Metabolic consequences from conversion of jejunoileal bypass to gastric bypass.

Conversion of jejunoileal bypass to gastric bypass was performed in 11 patients because of metabolic problems and physical discomforts, and in three patients because of insufficient weight loss. There was no mortality and little morbidity after operation. An additional mean weight loss of 6% occurred, and weight stabilized satisfactorily in most patients. Two patients regained significant weight. Serum cholesterol levels rose within a month in most patients, with a mean increase of 61%. However, levels remained within normal limits. Serum triglyceride levels did not change significantly, especially in patients whose weight remained stabilized. Plasma glucose levels remained normal in all patients, including four patients who had been clinically diabetic before jejunoileal bypass. These patients had become normoglycemic immediately after jejunoileal bypass, and remained normal after conversion to gastric bypass.     

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.     

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.     

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.     

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.     

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.     

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.     

Interval jejunoileal bypass reduces the morbidity and mortality of Roux-en-Y gastric bypass in the super-obese

Among Roux-en-Y gastric bypass (RYGB) patients, large male patients carry the greatest risk for severe, life-threatening complications. The higher complication rate is partly related to large amounts of intra-abdominal fat that increases the technical difficulty of the RYGB. In order to minimize the risk for complications, we established a staged approach for weight loss surgery for high-risk, super-obese patients. Patients with intra-abdominal fat at exploration which precluded the performance of RYGB underwent jejunoileal bypass (JIB). Following an initial period of weight loss (6-24 months), they were converted to a RYGB during a second operation. Twenty-four patients underwent initial JIB that was associated with a major complication rate of 8.3 per cent (2/24) and no mortality. Eight patients lost 53.4 +/- 6.3 kg prior to their conversion to RYGB (mean, 14.1 months). There was one major complication (12%) and no deaths (0%). Following RYGB, an additional period of weight loss resulted in overall excess weight loss (EWL) totaling 62 per cent. A two-step procedure is a safe and effective approach for minimizing complications for high-risk patients undergoing RYGB. The initial JIB was associated with low morbidity and no mortality, and the follow-up RYGB procedure was a technically simple operation that could be performed with few complications.     

The effectiveness of gastric bypass over gastric partition in morbid obesity: consequence of distal gastric and duodenal exclusion.

Eighty-seven morbidly obese patients were prospectively randomized to two operations: gastric bypass was performed on 42 and gastric partition on 45. Gastric bypass proved to be more effective; gastric bypass patients lost 15% more of their original weight at 12 months and 21% more at 18 months. There were no failures in the gastric bypass group; 28 of the 45 operations failed in the gastric partition group. An additional 60 patients underwent gastric bypass since the completion of the study. In the total series of 147 patients who underwent gastric bypass or gastric partition, there was no mortality, and the surgical complication rate was 12%. Because the gastric pouches and the anastomoses were similar in the two operations, the superiority of the gastric bypass may well be due to a heretofore unexplained effect of distal gastric and duodenal exclusion.     

Long-term outcome of reversal of small intestinal bypass operations

Between 1976 and 1987, 43 patients underwent reversal of jejunoileal bypass operations because of metabolic complications of the operation. Electrolyte imbalance, malnutrition, and diarrhea (16 patients); cirrhosis (9); nephrolithiasis (9); arthritis (7); and pathologic fractures (1) were the primary indications for reconstruction. Many patients had multiple complications of the jejunoileal bypass operation. Twenty-nine patients underwent gastroplasty at the time of reversal and 14 did not. Seventy three +/- 5 months after reversal, patients with a gastroplasty weighed significantly less than patients without a gastroplasty. Patients with electrolyte imbalance, malnutrition, and diarrhea were all improved after reconstruction. Two patients with cirrhosis died of liver failure after reconstruction; the distinguishing preoperative characteristic was ascites. Postoperative interval liver biopsies indicated improvement in histologic appearance in four patients and no change in three. Nephrolithiasis improved or disappeared in all patients after reconstruction, whereas arthritis improved in 5 of 7 patients. Gastroplasty produced no benefit in alleviation of metabolic complications of jejunoileal bypass operations. Although the survival rate in these patients at last follow-up was 95 percent, 28 percent were incapacitated. Simultaneous gastroplasty performed at the time of reversal significantly decreases body weight when compared with patients undergoing reversal without a gastroplasty.     

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.     

Complications of gastric bypass for morbid obesity

This report details the complications observed in 154 morbidly obese patients who had a gastric bypass performed in the period from April 1975 through March 1979. Thirteen intraoperative complications occurred. In the first 30 days after operation, one or more complications developed in 29 or 17.9 percent of the patients. One patient died from pulmonary embolism. The most serious complication unique to gastric bypass was a leak from the stomach or the anastomosis. The factors responsible are discussed and suggestions are made concerning the prevention of this complication. Sixteen late complications occurred in 13 patients. The 62 operative procedures performed incidental to gastric bypass and the 50 performed subsequently as a result of it are enumerated and discussed. The findings of this investigation document the serious complications that may occur with gastric bypass. The late complications of this operation are few and trivial compared with those that occur with jejunoileal bypass [1,2,4,5,9].     

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.     

A prospective comparison of the jejunoileal and gastric bypass operations for morbid obesity

A prospective, randomized clinical trial has been conducted in 38 morbidly obese patients to compare jejunoileal bypass (19 patients) with gastric bypass (19 patients). At this point the patients have been followed up for periods of from 1 month to 2 years, and 12 patients in each surgical group have been observed for 6 months or longer after operation. There was one death among the 38 patients, a woman with a gastric bypass who developed a pulmonary embolus 22 days postoperatively. Gastric bypass resulted in somewhat greater weight loss than jejunoileal bypass. Although the follow-up period has been short, jejunoileal bypass has resulted in greater morbidity and expense to the patient than gastric bypass. In particular, gastric bypass did not cause progression of liver lesions in any of the 6 patients who had liver biopsies 1 year postoperatively, while jejunoileal bypass was associated with development of fatty metamorphosis in the liver of 3 patients after 1 year. The entry of new patients into the clinical trial has been discontinued because we believe there is sufficient evidence to indicate that gastric bypass is superior to jejunoileal bypass in the treatment of morbid obesity.

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Résumé Nous avons réalisé un essai clinique prospectif et randomisé destiné à comparer le court-circuit jéjunoiléal (19 cas) et le court-circuit gastrique (19 cas) comme traitement de l'obésité grave chez 38 patients. Actuellement, les malades ont été suivis pendant 1 mois à 2 ans et 12 patients dans chaque groupe ont pu être observés pendant plus de 6 mois après l'intervention. Il y eut un décès, une femme qui mourut d'embolie pulmonaire 22 jours après avoir subi un court-circuit gastrique. Le by-pass gastrique entraîne une perte de poids un peu plus importante que le court-circuit jéjuno-iléal. Quoique la période d'observation soit courte, il apparaît que les courtcircuits jéjuno-iléaux sont grevés d'une plus grande morbidité que les by-pass gastriques. En particulier, le by-pass gastrique n'a pas entraîné de progression des lésions hépatiques chez les 6 malades qui ont subi une biopsie hépatique un an après l'intervention alors que le by-pass jéjuno-iléal s'est accompagné de métamorphose graisseuse chez 3 patients au bout d'un an. Nous avons arrêté cet essai thérapeutique contrôlé parce que nous croyons qu'il existe des preuves suffisantes de la supériorité du by-pass gastrique dans le traitement de l'obésité grave.

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Supported by Public Health Service Research Grant No. RR-46, from the General Clinical Research Centers Branch of the Division of Research Resources.     

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.     

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.     

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.     

Effects of jejunoileal bypass on food intake, amino acid levels, and indoleamine metabolism in rats

Adult rats were subjected to either a 90 to 95 percent jejunoileal bypass or a sham operation and were sacrificed 35 days after surgery. Rats with jejunoileal bypass lost 33 percent of their original weight, whereas the sham operated rats gained 14 percent. Food intake per 100 g body weight was significantly increased between postoperative days 14 and 35 in the jejunoileal bypass rats. Levels of tryptophan were significantly reduced in the cortex, hypothalamus, striatum, hippocampus, mesencephalon, diencephalon, pons-oblongata, and cerebellum, whereas serotonin concentrations were lowered in the diencephalon, pons-medulla, and cerebellum in jejunoileal rats compared with control rats. Levels of 5-HIAA were reduced in the hypothalamus, cortex, mesencephalon, and diencephalon. In the plasma of bypassed rats, concentrations of valine, leucine, isoleucine, tryptophan, methionine, threonine, and tyrosine were significantly lower than in the control rats. In the cerebral cortex, levels of phenylalanine, tyrosine, histidine, and glutamine were increased. The results suggest involvement of indoleamine metabolism in disrupted eating after jejunoileal bypass. The elevated brain levels of glutamine, phenylalanine, tyrosine, and histidine resemble similar changes seen after portosystemic shunting in rats.     

Skeletal abnormalities after jejunoileal bypass.

Jejunoileal bypass surgery is fraught with many longterm complications, among which is hypovitaminosis D. The relationship, if any, of hypovitaminosis D to the skeletal disease which may occur following this operation is, however, unknown. Consequently, we studied eight patients with low circulating levels of 25-hydroxyvitamin D who had undergone jejunoileal bypass at least two and one-half years previously. Despite the absence of skeletal symptoms, the bone biopsies of six of these patients were abnormal. The volume of trabecular bone was diminished in the group as a whole, and half the patients had an excess of unmineralized skeletal matrix. However, no noninvasive diagnostic technique identified those patients with skeletal disease. We therefore conclude that recognition of those jejunoileal bypass patients potentially at risk to develop clinically significant bone disease requires biopsy of the skeleton.     

腹腔镜胃旁路术和迷你胃旁路术对肥胖症合并2型糖尿病患者的短期治疗效果

目的探讨腹腔镜胃旁路手术和迷你胃旁路术对合并2型糖尿病的病态肥胖症患者的治疗效果。方法7例伴有2型糖尿病的单纯性肥胖症患者中1例行腹腔镜胃旁路术．6例行腹腔镜迷你胃旁路术,观察患者术后2型糖尿病治疗效果。结果7例患者手术顺利,手术时间100～170（平均135）min。无手术并发症。术后平均随访1年,体质量平均减少24．3kg,均已停用所有降糖药物,各项糖尿病检查指标均正常。结论腹腔镜胃旁路术或迷你胃旁路术对2型糖尿病短期治疗有效。