Edward R. Woodward

Jejunoileal Bypass for Morbid Obesity: Late Follow-up in 100 Cases

To evaluate the results of jejunoileal bypass for morbid obesity, we studied 100 patients with intact bypasses an average of more than five years after surgery. Mean weight loss at five years was 102.7 lb (46.6 kg) (33 per cent). Although nearly half the patients regained some weight between one and five years after surgery, only 17 per cent regained 20 lb (9 kg) or more. Medical benefits (such as improved glucose tolerance and lowered blood pressure) were maintained at five years, but side effects and complications continued to occur in the late postoperative period. Diarrhea (more than three stools per day) persisted in 58 per cent of the patients, and electrolyte disturbances occurred in over a third. Diminished levels of B12 or folate or both were present in 88 per cent. Twenty-one per cent of the patients had nephrolithiasis, and 20 per cent of those who were at risk required cholecystectomy. Progressive hepatic structural abnormalities occurred in 29 per cent of the patients, and there was a 7 per cent incidence of cirrhosis. Although 81 per cent of the patients had satisfactory results at five years, side effects and complications continued to occur, mandating careful follow-up indefinitely. The risk-to-benefit ratio at five years after surgery seems acceptable, but the continued untoward effects of the bypass in the late postoperative period have led us to abandon this procedure in favor of gastric bypass. Only continued longitudinal follow-up will determine whether on balance jejunoileal bypass represents such a serious long-term health hazard that prophylactic restoration of intestinal continuity is indicated.

Downstaging of esophageal cancer after preoperative radiation and chemotherapy

ObjectiveThis retrospective, nonrandomized review evaluates 125 patients with esophageal carcinoma (adenocarcinoma and squamous cell) who underwent either surgery only or preoperative chemotherapy and/or radiation therapy followed by surgery. Major end points were survival and postchemoradiation downstaging. MethodsForty-four patients underwent radiation therapy of 4500 cGy over 5 weeks. Fluorouracil and cisplatin were administered on the first and fifth week of radiotherapy. Ninety-eight patients underwent “potentially curative” resections–transhiatal esophagectomy (70), Lewis esophagogastrectomy (25), and left esophagogastrectomy (3). All patients with preoperative adjuvant therapy underwent endoscopy and biopsy before surgery. ResultsThere were no differences in overall mortality (5%) or surgical complications in either group. Fourteen of 44 patients (32%) downstaged to complete pathologic response, with 5-year survival of 57%. Fifteen of 44 patients (34%) downstaged to microscopic residual tumor, with 1− and 3-year survival of 77% and 31%, respectively. Twenty-eight of 29 patients in the two downstaged groups were lymph node negative. Overall, 5-year survival in the adjuvant therapy plus surgery group versus surgery only was 36% and 11% (p = 0.04). Five-year survival in lymph node-negative adjuvant therapy and surgery patients was 49% (p = 0.005). Positive nodes in the surgery only group was 48% versus 23% in the adjuvant therapy and surgery group (p = 0.02). ConclusionAlthough retrospective and nonrandomized, these results suggest that preoperative chemoradiation results in significant clinical and pathologic downstaging, increases survival, and may sterilize local and regional lymph nodes, accounting for both downstaging and survival statistics.

Hepatic effects of jejunoileal bypass for morbid obesity.

Abstract Experience with thirty-seven intestinal bypass operations in thirty-six patients is reported. Documented severe liver failure occurred in six patients with one death. The failure is manifested by the onset of anorexia, nausea, crampy abdominal pain, and vomiting. The earliest detectable functional abnormality appears to be a decrease in uptake of technetium sulfa colloid by the liver. Bromsulphthalein retention is followed by hypoalbuminemia and hypokalemia. Elevation of the SGOT, SGPT, and alkaline phosphatase levels may occur at this time. Fluid retention with weight gain, peripheral edema, and ascites is rapidly followed by hyperbilirubinemia of the conjugated type. Lesser degrees of abnormal liver function were discovered in eight other patients. Halothane anesthesia, hepatitis-associated antigen, alcoholism, and diabetes do not appear to be factors.

Long-Term Consequences After Jejunoileal Bypass for Morbid Obesity

This study assesses the long-term results ofjejunoileal bypass (JIB) in 43 prospectively followedpatients whose surgical bypass remained intact.Follow-up was 12.6 ± 0.25 years from JIB. Weightloss and improved lipid levels, glucose tolerance,cardiac function, and pulmonary function weremaintained. Adverse effects such as hypokalemia,cholelithiasis, and B12 or folate deficiency decreasedover time. The incidence of diarrhea remained constant(63% vs 64% at five years), while the occurrence ofhypomagnesemia increased (67% vs 43% at five years, P< 0.05). Nephrolithiasis occurred in 33% of patients. Hepatic fibrosis developed in 38% of patientsand was progressive. Overall, after more than 10 years,35% of patients appeared to benefit from JIB as definedby alleviation of preoperative symptoms and the development of only mild complications (vs47% at five years). On the other hand, irreversiblecomplications appeared to outweigh any benefit derivedfrom the JIB in 19% (vs no patients at five years; P < 0.01). In summary, patients with JIBremain at risk for complications, particularly hepaticfibrosis, even into the late postoperativeperiod.

Delayed gastric emptying of liquids and solids following Roux-en-Y biliary diversion.

Recent reports cite an increased incidence in delayed gastric emptying following Roux-en-Y biliary diversion for alkaline reflux gastritis. The effect of Roux-en-Y diversion on the gastric emptying of liquids and solids was evaluated following vagotomy and antrectomy and vagotomy and subtotal gastrectomy. Twenty dogs underwent placements of large Thomas cannula in the stomach. Four dogs with intact stomachs served as controls. Eight dogs each with vagotomy and antrectomy were subdivided into Roux-en-Y gastrojejunostomy (RYA) and a Billroth II (B-IIA) group. Eight dogs each with vagotomy and subtotal gastrectomy were subdivided into similar groups. Four dogsacRoux-en-Y (RSTG) and four dogsacBillroth II (B-IISTG). Gastric emptying of solid food, normal saline and 25% dextrose was evaluated. RYA dogs demonstrated a significant delay in gastric emptying of solids compared with corresponding B-IIA animals. RYA dogs had 76, 61 and 42% of solid food retained at three, five and eight hours while B-II animals retained 56, 41 and 20%, respectively. The results are highly significant at all time intervals (p ≤ 0.001 at five and eight hours). Control animals retained 34, 17 and 3% of solid food at three, five and eight hours. RSTG animals had 73, 52 and 28% retained solids at three, five and eight hours, while B-IISTG animals had 55, 42 and 13% retention, respectively (p ≤ 0.05 at eight hours). Normal saline was significantly delayed in both Roux-en-Y subgroups compared with B-II dogs (p ≤ 0.02 in V/A, p ≤ 0.05 in V/STG). There was a trend toward delayed emptying of 25% dextrose in the Roux-en-Y groups, but significance was achieved only in the RYA compared with B-IIA groups (p ≤ 0.02 at 30 minutes). Delayed gastric emptying following Roux-en-Y gastrojejunostomy is documented in the experimental animal which underwent vagotomy and appears greater in magnitude than that observed following vagotomy and B-II gastrectomy. These data corroborate the clinical observations of severe delayed gastric emptying in patients undergoing Roux-en-Y diversions for alkaline gastritis

Urinary tract stone after small bowel bypass for morbid obesity

Abstract There is a marked increase in the incidence of urinary tract stones in patients who have undergone intestinal bypass for obesity. Increased urinary excretion of oxalate is a regular finding in such patients. Taurine and cholestyramine did not influence hyperoxaluria in the two patients tested with each drug. In patients with small bowel bypass, caloric intake is an important factor in determining the magnitude of hyperoxaluria. We do not believe that the resultant susceptibility of these patients to renal calculi is a contraindication to intestinal bypass; however, it is a potential complication that should be considered preoperatively and brought to the attention of the patient.

Vagotomy and drainage procedure for duodenal ulcer: The results of seventeen years' experience.

During the 10 years prior to January, 1968, 455 duodenal ulcer patients were operated upon at the University of Florida affiliated hospitals. The early results were reported in 1969. The present study is a followup of the same patients now 7 to 17 years after vagotomy and drainage. Twenty-four per cent were lost to followup. The ulcer recurrence rate was 5.8 per cent. All the recurrent ulcers that were not gastric in location (4.9%) occurred within 5 years after the original operative procedure with a mean of 2.6 years. The gastric ulcers (0.9%) occurred at a much later date with a mean of 6 years. It is concluded that vagotomy and gastric drainage is a satisfactory modality of therapy for duodenal ulcer. It can be accomplished with an acceptable morbidity and mortality and the long-term recurrence rate is low. If recurrences due to incomplete vagotomy do not occur within 5 years, they are unlikely to recur.

Nissen fundoplication for reflux peptic esophagitis.

One hundred sixty-five patients with reflux peptic esophagitis have been treated by Nissen fundoplication. When compared with a group of 104 patients reported five years ago, the incidence of persistent or recurrent esophagitis remains approximately the same (10% versus 8%). This is consistent with the assumption that the Nissen procedure when initially successful tends to remain so and that late recurrence appears to be uncommon. The unpleasant postoperative sequela which we have termed the “gas-bloat syndrome” was noted in 1971 to be present in the early postoperative period in approximately one-half the patients. Late follow-up, however, averaging four years indicates a marked reduction in this disorder with cither absence or clinical insignificance in 87% of patients. Nonetheless, moderate symptoms persist in 11% and severe symptoms requiring active treatment in 2%. Manometric study of the lower esophageal sphincter indicates nearly a three-fold increase in resting pressure following Nissen fundoplication (p < .001). It is hoped that manometetric study will provide a more reliable prognostic measure of sphincter restoration than the measurement of pH across the gastroesophageal junction.

Clinical and radionuclide evaluation of Roux-Y diversion for postgastrectomy dumping

From 1973 to 1986, 22 patients underwent Roux-Y gastrojejunostomy for the early postgastrectomy dumping syndrome. In the early years, five patients underwent Roux-Y conversion with the addition of a 10 cm antiperistaltic jejunal segment interposed between the Roux-Y limb and the stomach. Within 4 years, all five patients had the jejunal segment removed due to severe symptoms of gastric retention. These patients underwent reconstruction to create Roux-Y limb only and joined the pool of 17 patients who underwent Roux-Y diversion only for the dumping syndrome. Overall, 19 of 22 patients (86 percent) had almost complete resolution of their dumping symptoms on long-term follow-up. Three patients showed no improvement, two with severe gastric retention and one with recurrent dumping symptoms. Overall, 5 of 22 patients (23 percent) had moderate to severe early and late postoperative gastric retention necessitating medical treatment in three and subsequent near-total gastrectomy in two. Although other procedures such as pyloric reconstruction or the addition of isoperistaltic or antiperistaltic jejunal interpositions have been reported to be equally successful in delaying gastric emptying and resolving dumping symptoms, we have preferred Roux-Y diversion for the treatment of combined alkaline reflux gastritis and dumping or the pure early vasomotor postgastrectomy dumping syndrome. As reported, we have abandoned the use of an antiperistaltic jejunal segment interposed between the stomach and the Roux-Y limb due to the high rate of postoperative gastric retention.

Surgical treatment of the postgastrectomy dumping syndrome

Fifteen patients were treated surgically for dumping syndrome at the University of Florida between 1972 and 1977. Five of them had a reversed jejunal segment interposed between the stomach and the Roux limb and 10 had simple 45 cm Roux-en-Y gastrojejunostomy. The reversed segment has been, in our experience, a uniform disappointment. Straight Roux-en-Y duodenal diversion, with the exception of temporary delay in gastric emptying in a few cases, has proved successful in treating the postgastrectomy dumping syndrome.