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World J Surg (2009) 33:19891994 DOI 10.1007/s00268-009-0101-8
The Role of Malabsorption in Bariatric Surgery
Vivek N. Prachand John C. Alverdy
Published online: 10 June 2009 Socit Internationale de Chirurgie 2009
History of malabsorptive weight loss surgery
Jejunoileal bypass (JIB), initially performed by Varco in 1953, was the rst gastrointestinal operation performed specically to treat severe obesity [1]. Based on the observation that massive small bowel resection led to substantial weight loss, the procedure was conceptually designed to radically alter the absorption of nutrients, and hence energy, from the intestinal tract in an effort to achieve massive weight loss in severely obese individuals. Numerous modications to the procedure were made in an effort to improve outcomes [2], and although JIB initially provided good weight loss results, over time both weight loss recidivism and clinically important complications (30 50%), including massive diarrhea, electrolyte disturbances, arthralgias, osteomalacia, oxalate kidney stones, and liver failure, were observed, with some series demonstrating renal and liver failure rates approaching 20% and 13% respectively [3]. As such, up to 30% of these operations required reversal [4], and by the late 1980s the JIB was abandoned, although not until nearly 100,000 operations had been performed.
Several of the serious morbidities associated with JIB were attributed to a blind-loop syndrome resulting from the presence of a long segment of bypassed small intestine lacking signicant intraluminal ow of secretions [5]. The relative stasis and bacterial overgrowth within the bypassed segment was hypothesized to cause complications via
direct mucosal injury, alterations in intestinal permeability to bacteria and their toxins, circulation and deposition of immune complexes [6], abnormal activation of complement, and excessive production of D-lactate by gram-positive anaerobes. Newer bariatric procedures that incorporate some degree of malabsorption as a mechanism for weight loss theoretically avoid the complications of a blind loop by ensuring luminal ow in each intestinal limb: oral intake in the Roux or alimentary limb, bile and pancreatic secretions in the bypassed small bowel or biliopancreatic limb, and admixture of the two streams in the common channel extending from the distal anastomosis to the cecum in the Roux-en-Y reconstruction.
In Roux-en-Y gastric bypass (RYGB), a small-volume (1530 ml) gastric pouch is created using the proximal stomach with the reconstruction consisting of a 100150-cm alimentary (Roux)...