Bariatric Times - September 2008 - (Page 24)

24 Surgical Perspective FIGURE 1. Preoperative upper gastrointestinal and small bowel contrast study. Note rapid transit of contrast solution into the colon. S=stomach; DI=distal Ileum; C=cecum. jejunoileostomy. Thereafter, in 1969, Payne further modified his approach from a jejunocolic bypass to a jejunoileal shunt by joining the first 35cm of jejunum to the last 10cm of ileum in an end-to-side anastomosis.1 The dramatic weight loss achieved with this procedure led to the spread of bariatric surgery as an attractive option for the treatment of obesity.2 This encouraged other surgeons to perform the JIB with their own personal modifications.9,13,14 Approximately 100,000 JIBs have been performed—mostly during the 10-year period that followed Payne’s report in 1969.15 Unfortunately, the impressive weight loss came at a very high price. The resulting malabsoprtion and diarrhea created a multitude of fluid and electrolyte abnormalities, including hypokalemia, hypocalcemia, hyperoxaluria, and hypoalbuminemia. This in turn led to the formation of renal calculi and liver failure.2,16 The long-term sequelae included cirrhosis,17,18 vitamin and mineral deficiencies,19 peripheral neuropathy,20 and chronic renal failure.19,21 The bypassed portion of small bowel is also responsible for some of the complications seen in JIB. Bacteria within the small bowel proliferate freely, developing chronic infections,3 and subsequently release bacterial toxins into the systemic circulation.2,22 Circulating antibodies then deposit in joint spaces causing immune complex arthritis and migratory polyarthritis.18,23 JIB is no longer recommended as a weight loss procedure because of these serious and lifethreatening complications.3 As a result, several centers have reported a substantial number of revisions and reversals. The most common causes for reversal of the JIB are severe diarrhea, renal stones or renal failure, cirrhosis or liver failure, and life-threatening malnutrition.2,24-26 Once the continuity of the intestinal tract is re-established, most of the bypassassociated symptoms and complications resolve.21,25,27-29 Most patients, however, regain a significant amount of weight.24,25,28 This weight gain has prompted some authors to simultaneously complement the JIB reversal with another weight loss procedure.24,30,31 Because of a high number of complications and the failure to lose adequate weight after restrictive procedures,32 most bariatric revisional procedures favor the creation of a gastric bypass. This combination results in an acceptable complication rate with appropriate weight loss.3,33-35 The severe metabolic complications and low quality of Bariatric Times • September 2008 FIGURE 2. Preoperative abdominal CT scan with oral contrast. Panel A shows contrast material in the antrum and duodenum (white arrows). Panel B shows contrast material in the proximal jejunum (white arrows). Panel C shows contrast material in the ileum (white arrows). Panel D shows contrast material in the ascending and descending colon (white arrows). Note the absence of contrast material in the rest of the small bowel in panels B, C, and D. FIGURE 3. Postoperative upper gastrointestinal contrast study after sleeve gastrectomy. GE=gastroesophageal junction; P=pylorus. life that our patient suffered prompted his JIB reversal. However, due to his normal BMI and poor health at the time of surgery, the JIB reversal was not complemented with another bariatric procedure. During the following months after the JIB reversal, the patient’s eating habits dramatically transformed, most likely the result of more than 30 years of meager food intake and chronic diarrhea. Despite professional nutritional and psychological consultation, the patient’s eating habits resulted once again in morbid obesity, which in turn required another bariatric procedure. Due to his previous condition, the patient refused any malabsorptive procedure as a treatment for his current obesity. Therefore, a restrictive procedure was selected. The sleeve gastrectomy (SG) has proven to be an adequate restrictive procedure for obesity,36 particularly in the super-obese patients.37,38 It was originally described by Marceau et al39 and Hess et al40 as the first step in the biliopancreatic diversion with duodenal switch, considered to be both restrictive and malabsorptive. SG achieves weight loss by restricting the amount of food that can be consumed without the potential risks and sequelae of malabsorption (Figure 4).41 Besides the restrictive mechanism conferred by the reduction of gastric capacity, the SG causes a significant decrease in the hungerregulating hormone ghrelin by resecting most of the ghrelinproducing cells in the fundus of the stomach.42,43 The weight loss effects of SG appear to exceed those of other restrictive procedures, including vertical banded gastroplasty41 and intragastric balloon.44 Because of the decrease in the production of the hunger-regulating ghrelin, SG also appears to be a better alternative than gastric banding.42 In fact, SG has also been used satisfactorily in gastric band reversal procedures. Baltasar et al reported the conversion of an adjustable gastric band to SG with continued weight loss and a significant improvement in quality of life.41 FIGURE 4. The sleeve gastrectomy. CONCLUSION Due to the large number of JIB procedures performed since the late 1960s, many JIB patients may still develop metabolic complications that will require revisional surgery. We believe that the need for performing a different bariatric procedure at the time of a JIB revision has to be individualized to each patient, as occurred in this case. Even after a

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Bariatric Times - September 2008 Emerging Technologies Case Report Sleeve Gastrectomy after a Jejunoileal Bypass Reversal Editorial Message Contents Editorial Board Walk from Obesity The Latest on Nutrition and Hair Loss in the Bariatric Patient Consultant’s Corner Journal Watch Calendar of Events Advertiser Index

Bariatric Times - September 2008

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