Outcomes of Duodenal Switch and Other Malabsorptive Procedures

The first bariatric operations were entirely malabsorptive and left the stomach untouched. They came to be known as jejunoileal bypass (JIB). In the most popular version of JIB, the jejunum was divided 14 inches beyond the ligament of Treitz and the proximal end anastomosed to the terminal ileum 4 inches from the ileocecal valve (the 14-4 operation). The stimulus to their development was derived from recognition of the short gut syndrome, in which it was clear that patients with massive intestinal resection lost weight despite a high oral intake. The first formal program to follow a series of obese patients after intestinal bypass was developed by a private practice surgeon (J. Howard Payne) and an endocrinologist (Loren DeWind) in Los Angeles, beginning in 1957. Their careful reports identified a number of serious complications that could make their appearance many years after the surgery. These complications included protein- calorie malnutrition and vitamin deficiencies, electrolyte imbalance, renal calculi, and local perianal problems, as a consequence of the extreme malabsorption and the diarrhea it produced. Further, arthropathy and progressive liver failure occurred in a significant percentage of patients, evidently the result of bacterial overgrowth in the lengthy blind loop of intestine (all but 45 cm). Despite the beneficial effects of weight loss and resolution of major comorbidities such as diabetes mellitus, hyperlipidemia, and obstructive sleep apnea, the frequency and potential severity of these problems, often requiring reversal of the bypass, led to the abandonment of intestinal bypass in favor of purely restrictive procedures or a Roux-en-Y reconstruction to a small gastric pouch.