Question:
What is a jejunoileal bypass and how is it different from today's RNY?

I read a post on Gastronews.com about a woman who had a jejunoileal bypass back in 1978 and had complication after complication all through the years. I'd never head of this surgery and wonder if and how it is different from today's RNY? Thanks!    — Lynette B. (posted on May 14, 2000)

May 14, 2000
This information and other surgery type history can be found at: http://asbs.org/html/story/ch_2.html <p> A modern variant of the Jejuno-ileal Bypass (JIB) is Biliopancreatic Diversion,(BPD)and to answer your question JIB differs greatly from the RNY..as stated in this report JIB modern variant is BPD.. <P> CHAPTER-2 <p> The trouble with jejuno-ileal bypass <p> JEJUNO-ILEAL BYPASS: (JIB) <p> Two variants of jejunoileal anastomosis were developed, the end-to-end (Scott)(Scott, Dean et al. 1973) and end-to side(Payne) (Payne and DeWind 1969) anastomoses of the proximal jejunum to distal ileum. In both instances an extensive length of small intestine was bypassed, not excised, excluding it from the alimentary stream. <p> In both these variants a total of only about 35 cms (18") of normally absorptive small intestine was retained in the absorptive stream, compared with the normal length of approximately 7 meters (twenty feet). In consequence, malabsorption of carbohydrate, protein, lipids, minerals and vitamins inevitably occur, Where the end-to-side technique was used, reflux of bowel content back up the defunctionalized small intestine allowed absorption of some of the refluxed material resulting in less weight loss initially and greater subsequent weight regain. <p> Bile is secreted by the liver, enters the upper small intestine by way of the bile duct, and is absorbed in the small intestine. Bile has an important role in fat digestion, emulsifying fat as the first stage in its digestion. Bypassing the major site of bile acid reabsorption in the small intestine therefore further reduces fat and fat soluble vitamin absorption. As a result, huge amounts of fatty acids which are normally absorbed in the small intestine, enter the colon where they cause irritation of the colon wall and the secretion of excessive volumes of water and electrolytes, especially sodium and potassium, leading to diarrhea. This diarrhea is the major patient complaint and has characterized jejunoileal bypass in the minds of patient and physician alike since the procedure was introduced. <p> Bile salts help to keep cholesterol in solution in the bile. Following JIB, the bile salt pool is decreased as a consequence of reduced absorption in the small intestine and bile salt losses in the stool. The relative cholesterol concentration in gallbladder bile rises and cholesterol crystals precipitate in the gallbladder bile, forming a nidus for development of cholesterol gallstones in the gallbladder. Specific vitamin deficiencies also occur, Vit D and Calcium deficiencies lead to thinning of bone with bone pain and fractures as a result of osteoporosis and osteomalacia. Bypass of the terminal ileum which is the specific site of Vitamin B12 absorption, leads to Vitamin B12 deficiency with a specific peripheral neuropathy. Vitamin A deficiency can induce night blindness. <p> Calcium Oxalate renal stones occur commonly following JIB, along with increased colonic absorption of oxalate. The colonic absorption of oxalate has been attributed to: <p> Exposure of colonic mucosa to excessive bile salts and possibly bile acids, increasing colonic permeability to oxalate or: Excessive quantities of fatty acids in the gut form soaps with calcium, reducing its availability to form insoluble calcium oxalate leading to the persistence of soluble and absorbable oxalate in the colon. Patients with intestinal bypass develop diarrhea 4-6 times daily. The frequency of stooling varying directly with fat intake. There is a general tendency for stooling to diminish with time, as the short segment of small intestine remaining in the alimentary stream increases in size and thickness, developing its capacity to absorb calories and nutrients, thus producing improvement in the patients nutrition and counterbalancing the ongoing weight loss. This happy result does not occur in every patient, but approximately one third of those undergoing "Intestinal Bypass" have a relatively benign course. Unfortunately, even this group is at risk of significant late complications, many patients developing irreversible hepatic cirrhosis several years after the procedure. <p> JIB is the classic example of a malabsorptive weight loss procedure. Some modern procedures utilize a lesser degree of malabsorption combined with gastric restriction to induce and maintain weight loss. Any procedure involving malabsorption must be considered at risk to develop at least some of the malabsorptive complications exemplified by JIB. The multiple complications associated with JIB while considerably less severe than those associated with Jejunocolic anastomosis, were sufficiently distressing both to the patient and to the medical attendant to cause the procedure to fall into disrepute. <p> Listing of jejuno-ileal bypass complications: <p> Mineral and Electrolyte Imbalance: <p> Decreased serum sodium, potassium, magnesium and bicarbonate. Osteoporosis and osteomalacia secondary to protein depletion, calcium and vitamin D loss, and acidosis, Protein Calorie Malnutrition: <p> Hair loss, anemia, edema, and vitamin depletion Cholelithiasis: <p> Enteric Complications: Abdominal distension, irregular diarrhea, increased flatus, pneumatosis intestinalis, colonic pseudo-obstruction, bypass enteropathy, volvulus with mechanical small bowel obstruction. Extra-intestinal Manifestations: <p> Arthritis: Acute liver failure may occur in the postoperative period, and may lead to death acutely following surgery. Liver disease, occurs in at least 30% Steatosis, "alcoholic" type hepatitis, cirrhosis, occurs in 5%, progresses to cirrhosis and death in 1-2% Erythema Nodosum, non-specific pustular dermatosis Weber-Christian Syndrome <p> Renal Disease: Hyperoxaluria, with oxalate stones or interstitial oxalate deposits, immune complex nephritis, "functional" renal failure. <p> Miscellaneous: Peripheral neuropathy, pericarditis. pleuritis, hemolytic anemia, neutropenia, and thrombocytopenia. <p> The multiple complications associated with JIB led to a search for alternative procedures, one of which was gastric bypass, a procedure which is described in detail later. <p> In 1983 Griffen et al. reported a comprehensive series comparing the results of jejuno-ileal bypass with gastric bypass. 11 of 50 patients who underwent JIB required conversion to gastric bypass within 5 years, leading Griffen to abandon jejuno-ileal bypass.(Griffen, Bivins et al. 1983) <p> <b>JIB can be summed up as having: <p> Good Weight Loss, Malabsorption with multiple deficiencies, Diarrhea. As a consequence of all these complications, jejuno-ileal bypass is no longer a recommended Bariatric Surgical Procedure. Indeed, the current recommendation for anyone who has undergone JIB and still has the operation intact, is to strongly consider having it taken down and converted to one of the gastric restrictive procedures. </b> CHAPTER-3 <p> Biliopancreatic Diversion <p> BILIOPANCREATIC DIVERSION: (BPD) <P> A modern variant of the Jejuno-ileal Bypass (JIB) is Biliopancreatic Diversion,(BPD), a procedure which differs from JIB in that no small intestine is defunctionalized and, consequently, liver problems are much less frequent. This procedure was developed by Professor Nicola Scopinaro, of the University of Genoa, Italy.(Scopinaro, Gianetta et al. 1996)
   — Victoria B.

May 15, 2000
Read more about the HISTORY OF GASTRIC BYPASS at: http://www.surgery.usc.edu/divisions/cr/obesity.html History of Obesity Surgery JEJUNOILEAL BYPASS "Obesity surgery" dates back to 1954, when the first jejunoileal bypass was done specifically for the purpose of weight loss. The procedure involved bypassing most of the small intestine, anastomosing 14 inches of jejunum to the last 4 inches of ileum. The jejunoileal bypass had severe metabolic side effects, due in large part to the nonfunctional portion of the intestine remaining. Toxic products from bacteria that overgrew in the defunctionalized intestine were absorbed directly into the portal venous system, causing liver failure. Other side effects included severe diarrhea, protein malnutrition and kidney stones. The jejunoileal bypass is no longer performed. PROXIMAL GASTRIC BYPASS A second obesity operation, developed in 1969, is the proximal gastric bypass. The surgery's main goal is to restrict eating by stapling off most of the stomach. What is eaten goes directly into the intestine, bypassing the duodenum and the first part of the jejunum. "Undigested food drops right into the intestine, resulting in a dumping syndrome,". "The side effects of this operation include transient abdominal cramps, bloating, systemic flushing (hot flashes), pain and diarrhea, causing some patients to develop an aversion to eating, particularly simple sugars, which eventually leads to weight loss. It's not a very pleasant way to lose weight." Very few surgeon, if any, are still performing the JIB and the BILIOPANCREATIC DIVERSION (BPD) without DS.
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