World .|. Surg. 1,757-768, 1977

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ORIGINAL SCIENTIFIC R E P O R T S A Prospective Comparison of the Jejunoileal and Gastric Bypass Operations for Morbid Obesity JOSEPH A . BUCKWAI.TER, M . D .

l)epartment of S.rgeo', North Carolina Memorial llospital and University o f North ('arolina School of Medicine, Chapel Hill, North Carolin.. U.S.A.

A prospective, randomized clinical trial has been conducted in 38 morbidly obese patients to compare jejunoileal bypass (19 patients) with gastric bypass (19 patients). At this point the patients have been followed up for periods of from I month to 2 )'ears, and 12 patients in each surgical group have been observed for 6 months or longer after operation. There was one death among the 38 patients, a woman with a gastric bypass who developed a pulmonary embolus 22 days postoperatively. Gastric bypass resulted in somewhat greater weight loss than jejunoileal bypass. Although the follow-up period has been short, jejunoileal bypass has resulted in greater morbidity and expense to the patient than gastric bypass, in particular, gastric bypass did not cau~ progression of liver lesions in any of the 6 patients who had liver biopsies 1 )ear postoperatively, while jejunoileal bypass was associated with development of fatty metamorphosis in the liver of 3 patients after I )'ear. The entry of new patients into the clinical trial has been discontinued because we believe there is sufficient evidence to indicate that gastric bypass is superior to jejunoileal bypass in the treatment of morbid obesity.

An individu~d is morbidly obese when m o r e than twice the ideal body weight is maintained for more than 5 years. Morbid is an appropriate w o r d since anatomical anti functional disturbances d e v e l o p in nearly all organ s y s t e m s s e c o n d a r y to the obesity. This c o m p r o m i s c s the quality of life and probably shortens its duration. Buchwald et al. have s u m m a rized the evidence of the morbkl effect o f obesity [1 I. Surgical therapy for morbid obesity should be considered only when it has been established that the patient cannot lose weight by dieting, in 1954, Kremen et i.d. described the use of j e j u n o i l c o s t o m y to reduce body weight [2]. In 1956 Payne ct al. began performing a jcjunocolic b y p a s s operation in morbidly obese patients [31. This operation, which bypassed all o f the small intestine except about 40 cm of proximal .jejunum, p r o d u c e d dramatic weight loss. H o w e v e r , it was a b a n d o n e d because of uncontrollable dian'hea, electrolyte imbalance, liver thilurc, and an tmacceptable mortality rate [4-7]. K r c m c n ' s concept of preserving the ileocecal valve then reemerged. Payne et al. [8] and others [91 reported satisfactory weight loss following an end-to-side anastomosis between various lengths of the proximal j e j u n u m and the distal ileum. Based on clinical studies c o m p a r i n g end-to-side and end-to-end jejunoileal bypass, Scott et al. [ 10, I l] c o n c l u d e d that the latter procedure resulted in a more predictable weight loss with no increase in morbidity. T o d a y , jejunoileal

Supported by Public Health Service Research Grant No, RR-46, from the (ieneral Clinical Research Centers Brarlch of lhe Division of Research Resources. Reprint rr Joseph A. Buckwaller, M.D., Clinical Research Unit, Department of Surgery, North Carolina Memorial Hospilal, Chapel Hill, North Carolina. U.S.A. 27514.

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bypass is the most commonly performed operation for the treatment of morbid obesity. The indications for the operation, technical considerations, complications, and results have been reviewed by Buchwald et al. [1, 12]. In 1966, Mason et al. [13] began to perform a gastric bypass operation for the treatment of morbid obesity. A retrocolic gastrojejunostomy is constructed between a small proximal gastric pouch, amounting to 10-15% of the stomach, and the jejunum. No stomach is removed. Interest in gastric bypass has been increasing [14-16]. In 1975, a randomized clinical comparison ofjejunoileal and gastric bypass was begun at North Carolina Memorial Hospital in an effort to determine which operation was more effective for the treatment of morbid obesity. This report describes the findings of this study through May, 1977. The reasons for terminating the clinical trial and deciding that gastric bypass is the better operation for the treatment of morbidly obese patients are presented.

Methods

All patients included in the clinical trial were interviewed, examined, operated upon, and seen at each postoperative visit by the author. The patients satisfied the following 5 criteria: (a) They weighed twice their normal body weight for at least 5 years. (b) There was a history of unsuccessful weight loss from dieting under adequate physician supervision. (c) The patient had to " w a n t " the operation after being apprised of the morbidity, mortality, and expected weight loss. No effort was made to "sell" the operation. (d) Historical, physical, operative, and laboratory findings were consistent with at least an 80% operation survival rate. (e) The patient agreed to be randomized for jejunoileal or gastric bypass.

A total of 38 patients were admitted to the Clinical Research Unit for the prospective study. The diagnostic studies performed preoperatively are shown in Table 1. Of the 38 patients involved in the study, 37 were females and 1 was male. The ages ofjejunoileal bypass patients ranged from 19 to 52 years with a mean of 35.5 years. The ages of the gastric bypass patients ranged from 18 to 50 years with a mean of 34.3 years. Operative procedures were randomized by computer. An end-to-end jejunoileal bypass, involving anastomosis of 30 cm of proximal jejunum to the terminal ileum 15-20 cm from the ileocecal valve, was performed upon 19 patients (Fig. 1). Gastric bypass was performed upon 19 patients. The critical features of this procedure were the construction of a proximal gastric pouch involving 10-15% of the stomach and a 11-12 mm gastrojejunostomy stoma. A retrocolic loop or a Roux-en-Y gastrojejunostomy was constructed (Fig. 2). A Silverman needle liver biopsy was done during the operation. The gallbladder was removed because of disease in 9 jejunoileal and 6 gastric bypass operations. Incisional or umbilical hernias were repaired when present. The operating time required for jejunoileal bypass ranged from 21/2 to 4 hours and for gastric bypass ranged from 31/2 to 6 hours. Prophylactic heparin was not used because it increases blood free fatty acid levels which are already elevated in morbidly obese patients [17]. An intravenous infusion of 5% dextrose was started on the night prior to operation to reduce blood free fatty acid levels and, thereby, decrease the possibility of venous thrombosis. The dextrose infusion was continued postoperatively until the patient was able to tolerate oral alimentation. Low-dose heparin in an intramuscular dose of 5,000 units every 8 hours is now being given after operation to favorably affect the coagulation mechanism without further elevating blood free fatty acid levels. Jejunoileal bypass patients were all seen one month

Table 1. Preoperative studies obtained prior to bypass surgery. Hematocrit White blood cell count Platelet count Blood electrolytes Blood urea nitrogen, creatinine, uric acid Blood calcium, phosphorous, magnesium Liver function tests (blood alkaline phosphatase, GOT, bilirubin, prothrombin, partial thromboplastin time, total protein, albumin) Blood cholesterol, triglycerides Blood total protein and albumin Blood glucose

Blood gastrin Arterial blood Po2, Pco2, pH Blood fipoprotein electrophoresis Blood vitamin B12 Urinalysis Electrocardiogram Chest x-ray Barium contrast upper gastrointestinal x-rays Barium enema x-rays Oral cholecystogram x-rays Medical photography Pulmonary function tests

J. A. Buckwalter: Jejunoileal and Gastric Bypass Operations for Morbid Obesity

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following discharge from the hospital and then as indicated by their course. Gastric bypass patients were seen 3 months postoperatively. All patients have been or will be readmitted to the Clinical Research Unit 1 and 2 years following operation for gastrointestinal x-rays, biochemical studies, and percutaneous liver biopsy. Patients have been followed up for from 1 month to 2 years.

Results

Hospital Morbidity and Mortality There have been no hospital deaths. Following either operation, patients were usually discharged from the hospital 7-10 days postoperatively. One jejunoileal and 2 gastric bypass patients developed wound infections. Neither significant pulmonary and urinary tract infections nor thrombophlebitis occurred. One patient developed a thrombosis of the axillary vein secondary to a central venous catheter. She received anticoagulation therapy with heparin and was discharged from the hospital on sodium warfarin treatment on the 17th postoperative day. At the time of discharge, there were prominent veins in the shoulder area and the arm was markedly swollen. Three months following operation the venous congestion was much less conspicuous and most of the swelling was gone. Two patients developed partial obstruction at the anastomosis following jejunoileal bypass. In both, spontaneous normal bowel function returned and they were discharged from the hospital on the 21st and 30th postoperative days, respectively. Obstruction has not recurred. One gastric bypass patient developed a leak at the anastomosis and a subphrenic abscess which was drained surgically. The patient was maintained by intravenous hyperalimentation and 3 months postoperatively the leak is closing and infection is subsiding.

Morbidity and Mortality After Hospital Discharge One gastric bypass patient who was discharged from the hospital on the 8th day after an uncomplicated postoperative course was readmitted 20 days after operation with an embolus to a popliteal artery which was removed. Death occurred 36 hours later following another embolus to a brachial artery. Autopsy revealed massive pulmonary embolism with no apparent source. Four bypass patients (3 jejunoileal and 1 gastric) have had low-grade, chronic infections and/or for-

.) Fig. 1. End-to-end jejunoileal bypass involving anastomo-

sis of 30 cm of proximal jejunum to the terminal ileum 1520 cm from the ileocecal valve.

eign body reactions related to suture material with drainage from the wound. Rehospitalization has not been required. Postoperative ventral hernias have occurred in 2 jejunoileal and 1 gastric bypass patients. Four months following jejunoileal bypass, 1 patient developed a low-grade fever, leukocytosis, abdominal discomfort, distention, and diffuse tenderness with increased peristalsis. Abdominal x-ray examinations showed distended loops of large and small bowel consistent with adynamic ileus. A diagnosis was made of bypass enteritis [18]. Intravenous ampicillin therapy resulted in regression of all findings within 48 hours. Oral ampicillin was given for an additional 2 weeks with no recurrence of the enteritis. One patient developed symptomatic gallstoncs requiring cholecystectomy 6 months after gastric bypass. A preoperative oral cholecystogram and the operative findings at the time of bypass indicated a

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,/

A

Fig. 2. Gastric bypass operation showing the proximal gastric pouch of 10-15% of the stomach anastomosed to the jejunum by a retrocolic gastrojejunostomy (A) or by Roux-en-Y gastrojejunostomy (B).

normal gallbladder. This patient also developed alkaline reflux gastritis 1 year after her gastric bypass operation, which improved with antacid therapy. Kidney stones were passed by 1 patient 6 weeks and 3 months after jejunoileal bypass. Diarrhea must follow jejunoileal bypass if the patient is to lose weight. The primary meclmnism of weight loss is the malabsorption of fat and, unfortunately, also of protein. A "Kwashiorkor"-like state results. Protein deficiency is probably the most important factor contributing to am increase in the fatty metamorphosis of the liver which occurs in some patients and which occasionally progresses to hepatic failure. The diarrhea, which began immediately after operation, varied unpredictably from 5 to more than 25 stools daily. If hemorrhoids were present prior to operation, they became worse. Diphenoxylate hydrochloride with atropine sulfate (Lomotil| codeine, paregoric, kaolin-pectin (Kaopectate| and cholestyramine usually were ineffective in controlling the diarrhea. Suppositories, topical steroids, or anesthetic ointments were helpful in controlling pain related to perianal and anal inflammation. Sitz baths were usually more effective than medications. Potassium supplementation was required to correct the hypokalemia which occurred with the diarrhea. Po-

tassium chloride (K-lyte% was the most satisfactory potassium preparation, given in a dose of 25-50 mEq daily until the diarrhea regressed and the hypokalemia disappeared. In most patients the diarrhea began to improve in 3 months and presented no serious problem after 6 months. Jejunoileal bypass patients were given calcium carbonate with glycine (Titralac| 2 tablets daily, to reduce the excessive oxalate absorption which may be responsible for the reported increased incidence of calcium oxalate urinary tract stones. Calcium carbonate also may help to control the diarrhea. One jejunoileal bypass patient developed hypocalcemia and hypomagnesiemia. The latter was corrected with 2 milk of magnesia, magnesium hydroxide tablets daily for 1 month, without significantly aggravating the diarrhea. Jejunoileal bypass patients were placed on a low-fat, high-protein, and low-liquid diet. It has not been necessary to close the jejunoileal bypass in any of the 19 patients included in the clinical trial. However, since the clinical trial began, 2 patients with jejunoileal bypasses performed elsewhere required closure of the bypass because of clinical evidence of progressive liver damage. Following jejunoileal bypass most patients voluntarily reduced their food intake and had a change in

J. A. Buckwalter: Jejunoileal and Gastric Bypass Operations for Morbid Obesity

food preferences [19]. Frequently they acquired a taste for salads, vegetables, and fruit, while " s n a c k foods", such as potato chips, pork rinds, popcorn, crackers, cakes, cookies, cheese dips, and high carbohydrate drinks, lost their appeal. In gastric bypass the small gastric pouch and tight gastrojejunostomy produce a mechanical barrier to excessive eating. In spite of repeated pre- and postoperative instructions to eat small amounts of wellchewed food, gastric bypass patients often tried to eat compulsively postoperatively. This resulted in nausea and vomiting. Patients usually continued these attempts to overeat for 2 or 3 months, after which most patients consciously or subconsciously accepted the inevitability and desirability of eating small amounts of well-chewed food. Most gastric bypass patients also reported a change in food preference. The preoperative preference for " s n a c k foods" was replaced by a new taste for vegetables, fruits, and salads. For a period of 6 months or longer, some gastric bypass patients had difficulty in eating even well-chewed meat. Revision of the gastrojejunostomy because of obstruction has not been necessary.

Liver Biopsy In Table 2 are recorded the liver biopsy findings. The degree of fatty metamorphosis varied. Periportal chronic inflammation and fibrosis were noted in some patients. A correlation was observed between the liver biopsy findings and both the patient's age and the duration and degree of obesity. The older the patient and the longerqasting and greater the amount of obesity, the more marked were the liver abnormalities. A second liver biopsy was performed 1 year postoperatively in 12 patients, in 3 patients with a jejunoileal bypass who had a normal liver biopsy at operation, fatty metamorphosis was present after 1 year (Fig. 3). No improvement in liver morphology occurred after 1 year in 3 other jejunoileal bypass patients who had pathologic changes in the liver at the time of bypass. In contrast, there has been no worsening of the liver biopsy picture in 6 gastric bypass patients 1 year after operation. In 3 of these, fatty metamorphosis which was present at the time of the bypass operation had disappeared 1 year later (Fig. 4).

Weight Loss In Table 3 the ideal, actual, and excess mean weights of the 38 patients are recorded. The ideal weight for each patient was computed by using the

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Metropolitan Life Insurance Company's height and weight tables [20]. Preoperative weights of patients treated by jejunoileal and gastric bypass were comparable, and the mean weight was almost 3 times the ideal weight, ranging from 102 to 213 kg. The mean weight losses observed at 3, 6, and 12 months postoperatively are also shown in Table 3. A larger percentage of preoperative and excess weight was lost following gastric bypass than after jejunoileal bypass at each postoperative interval. The greater weight loss observed at 6"months than at 12 months in the jejunoileal bypass group is a result of there being different patients included in the 6-month and 12month analyses.

Discussion

Most morbidly obese patients are "foodholics". Although they may be more socially accepted than alcoholics, they are often rejected by their families, peers, potential employers, and physicians who become frustrated and critical of them because of their continuing failure to adhere to prescribed diets. Most patients recognize that their obesity reduces the quality of their lives and may be lifethreatening. They feel thwarted in establishing satisfactory human relationships and obtaining desirable employment. However, they are unable to stop compulsive and excessive eating. This leads to a loss of selfesteem and self-confidence, depression, and feelings of hopelessness. Most morbidly obese patients are referred to the surgeon by others who have been " r e b o r n " as a result of the weight loss which usually follows a bypass operation. Self-image and esteem and the ability to ambulate and function are dramatically improved. For these reasons the informed and propTable 2. Liver biopsy findings in 19 patients who underwent jejunoileal bypass and 19 patients who underwent gastric bypass.

Jejunoileal bypass patients (n = 19) Preoperative liver biopsy Normal 5 Fatty metamorphosis 14 Results of preoperative biopsy Normal 3 Fatty metamorphosis 3 Results of postoperativebiopsy, 1 year Normal 0 Fatty metamorphosis 6

Gastric bypass patients (n 19) 4 15 0 6 3 3

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Fig. 3. Photomicrographs of liver biopsies obtained (top) at time ofjejunoileal bypass operation, showing normal liver, and (bottom) l year postoperatively, showing fatty metamorphosis (100 • magnification).

erly motivated morbidly obese patient is cooperative, appreciative, and a source of satisfaction to the surgeon. In general, the younger the patient, the more satisfactory is the weight loss and the lower is the morbidity after bypass surgery [21]. However, too rigorous patient selection based on age and organic disease eliminates some patients who might benefit from an operation. Frequently the more advanced the morbid

obesity and the greater the operative risk, the more urgent is the indication for surgery. A bypass operation is lifesaving in some unusually obese patients. More important than the operative risk is the attitude of the patient. If the patient has a strong desire to have the operation, it should be performed unless the risk is prohibitive. We operate upon patients if we feel that there is at least an 80% chance of survival. The mean weights of the patients included in this

J. A. Buckwalter: Jejunoileal and Gastric Bypass Operations for Morbid Obesity

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Fig. 4. Photomicrographs of liver biopsies obtained (top) at time of gastric bypass showing fatty metamorphosis, and (bottom) 1 year postoperatively showing normal liver (100 • magnification).

clinical trial are similar to those reported by Mason et al, [14] and greater than those reported by Herinreck et al. [15], Hornberger [16], and DeWind and Payne [22]. The amount of weight loss observed with jejunoileal and gastric bypass is similar to that reported by other authors. Weight loss has usually been expressed as a percentage of total body weight lost rather than a percentage of excess body weight lost. The latter is a more meaningful method of expressing weight loss since it corrects for the very

heavy patient who loses more weight than the less obese patient. The smaller amount of mean weight loss following jejunoileal bypass compared to gastric bypass is a result of the occasional patient who for no apparent reason does not develop significant diarrhea. Two jejunoileal bypass patients lost less than 25 kg of weight in 1 year, while a 33 kg weight loss was the lowest loss observed in the gastric bypass patients. No new patients will be added to this clinical trial.

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However, all patients who have had operations will be followed for 2 years in accordance with the project protocol. All morbidly obese patients who are candidates for surgery are now being treated by gastric bypass. This decision has been reached for the following reasons: Table 3. Preoperative weight and postoperative weight loss in patients who underwent jejunoileal and gastric bypass operations.

Preoperative No. patients Mean ideal weight--kg Mean actual weight--kg Mean excess weight--kg 3 months postoperative No. patients Mean weight loss--kg Mean weight loss--% Mean excess weight loss--% 6 months postoperative No. patients Mean weight loss--kg Mean weight loss--% Mean excess weight loss--% 12 months postoperative No. patients Mean weight loss--kg Mean weight loss--% Mean excess weight loss--% Less than 3 months postoperative No. patients

Jejunoileal bypass

Gastric bypass

19 54.6 142.7 88.1

19 56.0 140.9 84.9

5 15.0 10.7 18.1

3 25.0 20.1 35.8

5 34.8 21.1 31.5

7 34.6 25.5 46.5

6 31.5 24.8 42.7

6 43.0 30.1 48.2

3

3

1. Diarrhea which accompanies successful jejunoileal bypass has more serious physiological sequelae than the "compulsory dieting" which occurs after gastric bypass. 2. The diarrhea frequently disrupts the patient's social life and may interfere with his or her ability to work. Gastric bypass neither adversely affects the patient's social life nor his ability to work. 3. The jejunoileal bypass patient has substantial postoperative expense for medications related to efforts to control the diarrhea, to correct potassium and other deficits, and to prevent urinary tract stone formation. Frequent postoperative outpatient visits are always required and rehospitalization may be necessary. Postoperative medication costs for the gastric bypass patients are negligible and the amount of postoperative care required is much less. 4. Weight loss is greater and more predictable following gastric bypass. 5. The experiences reported by others indicate more serious late sequelae associated withjejunoileal bypass than with gastric bypass [14, 23, 24]. Persistent diarrhea may cause protein and electrolyte deficiencies. As we and others have found, fatty metamorphosis present in the liver of most patients at the time of bypass may progress postoperatively, and may even end in cirrhosis of the liver (Fig. 5) [25, 26]. Persistent protein deficiency with development of edema secondary to hypoalbuminemia and/or evidence of progressive liver damage are the common indications for closing thejejunoileal bypass [27-29]. Other late sequelae ofjejunoileal bypass are urinary

Fig. 5. Photomicrograph of liver biopsy obtained 4 years after jejunoileal bypass showing micronodular cirrhosis and fatty metamorphosis (90 • magnification).

J. A. Buckwalter: Jejunoileal and Gastric Bypass Operations for Morbid Obesity

tract stones [30], arthritis [31], and a persistence of the feeling of fatigue which interferes with social and other activities. In contrast, the late sequelae of gastric bypass are less frequent and less serious [1416]. Stomal ulcer has been noted in less than 2% of patients. Mild anemia occurs infrequently and is easily corrected. Alkaline gastritis, which rarely occurs with a loop gastrojejunostomy, can be treated and prevented by constructing a Roux-en-Y gastrojejunostomy. Griffen [32] has recently reported the findings of a similar clinical trial, and has concluded that gastric bypass is a better operation for morbid obesity for similar reasons. In 1976, at a symposium on jejunoileostomy for obesity, Iber and Cooper [33] reviewed the benefits and the short- and long-term complications of this operation. They concluded that in the United States the jejunoileal bypass is the only treatment effective more than half of the time for massive obesity. The evidence presented in this report suggests that there is another and better operation for treating morbid obesity, namely, gastric bypass. Technically, gastric bypass is a more difficult procedure than jejunoileal bypass. However, the technique has now been improved. The stomach is no longer transected and a proximal small gastric pouch is created by staples. A retrocolic Roux-en-Y gastrojejunostomy is constructed above the staple line using an anastomotic stapling instrument (Fig. 6). The implications of this improvement in technique are that operating time is halved and the morbidity is reduced [34].

R~sum~

Nous avons r6alis6 un essai clinique prospectif et randomis6 destin6 ~t comparer le court-circuit j6junoil6al (19 cas) et le court-circuit gastrique (19 cas) comme traitement de l'ob6sit6 grave chez 38 patients. Actuellement, les malades ont 6t6 suivis pendant 1 mois ~t 2 ans et 12 patients darts chaque groupe ont pu etre observds pendant plus de 6 mois apr6s l'intervention. I1 y eut un d6c6s, une femme qui mourut d'embolie pulmonaire 22 jours apr6s avoir subi un court-circuit gastrique. Le by-pass gastrique entra~ne une perte de poids un peu plus importante que le court-circuit j6juno-il6al. Quoique la pdriode d'observation soit courte, il apparait que les courtcircuits j6juno-ildaux sont grev6s d'une plus grande morbidit6 que les by-pass gastriques. En particulier, le by-pass gastrique n'a pas entrain6 de progression des 16sions h6patiques chez les 6 malades qui ont s u n une biopsie hdpatique un an aprbs l'intervention alors que le by-pass jdjuno-il6al s'est accompagn6 de

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Fig. 6. Revised gastric bypass operation using staples without transection of stomach. m6tamorphose graisseuse chez 3 patients au bout d'un an. Nous avons arr6t6 cet essai thdrapeutique contr616 parce que nous croyons qu'il existe des preuves suffisantes de la sup6riorit6 du by-pass gastrique dans le traitement de l'ob6sit6 grave. References

1. Buchwald, H., Schwartz, M.Z., Varco, R.L.: Surgical treatment of obesity. Adv. Surg. 7:235, 1973 2. Kremen, A.N., Linner, J.H., Nelson, C.H.: An experimental evaluation of the nutritional importance of proximal and distal small intestine. Ann. Surg. 140:439, 1954 3. Payne, J.H., DeWind, L.T., Commons, R.R.: Metabolic observations in patients with jejunocolic shunts. Am. J. Surg. 106:273, 1963 4. Bondar, G.F., Pisesky, W.: Complications of small intestinal short circuiting for obesity. Arch. Surg. 94:707, 1967 5. DeMuth, W.E., Rottenstein, H.S.: Death associated with hypocalcemia after small bowel short circuiting. N. Engl. J. Med. 270:1239, 1964 6. Editorial: Complications of intestinal bypass for obesity. J.A.M.A. 200:638, 1967 7. Wood, L.C., Chremos, A.N.: Treating obesity by "short circuiting" the small intestine. J.A.M.A. 186:63, 1963

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8. Payne, J.H., DeWind, L.T.: Surgical treatment of obesity. Am. J. Surg. 118:141, 1969 9. Salmon, P.A.: The results of small intestinal bypass operations for the treatment of obesity. Surg. Gynecol. Obstet. 132:965, 1971 10. Scott, H.W., Dean, R., Shatl, H.J., Abram, H.S., Webb, W., Younger, R.H., BriU, A.B.: New considerations in use of jejunoileal bypass in patients with morbid obesity. Ann. Surg. 177:723, 1973 11. Scott, H.W., Dean, R.H., Shull, H.J., Gluck, F.W., Abram, H.S., Webb, W., Brill, A.B., Price, R.R.: Surgical management of morbid obesity: current considerations in the use of extensive jejunoileal bypass. South. Med. J. 69:789, 1976 12. Buchwald, H., Varco, R.L., Moore, R.B., Schwartz, M.Z.: Intestinal bypass procedures. Curr. Probl. Surg. April, 1975 13. Mason, E.E., lto, C.: Gastric bypass in obesity. Surg. Clin. North Am. 47:1345, 1967 14. Mason, E.E., Printen, K.J., Hartford, C.E., Boyd, W.C.: Optimizing results of gastric bypass. Ann. Surg. 182:405, 1975 15. Hermreck, A.S., Jewell, W.R., Hardin, C.A.: Gastric bypass for morbid obesity: results and complications. Surgery 80:498, 1976 16. Hornberger, H.R.: Gastric bypass. Am. J. Surg. 131:415, 1976 17. Mason, E.E., Gordy, D.D., Chernigoy, F.A., Printen, K.J.: Fatty acid toxicity. Surg. Gynecol. Obstet. 133:992, 1971 18. Passaro, E., Drenick, E., Wilson, S.E.: Bypass enteritis. Am. J. Surg. 131:169, 1976 19. Benfield, J.R., Greenway, F.L., Bray, G.A., Barry, R.E., Lechago, J., Mena, I., Schedewie, H.: Experience with jejunoileal bypass for obesity. Surg. Gynecol. Obstet. 143:401, 1977 20. Four Steps to Weight Control, Metropolitan Life Insurance Co., p. 12, 1969 21. Printen, K.J., Mason, E.E.: Gastric bypass for morbid obesity in patients more than fifty years of age. Surg. Gynecol. Obstet. 144:192, 1977

22. DeWind, L.T., Payne, J.H.: Intestinal bypass surgery for morbid obesity. J.A.M.A. 236:2298, 1976 23. Winkleman, E.I.: Bypass operation loses favor in obesity treatment. Medical News. J.A.M.A. 236:2729, 1976 24. Bray, G.A., Barry, R.E., Benfield, J.R., CastelnuovoTedesco, P., Drenick, E.J., Passaro, E.: Intestinal bypass operation as a treatment for obesity. Ann. Intern. Med. 85:97, 1976 25. Buchwald, H., Lober, P.H. Varco, R.L.: Liver biopsy findings in seventy-seven consecutive patients undergoing jejunoileal bypass for morbid obesity. Am. J. Surg. 127:48, 1974 26. Salmon, P.A., Reedyk, L.: Fatty metamorphosis in patients with jejunoile~J bypass. Surg. Gynecol. Obstet. 141:75, 1975 27. Cegielski, M.M., Organ, C.H., Saporta, J.A.: Revision of intestinal bypass procedures. Surg. Gynecol. Obstet. 142:829, 1976 28. Mason, E.E., Printen, K.J.: Metabolic considerations in reconstitution of the small intestine after jejunoileal bypass. Surg. Gynecol. Obstet. 142:177, 1976 29. Hitchcock, C.T., Jewell, W.R., Hardin, C.A., Hermreck, A. S.: Management of the morbidly obese patient after small bowel bypass failure. Surgery 82: 356, 1977 30. O'Leary, J.P., Thomas, W.C., Woodward, E.R.: Urinary tract stone after small bowel bypass for morbid obesity. Am. J. Surg. 127:142, 1974 31. Wands, J.R., LaMont, J.T., Mann, E., Isselbacher, K.J.: Arthritis associated with intestinal bypass procedure for morbid obesity. N. Engl. J. Med. 294:121, 1976 32. Griffen, W.O., Young, L., Stevensen, C.C.: A prospective comparison of gastric and jejunoileal bypass procedures for morbid obesity. Ann. Surg. 186: 500, 1977 33. Iber, F.L., Cooper, M.: Jejunoileal bypass for the treatment of massive obesity. Prevalence, morbidity, and short- and lon~-term consequences. Am. J. Clin. Nutr. 30:4, 1977 34. Alden, J.F.: Gastric andjejunoileal bypass. Arch. Surg. 112: 799, 1977

INVITED C O M M E N T A R Y

operations produce comparable weight loss. Both of these studies also show that o v e r the first few years the metabolic and nutritional complications seen after intestinal bypass are not observed following gastric bypass. The difference between the two operations is noteworthy when viewed in the light of the recent surgical literature which has been dominated by reports of urinary oxylate stone formation, liver failure, bypass enteritis, and other complications of intestinal bypass. Both operations were the outgrowth of earlier experience with surgical diseases which required extensive resections of either the bowel or stomach.

EDWARD E. MASON, M.D.

University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A.

This prospective randomized comparison of two operations for morbid obesity, and a similar recent comparison by Griffen [1], show that gastric and intestinal bypasses can be performed with about the same early operative mortality rate, and that the two

A prospective comparison of the jejunoileal and gastric bypass operations for morbid obesity.

World .|. Surg. 1,757-768, 1977 'i ~ inl@ 1977nh~ the ~oc,(.t~crnal,o ale dc ('h, urg c ORIGINAL SCIENTIFIC R E P O R T S A Prospective Comparison...
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