The management of gross refractory obesity by jejuno-ileal bypass

Abstract

Jejuno-ileal bypass has been performed in 226 massively obese patients, 190 of whom have been followed for a minimum of 1 year. End-to-side and end-to-end anastomoses were compared and no difference in the weight reduction achieved by either technique was seen throughout the 5-year follow-up. There was no significant difference in weight reduction achieved between groups of patients in which the jejunal length varied from 10 to 35 cm and the ileal length from 35 to 10 cm. The weight reduction achieved in the entire series averaged 36-7 +/- 9-4 per cent at 2 years, after which no further loss occurred. Good psychological benefits were recorded. Remission of diabetes occurred in 12 of 13 patients and marked long term lowering of serum lipids was seen. Side effects included fluid and electrolyte disturbances and fatty changes in the liver during the first year, improving thereafter. Early cirrhosis of the liver occurred in 8-6 per cent. Other side effects included abdominal bloating, arthralgia and renal colic. The operative mortality was 0-9 per cent and the late mortality directly attributable to the jejuno-ileal bypass, 3-1 per cent. In 19 patients the bypass was discontinued because of severe side effects.

Biological effects of bariatric surgery on obesity-related comorbidities

“…While excellent weight loss is achieved, the blind jejunal-ileal limb leads to nutritional complications and hepatic cirrhosis secondary to bacterial overgrowth. [30][31][32] As such, this procedure was abandoned, and the BPD was devised to improve upon the JIB.…”

An epilogue to jejunoileal bypass

“…Electrolyte disturbances in later years thus should not be more than an occasional problem. Even so the author [1,41] observed subnormal values of serum magnesium in 18.4% of patients after 6 months, rising steadily to almost 42% by 5 years. These values were not grossly deranged and were usually not associated with deficiency symptoms.…”

“…Most of this elongation occurred in the ileal segment. There is no evidence that reflux into the defunctioned ileum influences weight reduction [1], as was implied in the original rationale of the Scott type of end-to-end bypass [11]. Increase in villus height due to hyperplasia has been reported in both the jejunum and ileum [9,12], again more so in the latter, suggesting that the ileum is more adaptable than the jejunum.…”

“…The pattern of weight reduction after jejunoileal bypass is one of rapid fall during the first year slowly descending to a plateau by 18-24 months. At this stage patients will have lost approximately 35% of their original body weight; this loss is sustained at 5 years [1,2] and 10 years [3,4]. Such a figure masks considerable variation, as most surgeons have recorded inadequate weight loss from the outset [5,6] or weight gain during the second year onward.…”

“…Subsequent mobilization of lipids from peripheral deposits causes a compensatory increase in bile acid synthesis in the liver [16]. Several authors have reported early, marked, and sustained falls in serum cholesterol values and to a lesser extent serum triglyceride levels [1,2,17]. A recent study [18] in 26 patients who had had end-to-end jejunoileal bypasses displayed prompt falls in total plasma cholesterol and low-density lipoprotein (LDL) cholesterol that persisted throughout the 2-year period of fol!ow-up.…”