Surgery: Bypassing the Small Bowel

When the unhappy clerical worker consulted Dr. Manrico Troncelliti of Pennsylvania’s Sacred Heart Hospital in Norristown, he seemed a veritable caricature of obesity. He was 5 ft. 2 in. tall andweighed 376 lbs. He could hardly walk a city block and not tie his own shoelaces. He had a bleeding ulcer on his leg that refused to heal—a common problem of the grossly overweight.

Satisfied that both diet and drugs had already been tried, Dr. Troncelliti decided on heroic measures. He prescribed a jejuno-colostomy (short-circuiting most of the small bowel), an operation devised in 1912 for patients suffering from incurable metabolic defects. Because the body absorbs most of its fats through the wall of the lower small bowel, by drastically shortening that absorbing wall the surgeon hoped to limit his patient’s assimilation of fat calories.

Blind Loop. Dr. Troncelliti opened the man’s abdomen and cut the small bowel about 42 inches below the point where it emerges from behind the large bowel (see diagram). He took the free end of this 42-inch loop and stitched it into the side of the transverse colon, leaving the remaining 15 to 20 feet of the small bowel as a nonfunctioning blind loop. When the man recovered from the operation, he continued to overeat, but the food digested in his stomach and duodenum passed more directly into his colon. He absorbed enough protein and starch to keep him alive but not enough fat to maintain his weight.

The patient lost 96 lbs. in little more than a year, and his leg ulcer healed. Then he developed a hernia at the operation scar, so the surgeons went in again. Since his weight loss had been only moderate, they cut out a foot of jejunum. That did it. The clerical worker is now down to a merely rotund 165 lbs.; he is back at his office desk, able to tie his shoelaces, and happy as never before.

No Panacea. After such surgery, now standardized with a 30-inch loop of jejunum, most patients suffer from some diarrhea, and at best must expect to have three or four bowel movements daily. This is not a high price to pay for the dramatic benefits, Dr. Troncelliti suggested in his report to the annual congress of the American College of Surgeons last week. At the same time, he emphasized that he is not recommending this “super-surgery as a panacea for the super-obese.” To qualify as a candidate for jejuno-colostomy, a patient must be at least 100 lbs. overweight, must have tried and failed with other reducing regimens, and must have some medical problem associated with excess weight—a high blood-cholesterol level, for example, or abnormally high blood pressure.

In most of the ten such cases Dr. Troncelliti has operated on at Norristown and at Bryn Mawr Hospital, the desired loss in weight has been accompanied by a lowering of cholesterol level or blood pressure, or both. A rare advantage of this operation is that it is reversible—if weight loss becomes too great, the jejunum and ileum can be hooked up again in the way that nature intended.