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.     

Long-term results after revisions of failed primary vertical banded gastroplasty

AIM: To compare the results after revision of primary vertical banded gastroplasty(Re-VBG) and conversion to sleeve gastrectomy(cS G) or gastric bypass(cR YGB).METHODS: In this retrospective single-center study, all patients with a failed VBG who underwent revisional surgery were included. Medical charts were reviewed and additional postal questionnaires were sent to update follow-up. Weight loss, postoperative complications and long-term outcome were assessed. RESULTS: A total 152 patients were included in this study, of which 21 underwent Re-VBG, 16 underwent c SG and 115 patients underwent c RYGB. Sixteen patients necessitated a second revisional procedure. No patients were lost-to-follow-up. Two patients deceased during the follow-up period, 23 patients did not return the questionnaire. Main reasons for revision were dysphagia/vomiting, weight regain and insufficient weight loss. Excess weight loss(%EWL) after Re-VBG, cS G and cR YGB was, respectively, 45%, 57% and 72%. Eighteen patients(11.8%) reported postoperative complications and 27% reported long-term complaints. CONCLUSION: In terms of additional weight loss, postoperative complaints and reintervention rate, Rouxen-Y gastric bypass seems feasible as a revision for a failed VBG.     

Evaluation of Quality of Life and Metabolic Improvement after Jejunoileal Bypass in a Community of Low Socioeconomic Status

Background: Bariatric operations are currently the only effective treatment for morbid obesity The first operation, jejunoileal bypass (JIB), has been superceded. However, JIB has left a heritage which must be followed. We report the long-term follow-up of a series of patients who had undergone JIB in south Brazil. Methods: 49 super-obese patients (85% female) from a poor community were submitted to JIB from 1987 to 2001. 5 deaths occurred and 4 patients were lost during follow-up. Quality of life was evaluated by means of the Bariatric Analysis and Reporting Outcome System (BAROS) applied to 40 patients. Results: Preoperatively, 11 patients (22.4%) were diabetic,13 (26.5%) were dyslipidemic, and 23 (46.9%) had high blood pressure. After a mean postoperative period of 64.3 ± 40.0 months, there was complete resolution of co-morbidites in all patients. Mean preoperative BMI was 52.8 ± 10.3 kg/m², and the postoperative mean excess weight loss was 58.9% ± 18.9%. Conclusion: JIB was adequate in reduction of weight, resolution of co-morbidites, and improvement in the quality of life as measured by BAROS. Since February 2001, we perform biliopancreatic diversion with duodenal switch, but we continue to follow our patients with JIB.     

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.     

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.     

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.     

Long-term follow-up and the role of surgery in adolescents with morbid obesity

PURPOSE: Obesity has become a health-care crisis in the United States. Adolescent obesity is now one of the most common childhood disorders, with 4.7 million American adolescents having a body mass index (BMI) greater than the 95th percentile. Most patients do not respond to diet modification or exercise programs and attention is now turning toward surgery as a source of weight loss in adolescents. Few studies have looked at the overall morbidity and mortality of weight loss surgery in this patient population. METHODS: This is a retrospective study of medical charts of 15 bariatric surgical procedures performed on 14 adolescents without known genetic syndromes associated with severe childhood obesity from 1971 to 2001 at the University of Minnesota. Procedures performed on these patients included vertical banded gastroplasty (n = 7), Roux-en-Y gastric bypass (n = 5), and jejunoileal bypass (n = 3). Jejunoileal bypass procedures were performed from 1971 to 1977, after which time this procedure was abandoned. Patient age ranged from 13 to 17 years (mean, 15.7 years). Mean follow-up time was 6 years, with 9 patients available for long-term follow-up. RESULTS: All procedures were performed using an open technique by 1 surgeon. There were no perioperative deaths; complications included 1 case of wound infection, 2 episodes of dumping syndrome that resolved without revision, 1 episode of hypoglycemia, and 1 case of short-term electrolyte imbalance in a patient who underwent jejunoileal bypass. The average BMI dropped from 58.5 +/- 13.7 to 32.1 +/- 9.7 kg/m(2) (P < .01)--a 45% reduction. CONCLUSIONS: Surgery for morbid obesity is safe and results in significant weight loss in adolescents who fail medical therapy.     

The effect of a low-carbohydrate, high-protein diet on post laparoscopic gastric bypass weight loss: a prospective randomized trial

BACKGROUND: Laparoscopic gastric bypass has become the standard surgical treatment for severe obesity in the United States. Less clear is what diet should be followed by these patients after surgery to maximize their weight loss. METHODS: Patients undergoing laparoscopic gastric bypass procedures for morbid obesity were randomly assigned to either a low-fat control diet based on American Heart Association recommendations or a low-carbohydrate, high-protein diet based on the South Beach Diet. One-on-one diet counseling with a bariatric nutritionist was provided preoperatively, postoperatively while in the hospital, and at postoperative clinic visits during the 12-month follow-up period. Investigators were blinded to diet assignment. Body composition including Body Mass Index (BMI) was recorded preoperatively and during postoperative visits at 3, 6, and 12 months. RESULTS: Thirty-two patients were included in the analysis with 13 control and 19 low-carbohydrate, high-protein subjects. No demographic or clinical preoperative variables, including preoperative BMI, showed statistical differences between the two groups. Both groups demonstrated significant yet similar weight loss both by reduction in BMI (at 12 months, low fat diet, -14.0 +/- 5.5% versus low carbohydrate, -17.0 +/- 4.5%; P = 0.15) and excess body weight lost (at 12 months, low-fat diet, -60.3 +/- 15.3% versus low carbohydrate, -59.6 +/- 13.0%; P = 0.96). CONCLUSIONS: Based on this limited prospective study, no weight loss advantage is observed in substituting a low-carbohydrate, high-protein diet in place of a standard low-fat diet in patients who have undergone laparoscopic gastric bypass surgery.     

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.     

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.     

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.     

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.     

Liver biopsy findings in seventy-seven consecutive patients undergoing jejunoileal bypass for morbid obesity

To clarify the status of hepatic morphology existent at the time of jejunoileal bypass in morbidly obese patients (those more than 100 pounds overweight) and the subsequent changes in liver architecture after jejunoileal bypass, we are performing intraoperative and yearly postoperative liver biopsies in all of our patients managed in this manner. This is the first report of our liver studies and this paper is an analysis of the histologic aspects of the liver at the time of bypass in seventy-seven consecutive patients.This study clearly demonstrates that the majority of markedly obese patients undergoing jejunoileal bypass have fatty metamorphosis of the liver at the time of their operative procedure. Previous similar reports from the literature are reviewed, and theories for the origin of hepatic fatty infiltration in obesity per se and after jejunoileal bypass are discussed.     

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.     

Laparoscopic gastric banding after heart transplantation

Background: Obesity often complicates the postoperative course of heart transplant recipients. Laparoscopic adjustable gastric banding (LAGB) represents a minimal invasive therapeutic possibility for weight reduction in non-transplanted patients. Case Report: We report a 55-year-old diabetic, morbidly obese male (weight 138 kg, height 173 m, BMI 46 kg/m²) in whom 6 years after orthotopic heart transplantation, LAGB and laparoscopic cholecystectomy were successfully performed. At follow-up of 28 months, the patient has lost 32 kg. His present weight is 106 kg (BMI 35.4). Diabetes improved, and oral diabetic medication was withdrawn. Cyclosporine dosage has not had to be changed after LAGB. Conclusion: In morbidly obese transplanted patients, LAGB should be considered as an effective alternative to dietetic measures to enable weight reduction and to improve comorbidities. In contrast to bariatric malabsorption techniques, like jejunoileal bypass and gastric bypass, cyclosporine pharmacokinetics do not appear to be influenced by gastric banding.     

Late hepatic histopathology after jejunoileal bypass for morbid obesity: Relation of abnormalities on biopsy and clinical course

Late biopsy results in 53 patients after jejunoileal bypass were reviewed and compared with 1 year postoperative biopsies. Patients were divided into groups based on clinical course and liver function tests. Of 24 patients with normal liver function tests and no clinical symptoms of liver failure, 8 (33 percent) had new or progressive lesions on late biopsy, while 1 of these 8 patients had cirrhosis. Thirty percent (6 of 20) of patients with liver function abnormalities but no evidence of liver failure showed evidence of progression on biopsy; 4 of these 6 patients had cirrhosis. Of those with clinical evidence of liver failure in the first year after operation, 44 percent had evidence of progression, but none had cirrhosis. Clinical parameters and liver function tests did not correlate with liver biopsies. In this series of patients, new and progressive lesions were found in the late postoperative period. Long-term serial biopsies are advisable in all patients after jejunoileal bypass to determine whether progressive deterioration in liver histology had occurred.     

Reversal of severe fatty hepatic infiltration after intestinal bypass for morbid obesity by calorie-free amino acid infusion

Hepatic fatty infiltration complicating jejunoileal bypass can be massive and may require restoration of gastrointestinal continuity. This fatty infiltration appears to be caused by protein depletion associated with adequate or high carbohydrate intake. The present study has shown that calorie-free amino acid alimentation can reverse these changes. In three of thirteen patients who underwent 12 inch to 6 inch jejunoileal bypass procedures, symptomatic hepatomegaly developed with near total replacement of hepatocytes by massive fatty infiltration. After undergoing liver scan, liver biopsy, and liver function tests, the patients were started on a peripheral infusion of 2 L per day of a 4.25 per cent crystalline amino acid solution, allowing for fat mobilization while preserving body protein stores. All oral intake was withheld except for water. At the end of a fourteen to twenty-one day infusion period, serum albumin levels increased by 1 gm in all patients. Decreases in liver volume of 83, 45, and 40 per cent occurred. During the infusion period ketonuria was 4+ in all patients indicating active lipolysis. Weight loss was impressive (17, 19, and 40 pounds). All patients showed marked symptomatic improvement, and postinfusion liver biopsy specimens showed a return to near normal architecture. Maintenance of normal liver size by a high-protein, low-carbohydrate diet was observed in a five to seven month follow-up period. In contrast to previous studies using standard hyperalimentation solutions, the use of calorie-free amino acid solutions reverses the hepatic fatty infiltration seen after intestinal bypass by mobilization of fat. This fat mobilization does not occur as readily in the presence of large amounts of glucose.     

Modified Jejunoileal Bypass Surgery with Biliary Diversion for Morbid Obesity and Changes in Liver Histology During Follow-up

BACKGROUND AND AIMS: Bariatric surgery is the most effective treatment for morbid obesity. The classic procedure, jejunoileal bypass, has many complications including rapid progress of liver disease. The senior author (I.F.) has developed a modification of jejunoileal bypass, which we believe overcomes many of the shortcomings of the classic procedure. METHODS: Consecutive patients referring for bariatric surgery were included. A modified jejunoileal bypass in which the defunctionalized limb is eliminated by anastomosing its ends to the gall bladder and cecum was performed. Liver biopsies were taken during operation and at a mean of 16 months later. The patients were followed for 5 years. RESULTS: Forty-three patients were enrolled. The mean value of weight and body mass index (BMI) fell from 128 kg and 46 kg/m(2) before operation to 85 kg and 31 kg/m(2) at 5 years, respectively (p < 0.001). There was no significant change in the degree of liver steatosis and necroinflammation. The mean liver fibrosis score increased from 0.1 to 0.9 (p = 0.015). No sign of advanced liver disease was observed during the 5-year follow-up. CONCLUSION: The modified jejunoileal bypass is very effective in inducing and maintaining weight loss for 5 years and does not lead to hepatic failure or rapid progression of liver disease.     

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.     

Report on Bariatric Surgery in the Ukraine

Background: Morbid obesity (MO) is a problem internationally, including in the Ukraine.We present the surgical treatment of MO in the Ukraine over the last 15 years, during which intestinal bypasses and various gastric reduction procedures were performed. Methods: 198 patients with MO underwent: jejunoileal (JI) bypass 64, non-adjustable gastric banding (NGB) 34, Roux-en-Y gastric bypass (RYGBP) 1, horizontal gastroplasty 1, vertical banded gastroplasty (VBG) 2, and abdominal lipectomy 96.The 96 men and 102 women weighed 160-290 kg (mean 210±SD18 kg). Mean body mass index was >60 kg/m2. These patients had a high incidence of hypertension, diabetes, sleep apnea, menstrual disorders, impotency in men and infertility in women. Results: At 1 year, after JI bypass 61 patients lost a mean of 62±17 kg and after NGB 11 kg. After JI bypass, 1 patient died in the early postoperative period from acute respiratory insufficiency and 2 died in the first year from acute liver insufficiency. The JI bypass was reversed in 2 patients due to uncontrollable malabsorption syndrome; 1 year after reversal, the weight of these patients exceeded their preoperative weight. In the early postoperative period, 1 patient died after NGB and 1 after RYGBP, from acute respiratory insufficiency. Postoperative weight loss was associated with decrease in the co-morbidities of MO, but after JIB, there was a high incidence of bypass enteritis, excessive malabsorption, formation of renal stones and gallstones. After NGB, no complications have been identified. Isolated lipectomy was performed in 44 patients, lipectomy combined with a bariatric operation in 31, and lipectomy after loss of the excess body weight in 21. Conclusions: Bariatric surgery was very effective in weight loss, accompanied by reduction or disappear ance of the co-morbidities of MO, with considerable improvement in quality of life.