Skip to main content
NCBI home page
Annals of Surgery logoLink to Annals of Surgery
. 1990 Sep;212(3):318–331. doi: 10.1097/00000658-199009000-00010

Partial ileal bypass for hypercholesterolemia. 20- to 26-year follow-up of the first 57 consecutive cases.

H Buchwald 1, D K Stoller 1, C T Campos 1, J P Matts 1, R L Varco 1
PMCID: PMC1358164  PMID: 2396883

Abstract

Between 1963 and 1968, 57 patients underwent partial ileal bypass (PIB) at the University of Minnesota for primary hypercholesterolemia. Preoperative total plasma cholesterol (TC) was 363.3 +/- 136.8 mg/dL (mean +/- SD) in these patients. Baseline and follow-up TC results demonstrated highly significant (p less than or equal to 0.001) TC reduction, 34% (n = 48), 28% (n = 49), 35% (n = 26), 35% (n = 11), and 30% (n = 25) at 1, 2 to 5, 6 to 10, 11 to 15, and more than 20 years, respectively, after PIB. In 21 patients with baseline, 1-year, and more than 20-year results TC decreased 33% by 1 year and remained 29% less than baseline more than 20 years after surgery (p = NS versus 1 year). Plasma triglyceride results were available in fewer patients, and no statistically significant changes developed after PIB. Two patients (3.5%) underwent PIB reversal, one for intractable diarrhea and one for recurrent nephrolithiasis. In the 25 nonreversed, long-term survivors, no statistically significant weight change was noted. Twenty-four per cent had 0 to 2, 52% had 3 to 5, and 24% had more than 5 bowel movements per day. Subsequent cholecystectomy was required in eight patients, and nephrolithiasis developed in 10 (40%). During 20 to 26 years, most survivors developed clinically apparent atherosclerosis: angina (60%), myocardial infarction (16%), or coronary artery bypass (28%). Coronary heart disease was the predominant cause of death among nonsurvivors (80%). Overall survival rates were 95% 88%, 75%, 59%, 53%, and 41% at 1, 5, 10, 15, 20, and 25 years, respectively, after PIB. Partial ileal bypass leads to highly significant TC reduction, which is sustained, essentially unchanged, more than 20 years after operation. In comparison to available epidemiologic and clinical trial data, these results support the hypothesis that TC reduction has a beneficial effect in patients with hypercholesterolemia.

Full text

PDF
318

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. BUCHWALD H., GEBHARD R. L. EFFECT OF INTESTINAL BYPASS ON CHOLESTEROL ABSORPTION AND BLOOD LEVELS IN THE RABBIT. Am J Physiol. 1964 Sep;207:567–572. doi: 10.1152/ajplegacy.1964.207.3.567. [DOI] [PubMed] [Google Scholar]
  2. BUCHWALD H. THE EFFECT OF ILEAL BYPASS ON ATHEROSCLEROSIS AND HYPERCHOLESTEROLEMIA IN THE RABBIT. Surgery. 1965 Jul;58:22–36. [PubMed] [Google Scholar]
  3. BUCHWALD H. VITAMIN B12 ABSORPTION DEFICIENCY FOLLOWING BYPASS OF THE ILEUM. Am J Dig Dis. 1964 Nov;9:755–759. doi: 10.1007/BF02231982. [DOI] [PubMed] [Google Scholar]
  4. Beil U., Crouse J. R., Einarsson K., Grundy S. M. Effects of interruption of the enterohepatic circulation of bile acids on the transport of very low density-lipoprotein triglycerides. Metabolism. 1982 May;31(5):438–444. doi: 10.1016/0026-0495(82)90231-1. [DOI] [PubMed] [Google Scholar]
  5. Blankenhorn D. H., Nessim S. A., Johnson R. L., Sanmarco M. E., Azen S. P., Cashin-Hemphill L. Beneficial effects of combined colestipol-niacin therapy on coronary atherosclerosis and coronary venous bypass grafts. JAMA. 1987 Jun 19;257(23):3233–3240. [PubMed] [Google Scholar]
  6. Brensike J. F., Levy R. I., Kelsey S. F., Passamani E. R., Richardson J. M., Loh I. K., Stone N. J., Aldrich R. F., Battaglini J. W., Moriarty D. J. Effects of therapy with cholestyramine on progression of coronary arteriosclerosis: results of the NHLBI Type II Coronary Intervention Study. Circulation. 1984 Feb;69(2):313–324. doi: 10.1161/01.cir.69.2.313. [DOI] [PubMed] [Google Scholar]
  7. Buchwald H., Gebhard R. L. Localization of bile salt absorption in vivo in the rabbit. Ann Surg. 1968 Feb;167(2):191–198. doi: 10.1097/00000658-196802000-00006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Buchwald H., Matts J. P., Fitch L. L., Varco R. L., Campbell G. S., Pearce M., Yellin A., Smink R. D., Jr, Sawin H. S., Jr, Campos C. T. Program on the Surgical Control of the Hyperlipidemias (POSCH): design and methodology. POSCH Group. J Clin Epidemiol. 1989;42(12):1111–1127. doi: 10.1016/0895-4356(89)90109-1. [DOI] [PubMed] [Google Scholar]
  9. Buchwald H., Moore R. B., Varco R. L. Ten years clinical experience with partial ileal bypass in management of the hyperlipidemias. Ann Surg. 1974 Oct;180(4):384–392. doi: 10.1097/00000658-197410000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. CORNFIELD J. Joint dependence of risk of coronary heart disease on serum cholesterol and systolic blood pressure: a discriminant function analysis. Fed Proc. 1962 Jul-Aug;21(4):58–61. [PubMed] [Google Scholar]
  11. Campos C. T., Matts J. P., Fitch L. L., Speech J. C., Long J. M., Buchwald H. Lipoprotein modification achieved by partial ileal bypass: five-year results of The Program on the Surgical Control of the Hyperlipidemias. Surgery. 1987 Aug;102(2):424–432. [PubMed] [Google Scholar]
  12. Campos C. T., Matts J. P., Santilli S. M., Fitch L. L., Long J. M., Speech J. C., Buchwald H. Predictors of total and low-density lipoprotein cholesterol change after partial ileal bypass. Am J Surg. 1988 Jan;155(1):138–146. doi: 10.1016/s0002-9610(88)80271-x. [DOI] [PubMed] [Google Scholar]
  13. Canner P. L., Berge K. G., Wenger N. K., Stamler J., Friedman L., Prineas R. J., Friedewald W. Fifteen year mortality in Coronary Drug Project patients: long-term benefit with niacin. J Am Coll Cardiol. 1986 Dec;8(6):1245–1255. doi: 10.1016/s0735-1097(86)80293-5. [DOI] [PubMed] [Google Scholar]
  14. Clayman R. V., Buchwald H., Varco R. L., DeWolf W. C., Williams R. D. Urolithiasis in patients with a jejunoileal bypass. Surg Gynecol Obstet. 1978 Aug;147(2):225–230. [PubMed] [Google Scholar]
  15. Frick M. H., Elo O., Haapa K., Heinonen O. P., Heinsalmi P., Helo P., Huttunen J. K., Kaitaniemi P., Koskinen P., Manninen V. Helsinki Heart Study: primary-prevention trial with gemfibrozil in middle-aged men with dyslipidemia. Safety of treatment, changes in risk factors, and incidence of coronary heart disease. N Engl J Med. 1987 Nov 12;317(20):1237–1245. doi: 10.1056/NEJM198711123172001. [DOI] [PubMed] [Google Scholar]
  16. Grundy S. M. Cholesterol and coronary heart disease. A new era. JAMA. 1986 Nov 28;256(20):2849–2858. [PubMed] [Google Scholar]
  17. Kannel W. B., Castelli W. P., Gordon T., McNamara P. M. Serum cholesterol, lipoproteins, and the risk of coronary heart disease. The Framingham study. Ann Intern Med. 1971 Jan;74(1):1–12. doi: 10.7326/0003-4819-74-1-1. [DOI] [PubMed] [Google Scholar]
  18. Kannel W. B., Neaton J. D., Wentworth D., Thomas H. E., Stamler J., Hulley S. B., Kjelsberg M. O. Overall and coronary heart disease mortality rates in relation to major risk factors in 325,348 men screened for the MRFIT. Multiple Risk Factor Intervention Trial. Am Heart J. 1986 Oct;112(4):825–836. doi: 10.1016/0002-8703(86)90481-3. [DOI] [PubMed] [Google Scholar]
  19. Koivisto P., Miettinen T. A. Long-term effects of ileal bypass on lipoproteins in patients with familial hypercholesterolemia. Circulation. 1984 Aug;70(2):290–296. doi: 10.1161/01.cir.70.2.290. [DOI] [PubMed] [Google Scholar]
  20. Leren P. The Oslo diet-heart study. Eleven-year report. Circulation. 1970 Nov;42(5):935–942. doi: 10.1161/01.cir.42.5.935. [DOI] [PubMed] [Google Scholar]
  21. Martin M. J., Hulley S. B., Browner W. S., Kuller L. H., Wentworth D. Serum cholesterol, blood pressure, and mortality: implications from a cohort of 361,662 men. Lancet. 1986 Oct 25;2(8513):933–936. doi: 10.1016/s0140-6736(86)90597-0. [DOI] [PubMed] [Google Scholar]
  22. Moore R. B., Frantz I. D., Jr, Buchwald H. Changes in cholesterol pool size, turnover rate, and fecal bile acid and sterol excretion after partial ileal bypass in hypercholesteremic patients. Surgery. 1969 Jan;65(1):98–108. [PubMed] [Google Scholar]
  23. Ross R. The pathogenesis of atherosclerosis--an update. N Engl J Med. 1986 Feb 20;314(8):488–500. doi: 10.1056/NEJM198602203140806. [DOI] [PubMed] [Google Scholar]
  24. Schouten J. A., Beynen A. C. Partial ileal bypass surgery in the treatment of heterozygous familial hypercholesterolemia: a review. Artery. 1986;13(4):240–263. [PubMed] [Google Scholar]
  25. Schwartz M. Z., Varco R. L., Buchwald H. Liver function and morphology following distal ileal excision in the rabbit. Surg Forum. 1971;22:355–356. [PubMed] [Google Scholar]
  26. Scott H. W., Jr, Stephenson S. E., Jr, Hayes C. W., Younger R. K. Effects of bypass of the distal fourth of small intestine on experimental hypercholesterolemia and atherosclerosis in rhesus monkeys. Surg Gynecol Obstet. 1967 Jul;125(1):3–12. [PubMed] [Google Scholar]
  27. Scott H. W., Jr, Stephenson S. E., Jr, Younger R., Carlisle B. B., Turney S. W. Prevention of experimental atherosclerosis by ileal bypass: 20 per cent cholesterol diet and I-131 induced hypothyroidism in dogs. Ann Surg. 1966 May;163(5):795–807. doi: 10.1097/00000658-196605000-00017. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Spengel F. A., Jadhav A., Duffield R. G., Wood C. B., Thompson G. R. Superiority of partial ileal bypass over cholestyramine reducing cholesterol in familial hypercholesterolaemia. Lancet. 1981 Oct 10;2(8250):768–770. doi: 10.1016/s0140-6736(81)90183-5. [DOI] [PubMed] [Google Scholar]
  29. Stamler J., Wentworth D., Neaton J. D. Is relationship between serum cholesterol and risk of premature death from coronary heart disease continuous and graded? Findings in 356,222 primary screenees of the Multiple Risk Factor Intervention Trial (MRFIT). JAMA. 1986 Nov 28;256(20):2823–2828. [PubMed] [Google Scholar]
  30. Vaislic C. D., Grondin P. R., Bourassa M. G., Campeau L. Partial ileal bypass in type II familial hypercholesterolemia. Eleven-year experience at the Montreal Heart institute. Am Surg. 1984 Mar;50(3):165–168. [PubMed] [Google Scholar]
  31. Van Niekerk J. L., Hendriks T., De Boer H. H. The treatment of familial hypercholesterolaemia by partial ileal bypass surgery. A review of the literature. Neth J Med. 1984;27(1):18–23. [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES