Laparoscopic Revision of Jejunoileal Bypass to Gastric Bypass
Condition: Clinically Severe Obesity; Metabolic Complications After Jejunoileal Bypass; Nutritional Complications After Jejunoileal Bypass; Obesity Recidivism; Inadequate Initial Weight Loss; Intestinal Malabsorptive Syndrome; Protein Malnutrition
MeSH terms: Obesity; Malnutrition; Obesity, Morbid; Kwashiorkor; Weight Loss
Study type: Observational

Summary: 
      This study objectives are the following.

        -  To describe the updated clinical presentation, indications, and multidisciplinary
           medical management of patients with a failed and/or complicated jejunoileal bypass
           (JIB).

        -  To analyze the feasibility, safety, and efficacy of one-stage laparoscopic re-operative
           gastric bypass surgery for failed and/or complicated Jejunoileal bypass (JIB) for weight
           loss.

        -  To determine what factors or strategies are associated with a successful outcome. In
           particular, the completion of the surgery in one stage with a laparoscopic approach.
    

Detailed description: 
      The epidemic of overweight and obesity in the United States of America along with its
      comorbidities continues to expand. Bariatric surgery has demonstrated to be the most
      effective and sustained method to control severe obesity and its comorbidities. For instance,
      type 2 diabetes mellitus was completely resolved in 76.8 percent, systemic arterial
      hypertension was resolved in 61.7 percent, dyslipidemia improved in 70 percent, and
      obstructive sleep apnea hypopnea syndrome was resolved in 85.7 percent. Furthermore,
      bariatric surgery significantly increases life expectancy (89 percent) and decreases overall
      mortality (30 to 40 percent), particularly deaths from diabetes, heart disease, and cancer.
      Lastly, preliminary evidence about downstream savings associated with bariatric surgery
      offset the initial costs in 2 to 4 years8.

      Since 1998, there has been a substantially progressive increase in bariatric surgery. In
      2005, the American Society of Metabolic and Bariatric Surgery "ASMBS" reported that 81
      percent of bariatric procedures were approached laparoscopically. 205,000 people, in 2007,
      had bariatric surgery in the United States from which approximately 80 percent of these were
      Gastric Bypass. Moreover, there is a mismatch between eligibility and receipt of bariatric
      surgery with just less than 1 percent of the eligible population being treated for morbid
      obesity through bariatric surgery. Along with the increasing number of elective primary
      weight loss procedures, up to 20 percent of post RYGB patients cannot sustain their weight
      loss beyond 2 to 3 years after the primary bariatric procedure. Thus, revisional surgery for
      poor weight loss and re-operations for technical or mechanical complications will rise in a
      parallel manner.

      Regardless of being an effective treatment of morbid obesity, JIB was abandoned in the early
      80s mostly because of its metabolic and nutritional complications. Multiple patients who
      underwent this procedure more than two decades ago are still alive. Close follow-up, in even
      asymptomatic patients, is necessary after JIB because they may present with nonreversible
      complications.

      As with any bariatric procedure, weight regain, inadequate initial weight loss, and late
      complications or a combination of them are the most widely accepted indications to undergo
      revisional bariatric surgery. Specifically, the JIB related late complications can be
      arbitrarily categorized into "malabsorption and malnutrition" and "bacterial overgrowth
      syndrome". The former might present with steatorrhea, electrolyte (K, Ca, P, Mg) and acid
      base imbalance (hyperchloremic metabolic acidosis), liposoluble (A, D, E, K) and hydrosoluble
      (B1, B12 and Folate) vitamin deficiencies, and protein calorie malnutrition "PCM". "The
      bacterial overgrowth syndrome" causes a variety of complications such as gas bloat syndrome,
      foul smelling flatulence, recurrent migratory polyarthralgia and necrotizing skin lesions.
      Other late non metabolic complications related to the bypassed bowel include intussusception,
      pseudo-obstruction, and bypass enteropathy.

      "PCM" is quickly and effectively treated by parenteral nutritional support. Diet optimization
      with consumption of high biological value protein (90 g per day) and a total calorie intake
      adjusted to ideal body weight might decrease the severity of the malabsorption syndrome and
      or prevent its recurrence.

      Transitory resolution of most symptoms caused by the bacterial overgrowth syndrome is
      accomplished by the administration, in divided doses, of oral tetracycline (2.0 g per day),
      amoxicillin-clavulanate (1 to 1.7g per day), clindamycin (0.9 to 1.8 g per day), and
      metronidazole (1 to 1.5 g per day) among others. Rapid symptomatic improvement is observed,
      however, over time, organisms become resistant to the systemic absorption of antibiotics,
      ceasing the benefit of this therapy. In addition, side effects including superinfections such
      as pseudomembranous colitis might present. Local instillation of antibiotic through an
      intestinal indwelling catheter placed in the excluded bowel limb has been described.

      When the JIB related complications present as intractable, severe or recurrent, surgical
      intervention is required. Liver, either acute liver failure or cirrhosis, (secondary to "PCM"
      and bacterial overgrowth syndrome) and kidney, either tubulointerstitial nephropathy or
      renoureteral lithiasis, (secondary to enteric hyperoxaluria and volume depletion) dysfunction
      are the most frequently described complications leading to death. However, after end stage
      liver (cirrhosis) and renal diseases are established, good judgment is needed to assess the
      risk benefit algorithm for operative intervention, as these conditions are irreversible.

      In the United States, the most popular type of intestinal bypass performed was the so called
      "14 plus 4" with an end to side jejunoileostomy, a 14 inches biliopancreatic limb with a 4
      inches common channel. Because of poor weight loss, some surgeons used to performed an end to
      end jejunoileostomy avoiding chyme to reflux into the defunctionalized limb; Through an
      ileocolostomy, the defunctionalized jejunoileal limb was drained into the cecum or sigmoid
      colon.

      Open reversal or conversion to gastric bypass has been shown to be effective procedures with
      defined complications. Since the 60s Payne, DeWind and Commons had already demonstrated that
      takedown and restitution of the gastrointestinal continuity is an effective strategy to solve
      the metabolic complications. However, relapse of obesity along with its comorbidities is the
      rule.

      Series from the 70s and 80s suggested that one stage open revision of JIB to gastric bypass
      was feasible and safe. However, most of these revisions were performed a couple of years
      after the original bariatric surgery with a completely different configuration (non divided
      horizontal pouch with a loop gastrojejunostomy) from how modern RYGB is performed in these
      days. Hence, outcome analysis of those series is not transferable in today context.

      Because of the long interval time between the JIB and the revision surgery, bowel adaptation
      is maximal causing a marked discrepancy in the lumen diameter and bowel thickness between the
      functional and defunctionalized bowel segments. Thus, different approaches have been
      described in the literature to deal with more extensive intestinal changes..

      Based on Cannova et al. report in which described the placement of an intestinal indwelling
      catheter in the excluded bowel limb, Dallal et al. with a minimally invasive approach
      established enteral nutritional support in the defunctionalized bowel limb, to revert its
      atrophy. After a three month period with extensive counseling to undergo conversion to a
      RYGB, the patient decided just to be reversed.

      Another staged option for revising the JIB is as follows. Initially, the JIB is dismantled
      and the normal gastrointestinal continuity restored. After the initially bypassed and
      atrophied small bowel regains its function and the bowel atrophy is partially overturned, the
      second stage (weight loss procedure) is performed, so weight loss can be maintained or
      achieved.

      The two accepted revisionary procedures described in the literature for failed JIB are mainly
      adjustable gastric banding (AGB) and gastric bypass. In 2000, O'Brien et al. reported a
      series of 50 revisions to adjustable gastric banding. As the primary bariatric procedure, two
      patients had a JIB. A one stage open revision was performed without providing specific subset
      outcome analysis.

      In 1993, Behrns et al. reported the outcome analysis of 61 open assorted revision surgeries
      from which 14 had a JIB. The indication for this subgroup was due to severe metabolic
      complications with a pre-revisional mean BMI of 34.2 kilograms per squared meter. Nine
      patients were revised to VBG and five patients to a non-divided, vertical RYGB. The percent
      excess weight loss for this five patients was 49.5 percent (overall follow-up was 23 months)
      with a 67 percent dissatisfaction rate of their new lifestyle because of the change in eating
      patterns caused by switching from a full size meal to a restricted diet.

      In 1996, Owens et al. reported the open surgical revision of 75 patients from which 23
      patients had a JIB as their primary procedure. Specific subgroup analysis was not provided.
      In 2005, khaitan et al. reported 37 patients who underwent 39 bariatric revisions, either
      open or laparoscopic. Originally, five had a JI bypass from which two were initially
      approached laparoscopically. However, specific subgroup analysis was not provided.

      In summary, there are just two manuscripts reporting cases of attempted laparoscopic
      conversion of JIB to RYGB with its modern anatomical construction. However, a one stage
      procedure has not been achieved up to date. Therefore, no outcomes with this approach have
      been documented as well. With this study, we will advance our knowledge about revision
      bariatric surgery and report excellent outcomes after conversion from a completely
      malabsorptive procedure to a mostly restrictive weight loss procedure, the gastric bypass and
      although JIB was abandoned long time ago, there are still living patients with this procedure
      and bariatric surgeons need to be aware of side effects and minimally invasive strategies for
      the management of these highly complex patients.
    

Observational model: Cohort
Time perspective: Retrospective
Sampling method: Non-Probability Sample
Study population: 
        Patients who underwent laparoscopic revision of JIB to Roux-en-Y gastric bypass (RYGB) for
        poor weight loss or JIB-related late complications were analyzed. Failed or JIB-related
        late complications, mostly metabolic, were considered for surgical intervention after
        optimized medical multidisciplinary management
      
Keywords: Failed jejunoileal bypass; Complicated jejunoileal bypass; Revision gastric bypass; Revisional surgery; Reoperations; Metabolic and nutritional complications