Radiographic Evaluation of Complications after Jejunoileal Bypass Surgery

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1 Radiographic Evaluation of Complications after Jejunoileal Bypass Surgery ALBERT A. MOSS, HENRY I. GOLDBERG, AND ROBERT E. KOEHLER A retrospective analysis of 89 patients who underwent jejunoileal bypass surgery for morbid obesity disclosed 33 complications that were detected radiographically. Intestinal obstruction (10.1% of patients), cholecystitis (5.6%), renal stones (4.5%), peptic ulcer (3.4%), megacolon (6.7%), and elongation of the small intestine with hypertrophy of the mucosal folds of the jejunum (6.7%) were diagnosed solely by radiographic means. Massive, intractable obesity has been successfully treated surgically by two methods of intestinal bypass I 1, 21. The Payne procedure is a jejunoileal anastomosis in which 14 inches of jejunum is anastomosed to 4 inches of terminal ileum in an end-to-side manner [3]. Although satisfactory weight reduction is achieved by most patients, a number of patients fail to reach or maintain adequate weight reduction. Some investigators [4, 5] have suggested that reflux of nutrients into the bypassed ileum may account for some of these failures. The Scott procedure [5] was designed to prevent reflux into the bypassed ileum. In this operation the proximal jejunum is anastomosed endto-end to the distal ileum, and the bypassed small intestine is diverted into the transverse or left colon. The incidence of various complications following jejunoileal bypass surgery is difficult to ascertain because most series are small and report only particular complications in depth [6-1 1 ]. The contribution of the radiologic examination of the intestine in detecting complications of jejunoileal bypass surgery has been all but ignored [4]. This retrospective study was undertaken to determine the number, type, and incidence of complications following jejunoileal bypass surgery in which radiographic findings were instrumental in the diagnosis. Materials and Methods The medical records and radiographs of all patients who underwent a jejunoileal bypass procedure at our institution from 1966 through 1974 were analyzed. The group consisted of 89 patients, 72 female and 17 male. Ages ranged from 15 to 61 years (mean, 36.8). The mean weight was kg (range ). The period of follow-up averaged 33 months. Of the 89 patients, 84 initially underwent a Payne type of intestinal bypass; five had a Scott procedure. Metabolic disturbances, electrolyte abnormalities, and hepatocellular complications were noted but not analyzed in detail. Follow-up surgical procedures such as hernia repairs and lipectomies were not considered complications for purposes of this analysis. Particular attention was paid to any complications in which radiographic evaluation played a significant role in locating or detecting the complication. Results A total of 33 postsurgical complications were detected radiographically (table 1 ). One complication occurred in 22 patients, and six patients experienced more than one complication. Intestinal obstruction (tabte 2) was the most common complication, occurring in 10.1% of the patients. Three cases of obstruction were due to jejunoileal (fig. 1 ). One patient had jejunojejunal of the bypassed segment, and volvulus or incarcerated hernia were encountered in four patients. Half of the obstructions occurred within 2 weeks of surgery, and all were diagnosed by barium examinations of the small bowel or plain films. Cholecystitis and cholelithiasis developed in five patients (5.6%) following jejunoileal bypass (table 3), while gallstones, cholecystitis, or both were found in six patients at the time of bypass surgery. Twelve patients had previous cholecystectomies for gallbladder disease. Thus 1 1 (14.3%) of 77 patients having gallbladders were found to have abnormal gallbladders at the time of initial bypass surgery or developed cholecystitis following jejunoileal shunt. Renal stones occurred in four patients (4.5%). In two instances the calculi proved to be oxalate stones. Uric acid stones were passed on four occasions by one patient. and radiopaque renal calculi developed in another patient. Peptic ulcer developed in three patients (3.4%). Two were found to have duodenal ulcers, and in one patient a large gastric ulcer developed 2 years after bypass surgery. In this patient an analysis for gastric acid before surgery demonstrated a basal acid output of 2.56 meq/hr and a maximum stimulated output of 39.6 meq/hr. After surgery, the basal acid output had increased to meq/hr and the stimulated output to meq/hr. Six patients (6.7%) had symptomatic megacolon (fig. 2 and table 4). Most had severe diarrhea and abdominal pain, and the colon in all instances was dilated to greater than 7 cm in diameter. Ulcerations were not identified, and persistent metabolic or electrolyte abnormalities were not observed. In one patient prostaglandin E1 was administered, but the colon did not contract. In six patients (6.7%) elongation of the jejunum and hypertrophy of mucosal folds of the jejunum and ileum were demonstrated and verified surgically (fig. 3A). Pathologic examination of specimens showed villous hypertrophy, wall thickening, and elongation of the bowel (fig. 38). All six patients failed to lose weight or to maintain adequate weight loss. Radiographically the bowel appeared Received February 23, 1976; accepted after revision June 16, Presented at the annual meeting of the American Roentgen Ray Society. Atlanta, Georgia, October A. E. Koehler is supported in part by training grant GM from the National Institute of General Medical Sciences, National Institutes of Health. 1 All authors: Department of Radiology. University of California School of Medicine, San Francisco, California Am J Roentgenol 127:

2 738 MOSS ET AL. Fig. 1. -Jejunoileal following Scott procedure. Jejunum telescopes over ileum resulting in reversed. TABLE 1 Radiographically Detected Postsurgical Complications Complication Frequency Patients 1%) IN 89) Obstruction Cholecystitis, cholelithiasis Renal stones Peptic ulcers Megacolon Elongation. hypertrophy TABLE 2 Intestinal Obstruction after Jejunoileal Bypass Surgery Age (Yr) Type of Bypass Cause of Obstruction Time of Onset after Bypass Payne (1 4 X 4 ) Jejunoileal Scott (1 2 X 1 2 ) Jejunoileal Note - All patients were female 1 5 mo 2 wk Payne (1 4 X 4 ) Jejunojejunal 2 yr Scott (1 2 X 4 ) Jejunoileal 9 mo Payne (13 X 5 ) Incarcerated umbilical 4 days hernia Payne (1 4 X 4 ) Incarcerated umbilical 4 yr hernia Payne (1 4 X 4 ) Volvulus jejunum 4 days Payne (1 4 X 4 ) Volvulus and herniation 7 days Payne (1 4 X 4 ) Misplaced suture 1 wk Fig. 2.-Barium study showing distention of colon to 8.5 cm. Patient had severe nonbloody diarrhea. TABLE 3 Gallbladder Disease after Jejunoileal Bypass Surgery Age (Yr) Complication Time of Onset after Bypass 49 Acute cholecystitis, cholelithiasis 4 yr 26 Acute cholecystitis, cholelithiasis 2 wk 28 Acute cholecystitis, cholelithiasis 4 wk 46 Acute cholecystitis, jaundice, stones in 3 mo common bile duct and gallbladder 25 Acute cholecystitis, cholelithiasis 3 yr Note. -All patients were female. dilated, and the length of bowel had increased over that measured at the finish of surgery. Several of these patients also had reflux of barium into their bypassed ileum (fig. 4). Discussion Fikri and Cassella [8] reported 34 operative and 73 delayed complications in 52 patients undergoing jejunoileal bypass surgery. Baber et al. [1 1 1 noted a 32.2% complication rate over a 10 year period in 86 patients who underwent bypass operations. While these reports mentioned that some complications were demonstrated by radiographic methods, the number and type of complications in which radiography played a significant role in detection were impossible to ascertain.

3 JEJUNOILEAL BYPASS SURGERY 739 TABLE 4 Megacolon after Intestinal Bypass Age (Yr) Type of Bypass Symptoms Turn: of Onset Scott ( 8 X 8 ) Diarrhea, weakness, nausea Payne (14 X 4 ) Massive diarrhea, abdominal pain Scott (13 X 5 ) Diarrhea, abdominal 2 distention Scott (13 X 5 ) Diarrhea Payne (14 X 4 ) Abdominal pain. 1 bloating, nausea Payne (14 X 4 ) Bloating, diarrhea 2 Note. - All patients were female. Our 89 patients suffered 33 complications which were diagnosed radiographically. The most common complication was intestinal obstruction. However, unlike most cases of intestinal obstruction, none was due to adhesions. Because of the extreme obesity of these patients, an umbilical hernia is often present which predisposes to incarceration of the intestine. Intussusception in the anastomotic region has been reported to be a common cause of postoperative intestinal obstruction [8, and the small bowel has been fixed to the root of the transverse mesocolon to prevent it [12]. Rearrangement of normal anatomy, mesenteric defects, and rapid weight loss may all be predisposing factors in the development of small bowel volvulus. Acute cholecystitis developing after jejunoileal bypass is a recognized complication of the procedure [1, 3, ii]. It occurs in patients having normal gallbladders [11] and (Yr) 1,. ( _ IA Fig Massive reflux of barium into blind loop of ileum in patient with inadequate weight loss following Payne-type jejunoileal bypass. in those with cholelithiasis but no evidence of cholecystitis present at surgery [1]. The high incidence of acute cholecystitis in the postoperative period has led some I

4 740 MOSS El AL. surgeons to consider prophylactic cholecystectomy [ Although we are not sure prophylactic cholecystectomies are indicated, we do believe that an oral cholecystogram should be part of the presurgical evaluation. If it is found to contain calculi or any evidence of disease, the gallbladder should be removed. Renal oxalate calculi can develop in patients with inflammatory disease of the ileum or those who have had resection of the terminal ileum [13, 14]. Renal oxalate calculi have also been noted in 6%-1O% of patients undergoing jejunoileal bypass [9]. The postoperative oxalate level in increased in approximately 90% of patients who form renal oxalate calculi [9]; this increase was documented in two of our four patients with renal stones. The finding of uric acid renal calculi in one patient raises the possibility that uric acid metabolism can be altered in some patients following bypass surgery. A transient increased rate of basal gastric secretion following massive small bowel resection has been noted in dogs [15, 16] and man [16]. We observed an increase in basal and maximum stimulated acid output in one patient who developed a gastric ulcer. The cause of the increased acid output is to date unknown. Megacolon is a complication of intestinal bypass surgery for which the radiologist has primary diagnostic responsibility. Counting our six cases, nine examples have now been reported [8]. The patients usually have severe diarrhea that develops from 5 months to 3 years after bypass surgery. The cause of the megacolon remains unknown. No consistent electrolyte abnormalities have been found, but the lack of colonic response to prostaglandin E1 administration suggests that some type of autonomic dysfunction occurs. Megacolon should be suspected if a plain film of the abdomen shows a colon measuring greater than 6.5 cm in diameter. Unlike toxic megacolon, the margins of the dilated colon are not irregular or ulcerated, and no clinical signs of toxicity are present. Reflux of barium into the bypassed ileum was noted in seven of our patients. Three subsequently had revision of their bypass because of inadequate weight reduction. The other four have begun to regain weight after a satisfactory initial weight reduction, and it is tempting to ascribe these shunt failures to reflux of nutrients into the ileum. Quaade et al. [17] failed to note any relation of blind loop reflux to weight reduction in patients with 12 inches of jejunum anastomosed to 12 inches of ileum. The relationship between reflux of barium into the bypassed ileum and amount of weight loss has not been evaluated for the Payne procedure. Elongation of the small bowel and hypertrophy of the mucosal folds may also be demonstrated radiographically. Dowling and Booth [18] confirmed these findings by surgical exploration and histologic examination of resected small bowel. In one series, elongated jejunum was found in 75% of patients who underwent jejunoileal revisions [3]. Ten of our patients had an elongated jejunum, six of whom have undergone revision of the jejunum for failure to maintain adequate weight loss. The time it took for elongation ranged from 6 months to 3 years after jejunoileal anastomosis. We recommend a radiographic examination of the small bowel in all patients shortly after bypass surgery to establish a baseline measurement. If weight gain then occurs, lengthening of the bowel can be confirmed on follow-up films. In rats after intestinal resection, epithelial cells migrate more rapidly up the intestinal villi [19]; in dogs an increased length of villi [20] and villose hypertrophy [21] have been demonstrated. Porus [22] found no quantitative evidence that hypertrophy of intestinal villi occurs in man after intestinal resection. However, he did note an increased number of cells per unit length of epithelial border. We found thickening of the folds in the proximal jejunum in six of our patients after the bypass surgery. All these patients also had elongation of the bowel and subsequently underwent surgical resection and reanastomosis for inadequate weight reduction. Pathologic examination revealed rugal hypertrophy, a hyperplastic mucosal pattern of the jejunum, and a pattern of abundant villi with individual thickening. The pathologic diagnosis was villose hypertrophy. The relationship of this villose hypertrophy and elongation of the bowel to inadequate weight reduction remains unknown. REFERENCES 1. Gazet J-C, Pilkington TRE. Kalucy AS. Crisp AH, Day S: Treatment of gross obesity by jejunal bypass. 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