Medicine: Bowel Bypass

Though doctors are not yet sure that lowering the amount of cholesterol in a patient’s blood will help to protect him against heart attacks, they are willing to try almost anything to find out. At Los Angeles, Dr. Henry Buchwald, 31, of the University of Minnesota’s famed pioneering department of surgery, told the Heart Association that an operation on the small bowel may be the most effective way to lower the blood’s content of cholesterol permanently.

Old Roadbed. The theory underlying the operation depends on a set of strange biochemical facts. Whether or not a man eats foods that contain cholesterol, his body manufactures the stuff every day. Much of it passes into the bloodstream through the filtering system in the wall of the lower third of the small bowel. Dr. Buchwald’s idea was to cut this part of the small gut out of the digestive circuit, leaving much of the cholesterol no place to go except through the large bowel, to be excreted.

For such major surgery Dr. Buchwald has chosen only patients who already had severe heart-artery disease and extremely high levels of blood cholesterol. On the operating table, he locates the ileocecal valve, where the small bowel joins the large, takes a tape measure and starts measuring upward. He measures off 6 ft., or about one-third of the bowel’s average total length of 15 to 20 ft. At this point, he sews the bowel tube shut, then makes a cut just above it. He takes the free end of the upper small bowel, pulls it down to the large bowel just below the ileocecal valve. Then he cuts a hole in the side of the large bowel, and sews the small bowel to it. The 6-ft. length of the lower end of small bowel is not removed but left like an old roadbed alongside a highway-straightening project.

Technically Simple. The Minneapolis surgeons do not try to make a substitute ileocecal valve; it would be too difficult, they say, and it does not seem to be necessary. The operation is technically simple, but to guard against a rash of premature operations performed unwisely all over the country, Dr. Buchwald emphasized that surgical teams in university medical centers should keep a monopoly on the procedure for a few years. It will take at least a year, he said, to be sure that the operation’s effectiveness in lowering blood cholesterol is reasonably permanent, and four or five years and many more cases to see whether this helps the patients to live longer.

The first four patients to have the operation had cholesterol levels rising to more than double the normal U.S. range. After their operations, these four show reductions averaging 40%, bringing their cholesterol levels down to the normal range, or close to it.