A prospective comparison of gastric and jejunoileal bypass procedures for morbid obesity.

A randomized prospective evaluation of the gastric and jejunoileal bypass procedures for morbid obesity was performed. The gastric bypass was performed predominantly as a 90% gastric exclusion with a Roux-en-Y reconstitution. The jejunoileal bypass was an end-to-end anastomosis between 30 cm of jejunum and 25 cm of terminal ileum, the bypassed segment of small bowel being decompressed by an end-to-side ileocolostomy. There were 32 patients in the gastric group and 27 in the jejunoileal group. The two groups were comparable in age, preoperative weight and height. There were no postoperative deaths, but the gastric bypass operation was associated with a slightly higher early complication rate indicating it is a more technically demanding procedure. Late sequellae were more prominent in the jejunoileal bypass group and included significant diarrhea in 56% and need for medication in 74%. Kidney stones and cholelithiasis also complicated the jejunoileal group and were not seen after gastric bypass. All patients showed fatty metamorphosis on the original liver biopsy. This had worsened in 75% of the jejunoileal group at one year whereas it had improved or was stable in all of the patients in the gastric group.     

Gastric bypass in the operative revision of the failed jejunoileal bypass.

Fifty-five patients with failed jejunoileal bypasses underwent reanastomosis and gastric bypass at the same operation. One patient died of undetermined cause three months postoperatively. The 54 surviving patients were all relieved of their preoperative symptoms, and 40 patients achieved satisfactory weight control. Technical complications prevented weight loss in 13 patients: four were given pouches too large to be effective, and nine had late disruption of the staple line. Two patients gained weight despite the fact that their pouches were of appropriate size. Reanastomosis will reverse the side effects of jejunoileal bypass, and a properly performed gastric bypass at the same operation will afford protection against subsequent weight gain.     

Reanastomosis after jejunoileal bypass

One hundred and one patients underwent jejunoileal bypass after careful preoperative evaluation. These patients were re-evaluated after operation on a frequent basis, and 23% have required restoration of intestinal continuity (reanastomosis) by a mean postoperative time of 44 months. The most frequent reasons for reanastomosis were liver dysfunction (5% of the entire series), severe malnutrition or weakness (5%), and late electrolyte imbalance (4%). Two patients did not survive reanastomosis, both having liver failure. Of the patients who did survive, weight gain (approaching prebypass weight) and improvement in liver function tests, electrolyte balance, serum vitamin levels, and diarrhea have been the rule. Of the entire series of 101 patients who underwent bypass, 58% either had life-threatening complications, had to be reanastomosed, or died. These morbidity and mortality rates raise the important question of whether jejunoileal bypass is an appropriate procedure for the treatment of morbid obesity.     

Gastric bypass in the surgical treatment of extreme adiposity

The gastric bypass is an effective surgical procedure for the treatment of extreme obesity. A small gastric reservoir and a narrow anastomosis are combined (to limit the possibility of food intake). In patients with a mean weight of 94% above the Broca value the normal weight is reached 18 months after the operation. Failure to lose weight can be caused by technical errors during the procedure or by a continuous food intake by the patients. Surgical complications are rare. The operative lethality is less than 1%, and anastomotic ulcers occur in 2% of cases. There is no reason to expect metabolic derangements as after jejunoileal bypass.     

Reoperative bariatric surgery. Lessons learned to improve patient selection and results.

OBJECTIVE: The purpose of this study was to determine the spectrum of presentation, safety, and efficacy of operative bariatric surgery. SUMMARY BACKGROUND DATA: The only lasting therapy for medically complicated clinically severe obesity is bariatric surgery. Several operative approaches have resulted in disappointing long-term weight loss or an unacceptable incidence of complications that require revisionary surgery. METHODS: Sixty-one consecutive patients who underwent reoperative bariatric surgery from 1985 to 1990 were observed prospectively. One, two, or three previous bariatric procedures had been performed in 77%, 18%, and 5% of patients, respectively. Reoperation was required for unsatisfactory weight loss after gastroplasty or gastric bypass (61%), metabolic complications of jejunoileal bypass (23%), or other complications (16%), including stomal obstruction, alkaline- or acid-reflux esophagitis, and anastomotic ulcer. Revisionary procedures included conversion to vertical banded gastroplasty (33% of operations) and vertical Roux-en-Y gastric bypass (52% of operations); partial pancreato-biliary bypass was used selectively in four patients with severe, medically complicated obesity. RESULTS: A single patient died postoperatively of a pulmonary embolus; serious morbidity occurred in 11%. Weight loss (mean +/- SEM) after reoperation for unsuccessful weight loss was greater with gastric bypass than with vertical banded gastroplasty (54 +/- 6% versus 24 +/- 6% of excess body weight). Metabolic complications of jejunoileal bypass were corrected, but 67% of the patients were dissatisfied with their postoperative lifestyle because of changes in eating habits or weight gain (64% of patients). Stomal complications and esophageal reflux symptoms were reversed in all patients. CONCLUSIONS: Reoperative bariatric surgery in selected patients is safe and effective for unsatisfactory weight loss or for complications of previous bariatric procedures. Conversion to gastric bypass provides more effective weight loss than vertical banded gastroplasty.     

Frequency distribution of weight loss percentage after gastric bypass and adjustable gastric banding

BACKGROUND: The results of surgical procedures for weight loss are often described in terms of the percentage of excess weight lost. Expressing outcomes using the mean and standard deviation might not adequately describe the clinical experience. This could in part be because the use of the mean +/- standard deviation assumes a normal or random distribution of outcomes. It has been our perception that the weight loss results after gastric bypass are relatively normally and tightly distributed around the mean, making it relatively predictable. However, we have found that the results after adjustable gastric banding are more highly variable. In fact, there appears to be 2 groups of patients after this restrictive operation. One group, that is able to work well and does not struggle much against the restriction, accepts the limits that it imposes, and another group, that does not easily learn to deal with the restriction and hence mal-adapts. METHODS: To evaluate the validity of our clinical perception, we undertook an analysis of the distribution of weight loss by the percentiles of excess weight lost. All patients with follow-up of > or =1 years after gastric bypass or adjustable banding were evaluated for this analysis. The demographics and percentage of excess weight loss were evaluated. The distribution of the percentage of excess weight loss in 10% increments was evaluated. RESULTS: Both groups were similar with respect to the mean patient age. However, the patients in the gastric bypass group had had a significantly greater mean preoperative body mass index and were more likely to be women. As expected, the weight loss of the gastric bypass patients fell in a normal single-peak distribution for < or =5 years of follow-up. The data from the adjustable gastric band patients at 1 year demonstrated a normal single-peak distribution, with a longer rightward tail. At 2 and 3 years postoperatively, the data from the band patients had a 2-peaked curve. CONCLUSION: The initial weight loss results after gastric banding are less predictable than those after gastric bypass. A similar analysis of long-term outcomes might be enlightening and assist in making clinical decisions.     

Critical analysis of jejunoileal bypass

This study analyzed a group of morbidly obese patients who underwent jejunoileal bypass over a 10 year period. Patients underwent either a Payne or Scott procedure. Weight loss was reported in terms of percent of excessive weight loss. Results showed that patients who had a Payne bypass had an average excess weight loss of 75 percent, whereas those with the Scott bypass had an average excess weight loss of 61 percent. All patients lost weight. Complications in this series were lower than what has been traditionally reported. The problem that occurred most often was kidney stones (8 percent of the patients). There has been only one death to date. The low incidence of complications can be attributed to the fact that the patients were evaluated, operated on, supervised, and followed by one doctor and his associated nurses. Thus, it is proposed that jejunoileal bypass, compounded with good patient care and careful patient selection, can produce positive results with a minimum number of problems.     

Effects of jejunoileal bypass on oxalate and mineral metabolism in rats.

OBJECTIVE--To reassess the effects of jejunoileal bypass on the gastrointestinal absorption and bone metabolism of certain minerals in rats, and to see if jejunoileal bypass in rats was a suitable model in which to study formation of calcium oxalate renal stones. DESIGN--Controlled study. SETTING--Division of Experimental Surgery, University of Erlangen, Germany. MATERIAL--43 male Sprague-Dawley rats. INTERVENTION--23 rate underwent jejunoileal bypass, and 20 laparotomy, with transsection and anastomosis of the jejunum and ileotomy and suture (sham operation). RESULTS--Rats that had undergone jejunoileal bypass ate less and gained less weight than those that had had sham operations. Absorption of calcium and phosphorus from the intestine was impaired, but that of magnesium was unchanged. Absorption of oxalate from the small intestine was unchanged, but that from the colon was increased. There were no signs of hyperoxaluria or urolithiasis. Serum mineral homeostasis was not affected by jejunoileal bypass nor were bone volume, density, or mineral concentrations. Serum concentrations of parathyroid hormone and 1,25-dihydroxycholecalciferol remained low, suggesting that jejunoileal bypass might have induced some calcium flux towards the vascular space. CONCLUSIONS--Jejunoileal bypass halts weight increase in rats; the model may be helpful in elucidating associations between enteric factors and calciotropic hormones, and several metabolic features that are altered by jejunoileal bypass in man are not altered in rats.     

Gastric bypass combined with reversal of intestinal bypass for morbid obesity

Many of the estimated 100,000 patients in the United States who have had jejunoileal bypass (JIB) for morbid obesity will develop lifethreatening complications which require that the JIB be reversed. To avoid the nearly certain recurrence of morbid obesity after reversal of JIB, gastric bypass (GB) was done at the time of the reversal in 19 patients. All patients are alive and healthy. There were no immediate serious postoperative complications. The arthritis, electrolyte imbalance, and multiple gastrointestinal symptoms (bloating, diarrhea, and flatulence) caused by JIB were immediately relieved. Patient acceptance of GB has been gratifying, and most patients continue to maintain a satisfactory weight reduction. The most significant late complication has been disruption of the gastric staple line, which was diagnosed in 4 patients 2 to 21 months after operation. All 4 patients were reoperated upon because of rapid gain in weight following the disruption. The staple line disruption is probably due to repeated overeating and, therefore, overdistention of the small gastric pouch. It is safe and prudent to perform GB in most patients when the JIB must be reversed.     

Near-total gastric bypass for morbid obesity

Among 50 morbidly obese patients who underwent gastric bypass, the gastric pouch was made only large enough to permit an anastomosis with the jejunum. Eighteen months after operation, the mean weight loss was 55 kg, and the mean excess weight loss was 70%. One half of the patients had less than 22.7 kg of residual excess weight. The most frequent immediate postoperative complication involved the respiratory tract (ten patients). Staple line failure in three of ten patients who had pouch construction by a single application of staples and iron deficiency anemia in six patients were the most important late complications. Near-total gastric bypass in which the pouch is constructed with two applications of staples is an effective operation for weight control and should virtually eliminate the need for revision caused by staple line failure or for a pouch that is too large.     

Jejunoileal bypass. A legacy of late complications

Since 1977, we have managed 56 patients (36 Payne and 20 Scott bypasses) with late (one to 18 years) complications resulting from a jejunoileal bypass. All patients underwent a one-stage conversion of the jejunoileal bypass to a gastric bypass. Patients were classified according to postbypass weight, the need for nutritional support, the type and severity of complication, and the time interval between jejunoileal bypass and the onset of the complication and correction of the complication. There were no operative deaths; one patient died 18 months after surgery of cirrhosis. The complication rate was 34%; however, most complications were minor. Our experience with this procedure has shown it to be highly effective in correcting complications other than polyarthritis. When coupled with nutritional support, it is safe even in malnourished patients.     

A 13-year review of jejunoileal bypass

One hundred and eighty patients had a jejunoileal bypass performed during the years 1971-1982. By leaving only 14 in. (35 cm) of intestine in continuity a mean weight loss of 34.4 per cent (s.d. = 8.5) was achieved over 2 years and, unless the operation had to be reversed for complications, this weight loss was maintained. The improvement in quality of life for a majority of patients should not be undervalued. Two-thirds of patients required admission for complications and eight patients died (4 per cent). Many of these problems were provoked by an inability to control eating. There have been no hospital deaths since 1976 which we attribute to better management of complications and a policy of early reversal for patients with excessive weight loss and signs of metabolic failure. Despite performing jejunoileal bypass less often in recent years we are still frequently reversing patients with electrolyte disturbances, metabolic failure, urinary calculi or arthritis. Thirty patients (16.7 per cent) have been reversed, half more than 5 years after bypass. Metabolic failure may occur even after many years of stable weight reduction. Because this is not well known the insidious onset of new weight loss and malaise may not be recognized, or not associated with the bypass many years before. Indefinite outpatient surveillance is mandatory. Changes in the operation have not significantly affected results. There has been no serious liver dysfunction in the 7:7:CJ group but this may reflect better management of lesser metabolic disturbances. Jejunoileal bypass remains the most effective operation for gross obesity and, with experience, can be performed safely. However, the complication rate and difficulty maintaining satisfactory follow-up on large numbers of young patients makes it an unacceptable procedure on any major scale.     

Experiences with antireflux valves in jejunoileal bypass surgery

Intussusception valves were created in the small intestine of jejunoileal bypass-operated dogs and patients with the intention to prevent reflux of chyme into the excluded intestinal loop and thereby increase weight loss. In the dogs the valves were shown to withstand a pressure of at least 100 cm of water. All patients with end-to-side bypass were at X-ray examination found to have sufficient valves whereas only four of fourteen with end-to-end bypass, where the defunctionalized loop was implanted into the cecum, had tight valves. During five years of observation no significant difference in weight loss was seen between the patients with valves and control groups without valves. It is concluded that reflux of chyme only plays a minor role for weight loss after jejunoileal bypass for obesity.     

Surgical management of the failed jejunoileal bypass

The jejunoileal bypass is an efficient surgical treatment for morbid obesity, but it has a high complication rate that necessitates reversal in about 25 percent of patients. Conversion to Roux-Y gastric bypass was associated with acceptable morbidity and provided excellent control of weight. On the other hand, conversion to gastric partition resulted in weight gain almost equal to that seen with simple reversal alone. Conversion to Roux-Y gastric bypass is an acceptable procedure in the surgical treatment of the unsuccessful jejunoileal bypass.     

Protein malnutrition following intestinal bypass for morbid obesity.

Intestinal bypass surgery, performed for weight reduction in the morbidly obese patient, is frequently complicated by the development and hepatic complications. In 44 morbidly obese individuals, 55 inches of proximal jejunum were anastomosed, end to side, to 5 inches of distal ileum. All the patients were followed with body composition measurements, performed by multiple isotope dilution, prior to and at regular time intervals following bypass surgery. In 33 patients a decrease in body fat accounted for the entire postbypass weight loss, while the lean body mass remained normal in both size and composition. In these patients, at 1 year, body weights had decreased by 24.4 +/- 2.1%, while the body cell masses had decreased by 2.1 +/- 7.1%. In the remaining 11 patients, the postbypass weight loss resulted from a loss of both body fat and body cell mass. Their body weights at 1 year had decreased by 27.0 +/- 3.0%, while the body fat and body cell mass. Their body weights at 1 year had decreased by 27.0 +/- 3.0%, while the body cell masses decreased by 22.0 +/- 6.1%. Furthermore, their body compositions were characteristic of protein malnutrition with a contracted body cell mass and an expanded extracellular mass. Six of these 11 patients have required admission to hospital on 10 occasions because of malaise, anorexia, debilitating weakness, hypokalemia, and abnormal liver function. They were treated for 14.5 +/- 1.9 days with an intravenous infusion of amino acids without additional nonprotein calories. The body composition, initially characteristic of malnutrition, became normal. Their symptoms disappeared and hepatic function returned to normal. Subsequently a high-protein diet was required to prevent a recurrence of symptoms and to maintain a normal body composition. The data indicate that protein malnutrition developed in 11 of 44 patients undergoing jejunoileal bypass for weight reduction.     

Gastroplasty conversion to Roux-en-Y gastric bypass at the lesser curvature due to weight loss failure

From January 1982 to April 1984, 20 patients with lesser curvature gastroplasty had conversion to Roux-en-Y gastric bypass at the lesser curvature for failure to lose more than 50 per cent of excess body weight within 12 months of the original gastroplasty. The average excess weight of these patients before gastroplasty was 103 lb, and the average excess weight before conversion to gastric bypass was 73 lb. The average weight loss after gastric bypass was doubled within 6 to 15 months. Only one patient failed to lose weight after conversion to gastric bypass, and this patient had endocrine problems. Late surgical complications occurred in two patients (10%); one had cholecystectomy and the other had vagotomy and hiatus hernia repair. There were no mortalities in this series.     

Liver injury following jejunoileal bypass. Are there markers?

Ninety-five of 105 patients who underwent jejunoileal bypass had preoperative and at least one set of postoperative liver tests and liver biopsy within 18 months of surgery. There were numerous and, at times, impressive histologic or biochemical abnormalities in obese patients who were not operated. No correlation was found between postoperative liver injury and the preoperative concentration of serum albumin or SGOT, or with the certain histologic lesions (steatosis, lobular necrosis or inflammation). However, the preoperative pericellular fibrosis persisted or progressed in eight of 11 of the patients. The rate of postoperative weight loss did not seem to influence liver morphology but the initial velocity of weight loss could not be determined in this study. Liver biopsy specimens demonstrated a trend for greater postoperative decreases of serum albumin concentrations (p less than 0.05) in those patients who developed more severe lesions. This study failed to demonstrate the presence of preoperative histologic or biochemical markers that could reliably predict the development of liver injury following jejunoileal bypass. The only exception was pericellular fibrosis, which was found in the preoperative liver biopsy specimens. Pericellular fibrosis is probably a risk factor for lobular fibrosis after jejunoileal bypass surgery in obese patients.     

Histological Findings in the Liver Before and After Gastric Bypass

Background: Bariatric surgery results in massive loss of excess weight, changes in co-morbidities and improvement in quality of life. In these patients, liver histology taken before or during surgery reveals several histological abnormalities. In a prospective study of patients previously submitted to gastric bypass, we determined the changes in liver histology late after the surgery. Methods: In 16 out of a total of 557 patients who were submitted to open gastric bypass, a second liver biopsy was taken during the repair of an incisional hernia, performed at a mean of 17 months after the gastric bypass. Results: All patients had lost weight, now having a mean BMI of 28.6 kg/m² (which had been 44.3 kg/m² before gastric bypass). One patient with normal pre-operative liver histology remained normal at the second study. 11 out of 15 who had had liver abnormalities returned to a normal condition or had only minimal change (73.3%). 2 patients (13.3%) showed improvement, while 1 patient presented a slight worsening of liver condition. One patient who had had liver cirrhosis showed no change. Conclusion: Gastric bypass for morbid obesity is followed by a dramatic improvement or normalization of liver histological abnormalities in the great majority of the patients. Liver cirrhosis in the one patient remained unchanged.     

Gastric bypass for morbid obesity

The gastric bypass operation is designed to decrease the size of the food receptacle so that a limited number of calories can be ingested. All food ingested is absorbed normally, thus eliminating problems that mey be associated with metabolic derangements. Although it is possible to overeat the gastric pouch, the overall result of gastric bypass, in terms of weight loss, is quite satisfactory, and the mortality rate of less than 2 per cent and the morbidity rate of less than 20 per cent are also acceptable. Late complications following gastric bypass are low: specifically, nephrolithiasis is eight to 10 times less frequent than after jejunoileal bypass. Liver disease has not been seen following gastric bypass.     

Resolution of hyperlipidemia after laparoscopic Roux-en-Y gastric bypass

BACKGROUND: Hyperlipidemia is an established risk factor for development of coronary artery disease. The aim of our study was to examine the changes in serum lipid profiles of morbidly obese patients complicated by hyperlipidemia, who underwent laparoscopic gastric bypass. STUDY DESIGN: We retrospectively reviewed the charts of 95 morbidly obese patients with documented hyperlipidemia who underwent laparoscopic gastric bypass. Mean duration of hyperlipidemia was 44+/- 56 months. Hyperlipidemia was defined as an elevated level of triglycerides (> 150 mg/dL) or total cholesterol (> 200 mg/dL). Changes in lipid profile of a subset of patients with subnormal levels of high-density lipoprotein cholesterol ( 130 mg/dL), and very-low-density lipoprotein cholesterol (> 40 mg/dL) were also examined. Fasting lipid profiles were measured preoperatively and at 3-month intervals. RESULTS: There were 68 women (72%) with a mean age of 43 +/- 10 years. Mean body mass index was 47+/- 5 kg/m2. Mean percentage of excess body weight loss at 12 months postoperatively was 66%. One year after gastric bypass, mean total cholesterol levels decreased by 16%; triglyceride levels decreased by 63%; low-density lipoprotein cholesterol levels decreased by 31%; very-low-density lipoprotein cholesterol decreased by 74%; total cholesterol/high-density lipoprotein cholesterol risk ratio decreased by 60%, and high-density lipoprotein cholesterol levels increased by 39%. Also, within 1 year, 23 of 28 (82%) patients requiring lipid-lowering medications preoperatively were able to discontinue their medications. CONCLUSIONS: Weight loss after laparoscopic gastric bypass substantially improves lipid profiles in morbidly obese patients who have hyperlipidemia. Improvement in lipid profiles was observed as early as 3 months postoperatively and was sustained at 1 year. Improvement of lipid profiles after laparoscopic gastric bypass can reduce health risks associated with high levels of atherogenic lipoproteins.