Sleeve Gastrectomy after a Jejunoileal Bypass Reversal: Case Report and Review of the Literature

by Sheetal M. Patel, MD; Tomas Escalante-Tattersfield, MD; Samuel Szomstein, MD, FACS; and Raul Rosenthal, MD, FACS

All from the Bariatric Institute, Section of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, Florida

INTRODUCTION
The jejunoileal bypass was first performed in 1969 for the treatment of obesity, achieving dramatic weight loss. Severe malabsorption, however, caused multiple metabolic complications that eventually led to the abandonment of this procedure. More than 100,000 jejunoileal bypass procedures have been performed, many of which may still develop complications that need revisional surgery. We present the case of a morbidly obese male patient who developed several chronic complications after a jejunoileal bypass that was performed more than 30 years ago. After reversal of the jejunoileal bypass, the patient became morbidly obese again and required a new bariatric procedure. The life-threatening complications of his previous malabsorptive procedure warranted the selection of a restrictive sleeve gastrectomy as his treatment. This is the first report of a sleeve gastrectomy following the reversal of a jejunoileal bypass.

Case Report
A 57-year-old male was referred to our institution for the reversal of a JIB that had been performed 35 years earlier (Figure 1 and Figure 2). His initial preoperative weight was 141Kg (312 pounds), which equates to a body mass index (BMI) of 43.5. At the time of referral, he was suffering from multiple complications secondary to chronic malabsorption, including worsening renal insufficiency and hepatic dysfunction. He also had a history of chronic pancreatitis, chronic malabsorptive diarrhea, and peripheral neuropathy. His past surgical history included a cholecystectomy 10 years after the JIB. He had recurrent nephrolithiasis that warranted repeated hospitalizations for urosepsis. He was being treated for thrombocytopenia and the related coagulopathy. His weight and BMI were 77Kg (169 pounds) and 23.6, respectively.

Because of several previous surgeries, an exploratory laparotomy was performed through a midline incision. After a complete abdominal exploration and an extensive lysis of adhesions, the JIB was reversed with the creation of a side-to-side jejunojejunal stapled anastomosis. Because of the unknown response of the previously bypassed bowel, a gastrostomy tube was also fashioned. His hospital stay was uneventful; he was started on a clear liquid diet 24 hours after surgery and was progressively advanced as tolerated. He was subsequently discharged six days after surgery. Four days later, he developed a wound infection that was successfully treated with antibiotics and local wound care.

Twelve months after the JIB reversal, his weight was 135Kg (298 pounds), with a BMI of 41.6. A nutritional evaluation revealed excessive fat intake, frequent snacking at night, and consumption of large portions of food. His medical evaluation was unremarkable with normal renal and liver function. After a thorough preoperative workup, he was scheduled for an elective laparoscopic sleeve gastrectomy. Due to the patient’s history of multiple surgeries, the procedure was converted to open secondary to excessive adhesions.

In brief, the procedure involved ligation of the vessels along the great curvature of the stomach from the left crus to 7cm proximal to the pylorus. This was performed with an ultrasonic scalpel. The stomach was then sectioned with a linear stapler over a 52-Fr bougie. The staple line was oversewn with an inverting running 2-0 silk suture.

A postoperative gastrografin swallow study revealed free flow of contrast through the gastric sleeve without a leak or extravasation of contrast (Figure 3). The patient was started on a clear liquid diet 24 hours after surgery and discharged from the hospital 48 hours after the procedure. Three weeks after surgery, he was tolerating a protein-rich liquid diet and was started on a solid diet. Six months after surgery he reported no issues with regard to his diet. His weight at that time was 119Kg (262 pounds) and his BMI was 36.7.

Discussion
Bariatric surgery began in 1952 when the first surgical operation with the specific purpose of losing weight was performed.7,8 After observing the effects of massive bowel resections in different diseases, Henriksson of Sweden was the first to surgically treat an obese patient by means of a small bowel resection.9 Two years later, Kremen et al were the first to bypass 90 percent of the small bowel without intestinal resection and produced significant weight loss.10 In 1956, Payne developed the jejunocolic bypass, generating a dramatic decrease in weight loss in 10 patients.1,11 Several postoperative complications, however, prompted the reversal of this malabsorptive procedure.1,9 Sherman et al modified the jejunocolic bypass in 1965,12 creating a less aggressive jejunoileostomy. Thereafter, in 1969, Payne further modified his approach from a jejunocolic bypass to a jejunoileal shunt by joining the first 35cm of jejunum to the last 10cm of ileum in an end-to-side anastomosis.1

The dramatic weight loss achieved with this procedure led to the spread of bariatric surgery as an attractive option for the treatment of obesity.2 This encouraged other surgeons to perform the JIB with their own personal modifications.9,13,14 Approximately 100,000 JIBs have been performed—mostly during the 10-year period that followed Payne’s report in 1969.15

Unfortunately, the impressive weight loss came at a very high price. The resulting malabsoprtion and diarrhea created a multitude of fluid and electrolyte abnormalities, including hypokalemia, hypocalcemia, hyperoxaluria, and hypoalbuminemia. This in turn led to the formation of renal calculi and liver failure.2,16 The long-term sequelae included cirrhosis,17,18 vitamin and mineral deficiencies,19 peripheral neuropathy,20 and chronic renal failure.19,21 The bypassed portion of small bowel is also responsible for some of the complications seen in JIB. Bacteria within the small bowel proliferate freely, developing chronic infections,3 and subsequently release bacterial toxins into the systemic circulation.2,22 Circulating antibodies then deposit in joint spaces causing immune complex arthritis and migratory polyarthritis.18,23

JIB is no longer recommended as a weight loss procedure because of these serious and life-threatening complications.3 As a result, several centers have reported a substantial number of revisions and reversals. The most common causes for reversal of the JIB are severe diarrhea, renal stones or renal failure, cirrhosis or liver failure, and life-threatening malnutrition.2,24-26 Once the continuity of the intestinal tract is re-established, most of the bypass-associated symptoms and complications resolve.21,25,27-29 Most patients, however, regain a significant amount of weight.24,25,28 This weight gain has prompted some authors to simultaneously complement the JIB reversal with another weight loss procedure.24,30,31 Because of a high number of complications and the failure to lose adequate weight after restrictive procedures,32 most bariatric revisional procedures favor the creation of a gastric bypass. This combination results in an acceptable complication rate with appropriate weight loss.3,33-35

The severe metabolic complications and low quality of life that our patient suffered prompted his JIB reversal. However, due to his normal BMI and poor health at the time of surgery, the JIB reversal was not complemented with another bariatric procedure. During the following months after the JIB reversal, the patient’s eating habits dramatically transformed, most likely the result of more than 30 years of meager food intake and chronic diarrhea. Despite professional nutritional and psychological consultation, the patient’s eating habits resulted once again in morbid obesity, which in turn required another bariatric procedure. Due to his previous condition, the patient refused any malabsorptive procedure as a treatment for his current obesity. Therefore, a restrictive procedure was selected.

The sleeve gastrectomy (SG) has proven to be an adequate restrictive procedure for obesity,36 particularly in the super-obese patients.37,38 It was originally described by Marceau et al39 and Hess et al40 as the first step in the biliopancreatic diversion with duodenal switch, considered to be both restrictive and malabsorptive. SG achieves weight loss by restricting the amount of food that can be consumed without the potential risks and sequelae of malabsorption (Figure 4).41 Besides the restrictive mechanism conferred by the reduction of gastric capacity, the SG causes a significant decrease in the hunger-regulating hormone ghrelin by resecting most of the ghrelin-producing cells in the fundus of the stomach.42,43 The weight loss effects of SG appear to exceed those of other restrictive procedures, including vertical banded gastroplasty41 and intragastric balloon.44 Because of the decrease in the production of the hunger-regulating ghrelin, SG also appears to be a better alternative than gastric banding.42 In fact, SG has also been used satisfactorily in gastric band reversal procedures. Baltasar et al reported the conversion of an adjustable gastric band to SG with continued weight loss and a significant improvement in quality of life.41

Conclusion
Due to the large number of JIB procedures performed since the late 1960s, many JIB patients may still develop metabolic complications that will require revisional surgery. We believe that the need for performing a different bariatric procedure at the time of a JIB revision has to be individualized to each patient, as occurred in this case. Even after a reversal of their bariatric procedures, these patients require constant medical, nutritional, and psychological follow-up. This is the first report of a JIB reversed to SG, resulting in successful weight loss. Although SG is relatively new to the bariatric surgery arsenal, it has been proven to be a safe and efficient weight loss procedure. Long-term results, however, have yet to be determined. In the meantime, SG is an attractive alternative in JIB patients who are not eligible for gastric bypass because of their malabsorptive-induced metabolic complications.

References
1. Payne JH, DeWind LT. Surgical treatment of obesity. Am J Surg. 1969;118:141–7.
2. Requarth JA, Burchard KW, Colacchio TA, et al. Long-term morbidity following jejunoileal bypass; the continuing potential need for surgical reversal. Arch Surg. 1995;130:318-25.
3. Livingston EH. Complications of bariatric surgery. Surg Clin N Am. 2005;85:853–68.
4. Buckwalter JA, Herbst CA Jr. Reversal of jejunoileal bypass. Surg Gynecol Obstet. 1984;159:348–52.
5. Anderson PE, Pilkington TRE, Gazet JC. Reversal of jejunileal bypass in patients with morbid obesity. Br J Surg. 1994;81:1015–7.
6. Våge V, Solhaug JH, Berstad A, et al. Jejunoileal bypass in the treatment of morbid obesity: a 25-year follow-up study of 36 patients. Obes Surg. 2002;12:312–8.
7. Baddeley RM. Results of jejuno-ileostomy for gross refractory obesity. Br J Surg. 1976;63:801–6.
8. Hallberg D. Surgical treatment of obesity. Prog Surg. 1975;14:46–83.
9. Garcia-Diaz S, Garcia-Fernandez S. Medical and surgical indications for treatment of morbid obesity. World J Surg. 1981;5:795–9.
10. Kremen AT, Linner JH, Nelson CH. Experimental evaluation of nutritional importance of proximal and distal small intestine. Ann Surg. 1954;140:439–48.
11. Leger L, Moullé P, Chiche B, et al. Courts-circuit jejuno-ileaux dans le traitment de l’obesite. 16 cas personnels. J Chir. 1977;113:229–48.
12. Sherman CD Jr., May AG, Nye W, et al. Clinical and metabolic studies following bowel bypassing for obesity. Ann NY Acad Sci. 1965;131:614–22.
13. Salmon PA: The results of small intestinal bypass operations for the treatment of obesity. Surg Ginecol Obst. 1971;132:965–79.
14. Scott HW Jr., Sandstead HH, Brill AB, et al. Experience with a new technique of intestinal bypass in the treatment of morbid obesity. Ann Surg. 1971;174:560–72.
15. Deitel M. Delayed sequelae of jejunoileal bypass. In: Deitel M, ed. Update: Surgery for the Morbidly Obese Patient. Toronto, Canada: Mothersill Printing Inc. 2000;105–111.
16. Jewell R, Hemrock AS, Hardin CA. Complications of jejunoileal bypass for morbid obesity. Arch Surg. 1975;110:1039–42.
17. Lowell JA, Shenoy S, Ghalib R, et al. Liver transplantation after jejunoileal bypass for morbid obesity. J Am Coll Surg. 1997;185:123–7.
18. Markowitz JS, Seu P, Goss JA, et al. Liver transplantation for decompensated cirrhosis after jejunoileal bypass: a strategy for management. Transplantation. 1998;65:570–2.
19. Balsiger BM, Murr MM, Poggio JL, et al. Surgery for weight control in patients with morbid obesity. Med Clin North Am. 2000;84:477–89.
20. Thaisetthawatkul P, Collazo-Clavell ML, Sarr MG, et al. A controlled study of peripheral neuropathy after bariatric surgery. Neurology. 2004;63:1462–70.
21. Mole DR, Tomson CRV, Mortensen N, et al. Renal complications of jejuno-ileal byass for obesity. Q J Med. 2001;94:69–77.
22. Drenick EJ, Ament ME, Finegold SM, et al. Bypass enteropathy. Intestinal and systemic manifestations following small-bowel bypass. JAMA. 1976;236:269–72.
23. DeMaria EJ, Jamal MK. Surgical options for obesity. Gastroenterol Clin N Am. 2005;34:127–42.
24. Buckwalter JA, Herbst CA Jr. Reversal of jejunoileal bypass. Surg Gynecol Obstet. 1984;159:348–52.
25. Anderson PE, Pilkington TRE, Gazet JC. Reversal of jejunileal bypass in patients with morbid obesity. Br J Surg. 1994;81:1015–7.
26. Våge V, Solhaug JH, Berstad A, et al. Jejunoileal bypass in the treatment of morbid obesity: a 25-year follow-up study of 36 patients. Obes Surg. 2002;12:312–8.
27. Dhar NB, Grundfest S, Jones JS, et al. Jejunoileal bypass reversal: effect on renal function, metabolic parameters and stone formation. J Urol. 2005;174:1844–6.
28. Halverson JD, Wise L, Wazna MF, et al. Jejunoileal bypass for morbid obesity. A critical appraisal. Am J Med. 1978;64:461–75.
29. Hanni CL, Pool LR, Dean RE, et al. Treatment of jejunoileal bypass failure by anastomosis and gastroplasty in a single-stage procedure. Review of 47 cases. Am Surg. 1984;50:354–7.
30. Dean J. Long-term outcome of reversal of small intestine bypass operations. Am J Surg. 1990;159:118–23.
31. Economou TP, Cullen JJ, Mason EE, et al. Reversal of small intestinal bypass operations and concomitant vertical banded gastroplasty: long-term outcome. J Am Coll Surg. 1995;181:160–4.
32. van Gemert WG, van Wersch MM, Greve JWM, et al. Revisional surgery after failed vertical banded gastroplasty or conversion to gastric bypass. Obes Surg. 1998;8:21–8.
33. Behrns KE, Smith CD, Kelly KA, et al. Repoerative bariatric surgery. Lessons learned to improve patient selection and results. Ann Surg. 1993;218:646–53.
34. Jones KB. Revisional bariatric surgery – safe and effective. Obes Surg. 2001;11:183–9.
35. Gagner M, Gentileschi P, de Csepel J, et al. Laparoscopic reoperative Bariatric surgery: experience from 27 consecutive patients. Obes Surg. 2002;12:254–60.
36. Moon-Han S, Won-Woo K, Oh JH. Results of laparoscopic sleeve gastrectomy at 1 year in morbidly obese Korean patients. Obes Surg. 2005;15:1469–75.
37. Almogy G, Crookes PF, Anthone GJ. Longitudinal gastrectomy as a treatment for the high-risk super-obese patient. Obes Surg. 2004;14:492–7.
38. Catheline JM, Cohen R, Khochtali I, et al. Treatment of super super morbid obesity by sleeve gastrectomy. Presse Med. 2006;35:383–7.
39. Marceau P, Biron S, Bourque RA, et al. Biliopancreatic diversion with a new type of gastrectomy. Obes Surg. 1993;3:29–35.
40. Hess DS, Hess DW. Biliopancreatic diversion with duodenal switch. Obes Surg. 1998;8:267–82.
41. Baltasar A, Serra C, Pérez N, et al. Laparoscopic sleeve gastrectomy: a multi-purpose Bariatric operation. Obes Surg. 2005;15:1124–8.
42. Langer FB, Reza Honda MA, Bohdjalian A, et al. Sleeve gastrectomy and gastric banding: effects on plasma ghrelin levels. Obes Surg. 2005;15:1024–9.
43. Kotidis EV, Koliakos G, Papavramidis TS, et al. The effect of biliopancreatic diversion with pylorus-preserving sleeve gastrectomy and duodenal switch on fasting ghrelin, leptin and adiponectin levels: is there a hormonal contribution to the weight-reducing effect of this procedure? Obes Surg. 2006;16:554–9.
44. Milone L, Strong V, Gagner M. Laparoscopic sleeve gastrectomy is superior to endoscopic intragastric balloon as a first stage procedure for super-obese patients (BMI>50). Obes Surg. 2005;15:612–7.

Category: Case Report, Past Articles