Current status of jejunoileal bypass in the treatment of morbid obesity

Surgeons can offer a satisfactory treatment for a morbid state, which our medical colleagues often find impossible to manage. Obesity which has been unsuccessfully managed and which has reached the level of more than 100 pounds above ideal weight is a clear-cut indication. Preoperative work-up studies need not be more elaborate than those carried out for an ordinary elective intestinal operation. Common sense dictates that certain patients should not undergo the bypass operation, namely, the uncooperative, the emotionally disturbed, the alcoholic and those with significant liver, kidney or intestinal disease. The operation of choice is the end-to-side jejunoileal anastomosis. While Payne originally recommended 14 inches of jejunum and 4 inches of ileum, we and others have been using even less jejunum and at present favor 12 to 4 inches. Efforts to prevent reflux into the proximal part of the ileum by simply approximating jejunum to ileum with six to eight sutures, while not proved to be of value, probably should be done. If after one or two years weight loss is inadequate, reoperation might reveal the presence of too much functional small intestine, usually the result of inaccurate measurement at the initial operation. Shortening of the jejunoileal length to 14 to 16 inches often results in further weight loss. Whether the anastomosis should be converted to an end-to-end arrangement is still uncertain and requires an evaluation of factors such as the amount of weight lost, the length of small intestine in the food circuit and the intensity of the diarrhea. Among the reported revisions, more successes were obtained by shortening the intestinal length than were noted by converting an end-to-side to an end-to-end anastomosis. If the diarrhea is excessive and electrolyte balance becomes unmanageable, these difficulties can usually be brought under control by inserting more intestine into the circuit. Take-down of the shunt is not required for this complication. Among 1,792 patients in ten different clinics only 7% required revisions. This incidence is made higher than it should be, because of the persistent revisions of some in their relentless efforts to achieve good weight reduction. If their series were omitted, the corrected revision rate would be 3.5%. The decision to restore normal intestinal continuity when liver decompensation or recurrent renal stones do not respond to therapy is usually not a difficult one, although it is disappointing because the patients usually regain their weight. Fortunately, this decision does not have to be made too frequently. Among the collected series in ten clinics, take-down of the shunt was only carried out in 4.4%. The issue has been raised frequently as to who is qualified to do this operation and how large a team should be included in the cooperative effort. Only two articles have been published to furnish information specifically on this subject. Prian and associates compared the reported results from several university centers and those obtained by private practitioners in the community hospitals in Denver. Close similarities were found in patient selection, mortality, morbidity and weight loss results. On the other hand, Garrison and associates evaluated the results among 79 patients operated upon by 18 community surgeons in Louisville, Kentucky and concluded that bypass procedures are 'best confined to those institutions where there is special interest in the full range of medical and surgical care of obese patients.' Unfortunately, their conclusion is not supported by their data which revealed three operative deaths, three late deaths, five reversals and four revisions. These values are not much different from those obtained in a variety of university centers. What is different is their higher incidence of wound infections and their lower rate of satisfactory results, derived in a rather complicated manner. No explanation can be offered for the former finding, but certainly wound infections are not a complication specifically related to bypass procedures. A possible explanation for the supposed, lower than average satisfactory result which they reported might be the fact that 32 of their 79 patients had 22 or more inches included in the food circuit. This observation would not support their argument that the bypass procedures should be done only in special university centers, but rather that those doing the operation should do it correctly. In our experience, results were not different in patients operated upon in university as opposed to community hospitals. Careful selection of patients and follow-up examinations are the key to success and safety in the use of this modality for the treatment of obesity. When complications appear, they should be treated as described in the aforementioned test and in the listed references. Common sense and surgical judgment will usually produce the desired result.