other aspects of pulmonary function. Cardiovascular appraisal included roentgenograma of the chest, electrocardiograms and Master’s test, and determination of serum lipids including cholesterol, free fatty acids, triglycerides, and lipoproteins. In addition to an extensive dietary history, gastroenteralogic studies included x-ray examinations of the stomach, small bowel, and colon and measurement of gastric acid secretion in a twelve hour nocturnal collection of gastric juice. Intestinal absorption was evaluated by vitamin A tolerance tests, d-xylose tolerance tests, glucose tolerance tests, and the cobalt 60 vitamin B,, absorption test (Shilling test). Preoperative measurements of serum calcium, potassium, magnesium, and other electrolytes as well as vitamins C, E, Btz, and falic acid were carried out. Dietary intake was calculated and recorded and serial three day collections of stool with daily collections of urine were obtained. These were analyzed for calcium, magnesium, potassium, and nitrogen and stools were also analyzed for fat. Studies of body composition included determination of exchangeable sodium, total body potassium, total body and extrecellular water volume, and red cell and plasma volumes using whole body counting and isotope dilution methods. Psychologic evaluation of each patient involved the use of standard psychologic tests including Wechsler adult intelIigence scale, Bender-Gestalt, Rorschach, and Thermatic Apperception tests as well as interviews with a staff psychiatrist. Operative Procedure Preoperative preparation included a three to five day bowel cleansing regimen involving liquid diet, castor oil, cleansing enemas, and oral kanamycin. Anesthesia in each patient consisted of endotracheal halothane with bag as247
Scott and Law
Fig. 1.
248
Anterior
and lateral
photographs
of five patients
with morbid
obesity prior to operation.
The American
Journa
lof Surgery
Jejunoileal Shunt in Morbid sistance and succinylcholine intravenously as a muscle relaxant. For these extremely large patients the standard operating table has inadequate width and was abandoned in favor of a delivery table. A twenty minute scrub of the large redundant expanse of skin of the abdomen and upper thighs was carried out in each instance with an iodine-containing soap solution. A transverse elliptic incision was placed excising the redundant fatty apron and usually the umbilicus. The weight of the excised panniculus ranged from 15 to 31 pounds. Care was taken not to undermine the edges of the fatty panniculus. Both rectus muscles were divided transversely and with the use of large retractors, coupled with liberal administration of muscle relaxants, the celomic cavity was explored. The upper jejunum was identified and carefully measured along its mesenteric border to a point 14 inches from th,e ligament of Treitz. At this point the jejunum was transected. The distal end was closed in two layers with interrupted nonabsorbable sutures and anchored to the root of the transverse mesocolon in the left upper quadrant of the abdomen to prevent postoperative intussusception. The proximal jejunum was then anastomosed to the side of the terminal ileum exactly 4 inches from the ileocecal valve. The mesenteric defects were then carefully closed with interrupted nonabsorbable sutures. The appendix was removed routinely and in two patients additional gynecologic procedures were carried out. Prior to closure of the abdominal incision copious peritoneal lavage with saline solution was used. The transverse incisions were closed with through and through stay sutures of No. 2-O nylon, interrupted No. 1-O Dacron@ sutures to the peritoneum and posterior sheath, and interrupted No. 1-O Dacron to the anterior rect.us fascia and external oblique aponeurosis. Suction drainage catheters were placed in the subcutaneous layer and exteriorized through stab wounds. The thick fatty layer was closed with interrupted No. 2-O and 3-O plain catgut sutures and skin edges were approximated by tying the stay sutures and applying vertical mattress sutures of fine Dacron. In the immediate postanesthesia period, the endotracheal tube was left in situ and each patient was maintained on a respirator for six to twelve hours. Figure 2 shows a diagram of the operative procedure. Results Weights at the time of admission to our study ranged from 300 to 542 pounds. Aside from massive obesity, preopera.tive clinical Vol.l17,February1969
Obesity
Fig. 2. Diagram of the operative procedure of extensive distal intestinal bypass with preservation of the ileocecal valve (Payfle).
evaluation of these five patients showed remarkably few abnormalities of any significance. The largest patient in the group (L. Be.) had been treated for congestive heart failure with digitalis and diuretics a few weeks prior to our evaluation, but was well compensated when we first saw him. Endocrine status was normal in all five patients. Cardiac evaluation prior to operation showed slightly elevated diastolic arterial pressures in the range of 90 to 100 mm. Hg in four of the five patients. The exception was the largest patient in the group whose diastolic pressure was 80 mm. Hg. Roentgenograms of the chest showed no cardiac enlargement in any patient. E!ectrocardiograms were within normal limits in three of the five patients, whereas one patient had a right axis deviation but negative results on the Master’s test. One patient showed a borderline abnormality on the electrocardiogram with Q waves in lead III and AVF. Serum cholesterol levels were normal in each instance. Spirometry showed diminution of total vital capacity to 53 and 77 per cent of normal in two of the patients. One of these (L. Be.) had transitory manifestations of the Pickwickian syndrome prior to entry, but these manifestations had cleared before his admission to our study. Blood gas studies in this patient showed arterial pH 7.4 with pCO,41 to 49 mm. Hg and ~0, 65 to 70 mm. Hg. Blood gas studies gave normal results in two other patients (A.P. and P.H.). 249
Scott and Law
TABLE
I
Pre- and Postoperative
2. P.H. 3. J.G. 4. H.Bu 5. L.Be
>95
50-300
150-250
c4.5
>2.5
Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative
1.0-3.3 22-28 1.9-4.8 64-157 2.7-3.0 24-42 6.7-7.0 16-23 1.4-4.8 30-107
97 60-80 98 30-33 96 68-86 97 24-40 97 30-50
38-50 20 96 13 79 22-31 76-95 31 53 44
175-214 130 225 95-130 190-240 145-160 165-220 155-190 210-225 135
4.4-7.0 2.9 7.0 3.6-3.9 5.0 3.4 6.6 3.1 6.7 2.1
0.8-1.2 3.2-3.5 1.5 4.6-6.4 1.3-2.3 0.8-1.9 2.5-3.1 2.3-3.4 0.7-1.9 2.2-7.0
'
550 500
2 a z
450
5 g
350 300
p
250
Fecal Nitrogen (gm. per cent)
Cl.5
650
$
Obesity
Normal
Preoperative appraisal of intestinal fat and carbohydrate absorption, as indicated by the data in Table I, was normal in each patient. It is of interest, however, that four of the five patients showed low or low normal serum albumin levels before operation and one of these had slightly elevated fecal nitrogen excretion. Other preoperative parameters of absorptive capacity were essentially normal although two patients had low serum magnesium levels ; each of these had recently received diuretic treatment. Psychiatric study revealed no single common denominator in the personality structure of these obese patients. Three of the five patients demonstrated mild depression, anxiety, and passive dependence on psychologic testing. The diagnostic impression in two patients was “passive aggressive personality.” All patients were thought by the staff who dealt with them to be relatively immature. After operation each patient was maintained in the Surgical Intensive Care Unit with spe-
600
with Morbid
D-Xylose Tolerance Serum Coefficient of Serum Cholesterol (gm./5 hr. urine Fat Absorption Carotene Fecal Fat collection) (gm. per day) (per cent) (pg. per cent) (mg. per cent)
Patient
1. A.P.
Values in Five Patients
x.
4m 00
200 -I
Fig. 3. Chronology of weight loss in five patients with morbid obesity after jejunoileal shunt.
cial attention paid to respiratory support and pulmonary toilet. The use of the respirator to assist respiration in the first slix to twelve hours after anesthesia facilitated satisfactory return to normal respiratory function. Although a low grade fever, which was possibly pulmonary in origin, occurred in each patient in the first f.ew days after operation, no significant instance of atelectasis or pneumonitis was encountered. Three patients had healing of the large abdominal wound per primum and without evidence of seroma or infection. However, major infections developed in the subcutaneous layer of the wound in two patients, requiring drainage and delayed convalescence. In both instances tight stay sutures caused extensive lacerations of the skin and subcutaneous tissue. As oral intake was increased in the early postoperative period, diarrhea became progressively severe. Low fat diet, restriction of fluids with meals, and diphenoxylate hydrochloride in a d’osage of 5 mg. three to four times per day resulted in considerable improvement while patients were in the hospital. All patients had a transient but significant drop in serum albumin levels during the first month after operation. After discharge from the hospital each patient was followed up on a regular basis in the clinic with periodic readmission to a metabolic ward. A three to twenty month appraisal of the effects of operation has been obtained in the five patients. Figure 3 documents the chronology of weight loss in pounds during the follow-up period. Three of the five patients have returned to active full time work at their preoperative ocThe American Journal
of Surgery
Jejunoileal
TABLE
I
Serum Albumin/Globulin (gm. per cent)
Pre- and
Postoperative
Serum Uric Acid (mg. per cent)
Values
Prothrombin Time (per cent)
in Five Patients
Serum Vitamin A
Serum Vitamin C
(rg. per cent)
(mg. per cent)
with
Morbid
Serum Calcium (mg. per cent)
Obesity
Shunt
in Morbid
(continued)
Serum Magnesium (mW.L.)
Serum Potassium (mW-.)
3.55/l.%3.2
3-6
60-100
26-82
>0.5
8.5-11
1.4-1.8
3.5-5
413.4 4.412.7 3.512.9 3.2-3.513-3.4
9-12 a 6.8 5.7
73 81 76 56-76
37 ;:oo, 16
0.9 0.9 ... 1.0
9.4 9.0 9.0 8.5-9.2
x413.3 3.5-3.6/Z.%3.0 3.413.2-3.9 3.8-4.413.6-4.3 3.2-3.313.4-3.6 3.313.6
8.1 6.8-8.2 4.2 9.6-9.7 9.1-10.8 7.5
73-80 a7 80-87 70 67 76
33 39 23-33 36 21 24
0.9 0.8 1.5 0.3 1.3 0.8
9.0 10.1 9.6-9.9 10-11.2 9.6 8.6
1.54 1.58 1.70 1.5-1.8 1.3 1.1-1.2 1.84 1.42 1.1-1.3 1.3
4.1 4.0 4.4 4.2-4.5 4.0 4.7 3.9-4.3 3.5 4.o-4.7 3.4
cupations. One patient who was incapacitated by massive obesity prior to operation has since undertaken a professional career in nursing. The most recent patient who was also severely incapacitated by his morbid obesity is now seeking employment only three months after jejunoileostomy. In general, the voracious appetites and the large caloric intakes have been unchanged by the operative procedure. There have been sporadic episodes of unexplained nausea and vomiting since operation in four of the patients. Diarrhea has continued to be a significant problem for two patients (P.H. and J.G.) despite dietary instruction and treatment with diphenoxylate hydrochloride and deodorized tincture of opium. A therapeutic trial of Questran@ (cholestyramine) 12 gm. per day in one of these patients failed to decrease the diarrhea. Under dietary supervision in the hospital, however, both patients had considerable improvement. Excessive liquid and fat intakes appear to be instrumental in the production of persistent diarrhea. Table I documents the changes in the absorptive and metabolic parameters which have resulted from jejunoileostomy. Severe &atorrhea has developed in every instance with a resultant fall in serum carotene and cholesterol levels. As measured by d-xylose tolerance, a significant reduction in carbohydrate absorption has resulted in each patient. In three patients fecal nitrogen excretion has exceeded normal ranges. Total serum proteins have been maintained in the preoperative range and the trend toward hypoalbuminemia has persisted in four of the five patients. The absorption of vitamins K, A, C, and D as reflected by prothrombin times, serum levels of vitamins A vol. 117, February1969
Obesity
Hematocrit (per cent) ...-____ 44-483’ 37-46 0 50-54 43-51 40-45 36-41 41-44 41 41-45 50 41-48 39
and C, and adequate serum calcium concentrations appears to be satisfactory except in one patient (P.H.) with subnormal vitamin A levels and in another (H.Bu.) whose postoperative serum level of vitamin C is below normal. Mild hypomagnesemia has persisted in the two patients in whom this cation was subnormal before operation, and one of these also had a decline in serum potassium concentrations since operation. Hematocrits have shown slight reduction since operation in three of the five patients but have remained within the normal range. Results of the Shilling test for estimation of vitamin B12 absorption after jejunoileostomy have been 8 and 12 per cent (low normal) in the two patients studied thus far. Metabolic balance studies, serial lipid profiles, and serial analysis of body composition in these pati’ents will be reported after a longer period of follow-up study. As abdominal girth has declined six to twelve months after operation, each of the three female patients has been found to have a palpably enlarged liver with an edge three to four fmgerbreadths below the costal margin. At operation the liver was considered to be normal in size and appearance in each instance. Follow-up studies in these patients of prothrombin times, serum bilirubin, alkaline phosphatase, lactic dehydrogenase (LDH), and transaminase oxalacetic glutamic serum (SGOT) were within normal limits except in one patient (H.Bu.) who had minimal elevations of LDH and SGOT. However, there was bromsulphalein retention of 6 to 29 per Cent in each of the three patients. Needle aspiration biopsy in each of these three patients Sk to twelve months after operation revealed marked fatty metamorphosis of the liver. (Fig. 4.) 251
Scott and Law
Fig. 4. Photomicrographs of liver biopsy specimens showing extensive fatty metamorphosis in two patients (J.G. and P.H.) with morbid obesity six and twelve months after jejunojfeal shunt.
Comments The problems of etiology and practical management of morbid obesity are as yet unsolved. The serious social, economic, and health complications of this unfortunate disorder warrant continued study. The major obstacle to successful medical therapy seems to be the patients’ lack of ability to control his gluttonous dietary habits over a prolonged period of time. For these reasons serious consideration has been given to operative procedures which induce and maintain weight loss despite the patient’s continued gluttony. Initial experience with extensive intestinal bypass and jejunocolic anastomosis [2,3] demonstrated that obligatory weight reduction could be achieved in these patients, but the excessive diarrhea and serious metabolic complications prompted the continued search for a more acceptable procedure. DeWind and Payne [4] have reported that intestinal bypass with jejunoileostomy and preservation of the ileocecal valve accomplishes satisfactory weight loss with fewer unpleasant sequelae. This procedure has attracted the attention of both patients and surgeons and the operation is being performed with increasing frequency. DeWind and Payne [4] have carried out a careful 252
clinical study of their patients and have cautioned against considering jejunoileostomy as a preferred therapy for obesity and have restricted it to carefully selected patients. The initial results of our study confirm that weight loss can be accomplished by the application of this procedure with symptomatic sequelae which are acceptable to four of our five patients. Clinically, we consider that three patients have had a good result with social and economic rehabilitation, significant weight loss, and two to five controllable bowel movements daily. One patient is considered to have a fair result with attacks of severe diarrhea and the fifth patient must be considered a poor result because of persistent and often uncontrollable diarrhea and anal irritation requiring recurrent hospitalization. It is of note that this last patient had a previous history of alcoholism and an irritable colon syndrome. Despite the documented clinical improvement in most reported series there is as yet only one thorough metabolic evaluation of the consequences of the procedure. Morgan and Moore [5] showed in a meticulous study of an obese patient treated by jejunoileostomy that the compositional deformity as determin’ed by isotope dilution studies was not corrected by a 41 kg. weight 10~s~ nor a year of stable weight at 200 pounds. Another concern is the finding of hepatomegaly and fatty liver in both DeWind and Payne’s patients and in our own. Subsequent development of irreversible liver disease must be considered a potential hazard in these persons. In addition, other potential long-term consequences of a severe malabsorption syndrome must be considered. Spotty and unpredictable deficits of specific nutrients in our small series are in keeping with findings in other malabsorptive states and suggest the need for very careful clinical and metabolic follow-up study of all patients if this procedure is to be performed. We wish to express our appreciation for the valuable assistance given in the management and continuing follow-up study of the initial patient in this study by Dr. A. Hare11 and Dr. A. Farhi, Tel-Aviv, Israel. Acknowledgment:
References 2.
VARCO,R. Personal communication. PAYNE, J. H., DEWIND, L. T., and COMMONS, R. R. Metabolic observations in patients with jejunocolic shunts. Am. J. Surg.,
3.
LEWIS, L. A., TURNBULL,R. B., JR., and PAGE, H. Effects of jejuno-colic shunt on obesity,
1.
102:2’73,
1963.
The American
Journal
of Surgery
Jejunoileal
4. 5.
serum lipoproteins, lipids, and electrolytes. Arch. Int. Med., 117:4, 1966. DEWIND, L. T. and PAYNE, J. H. Morbid obesity treated by intestinal bypass. A follow-up study. J.A.M.A., in press. MORGAN,A. P. and MOORE,F. D. Jejuno-ileostomy for extreme obesity: rationale, metabolic observations and results in a single case. Am. Surg., 166:75, 1967.
Discussion J. HOWARDPAYNE (Los Angeles, Calif.) : This is a significant piece of research and represents the type of study that is necessary to evaluate the intestinal bypass operation and determine its place in the treatment of morbid obesity. We at the University of Southern California have had twelve years’ experience with the bypass procedure, the last six years with our final modification of the operation which is similar to that discussed bv Dr. Scott. We have nerformed eighty-three such operations. We did not arrive at the figures of 14 inches and 4 inches at once, but by trial. It soon became evident that these measurements are extremely critical. With 1 or 2 inches more, the patient will initially lose 40 to 60 pounds and then his weight will level off; some have even gained weight with 15 inches of jejunum and 5 inches of ileum. Our present recommendation is 14 inches of jejunum and 4 inches of ileum since we have had our most consistent results with these measurements. For instance, one male patient weighing 535 pounds has now leveled off at 190 pounds. It should be pointed out that this is the only approach to morbid obesity that offers the patient a safeguard against regaining the lost weight. They cannot regain their weight, but it may vary a few pounds. Another important thing about the jejunoileal shunt is that the ileocecal valve and the ascending colon are in the circuit. The devastating diarrhea seen in patients with jejunocolic shunts is not present. All of our patients eventually have two or three semisolid stools a day. Diarrhea may be a factor
Vol.l17,February1969
Shunt in Morbid Obesity
if they overindulge in large amounts of liquid or go on a fat or carbohydrate binge. I would like to emphasize that we still consider this an experimental procedure. Anyone who is going to perform the operation must commit himself and the patient to long-term follow-up study. DAVID H. LAW, IV (closing) : I cannot stress enough that I consider, and I believe our whole group considers, that this operation is still an experimental procedure. The long-term effects are unknown. We have had an inkling of some of the conseauences mentioned by Dr; Scott and Payne, that is, severe fatty liver which occurred in three of our patients as well as in a number of Dr. Payne’s. One must be alert to the late occurrence of osteomalacia and osteoporosis which have been noted with other chronic malabsorption syndromes. We have noted deficits of specific nutrients, such as vitamin A and C and magnesium, in these patients and we are looking for zinc deficiency. Maintenance of an abnormal body composition profile or even a further exaggeration of that abnormality after weight loss has occurred, as has been reported by Morgan and Moore, gives further pause when considering long-term effects. Also, one must consider the potential psychiatric problems of morbidly obese persons who are reverted to relatively normal configuration. For these and for many more reasons, we have undertaken the present preliminary study. Any procedure that effectively decreases weight has a great appeal to patients as well as physicians since these persons are difficult to deal with. Although Dr. Payne has been most conservative in his consideration of this procedure, I cannot help equate it with some of the other recent therapeutic procedures that have rapidly gained attention at an early phase and have received widespread use only to fall into disrepute after adequate study was undertaken. It is rather premature to undertake intestinal bypass unless you are willing and able to make very meaningful long-term metabolic and clinical evaluation of the patient. I believe it will take another several years at least before this should be considered as a therapeutic venture.
253
The cause of morbid obesity remains obscure. No specific endocrinopathy has been implicated and although various explanations have been advanced, no uniformly practical medical or psychiatric program of effective treatment has evolved. The basic factor of gluttony with enormous caloric intake, coupled with indolent or absent exercise activity, appears to be the common denominator in most massively obese patients. Although no precise definition for this syndrome is generally accepted, we identify morbid obesity as existing in any person whose weight has reached a level two to three or more times his ideal weight and who has maintained this level of obesity for five years or more despite efforts by himself, family, friends, and physicians to bring about effective and sustained reduction of weight to medically acceptable standards. In the last fifteen years several groups of investigators have attempted to cope with the problem of massive intractable obesity by surgical operation. The basis for a surgical approach to the problem is the dual concept that massive obesity of the “fat man in the circus” variety is a serious disease of life-shortening severity and that long-term dietary control is usually unsatisfactory. The record of accomplishment in medical treatment of such persons by dietary restriction, including rigid inhospital dietary programs of 800 to 0 calories per day for periods up to 300 days, has been marred by the extremely high rate of recurrence of obesity once rigid conditions of dietary control are relinquished. From the Departments of Surgery and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee. This work was supported by U.S.P.H.S. Grant FR-95. Clinical Research Center, Vanderbilt University Hospital and the Irvin Strasburger Memorial Fund. Presented at the Ninth Annual Meeting of the Society for Surgery of the Alimentary Tract, San Francisco, California, June 15 and 16, 1968.
246
SCOTT,
JR.,
H. LAW, IV, M.D.,
M.D., Nashville,
Nashville,
Tennessee
Tennessee
Varco [I] at the University of Minnesota was among the first to suggest the use of surgical bypass of the distal small intestine to reduce the absorptive capacity of patients with morbid obesity. It was his concept that such an operation would combine the advantages of technical simplicity, low risk, reversibility if necessary, and hopefully minimal functional impairment coupled with obligatory reduction in weight, despite an anticipated continued large caloric intake. In the last three years Payne, DeWind, and Commons [2] of Los Angeles and Lewis, Turnbull, and Page [3] of Cleveland have described their respective experience with extensive small bowel bypass and jejunocolic anastomosis in massively obese patients. Although significant weight loss occurred in their patients when only about 30 inches of small bowel or less were maintained in alimentary continuity, many of their patients had serious water, electrolyte, and other nutritional problems coupled with severe diarrhea. Parenteral alimentation and extensive and prolonged nutritional supplementation were required in a number of these persons. In the last year DeWind and Payne [4] have described their experience with a modification of the intestinal bypass operation in which the integrity of the ileocecal valve is maintained. Payne’s procedure consists of dividing the jejunum 14 inches from the ligament of Treitz and anastomosing this proximal jejunal segment to the side of the terminal ileum 4 inches from the ileocecal junction. Satisfactory reduction in weight has resulted in over thirty patients treated in this way with minimal morbidity. Fluid, electrolyte, and vitamin supplementations have not been necessary after this procedure according to DeWind and Payne, and diarrhea has occurred only when the patient has overindulged in fats and/or liquids. We have begun a study of morbid obesity and in the last two years have applied Payne’s The
American
Journal
of Surgery
Jejunoileal
procedure in five carefully selected massiveiy obese patients. A clinical and metabolic appraisal of these patients has prompted this report. Criteria
for Selection
of Patients
We have used essentially the same criteria as DeWind and Payne [4] in selecting patients as candidates for jejunoileal shunt. These can be summarized as follows : 1. Obesity of massive degree (weights two or three times ideal levels) of at least five years’ duration. 2. Evidence from attending physician indicating failure of dietary efforts to correct obesity over a period of years. 3. Evidence from patients’ history and evaluation indicating patients’ apparent incapability to adhere to prescribed dietary regimens and/or exercise programs. 4. Absence of any correctible endocrinopathy (such as hypothyroidism and Cushing’s syndrome) which might be the cause of obesity. 5. Absence of any other unrelated significant disease which might increase operative risk. 6. Presence of certain complications such as Pickwickian syndrome, adult onset of diabetes, and hypertension, which might be alleviated by significant weight reduction. 7. Assurance of patients’ cooperation in conduct of pre- and postoperative metabolic and body compositional studies and prolonged fallow-up study. Study
of Patients
Five patients who have met these criteria have thus far been admitted to our study. These are three women and two men ranging in age from twenty-three to forty-seven years. After preliminary appraisal, each of these has been accepted for study and submitted to operation. Figure 1 shows the habitus of each patient immediately prior to operation. There was a long history (ten years or more) of massive obesity in each instance. In two persons maximal weights were in the 350 pound range whereas in the other three maximal weights were 475 to 618 pounds. In each instance there was firm assurance by the referring physician of failure of various dietary and drug programs designed to effect weight reduction and control of obesity. Each patient was admitted to a metabolic ward prior to operation for base-line studies with special attention directed toward possible endocrine causes of obesity, evaluation of carVol. 117,
February
1969
Shunt
in Morbid
Obesity
diopulmonary status, base-line absorptive and metabolic studies, psychiatric evaluation, and body composition studies. The endocrine studies included evaluation of thyroid function by determination of serum protein bound iodine and basal metabolic rate. Studies of adrenal function included plasma F determinations and twenty-four hour urine collections for measurement of 1’7-hydroxycorticosteroid and 1’7-ketosteroids. Films of the skull and long bones were taken in each instance. Pulmonary studies included measurement of arterial pOZ, pCO,, and pH in addition to spirometry for determination of respiratory rate, tidal volume, inspiratory capacity, inspiratory reserve volume, forced vital capacity, and other aspects of pulmonary function. Cardiovascular appraisal included roentgenograma of the chest, electrocardiograms and Master’s test, and determination of serum lipids including cholesterol, free fatty acids, triglycerides, and lipoproteins. In addition to an extensive dietary history, gastroenteralogic studies included x-ray examinations of the stomach, small bowel, and colon and measurement of gastric acid secretion in a twelve hour nocturnal collection of gastric juice. Intestinal absorption was evaluated by vitamin A tolerance tests, d-xylose tolerance tests, glucose tolerance tests, and the cobalt 60 vitamin B,, absorption test (Shilling test). Preoperative measurements of serum calcium, potassium, magnesium, and other electrolytes as well as vitamins C, E, Btz, and falic acid were carried out. Dietary intake was calculated and recorded and serial three day collections of stool with daily collections of urine were obtained. These were analyzed for calcium, magnesium, potassium, and nitrogen and stools were also analyzed for fat. Studies of body composition included determination of exchangeable sodium, total body potassium, total body and extrecellular water volume, and red cell and plasma volumes using whole body counting and isotope dilution methods. Psychologic evaluation of each patient involved the use of standard psychologic tests including Wechsler adult intelIigence scale, Bender-Gestalt, Rorschach, and Thermatic Apperception tests as well as interviews with a staff psychiatrist. Operative Procedure Preoperative preparation included a three to five day bowel cleansing regimen involving liquid diet, castor oil, cleansing enemas, and oral kanamycin. Anesthesia in each patient consisted of endotracheal halothane with bag as247
Scott and Law
Fig. 1.
248
Anterior
and lateral
photographs
of five patients
with morbid
obesity prior to operation.
The American
Journa
lof Surgery
Jejunoileal Shunt in Morbid sistance and succinylcholine intravenously as a muscle relaxant. For these extremely large patients the standard operating table has inadequate width and was abandoned in favor of a delivery table. A twenty minute scrub of the large redundant expanse of skin of the abdomen and upper thighs was carried out in each instance with an iodine-containing soap solution. A transverse elliptic incision was placed excising the redundant fatty apron and usually the umbilicus. The weight of the excised panniculus ranged from 15 to 31 pounds. Care was taken not to undermine the edges of the fatty panniculus. Both rectus muscles were divided transversely and with the use of large retractors, coupled with liberal administration of muscle relaxants, the celomic cavity was explored. The upper jejunum was identified and carefully measured along its mesenteric border to a point 14 inches from th,e ligament of Treitz. At this point the jejunum was transected. The distal end was closed in two layers with interrupted nonabsorbable sutures and anchored to the root of the transverse mesocolon in the left upper quadrant of the abdomen to prevent postoperative intussusception. The proximal jejunum was then anastomosed to the side of the terminal ileum exactly 4 inches from the ileocecal valve. The mesenteric defects were then carefully closed with interrupted nonabsorbable sutures. The appendix was removed routinely and in two patients additional gynecologic procedures were carried out. Prior to closure of the abdominal incision copious peritoneal lavage with saline solution was used. The transverse incisions were closed with through and through stay sutures of No. 2-O nylon, interrupted No. 1-O Dacron@ sutures to the peritoneum and posterior sheath, and interrupted No. 1-O Dacron to the anterior rect.us fascia and external oblique aponeurosis. Suction drainage catheters were placed in the subcutaneous layer and exteriorized through stab wounds. The thick fatty layer was closed with interrupted No. 2-O and 3-O plain catgut sutures and skin edges were approximated by tying the stay sutures and applying vertical mattress sutures of fine Dacron. In the immediate postanesthesia period, the endotracheal tube was left in situ and each patient was maintained on a respirator for six to twelve hours. Figure 2 shows a diagram of the operative procedure. Results Weights at the time of admission to our study ranged from 300 to 542 pounds. Aside from massive obesity, preopera.tive clinical Vol.l17,February1969
Obesity
Fig. 2. Diagram of the operative procedure of extensive distal intestinal bypass with preservation of the ileocecal valve (Payfle).
evaluation of these five patients showed remarkably few abnormalities of any significance. The largest patient in the group (L. Be.) had been treated for congestive heart failure with digitalis and diuretics a few weeks prior to our evaluation, but was well compensated when we first saw him. Endocrine status was normal in all five patients. Cardiac evaluation prior to operation showed slightly elevated diastolic arterial pressures in the range of 90 to 100 mm. Hg in four of the five patients. The exception was the largest patient in the group whose diastolic pressure was 80 mm. Hg. Roentgenograms of the chest showed no cardiac enlargement in any patient. E!ectrocardiograms were within normal limits in three of the five patients, whereas one patient had a right axis deviation but negative results on the Master’s test. One patient showed a borderline abnormality on the electrocardiogram with Q waves in lead III and AVF. Serum cholesterol levels were normal in each instance. Spirometry showed diminution of total vital capacity to 53 and 77 per cent of normal in two of the patients. One of these (L. Be.) had transitory manifestations of the Pickwickian syndrome prior to entry, but these manifestations had cleared before his admission to our study. Blood gas studies in this patient showed arterial pH 7.4 with pCO,41 to 49 mm. Hg and ~0, 65 to 70 mm. Hg. Blood gas studies gave normal results in two other patients (A.P. and P.H.). 249
Scott and Law
TABLE
I
Pre- and Postoperative
2. P.H. 3. J.G. 4. H.Bu 5. L.Be
>95
50-300
150-250
c4.5
>2.5
Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative
1.0-3.3 22-28 1.9-4.8 64-157 2.7-3.0 24-42 6.7-7.0 16-23 1.4-4.8 30-107
97 60-80 98 30-33 96 68-86 97 24-40 97 30-50
38-50 20 96 13 79 22-31 76-95 31 53 44
175-214 130 225 95-130 190-240 145-160 165-220 155-190 210-225 135
4.4-7.0 2.9 7.0 3.6-3.9 5.0 3.4 6.6 3.1 6.7 2.1
0.8-1.2 3.2-3.5 1.5 4.6-6.4 1.3-2.3 0.8-1.9 2.5-3.1 2.3-3.4 0.7-1.9 2.2-7.0
'
550 500
2 a z
450
5 g
350 300
p
250
Fecal Nitrogen (gm. per cent)
Cl.5
650
$
Obesity
Normal
Preoperative appraisal of intestinal fat and carbohydrate absorption, as indicated by the data in Table I, was normal in each patient. It is of interest, however, that four of the five patients showed low or low normal serum albumin levels before operation and one of these had slightly elevated fecal nitrogen excretion. Other preoperative parameters of absorptive capacity were essentially normal although two patients had low serum magnesium levels ; each of these had recently received diuretic treatment. Psychiatric study revealed no single common denominator in the personality structure of these obese patients. Three of the five patients demonstrated mild depression, anxiety, and passive dependence on psychologic testing. The diagnostic impression in two patients was “passive aggressive personality.” All patients were thought by the staff who dealt with them to be relatively immature. After operation each patient was maintained in the Surgical Intensive Care Unit with spe-
600
with Morbid
D-Xylose Tolerance Serum Coefficient of Serum Cholesterol (gm./5 hr. urine Fat Absorption Carotene Fecal Fat collection) (gm. per day) (per cent) (pg. per cent) (mg. per cent)
Patient
1. A.P.
Values in Five Patients
x.
4m 00
200 -I
Fig. 3. Chronology of weight loss in five patients with morbid obesity after jejunoileal shunt.
cial attention paid to respiratory support and pulmonary toilet. The use of the respirator to assist respiration in the first slix to twelve hours after anesthesia facilitated satisfactory return to normal respiratory function. Although a low grade fever, which was possibly pulmonary in origin, occurred in each patient in the first f.ew days after operation, no significant instance of atelectasis or pneumonitis was encountered. Three patients had healing of the large abdominal wound per primum and without evidence of seroma or infection. However, major infections developed in the subcutaneous layer of the wound in two patients, requiring drainage and delayed convalescence. In both instances tight stay sutures caused extensive lacerations of the skin and subcutaneous tissue. As oral intake was increased in the early postoperative period, diarrhea became progressively severe. Low fat diet, restriction of fluids with meals, and diphenoxylate hydrochloride in a d’osage of 5 mg. three to four times per day resulted in considerable improvement while patients were in the hospital. All patients had a transient but significant drop in serum albumin levels during the first month after operation. After discharge from the hospital each patient was followed up on a regular basis in the clinic with periodic readmission to a metabolic ward. A three to twenty month appraisal of the effects of operation has been obtained in the five patients. Figure 3 documents the chronology of weight loss in pounds during the follow-up period. Three of the five patients have returned to active full time work at their preoperative ocThe American Journal
of Surgery
Jejunoileal
TABLE
I
Serum Albumin/Globulin (gm. per cent)
Pre- and
Postoperative
Serum Uric Acid (mg. per cent)
Values
Prothrombin Time (per cent)
in Five Patients
Serum Vitamin A
Serum Vitamin C
(rg. per cent)
(mg. per cent)
with
Morbid
Serum Calcium (mg. per cent)
Obesity
Shunt
in Morbid
(continued)
Serum Magnesium (mW.L.)
Serum Potassium (mW-.)
3.55/l.%3.2
3-6
60-100
26-82
>0.5
8.5-11
1.4-1.8
3.5-5
413.4 4.412.7 3.512.9 3.2-3.513-3.4
9-12 a 6.8 5.7
73 81 76 56-76
37 ;:oo, 16
0.9 0.9 ... 1.0
9.4 9.0 9.0 8.5-9.2
x413.3 3.5-3.6/Z.%3.0 3.413.2-3.9 3.8-4.413.6-4.3 3.2-3.313.4-3.6 3.313.6
8.1 6.8-8.2 4.2 9.6-9.7 9.1-10.8 7.5
73-80 a7 80-87 70 67 76
33 39 23-33 36 21 24
0.9 0.8 1.5 0.3 1.3 0.8
9.0 10.1 9.6-9.9 10-11.2 9.6 8.6
1.54 1.58 1.70 1.5-1.8 1.3 1.1-1.2 1.84 1.42 1.1-1.3 1.3
4.1 4.0 4.4 4.2-4.5 4.0 4.7 3.9-4.3 3.5 4.o-4.7 3.4
cupations. One patient who was incapacitated by massive obesity prior to operation has since undertaken a professional career in nursing. The most recent patient who was also severely incapacitated by his morbid obesity is now seeking employment only three months after jejunoileostomy. In general, the voracious appetites and the large caloric intakes have been unchanged by the operative procedure. There have been sporadic episodes of unexplained nausea and vomiting since operation in four of the patients. Diarrhea has continued to be a significant problem for two patients (P.H. and J.G.) despite dietary instruction and treatment with diphenoxylate hydrochloride and deodorized tincture of opium. A therapeutic trial of Questran@ (cholestyramine) 12 gm. per day in one of these patients failed to decrease the diarrhea. Under dietary supervision in the hospital, however, both patients had considerable improvement. Excessive liquid and fat intakes appear to be instrumental in the production of persistent diarrhea. Table I documents the changes in the absorptive and metabolic parameters which have resulted from jejunoileostomy. Severe &atorrhea has developed in every instance with a resultant fall in serum carotene and cholesterol levels. As measured by d-xylose tolerance, a significant reduction in carbohydrate absorption has resulted in each patient. In three patients fecal nitrogen excretion has exceeded normal ranges. Total serum proteins have been maintained in the preoperative range and the trend toward hypoalbuminemia has persisted in four of the five patients. The absorption of vitamins K, A, C, and D as reflected by prothrombin times, serum levels of vitamins A vol. 117, February1969
Obesity
Hematocrit (per cent) ...-____ 44-483’ 37-46 0 50-54 43-51 40-45 36-41 41-44 41 41-45 50 41-48 39
and C, and adequate serum calcium concentrations appears to be satisfactory except in one patient (P.H.) with subnormal vitamin A levels and in another (H.Bu.) whose postoperative serum level of vitamin C is below normal. Mild hypomagnesemia has persisted in the two patients in whom this cation was subnormal before operation, and one of these also had a decline in serum potassium concentrations since operation. Hematocrits have shown slight reduction since operation in three of the five patients but have remained within the normal range. Results of the Shilling test for estimation of vitamin B12 absorption after jejunoileostomy have been 8 and 12 per cent (low normal) in the two patients studied thus far. Metabolic balance studies, serial lipid profiles, and serial analysis of body composition in these pati’ents will be reported after a longer period of follow-up study. As abdominal girth has declined six to twelve months after operation, each of the three female patients has been found to have a palpably enlarged liver with an edge three to four fmgerbreadths below the costal margin. At operation the liver was considered to be normal in size and appearance in each instance. Follow-up studies in these patients of prothrombin times, serum bilirubin, alkaline phosphatase, lactic dehydrogenase (LDH), and transaminase oxalacetic glutamic serum (SGOT) were within normal limits except in one patient (H.Bu.) who had minimal elevations of LDH and SGOT. However, there was bromsulphalein retention of 6 to 29 per Cent in each of the three patients. Needle aspiration biopsy in each of these three patients Sk to twelve months after operation revealed marked fatty metamorphosis of the liver. (Fig. 4.) 251
Scott and Law
Fig. 4. Photomicrographs of liver biopsy specimens showing extensive fatty metamorphosis in two patients (J.G. and P.H.) with morbid obesity six and twelve months after jejunojfeal shunt.
Comments The problems of etiology and practical management of morbid obesity are as yet unsolved. The serious social, economic, and health complications of this unfortunate disorder warrant continued study. The major obstacle to successful medical therapy seems to be the patients’ lack of ability to control his gluttonous dietary habits over a prolonged period of time. For these reasons serious consideration has been given to operative procedures which induce and maintain weight loss despite the patient’s continued gluttony. Initial experience with extensive intestinal bypass and jejunocolic anastomosis [2,3] demonstrated that obligatory weight reduction could be achieved in these patients, but the excessive diarrhea and serious metabolic complications prompted the continued search for a more acceptable procedure. DeWind and Payne [4] have reported that intestinal bypass with jejunoileostomy and preservation of the ileocecal valve accomplishes satisfactory weight loss with fewer unpleasant sequelae. This procedure has attracted the attention of both patients and surgeons and the operation is being performed with increasing frequency. DeWind and Payne [4] have carried out a careful 252
clinical study of their patients and have cautioned against considering jejunoileostomy as a preferred therapy for obesity and have restricted it to carefully selected patients. The initial results of our study confirm that weight loss can be accomplished by the application of this procedure with symptomatic sequelae which are acceptable to four of our five patients. Clinically, we consider that three patients have had a good result with social and economic rehabilitation, significant weight loss, and two to five controllable bowel movements daily. One patient is considered to have a fair result with attacks of severe diarrhea and the fifth patient must be considered a poor result because of persistent and often uncontrollable diarrhea and anal irritation requiring recurrent hospitalization. It is of note that this last patient had a previous history of alcoholism and an irritable colon syndrome. Despite the documented clinical improvement in most reported series there is as yet only one thorough metabolic evaluation of the consequences of the procedure. Morgan and Moore [5] showed in a meticulous study of an obese patient treated by jejunoileostomy that the compositional deformity as determin’ed by isotope dilution studies was not corrected by a 41 kg. weight 10~s~ nor a year of stable weight at 200 pounds. Another concern is the finding of hepatomegaly and fatty liver in both DeWind and Payne’s patients and in our own. Subsequent development of irreversible liver disease must be considered a potential hazard in these persons. In addition, other potential long-term consequences of a severe malabsorption syndrome must be considered. Spotty and unpredictable deficits of specific nutrients in our small series are in keeping with findings in other malabsorptive states and suggest the need for very careful clinical and metabolic follow-up study of all patients if this procedure is to be performed. We wish to express our appreciation for the valuable assistance given in the management and continuing follow-up study of the initial patient in this study by Dr. A. Hare11 and Dr. A. Farhi, Tel-Aviv, Israel. Acknowledgment:
References 2.
VARCO,R. Personal communication. PAYNE, J. H., DEWIND, L. T., and COMMONS, R. R. Metabolic observations in patients with jejunocolic shunts. Am. J. Surg.,
3.
LEWIS, L. A., TURNBULL,R. B., JR., and PAGE, H. Effects of jejuno-colic shunt on obesity,
1.
102:2’73,
1963.
The American
Journal
of Surgery
Jejunoileal
4. 5.
serum lipoproteins, lipids, and electrolytes. Arch. Int. Med., 117:4, 1966. DEWIND, L. T. and PAYNE, J. H. Morbid obesity treated by intestinal bypass. A follow-up study. J.A.M.A., in press. MORGAN,A. P. and MOORE,F. D. Jejuno-ileostomy for extreme obesity: rationale, metabolic observations and results in a single case. Am. Surg., 166:75, 1967.
Discussion J. HOWARDPAYNE (Los Angeles, Calif.) : This is a significant piece of research and represents the type of study that is necessary to evaluate the intestinal bypass operation and determine its place in the treatment of morbid obesity. We at the University of Southern California have had twelve years’ experience with the bypass procedure, the last six years with our final modification of the operation which is similar to that discussed bv Dr. Scott. We have nerformed eighty-three such operations. We did not arrive at the figures of 14 inches and 4 inches at once, but by trial. It soon became evident that these measurements are extremely critical. With 1 or 2 inches more, the patient will initially lose 40 to 60 pounds and then his weight will level off; some have even gained weight with 15 inches of jejunum and 5 inches of ileum. Our present recommendation is 14 inches of jejunum and 4 inches of ileum since we have had our most consistent results with these measurements. For instance, one male patient weighing 535 pounds has now leveled off at 190 pounds. It should be pointed out that this is the only approach to morbid obesity that offers the patient a safeguard against regaining the lost weight. They cannot regain their weight, but it may vary a few pounds. Another important thing about the jejunoileal shunt is that the ileocecal valve and the ascending colon are in the circuit. The devastating diarrhea seen in patients with jejunocolic shunts is not present. All of our patients eventually have two or three semisolid stools a day. Diarrhea may be a factor
Vol.l17,February1969
Shunt in Morbid Obesity
if they overindulge in large amounts of liquid or go on a fat or carbohydrate binge. I would like to emphasize that we still consider this an experimental procedure. Anyone who is going to perform the operation must commit himself and the patient to long-term follow-up study. DAVID H. LAW, IV (closing) : I cannot stress enough that I consider, and I believe our whole group considers, that this operation is still an experimental procedure. The long-term effects are unknown. We have had an inkling of some of the conseauences mentioned by Dr; Scott and Payne, that is, severe fatty liver which occurred in three of our patients as well as in a number of Dr. Payne’s. One must be alert to the late occurrence of osteomalacia and osteoporosis which have been noted with other chronic malabsorption syndromes. We have noted deficits of specific nutrients, such as vitamin A and C and magnesium, in these patients and we are looking for zinc deficiency. Maintenance of an abnormal body composition profile or even a further exaggeration of that abnormality after weight loss has occurred, as has been reported by Morgan and Moore, gives further pause when considering long-term effects. Also, one must consider the potential psychiatric problems of morbidly obese persons who are reverted to relatively normal configuration. For these and for many more reasons, we have undertaken the present preliminary study. Any procedure that effectively decreases weight has a great appeal to patients as well as physicians since these persons are difficult to deal with. Although Dr. Payne has been most conservative in his consideration of this procedure, I cannot help equate it with some of the other recent therapeutic procedures that have rapidly gained attention at an early phase and have received widespread use only to fall into disrepute after adequate study was undertaken. It is rather premature to undertake intestinal bypass unless you are willing and able to make very meaningful long-term metabolic and clinical evaluation of the patient. I believe it will take another several years at least before this should be considered as a therapeutic venture.
253