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Bariatric surgery is an effective option for managing obesity and has gained general acceptance among patients in recent years. Generally, despite the high caloric intake, a bad nutritional habit of obese people results in the deficiency of several vitamins, minerals, and trace elements essential for body metabolism and normal physiological processes. Additionally, the current bariatric surgical approaches such as sleeve gastrectomy (SG), Roux-en-Y-gastric bypass (RYGB), laparoscopic adjustable gastric banding (LAGB), and jejunoileal bypass (JIB) can cause or exacerbate these deficiencies. Based on several reports, it appears that the various bariatric surgical procedures affect nutrient absorption differently. Being purely restrictive, LAGB and SG affect the absorption of iron, selenium, and vitamin B12, while RYGB, JIB, and biliopancreatic diversion have a more profound impact on the absorption of essential vitamins, minerals, and trace elements. Nutritional deficiencies in vitamins, minerals, and trace elements may follow bariatric surgery and are associated with clinical manifestations and diseases, including anemia, ataxia, hair loss, and Wernicke encephalopathy. The present review summarizes some of the major vitamin and micronutrient deficiencies associated with bariatric surgery, particularly those presented post-surgically. To avoid any adverse consequences of vitamin and trace element deficiency, proper monitoring and tests are recommended at any stage, from pre- to post-surgery (periodical check-up), followed by specific and individual nutritional supplementation treatments and a proper healthy diet.

Background Bariatric surgery produces anatomic changes in the digestive tract that can affect the intestinal microbiome and, in some cases, can cause small intestinal bacterial overgrowth. Since the inception of the sleeve gastrectomy with jejunal bypass (SGJB) in 2004, there has been discussion regarding the possible development of those complications associated with the now abandoned jejunoileal bypass (JIB) procedure. Objectives The primary endpoint was to characterize the bacteriologic and histopathologic findings in the defunctionalized jejunal loop after the SGJB procedure and to analyze the liver profile. The secondary endpoint was to report SGJB conversions or reversions and to review the differences between SGJB and JIB. Setting Academic medical center. Methods We conducted a prospective study of patients who underwent laparoscopy for any reason, having previously had an SGJB. A 5-cm segment at the proximal end of the excluded limb was resected. Luminal liquid and tissue samples were taken from this segment for aerobic and anaerobic cultures, and pathologic examination of the bowel wall was performed to evaluate trophism and signs of chronic inflammation. Other variables were liver function and pre- and postoperative status. Finally, we retrospectively reviewed the causes of revisional surgery in the prospective database. Results Eleven patients underwent laparoscopy. The median time after SGJB was 14 months (range, 10–144 months). There were no complications from the procedure. Eight (72.7%) of the procedures were cholecystectomies. None of the patients showed histologic alterations or signs of chronic infection. The liquid and tissue cultures were negative. The liver tests and the laparoscopic morphology of the liver were normal in all patients, except in 1 with previously documented liver cirrhosis. The number of SGJB revisions was 19 of 1074 (1.8 %), and all of them were converted to Roux-en-Y gastric bypass for severe gastroesophageal reflux. Conclusions In this study, we were unable to demonstrate the presence of symptoms or histologic alterations that would suggest that patients undergoing SGJB develop small intestinal bacterial overgrowth in the short- and medium-term follow-up, unlike those who have undergone JIB. The study constitutes an initial step toward establishing what happens to the defunctionalized jejunal limb as a result of this surgical technique.

Universally, obesity has been affected more than 650 million and converts as global health problem. Obesity is equally affecting starting from children to elder population. Obese subjects are converting into severe obese and then into morbid obesity. Body mass index is proning from 30 to 50 kg/m2 in the adult population. Obesity is connected with the future complications of hypertension, type 2 diabetes mellitus, cardiovascular, stroke, osteoarthritis, obstructive sleep apnea and liver diseases. Loosing of body fat is the only option to avoid obesity and this could be achieved with routine physical activity and diet modifications. Obesity subjects may fail to achieve the daily routine activities or insufficient activity may be involved and finally fail to lose the body fat after the medical course. Then these severe or morbidity obese can be lose with the existing surgery. Currently, Bariatric Surgery (BS) has become the active treatment for long-term weight loss. Various types (Roux-en-Y gastric bypass, sleeve gastrectomy and duodenal switch and the jejunoileal bypass) of BS are performed on the gastrointestinal tract. Throughout the world population, BS has found to be safe in losing the weight and avoiding the future and long-term complications. The prevalence of overweight and obesity in Saudi Arabia is an issue in terms of incidence and health consequences. Maximum obesity studies involved in Saudi Arabia has proven to be develop the long-term complications in the future involving from child to morbid obesity. Limited bariatric studies carried out in the Saudi subjects confirmed as effective tool in lowering the body fat and avoiding the life-threatened complications of human diseases. So, this review recommends BS as effective and safe surgical treatment to lose body fat in the Saudi population. However, post-operative monitoring is mandatory to follow-up.

BACKGROUND Bariatric surgery (BS) may be associated with significant malabsorption and nutritional deficiencies. METHODS Between March 1987 and January 2017, we performed 922 liver transplants (LT) at our institution; 33 had antecedent BS. We matched the BS cohort to LT recipients without BS (1:3 matching) based on exact matching for gender and cancer and inverse variance matching for age, LT body mass index, MELD score, and transplant date. RESULTS We analyzed outcomes in 132 LT recipients (33 BS; 99 non-BS). The BS cohort comprised 26 (79%) women with a mean age of 52.4 years. The BS procedures included 20 Roux-en-Y gastric bypass (61%), 6 jejunoileal bypass (18%), 3 gastric band (9%), 2 sleeve gastrectomy (6%), and 1 duodenal switch (3%). The primary indications for LT listing were alcoholic cirrhosis (9; 27%), nonalcoholic steatohepatitis (7; 21%), hepatitis C (8; 24%), and hepatocellular carcinoma (3; 9%). At LT, body mass index for the BS cohort was 29.6, and MELD was 24. Compared with matched controls, BS recipients did not have longer LT length of hospital stay (17.8 versus 15.7 d, P = 0.71), longer intensive care unit length of stay (5.3 versus 4.1 d, P = 0.16), or higher 30-day complication rate (76% versus 85%, P = 0.43). Overall patient survival was similar (1- and 3-y survival was 90.1% and 75.9% for BS; 90.9% and 76.4% for non-BS, P = 0.34). CONCLUSIONS A history of BS does not portend a deleterious effect on LT outcomes.

The purpose of this study was to conduct a systematic review of the existing literature to determine the effect of bariatric surgery on various pharmacokinetic parameters of oral antibiotic absorption as well as overall patient outcomes. MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched up to February 2020. Outcomes of interest included change in pharmacokinetic parameters of oral antibiotics administered to patients following bariatric surgery, using variables such as maximum plasma concentration (Cmax), time to reach maximum plasma concentration (Tmax), area under the concentration-time curve (AUC), clearance, and volume of distribution. MINORS and Cochrane risk of bias tools were used to assess quality of evidence. Ten studies with 100 patients assessing 8 oral antibiotics were included. The majority (77%) of patients underwent Roux-en-Y gastric bypass (RYGB), with fewer undergoing ventral banded gastroplasty (VBG) (14%), jejunoileostomy (6%), and jejunoileal bypass (3%). Antibiotic classes investigated included beta-lactams (5 studies), fluoroquinolones (2 studies), macrolides (2 studies), and oxazolidinones (1 study). Heterogeneity between studies precluded meaningful pooling or meta-analysis of data. Overall risk of bias was fair. Patients given oral beta-lactams and macrolides warrant close monitoring due to unpredictable absorption post-bariatric surgery, whereas oral fluoroquinolones and linezolid may not be affected. Several studies also showed decreased absorption following RYGB, as well as lower serum exposure in patients with obesity compared to non-obese controls. Clinicians should monitor patients on a case-by-case basis for signs of antibiotic failure or toxicity and reassess dosing accordingly.

Surgery for severe obesity started in the 1950s. The development of different operations, including variants of jejuno-ileal bypass, gastric bypass, gastric restrictive surgery and biliopancreatic diversion are discussed. Laparoscopic surgery, and novel approaches including endoscopic procedures and neuromodulation are also presented.

Highlights • Chronic partial jejunal obstruction leading to various non specific abdominal symptoms since 40 years. • The first reported case of Lapsi seed stones causing partial jejunal obstruction. • No change in morphological features of Lapsi seed stones when resided for long within human Gastrointestinal tract. • First demonstration of radiological features of Lapsi seed stones both in vivo as well as in vitro. • When patient not evaluated by non-physician and non-surgeon could delay diagnosis and improper treatment., Introduction Foreign body ingestion is less common in healthy adult population. Obstructive symptom caused by foreign body at unusual site of gastrointestinal (GI) tract is even rarer. Presentation of case A 60-year-old female presented to the surgery outpatient department (SOPD) with 40-years of non-specific abdominal pain. Over the years, at various health facilities, multiple abdominal and pelvic ultrasounds were performed. No etiology was identified. A contrast enhanced computed tomography (CECT) of the abdomen found a short segment stricture in distal jejunum and dilated proximal jejunum with multiple hyper dense foreign bodies within the distal part of dilated jejunum. An exploratory laparotomy revealed multiple seed stones of Nepali Hog Plum (Scientific name: Choerospondias axillaris; Nepali Language: Lapsi) resided freely within the dilated and inflamed distal jejunum along with two marked strictures and a narrowed lumen at 7 cm apart at the terminal part of unhealthy jejunum. The seeds were successfully removed and a jejunoileal bypass was performed. The patient had an uneventful postoperative recovery. Discussion Lapsi seeds could reside in human gastrointestinal tract for prolonged period and are indigestible in human digestive system that could lead to various inflammatory changes in gastrointestinal tracts causing obstructive symptoms. Widely consumed fruits in Nepal, lapsi seeds when swallowed even by healthy individuals, could effect in gastrointestinal tract. Conclusion Lapsi seeds could act as foreign body and obstruct human gastrointestinal tract. Healthcare professionals must approach mystery cases with diligence and thoroughness and timely referral to well equipped center could prevent significant morbidity.

Patient: Male, 48 Final Diagnosis: Gallstone ileus in biliointestinal bypass Symptoms: Abdominal pain • jaundice • vomiting Medication: — Clinical Procedure: — Specialty: Surgery Objective: Unusual clinical course Background: Biliointestinal bypass is a malabsorptive procedure for surgical treatment of morbid obesity. It is the evolution of jejunoileal bypass, and it is characterized by a cholecysto-jejunostomy on the proximal end of the excluded jejunum, therefore, allowing bile flow through the excluded bowel loop reducing the risk of postoperative diarrhea and malabsorption syndrome. Obesity is a well-known risk factor for cholelithiasis; moreover, bariatric surgery has been showed to increases the risk of gallstones formation. Case Report: A 48-years-old male (body mass index 42 kg/m2) received a laparoscopic biliointestinal bypass. Nine years later, the patient received a cholecystotomy for removal of biliary stones. No surgical procedures were performed on the cholecysto-jejunostomy. Fourteen years after the bariatric treatment, the patient underwent enterolithotomy after a diagnosis of gallstone ileus. The impacted biliary stone was documented in the excluded loop proximal to the anti-reflux valvular system. The postoperative course and 1-year follow-up were uneventful. Conclusions: Few cases of gallstone ileus following biliointestinal bypass have been described in the literature. We report a new case and also propose few tips and tricks for cholelithiasis and gallstone ileus prevention after biliointestinal bypass.

Background Duodenal switch (BPD/DS) is gaining popularity as a secondary procedure for inadequate weight loss after an initial operation. Objectives We aimed to generate expert consensus points on the appropriate use of BPD/DS in the revisional bariatric surgical setting. Setting Data were gathered at an international conference with attendees from a variety of different institutions and settings. Methods Sixteen lines of questioning regarding revisional BPD/DS were presented to an expert panel of 29 bariatric surgeons. Current available literature was reviewed extensively for each topic and proposed to the panel before polling. Responses were collected and topics defined as achieving consensus (≥70% agreement) or no consensus ( Results Consensus was present in 10 of 16 lines of questioning, with several key points most prominent. Conclusions As a second-stage procedure, BPD/DS is most appropriate after sleeve gastrectomy (SG) for the treatment of super morbid obesity (96.7% agree) or as a subsequent operation for a reliable patient with insufficient weight loss after SG (88.5%). In a patient with weight regain and reflux and/or enlarged fundus after SG, Roux-en-Y gastric bypass is preferable and BPD/DS should be avoided (90%). BPD/DS should not be used prophylactically in patients with a history of jejunoileal bypass who are otherwise doing well (80.8%). Applicability of BPD/DS is limited by technical difficulty; 86.2% of experts would routinely recommend or consider the procedure if it were more technically feasible after failed bypass. No consensus was found on approaches to revision of BPD/DS for protein malnutrition.

Ki-67 in ascending colon: A) experiment and B) control, Background: Intestinal diversions have revolutionized the treatment of morbid obesity due to its viability and sustained response. However, experimental studies suggest, after these derivations, a higher risk of colon cancer. Aim: To analyze the histological and immunohistological changes that the jejunojejunal shunt can produce in the jejunum, ileum and ascending colon. Method: Twenty-four male Wistar rats were randomly divided into two groups, control (n=12) and experiment (n=12) and subdivided into groups of four. Nine weeks after the jejunojejunal shunt, segmental resection of the excluded jejunum, terminal ileum and ascending colon was performed. Histological analysis focused on the thickness of the mucosa, height of the villi, depth of the crypts and immunohistochemistry in the expression of Ki-67 and p53. Results: Significant differences were found between the experiment and control groups in relation to the thickness of the mucosa in the jejunum (p=0.011), in the ileum (p

The change in gut microbiota is an important mechanism of the amelioration of type 2 diabetes mellitus (T2DM) after bariatric surgery. Here, we observe that the modified jejunoileal bypass effectively decreases body weight gain, fasting blood glucose, and lipids level in serum; additionally, islet β-cell function, glucose tolerance, and insulin resistance were markedly ameliorated. The hypoglycemic effect and the improvement in islet β-cell function depend on the changes in gut microbiota structure. modified jejunoileal bypass increases the abundance of gut Escherichia coli and Ruminococcus gnavus and the levels of serum glycine, histidine, and glutamine in T2DM rats; and decreases the abundance of Prevotella copri and the levels of serum branched chain amino acids, which are significantly related to the improvement of islet β-cell function in T2DM rats. Our results suggest that amino acid metabolism may contribute to the islet β-cell function in T2DM rats after modified jejunoileal bypass and that improving gut microbiota composition is a potential therapeutic strategy for T2DM.

Although jejunoileal bypass has been abandoned due to the high rate of hepatic complications, cases of hepatic complications of current bariatric procedures are still reported. Even though weight loss after bariatric surgery frequently induces an improvement of non-alcoholic fatty liver disease, non-alcoholic steatohepatitis, and fibrosis, bariatric procedures have been also associated with cases of acute liver failure or of chronic liver disease evolving until cirrhosis. The clinical manifestations of hepatic complications after bariatric surgery vary from elevated liver enzymes, hypoproteinemia, and hyperammonemia to liver failure. Possible underlying mechanisms include (1) rapid and drastic weight loss, (2) protein–calorie malnutrition, (3) gut microbiota alteration and bacterial overgrowth, and (4) pre-existing chronic hepatic diseases. Although the incidence is low, bariatric surgeons should be alert to this catastrophic complication, recognize high-risk patients, select appropriate procedures, and follow the patients carefully including early diagnosis and appropriate treatment.

Introduction Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric surgery in recent years, and some modifications have emerged to improve its efficacy. Melissas has described SG plus jejuno-ileal bypass (JIB), which has reported good results in a few studies. We performed this procedure in 21 cases and in one case, we observed acute liver failure (ALF) that has not been reported before. Case presentation A 38-year-old female (BMI: 56.1 kg/m2) underwent laparoscopic SG plus JIB. There was no sign of diarrhea, malnutrition or liver failure for eight months and her BMI was 43.0 kg/m2. At the 9th month, she was hospitalized for abdominal pain, jaundice and ALF. The patient was treated by plasmapheresis and molecular absorptive recirculation system. She was planned to undergo liver transplantation but died of multiorgan failure on the 40th day of hospitalization. Conclusion ALF can be observed following SG plus JIB. JIB reversal before compromising liver functions should be taken into consideration.

In patients with type 2 diabetes (T2D), evidence has evolved rapidly in recent years demonstrating major benefits of metabolic surgery on control of blood glucose (1–3) and a wide range of cardiovascular (CV) and renal outcomes (4–6). Historically, the relative risks versus benefits of surgical treatment of obesity remained controversial for two principal reasons: the complicated nature of the surgery and the absence of compelling evidence for meaningful clinical benefits. Both of these concerns have now been substantially clarified, but there remains considerable scientific work to be done. Surgical treatment of obesity started more than half a century ago with complicated operations such as intestinal rerouting procedures (e.g., jejunoileal bypass). Severe adverse outcomes from these procedures, including malnutrition and liver failure, seemed to outweigh the benefits. Over the years, surgical innovations have resulted in the development of less complicated and less invasive, but metabolically effective, alternative procedures targeting the stomach (e.g., gastric bypass). In parallel, the growing epidemics of obesity and T2D and absence of effective and durable pharmacotherapy for severe obesity have resulted in increased demand for more effective treatments, which has fueled surgical innovations. The increased acceptance of metabolic surgery has been enhanced by many advancements in minimally invasive surgical techniques, formal training of bariatric surgeons, a rigorous accreditation process for recognition of bariatric surgeons and bariatric centers, and emergence of less invasive procedures (e.g., sleeve gastrectomy). Evidence generated through collaboration between the medical and surgical communities has strongly suggested that the metabolic and CV benefits of surgical procedures extend beyond the effects of weight loss alone (7,8). As …

Sleeve gastrectomy with duodenojejunal bypass (SG-DJB) is expected to become a popular procedure in East Asia. The aim of this study was to evaluate the effects of duodenojejunal bypass on glucose metabolism in a rat model of sleeve gastrectomy (SG). Twenty-four Sprague–Dawley rats were divided into two groups: SG-DJB and SG alone. 6 weeks after surgery, body weight, feed intake, and metabolic parameters were measured, and oral glucose tolerance tests (OGTT) were performed. The mRNA expression of factors related to gluconeogenesis and glucose transport was evaluated using jejunal samples. Protein expression of factors with significantly different mRNA expression levels was evaluated using immunohistochemistry. Body weight and metabolic parameters did not significantly differ between the two groups. During the OGTT, the SG-DJB group showed an early increase in serum insulin followed by an early decrease in blood glucose compared with the SG group. Expression levels of glucose transporter 1 (GLUT1) and sodium-glucose cotransporter 1 (SGLT1) mRNA and protein in the alimentary limb (AL) were greater in the SG-DJB group than in the SG group. The additional effects of duodenojejunal bypass on glucose metabolism after SG may be related to increased expression of GLUT1 and SGLT1 in the AL.

Laparoscopic greater curvature plication (LGCP) is a new bariatric procedure that is similar to laparoscopic sleeve gastrectomy (LSG) in that it uses a restrictive mechanism. Comparative studies between LGCP and LSG were still limited. The aim of this study was to compare the clinical outcomes of the two procedures based on the same clinical conditions. From January 2012 to December 2015, 260 patients with morbid obesity underwent LGCP and LSG in a single center. Data on patient demography, operation time, complications, hospital stay, body mass index loss, percentage of excess weight loss (%EWL), and improvement in comorbidities were collected. A propensity-matched analysis, incorporating pre-operative variables, was used to compare the short-term outcomes between LGCP and LSG. Propensity matching produced 48 patients in each group. Patients who underwent LGCP were predominately female (75.5%, 41.1% of the LSG patients were female, p = 0.028). Baseline BMI and excess weight were significantly lower in the LGCP group (p

Single-anastomosis duodenal switch (DS) was introduced by Sanchez-Pernaute et al. as a modification of the biliopancreatic diversion with duodenal switch. We have published preliminary results of the loop DS as the first report of the procedure in the USA. This study aims to evaluate the loop DS procedures again, in terms of weight loss, comorbidity resolution, complication rate, and address the nutritional concerns. A retrospective chart review was performed on initial 128 patients who underwent laparoscopic or robot-assisted laparoscopic single-stage loop DS between December 17, 2013 and September 23, 2016. Sixteen additional patients were prospectively enrolled from September 24, 2016 to May 4, 2017. A total of 102 female and 38 male patients were included in this study with a mean age of 41.2 ± 9.6 years. The mean body mass index (BMI) at the time of procedure was 57.3 ± 9.2 kg/m2. Percentage of total weight loss was 23.1, 37.1, 42.9, and 44.7% at 6, 12, 18, and 24 months, respectively. Percentage of excess BMI loss was 41.9, 68.1, 76.6, and 80.8% at 6, 12, 18, and 24 months, respectively. Mean levels of HbA1c, triglyceride, and LDL-cholesterol decreased significantly after the loop DS. Regarding the fat-soluble vitamins, majority of patients had vitamin A and E levels in the normal range. However, 42 to 56% of the patients had low levels of vitamin D at 6, 12, and 24 months following the procedure. Mean length of hospital stay was 4.1 ± 2.7 days. Thirty-day readmission rate was 7.6% (n = 11), and 30-day reoperation rate was 6.9% (n = 10). Loop DS seems to be effective in weight loss and is a feasible operation in the super-obese population. However, close monitoring of liver enzymes is warranted in addition to nutritional follow-up.

The laparoscopic Roux-en-Y gastric bypass (LRYGB) has been considered a reference procedure in the bariatric surgery. The linear-stapled gastrojejunostomy (GJ) has proved to be safe and effective, but its optimal size referred to postoperative weight loss remains poorly understood. Evaluate the role of the linear-stapled GJ size in the mid-term post-LRYGB weight loss and occurrence of complications. From January to April 2014, 128 patients underwent LRYGB with linear-stapled GJ in a 2-year follow-up. The LRYGB were carried out with the same technical steps, except for the length of the GJ. In GJ-15-mm group (n = 64), the GJ was constructed with white 45-mm cartridge in an extension of only 15 mm whereas in GJ-45-mm group (n = 64), the GJ was achieved using full extension of the cartridge. The body mass index (BMI) reduction was recorded for 24 months after procedure. The mean ages were 38 ± 10.6 and 41.3 ± 12.3 years, and there were 45 (70.3%) and 51 (79.7%) females in the GJ-15-mm and GJ-45-mm groups, respectively. The analysis on raw BMI data showed that both groups had significant reduction of BMI over time (p ≤ 0.05); however, reduction was greater in the GJ-15-mm group from 18 months onwards (p ≤ 0.05). The only complication observed was a case (1.56%) of stenosis in the group GJ-15 mm. The global analysis of BMI reduction indicated that the narrower GJ used (GJ-15-mm group) represented a favoring factor decreasing significantly more the BMI when compared to the wider one (GJ-45-mm group).

We believe this to be the first case report of jejunosigmoid bypass harboring small bowel adenocarcinoma. The mechanism of malignant degeneration could be similar to that of carcinogenesis of ureterosigmoidostomy that is of historical interest. This case represents an example of why it is imperative for surgeons to be diligent in their preparation and workup of a patient before a complex operation, especially in patients with peculiar or unknown surgical histories

INTRODUCTION: Acquired copper deficiency myelopathy is a rare disorder associated with hematologic abnormalities, peripheral neuropathy, and sensory ataxia. Although its clinical presentation and radiographic findings are similar to other nutrient deficiencies, practitioners often fail to diagnose copper deficiency. This report describes a case of copper deficiency decades after a jejunoileal bypass (JIB) to draw attention to potential long-term sequelae associated with this now abandoned procedure. CASE PRESENTATION: A 67-year-old female presented with bilateral paresthesias of her hands and legs, accompanied by gait instability and frequent falls. The individual had a significant history of malabsorption and malnutrition related to a 40 years prior JIB for weight loss. MRI demonstrated T2 hyperintense signal in the dorsal spinal cord between C3 and C5. She was found to have copper deficiency, underwent IV repletion, prescribed oral repletion, and was discharged home. She subsequently developed progressive symptoms over the following year and remained unable to function at home. Treatment required inpatient copper repletion followed by inpatient rehabilitation. Following rehabilitation, the individual demonstrated significant improved independence. DISCUSSION: Although JIB surgery is not currently performed, it is important to recognize the metabolic consequences of nutrient deficiencies related to this procedure and the potential for the development of neurological sequelae including myelopathy. Furthermore, additional causes of copper deficiency to consider in cases of undifferentiated myelopathy include congenital metabolic syndromes, zinc toxicity, and malabsorption. This case demonstrates the potential of intensive physical and occupational therapy regimens, along with symptomatic treatment and nutrient repletion, to help an individual regain independence and improve activities of daily living.

Background Protein malnutrition and bacterial overgrowth occurring after bariatric surgery (BS) might cause severe liver failure (LF) needing liver transplantation (LT). Objectives To evaluate indications and outcomes of LT for BS-related LF. Setting University hospital in France. Methods The EMBASE, MEDLINE, and COCHRANE central databases were systematically searched according to the PRISMA criteria from inception up through December 2017 for articles describing LT for LF after BS. Results Fourteen studies reporting 36 patients listed for LT, of which 32 underwent the procedure, were retained. The types of previously performed BS included jejunoileal bypass (n = 16), bilio-pancreatic diversion according to Scopinaro (n = 14) or with duodenal switch (n = 3), bilio-intestinal bypass (n = 1), long-limb Roux-en-Y gastric bypass (n = 1), and single anastomosis omega gastric bypass (n = 1). Liver failure developed a median of 20 months after BS (mean ± SD: 105 ± 121 mo; range, 5–300 mo). This interval of time was significantly shorter after biliopancreatic diversion than jejunoileal bypass (mean ± SD: 22 ± 21 mo versus 269 ± 27 mo; P = .0001). Four patients (11.1%) died while on the waiting list for LT, and 4 more (12.5%) died after LT. Morbidity and liver retransplantation were reported in 8 (25%) and 2 (6.2%) patients, respectively. Twenty-one patients (65.6%) had their BS procedure reversed (1 patient before, 15 patients during, and 5 patients after LT, respectively). Biopsy-proven steatosis recurrence after LT was reported in 6 patients (18.7%), 4 of whom did not have BS reversal. Conclusions Severe LF occurring after BS, although rare, might require LT. When indicated, LT is effective at restoring liver function, even when BS reversal is performed synchronously.

CONTEXT AND OBJECTIVE: Occurrences of liver failure following jejunoileal bypass were extensively reported in the past and were one of the main factors that led to abandonment of this procedure. The newer predominantly malabsorptive procedures called biliopancreatic diversions (BPDs) have also been implicated in several cases of acute and subacute liver failure. The aim here was to review the current available evidence on occurrences of liver failure following BPDs. DESIGN AND SETTING: Narrative review; bariatric surgery service of a public university hospital. METHODS: A review of the literature was conducted through an online search of medical databases. RESULTS: Associations between BPDs and liver failure have only infrequently been reported in the literature. However, they appear to be more than merely anecdotal. The pathophysiological mechanisms remain obscure, but they seem to be related to rapid weight loss, protein malnutrition, deficits of hepatotrophic factors, high circulating levels of free fatty acids and bacterial overgrowth in the bypassed bowel segments. Reversal of the BPD may ameliorate the liver impairment. CONCLUSIONS: Although infrequent, liver failure remains a concern following BPDs. Careful follow-up is required in individuals who undergo any BPD. RESUMO CONTEXTO E OBJETIVO: A ocorrência de falência hepática após a derivação jejunoileal foi extensivamente descrita no passado e foi um dos principais fatores que levaram ao abandono do procedimento. Os procedimentos predominantemente malabsortivos mais modernos, chamados de derivações biliopancreáticas, também já foram implicados em diversos casos de falência hepática aguda e subaguda. O objetivo foi revisar a atual evidência disponível sobre a ocorrência de insuficiência hepática após derivações biliopancreáticas. TIPO DE ESTUDO E LOCAL: Revisão narrativa; Serviço de Cirurgia Bariátrica de hospital universitário. MÉTODOS: Revisão da literatura conduzida por meio de pesquisa online de bancos de dados médicos. RESULTADOS: A associação entre derivações biliopancreáticas e falência hepática na literatura é infrequente. Entretanto, ela aparenta ser mais do que meramente anedótica. Os mecanismos fisiopatológicos continuam pouco compreendidos, mas parecem estar relacionados à rápida perda de peso, desnutrição proteica e déficit de fatores hepatotróficos, altos níveis circulantes de ácidos graxos livres e supercrescimento bacteriano em segmentos intestinais excluídos do trânsito. A reversão da cirurgia pode melhorar o comprometimento hepático. CONCLUSÕES: Embora infrequente, a falência hepática continua sendo preocupante após as derivações biliopancreáticas. Seguimento cuidadoso é mandatório em indivíduos submetidos a essas cirurgias.

Laparoscopic sleeve gastrectomy with duodenojejunal bypass (LSG-DJB) has been designated as a novel bariatric surgery procedure. This combination of sleeve gastrectomy and proximal intestinal bypass theoretically offers an effective and prolonged anti-diabetes effect. This is a follow-up of our institution’s previous report on the short-term effects of LSG-DJB on type 2 diabetes mellitus (T2DM), which a 68.7 % remission (HbA1c

Based on the mechanisms of drug absorption, increased levothyroxine requirements are expected after bariatric surgery. However, there are conflicting data on this topic. This review evaluates the effects of bariatric surgery on levothyroxine dosing. Data were obtained from PubMed, Scopus, and review of published bibliographies. Six of 10 studies demonstrated decreased postoperative requirements. Most demonstrated correlations between weight loss and dose. Only 3 case reports and 1 case series demonstrated increased levothyroxine requirements, attributed to malabsorption. The loss of both fat and lean body mass may counteract malabsorptive effects from surgery, resulting in decreased postoperative levothyroxine requirements. In addition, the reversal of impaired levothyroxine pharmacokinetics and an altered set point of thyroid hormone homeostasis may also contribute to postoperative levothyroxine reductions.

Archaic surgical procedures such as the jejunoileal bypass, vertical banded gastroplasty and duodenal switch have contributed to the current best practice of Roux-en-Y gastric bypass (RYGB) procedure for the treatment of obesity and its consequences. Despite this, RYGB has been blighted with late occurring adverse events such as severe malnutrition, marginal ulcer and reactive hypoglycemia. Despite this, RYGB has given us an opportunity to examine the effect of surgery on gut hormones and the impact on metabolic syndrome which in turn has allowed us to carry out a lower impact but equally, if not more effective, procedure - the vertical sleeve gastrectomy (VSG). We examine the benefits of sleeve gastrectomy from the less challenging technical aspect to the effect on obesity and its metabolic syndrome long-term and have concluded that sleeve gastrectomy is possibly the next current best practice.

Introduction: Oxalate nephropathy after RYGB, albeit rare, has a poor prognosis with a rapid progression to kidney failure. Oxalate nephropathy has many etiologies and is one of the rare causes of renal failure. Case Presentation: A 39-year-old diabetic woman came to our nephrology clinic because of a progressive increase in serum creatinine from 1 to 4.2. She had a history of Roux-en-Y gastric bypass (RYGB) surgery six months earlier. In view of the unexplained progressive increase in creatinine, a kidney biopsy was done. The histological diagnosis of oxalate nephropathy with diabetic nephropathy class 2b was made. Conclusions: Oxalate nephropathy is a rare and most severe renal complication after bariatric surgery that is reported in some patients after jejunoileal bypass and RYGB surgery. Oxalate nephropathy is progressive in nature and has a poor prognosis. In our case, oxalate nephropathy and kidney failure occurred six months after RYGB surgery. Since the histological finding in our patient revealed oxalate nephropathy with diabetic nephropathy class 2b, it seems diabetic nephropathy can probably facilitate calcium oxalate crystals formation. This important point should be considered that oxalate nephropathy could rapidly progress to renal failure; so, patients who undergo Roux-en-Y gastric bypass surgery should have regular follow-ups.

Metabolic surgery dates back to the late nineteenth century. First funded in 1975, the NIH-sponsored Program on the Surgical Control of the Hyperlipidemias (POSCH) was the first randomized controlled trial (RCT) to use a metabolic surgery procedure as the intervention modality; it was also the first trial definitively to demonstrate the cardiovascular and life expectancy benefits of marked lipid reduction. In 1978, we defined metabolic surgery, “as the operative manipulation of a normal organ or organ system to achieve a biological result for a potential health gain.”

Management of failed laparoscopic gastric plication (LGP), defined as weight regain or inadequate weight loss, is a challenging issue. This prospective investigation was conducted in individuals with morbid obesity who had undergone LGP from 2000 to 2016. Patients with weight loss failure, weight regain, and regain-prone cases were indicated for reoperation. Re-plication, laparoscopic one anastomosis gastric bypass (LOAGB), and modified jejunoileal bypass were done as revisional surgery. Revisional surgery was performed in 102 of 124 patients who needed reoperation. Overall, 39 re-plication, 38 LOAGB, and 25 malabsorptive procedures were performed. Re-plication was the shortest surgery and had the shortest length of hospital stay. The percentage of TWL at 6, 12, and 24 months of follow-up was 20.5%, 25%, and 26.8% for re-plication; 20.2%, 27%, and 30.5% for LOAGB; and 22.9%, 28.9%, and 32.6% for the malabsorptive procedure, respectively. In addition, the percentage of EWL at 6, 12, and 24 months of follow-up was 62%, 74.6%, and 79.6% for re-plication; 51.6%, 68.2%, and 75.9% for LOAGB; and 55.4%, 70.1%, and 79.1% for malabsorptive procedure, respectively. In long-term follow-up, according to %TWL, LOAGB and malabsorptive procedure had better outcome compared to re-plication, whereas there was no statistically significant difference in %EWL among the three surgical approaches. In terms of weight loss, reoperation on failed LGP was completely successful and no treatment failure was reported. All three revisional procedures, including re-plication, LOAGB, and malabsorptive procedure showed promising results and provided substantial weight loss. Since there is little information about the long-term efficacy and safety of revisional surgery on failed LGP, we highly recommend further investigations to confirm our results.

Highlights • Jejunoileal bypass is a surgery of the past however still affects patients being see by surgeons today. • The pathophysiology is complicated and it should be known these patients suffer from chronic kidney disease, liver failure, chronic diarrhea and many vitamin deficiencies. • Bypass reverseal can help preserve kidney function but may not reverse damages already done. • From our experience, Bypassed bowel incorporation back into enteric tract can produced a immune response causing functional obstruction only relieved by removal of this bowel., Introduction Jejunoileal bypass (JIB) was an effective treatment for morbid obesity in the 1970s, but shortly after it fell out of favor due to horrific side effects, including liver failure, nephrolithiasis and drastic vitamin deficiencies. Although there are few living people with JIB, the management of these patients can be challenging. Case presentation We describe a case of a 58-year-old female with a history of JIB 46 years prior who had an impending renal failure due to nephrolithiasis. She underwent a jejunostomy feeding tube prior to reversal. After reversal, our patient developed failure to thrive with functional obstruction of the newly incorporated small bowel. This bypassed bowel underwent a severe inflammatory transformation after the introduction of enteric feeds, suggesting an immunological type response to antigens in food. It wasn’t until a long and debilitating 12 months and resection of this inflamed bowel that our patient was able to regain bowel function and gain weight. Conclusion Jejunoileal bypass is an archaic procedure for morbid obesity. Due to its debilitating and at times lethal side effects, it has been replaced with newer techniques. Despite advances, there are still patients out there who have had a jejunoileal bypass. This case report and review of the literature details our experience with this procedure.

Jejunoileal bypass (JIB) was a malabsorptive bariatric procedure developed in the 1950s based on pioneering work in canine models. All described variants involved anastomosis between the proximal jejunum and terminal ileum. Long-term weight loss and improvement in hyperlipidemia were found to be particularly impressive. However, it became clear by the 1980s that morbidity and mortality associated with JIB were unacceptably high. The procedure was abandoned, and many patients underwent reversal to normal intestinal continuity, or revision to other bariatric procedures. Two main mechanisms underlie the complications with JIB. Malabsorption caused excessive diarrhea, nutritional and metabolic failure, and hyperoxaluria, leading to urolithiasis. Bacterial overgrowth in the defunctioned small intestine was thought to lead to immune complex-mediated development of inflammatory arthritis, and the so-called bypass enteritis syndrome. A combination of these two mechanisms was thought to be responsible for hepatic dysfunction and failure after JIB.

Objectives: Jejuno-ileal bypass (JIB) was a kind of bariatric surgery performed from 1960s to 1980s, able to induce sustainable weight loss by creating a surgical short bowel syndrome.Materials and methods: We report a case of an octogenarian woman who underwent in the early eighties this kind of surgery with consequent 40 kg weight loss. After 27 years, she first developed a reversible metabolic cardiomyopathy that began with signs and symptoms of heart failure. Thereafter, she was diagnosed with severe intractable liver insufficiency.Results: Despite her old age, the patient underwent reversal of JIB with consequent early improvement of hepatic function.Conclusions: This case demonstrate that in case of long-term and life-threatening complications, it is possible to successfully reverse JIB surgery after upto 30 years. The hypothesis on pathophysiology of heart and liver insufficiency are discussed.

The ideal bariatric operation achieves 70–100 % maintained excess weight loss, is simple with low operative risks, and maintains absorption of trace elements. Our aim was to find a bariatric procedure that achieves the above while avoiding drawbacks of current options. A standard sleeve gastrectomy was combined with a modified jejuno-ileal bypass dividing the small bowel 75 cm distal to the duodeno-jejunal flexure, anastomosing it to the ileum 75 cm proximal to the ileocaecal valve. Operative and follow-up data were collected prospectively between December 2004 and January 2013. One hundred sixty-eight procedures were analysed (110 female, 58 male). Mean patient age was 43 years (IQR 37–47), and median preoperative body mass index (kg/m2) was 52 (IQR 49–59). All operations were completed laparoscopically. Excess weight loss was 78 % (IQR 70–83 %, 12 months, n = 168), 79 % (IQR 70–85 %, 24 months), maintained at most recent follow-up with 77 % (IQR 68–84 %, n = 168), and for 8 year follow-up alone 75 % (IQR 66–84 %, n = 18). There was no operative mortality and 5.4 % morbidity. A 6.5 % of patients experienced transient vomiting. No symptoms of dumping or bacterial overgrowth were observed. All had normal liver enzymes. Hypocalcaemia (20.8 %) and zinc deficiency (25.6 %) resolved with oral supplementation. Type 2 diabetes mellitus resolved in 80.3 % and improved in the remainder of patients, hypertension resolved in 92.3 % and improved in the rest. Whilst currently an investigative procedure, and within the studies limitations combined sleeve gastrectomy with modified jejuno-ileal bypass is safe and effective, and evades many problems associated with current bariatric operations whilst offering maintained excess weight loss.

Acute oxalate nephropathy can occur due to primary hyperoxaluria and secondary hyperoxaluria. The primary hyperoxalurias are a group of autosomal recessive disorders of endogenous oxalate overproduction. Secondary hyperoxaluria may occur as a result of excess dietary intake, poisoning with oxalate precursors (ethylene glycol), or enteric hyperoxaluria. The differential diagnosis of enteric hyperoxaluria includes inflammatory bowel disease, short bowel syndrome, bariatric surgery (with jejunoileal bypass or Roux-en-Y gastric bypass), celiac disease, partial colectomy, and chronic pancreatitis. The common etiology in all these processes is fat malabsorption, steatorrhea, saponification of calcium, and absorption of free oxalate. Hyperoxaluria causes increased urinary oxalate excretion, urolithiasis (promoted by hypovolemia, decreased urinary pH caused by metabolic acidosis, and decreased citrate and magnesium concentrations in urine), tubulointerstitial oxalate deposits, and tubulointerstitial nephritis. We report a rare case of acute oxalate nephropathy due to pancreatic atrophy and exocrine insufficiency caused by newly diagnosed pancreatic cancer.

Nonalcoholic fatty liver disease (NAFLD) comprises a spectrum of clinical and histopathological changes including "simple" steatosis, steatosis with inflammation, steatohepatitis, cirrhosis, and hepatocellular carcinoma. It was initially described in the context of drug-induced liver injury and acute liver disease following jejunoileal bypass surgery, but since the early 1980s it has been widely acknowledged as the hepatic manifestation of metabolic syndrome. It now represents a burgeoning public health crisis and is fast becoming the main indication for liver transplantation in some parts of the world. Its true incidence and prevalence are unknown, although estimates have been made from large imaging studies. Liver biopsy interpretation is still regarded as the gold standard for making accurate diagnoses in NAFLD, but sampling limitations are recognized. Furthermore, clear definitions for key histopathological components have been lacking, resulting in significant interobserver variations in making a diagnosis of steatohepatitis. In this review the authors consider some aspects of classification and variant forms of NAFLD such as that occurring in children. They provide an update on grading and staging systems and histopathological prognostic factors, and address the role of liver biopsy in contemporary clinical care of patients with NAFLD.

Dual-path side-to-side jejunoileal bypass (SSJIB) can markedly ameliorate diabetes and obesity. However, whether SSJIB requires the ligation of the bypassed loop (single-path) and what is the most appropriate length of the bypassed small bowel remain unknown. The aim of this study was to evaluate the role of ligation and the length of the bypassed small bowel in mediating changes in glucose homeostasis after SSJIB in streptozotocin (STZ)-induced diabetic rats. Fourteen STZ-induced diabetic rats were randomized into two groups: one group was subjected to 50% SSJIB (SSJIB-50 group) and one group was subjected to sham surgery (sham group). Three weeks later, the SSJIB-50 group was re-operated, and the bypassed segment was ligated (SSJIBL-50 group). Three weeks later, the SSJIBL-50 group was operated again, and 60% of the length of the proximal small intestine was bypassed (SSJIBL-60 group). The measured primary outcomes were body weight, food intake, fasting blood glucose (FBG), and oral glucose tolerance test (OGTT). Body weight in the SSJIBL-60 group was lower than that in the sham group. Food intakes in the SSJIBL-50 and SSJIBL-60 groups were lower than that in the sham group. FBG and OGTT were not improved in the SSJIB-50 group compared with the sham group. However, FBG and OGTT were improved in the SSJIBL-50 group and were further improved in the SSJIBL-60 group. Ligation of the first portion of the bypassed loop is essential to SSJIB, and bypassing approximately 60% of the small intestine length may be appropriate in SSJIBL.

The relationship between calcium oxalate kidney stone formation and inflammatory bowel disease (IBD) was first noted in two large retrospective case series from the 1960s. In over 1,400 patients with inflammatory bowel disease, 92 of 1,468 patients (6%) were identified to have developed renal stones, an occurrence that appeared as frequent as other systemic complications of this disease process [1, 2]. The mechanisms behind this high stone incidence were confirmed in the 1970s to be a complication of fat malabsorption and chronic diarrhea, which resulted in enteric hyperoxaluria, decreased urine citrate concentration and pH, and decreased urine volumes [3, 4]. Since those early descriptions, other malabsorptive intestinal disease states have also been added to the IBD/stone- associated list, including jejunoileal bypass (historical) and Roux-en-Y gastric bypass for obesity, chronic mesenteric ischemia, and small bowel ostomies [5, 6]. In general, patients with ileocolonic disease (9–17%) tend to be more commonly affected than those with ileal (6–8%) or colonic disease (3–5%) alone, and stone composition varies between calcium oxalate (malabsorptive diseases, ileocolonic Crohn’s disease) and uric acid (copious diarrhea, small bowel ostomies) depending on the disease state and amount of volume loss/diarrhea. This chapter will highlight the urinary abnormalities seen in modern bariatric surgical patients and in patients with the two most common forms of IBD (Crohn’s, ulcerative colitis) with a focus on the nutritional aspects that can be improved in these stone-forming populations.

This study aimed to evaluate the outcomes of 67 patients who underwent revisional bariatric surgeries over a 29-year period in a Brazilian public hospital. The records of all patients who underwent revisional bariatric surgery from January 1987 to December of 2016 at our hospital were analyzed for weight loss and complications. Descriptive statistics and paired t tests were computed. Sixty-seven patients were included in the study. The primary surgeries previously performed on these patients were biliopancreatic diversion with duodenal switch (BPD-DS) (37 cases, 55.2%), jejunoileal bypass (JIB) (24 cases, 35.8%), sleeve gastrectomy (4 cases, 5.9%), Roux-en-Y gastric bypass (RYGB) (1 case, 1.5%), and laparoscopic adjustable gastric band (1 case, 1.5%). The indications for revisional surgery were as follows: malnutrition in 29 cases (43.3%), failure to lose weight in 27 cases (40.3%), weight regain in 5 cases (7.5%), and untreatable diarrhea in 6 cases (9.2%). Most revisional surgeries were performed using JIB or BPD-DS. Operative mortality was higher after the revisional procedures compared with that following the primary bariatric surgeries. Most patients requiring a revisional surgery had undergone a primary BPD-DS or JIB. Severe and untreatable malnutrition and diarrhea were the main indications for the revisional procedures. RYGB produced significant and sustainable weight loss and exhibited a low risk of malnutrition or requiring revisional surgery.

Jejunoileal bypass (JIB) was developed as a surgical treatment for morbid obesity in the early 1950s. However, this procedure is now known to be associated with multiple metabolic complications and has subsequently been abandoned as a viable bariatric procedure. Some of these known complications include renal stone formation, liver failure, migratory arthritis, fat-soluble deficiencies, blind-loop syndrome and severe diarrhea. Additionally, there have been animal models suggesting colon dysplasia after JIB. To our knowledge however, in humans, no colon cancers have been attributed to JIB in the literature. Here we report a 63-year-old morbidly obese female who had a JIB surgery in 1973 and subsequently was found to have numerous sessile colonic polyps throughout her colon and adenocarcinoma of the ascending colon without any family history of colonic polyposis syndromes or colon cancer.

The surgical treatment of patients with morbid obesity first began in the mid-twentieth century. Its inception was based upon the fundamental principles that malabsorption of food particles and restriction of intake could help obese patients lose significant amounts of weight and resolve their comorbid medical conditions.

Non-alcoholic fatty liver disease is becoming the leading cause of disease resulting in liver transplantation (LT). As a result of this trend, more liver transplant candidates are presenting with prior history of bariatric surgery (BS). Over the last decade, 960 patients underwent LT at our institution; 11 (1.1%) had prior BS. Most common type of BS was Roux-en-Y gastric bypass (n=9) with 1 sleeve gastrectomy and 1 jejunoileal bypass. Nine patients underwent LT alone and 2 underwent simultaneous liver-kidney transplantation. Most common indication for LT was non-alcoholic steatohepatitis (n=10) with 5 having additional diagnosis of alcoholic liver disease. Thirty-day reoperation rate was 36.4% (n=4); indications were bile duct repair (n=3) and wound repair (n=1). In first 6 months after LT, biliary complications were seen in 54.5% (n=6) of the patients. Both patient and graft survival rates at 1 and 2 years were 81.8% (n=9) and 72.7% (n=8), respectively. Eight patients (72.7%) had indications for liver biopsy post-LT; significant macro-vesicular steatosis was found in 2 (18.2%). In patients with history of alcohol consumption, 2 (40.0%) relapsed post-LT. Two patients (18.2%) had history of diet-controlled diabetes pre-LT; 1 of these patients became insulin dependent post-LT. Mean body mass index at LT was 31.0±5.7. Mean body mass index at 1, 6, and 12 months post LT was 28.3±5.8, 28.0±3.2 and 31.0±6.6, respectively. Mean preoperative albumin was 2.6±0.6 mg/dl. Patients showed improvement in albumin post-LT, with mean albumin of 2.7±0.6 and 3.2±0.5 mg/dl, at 1 and 3 months, respectively. Liver profile was stable post-LT, with mean AST of 32.9±18.4 and 26.6±19.8 IU/L and ALT of 28.0±17.5 and 30.2±17.0 IU/L at 6 and 12 months, respectively. In conclusion, outcomes of LT patients with prior BS are comparable to other transplant recipients with regards to patient and graft survival, and post-LT complication rates. This article is protected by copyright. All rights reserved.

Jejunoileal bypass (JIB) can markedly ameliorate diabetes in obese patients and rodents. The aim of this study is to systematically evaluate the role of the operational manner and the retained distal small bowel length in mediating changes in glucose homeostasis after intestinal bypass surgeries in nonobese diabetic rats. Streptozotocin-induced diabetic rats underwent side-to-side jejunoileal bypass plus proximal loop ligation (SSJIBL), end-to-side jejunoileal bypass (ESJIB), proximal small bowel resection (PBR), and sham operation. Each operational manner included two subgroups, in which 30 cm (L-30) or 40 cm (L-40) distal small bowel was retained. Main outcome measures were fasting blood glucose levels (FBG), insulin sensitivity, serum insulin, glucagon-like peptide-1 (GLP-1), bilirubin (BIL), and total bile acids (TBA) levels. Global food intake in the sham group was higher than in the operation groups, and global body weight and food intake in the SSJIBL group were higher than in the ESJIB and PBR groups. Global body weight and food intake in L-40 group were higher than in L-30 group. The SSJIBL procedure induced better improvement in glucose homeostasis and insulin sensitivity than the ESJIB and PBR procedures, and L-30 group showed better antidiabetic effects than L-40 group. Serum GLP-1, BIL, and TBA levels in SSJIBL group were higher than in ESJIB and PBR groups. This study shows that side-to-side jejunoileal bypass induced better glucose-lowering effects than end-to-side jejunoileal bypass and proximal small bowel resection, and intestinal bypass surgery that retained shorter distal small bowel yielded better antidiabetic effects.

PURPOSE:To evaluate the effects of duodenal-jejunal bypass (DJB) on serum and hepatic profiles of obese rats fed on a western diet (WD).METHODS: Twenty eight male Wistar rats were fed a standard rodent chow diet (CTL group) or WD ad libitum. After 10 weeks, WD rats were submitted to sham (WD SHAM) or duodenal-jejunal bypass (WD DJB). Body weight, fat pad depots, glycemia, insulinemia, HOMA-IR, TyG, lipids profile and hepatic analyses were evaluated two months after surgery.RESULTS:The WD SHAM group presented greater obesity, hyperglycemia, hyperinsulinemia, insulin resistance, hypertriglyceridemia and hepatic steatosis than the CTL group. WD DJB rats presented decreased serum glucose and insulin resistance, when compared to WD SHAM animals, without changes in insulinemia. In addition, DJB surgery normalized serum TG and attenuated TG accumulation and steatosis in the liver of the WD DJB group. Hepatic ACC and FAS protein expressions were similar in all groups.CONCLUSION:Duodenal-jejunal bypass attenuates hepatic parameters of non-alcoholic fatty liver disease in obese rats fed on a western diet.

Background & Aims Bariatric surgery has been reported to lead to complete resolution of nonalcoholic fatty liver disease (NAFLD) following the sustained weight loss induced in obese patients. We performed a systematic review and meta-analysis to evaluate the effects of bariatric surgery on NAFLD in obese patients. Methods We searched MEDLINE, EMBASE, CENTRAL, and Web of Science databases through May 2018 for studies that compared liver biopsy results before and after bariatric surgery in obese patients. Primary outcomes were biopsy-confirmed resolution of NAFLD and NAFLD activity score. Secondary outcomes were worsening of NAFLD after surgery and liver volume. The Grading of Recommendations, Assessment, Development, and Evidence approach was conducted to assess overall quality of evidence. Results We analyzed data from 32 cohort studies comprising 3093 biopsy specimens. Bariatric surgery resulted in a biopsy-confirmed resolution of steatosis in 66% of patients (95% CI, 56%–75%), inflammation in 50% (95% CI, 35%–64%), ballooning degeneration in 76% (95% CI, 64%–86%), and fibrosis in 40% (95% CI, 29%–51%). Patients' mean NAFLD activity score was reduced significantly after bariatric surgery (mean difference, 2.39; 95% CI, 1.58–3.20; P Conclusions Through this systematic review and meta-analysis, we found that bariatric surgery leads to complete resolution of NAFLD in obese patients. However, some patients develop new or worsened features of NAFLD. Randomized controlled trials are needed to further examine the therapeutic benefits of bariatric surgery for patients with NAFLD.

We present he results of surgical treatment of 136 patients with metabolic syndrome at long-term period of evaluation (up to 15 years). All patients had jejunoileal bypass surgery in modification prof. Y.I. Sedletsky. We show the effect of surgery on overweight, hypertension, dyslipidemia, and hyperglycemia. We've traced above changes depending on the period elapsed since the time of the operation. The results prove the efficiency and stability of effects of jejunoileal bypass surgery on components of the metabolic syndrome. Evaluation of the complications rate of this method is also presented in the article.

INTRODUCTION: Neuroimaging studies suggest that obese people might show hyperactivity of brain areas regarding reward processing, and hypoactivity of brain areas concerning cognitive control, when exposed to food cues. Although the effects of bariatric surgery on the central nervous system and eating behavior are well known, few studies have used neuroimage techniques with the aim of investigating the central effects of bariatric surgery in humans. OBJECTIVES: This paper systematically and critically reviews studies using functional neuroimaging to investigate changes on the patterns of activation of central areas related to the regulation of eating behavior after bariatric surgery. METHOD: A search on the databases Medline, Web of Science, Lilacs and Science Direct on Line, was conducted in February 2013, using the keywords "Neuroimaging", "Positron-Emission Tomography", "Magnetic Resonance Imaging", "Gastric Bypass", "Gastroplasty", "Jejunoileal Bypass", "Bariatric Surgery". RESULTS: Seven manuscripts were included; the great majority studied the central effects of Roux en Y gastric bypass, using positron emission tomography or functional magnetic resonance. CONCLUSIONS: Bariatric surgery might normalize the activity of central areas concerned with reward and incentive salience processing, as the nucleus accumbens and mesencephalic tegmental ventral area, as well as circuitries processing behavioral inhibition, as the dorsolateral prefrontal cortex. INTRODUÇÃO: Estudos de neuroimagem sugerem que indivíduos obesos podem apresentar hiperatividade de áreas cerebrais associadas à recompensa e hipoatividade em áreas associadas ao controle cognitivo quando expostos a pistas alimentares. Apesar do conhecimento dos efeitos da cirurgia bariátrica sobre o sistema nervoso central e sobre o comportamento alimentar, poucos estudos empregaram técnicas de neuroimagem para estudar os efeitos centrais da cirurgia bariátrica em humanos. OBJETIVOS: O presente trabalho revisa sistemática e criticamente os estudos de neuroimagem funcional a respeito das alterações na ativação de regiões centrais relacionadas à regulação do comportamento alimentar após a cirurgia bariátrica. MÉTODO: Foi realizada uma busca nas bases de dados Medline, Web of Science, Lilacs e Science Direct on Line, em fevereiro de 2013, utilizando-se as palavras-chave "Neuroimaging", "Positron-Emission Tomography", "Magnetic Resonance Imaging", "Gastric Bypass", "Gastroplasty", "Jejunoileal Bypass", "Bariatric Surgery". RESULTADOS: Foram incluídos sete trabalhos, dos quais a grande maioria estudou os efeitos centrais do bypass gástrico em Y de Roux empregando tomografia por emissão de pósitrons ou ressonância magnética funcional. CONCLUSÕES: A cirurgia bariátrica parece regular a atividade de áreas centrais associadas ao processamento da recompensa e da saliência de incentivo diante de pistas alimentares, como o núcleo accumbens e a área tegmental ventral do mesencéfalo, e também de circuitos neurais que processam a inibição comportamental, como o córtex pré-frontal dorsolateral.

Summary Reasons for performing the study There is disagreement among surgeons over whether jejunoileostomy (JI) or jejunocaecostomy (JC) is the better method of anastomosis following proximal ileal resection. Objective To compare short- and long-term complications and outcome in horses undergoing jejunojejunostomy (JJ), JI and JC and to test the hypotheses that a higher proportion of horses undergoing JI would have short-term complications and mortality compared with horses undergoing JC or JJ and that JC would be associated with a higher long-term mortality and occurrence of colic. Study design Retrospective cross-sectional study. Methods Medical records of horses undergoing celiotomy for a small intestinal obstruction and JJ, JI or JC from 2005 to 2010 were reviewed. Post operative complications were recorded. Short-term outcome was alive vs. dead at hospital discharge and was analysed using a Chi-squared test. Long-term follow-up was obtained and a Kaplan–Meier estimate of the survivor function was performed. Results There were 112 horses included. A higher proportion of JI horses had a repeat celiotomy during hospitalisation compared with horses undergoing JC. The number of horses alive at hospital discharge was not different between groups: JJ 79% (95% confidence interval [CI] 68–90%), JI 78% (95% CI 61–96%), JC 83% (95% CI 71–96%). Among horses discharged with long-term follow-up, more horses had colic after JC compared with JJ or JI. Long-term post discharge survival based on the Kaplan–Meier survivor function was lower for horses undergoing JC than JJ or JI (P = 0.04). Conclusion While there was no difference in short-term outcome between groups, more horses with JI underwent a repeat celiotomy during hospitalisation. Horses with a JC were more likely to have long-term complications with colic. Horses that were subjected to euthanasia because of colic within 12 months of hospital discharge either had a JC or repeat celiotomy. The results suggest that, when possible, a JI may be the preferred method of anastomosis based on more favourable survival and lower occurrence of colic long term.

Few data are available for assessing the outcomes of bariatric surgery for patients who have undergone orthotopic liver transplantation (OLT). The University of Minnesota bariatric surgery database and transplant registry were retrospectively reviewed to identify patients who had undergone OLT and then open Roux-en-Y gastric bypass (RYGB) surgery between 2001 and 2009. Comorbidity-appropriate laboratory values, body mass indices (BMIs), histopathology reports, and immunosuppressive regimens were collected. Seven patients were identified with a mean age of 55.4 ± 8.64 years and a mean follow-up of 59.14 ± 41.49 months from the time of RYGB. The mean time between OLT and RYGB was 26.57 ± 8.12 months. The liver disease etiologies were hepatitis C (n = 4), jejunoileal bypass surgery (n = 1), hemangioendothelioma (n = 1), and alcoholic cirrhosis (n = 1). There were 2 deaths for patients with hepatitis C 6 and 9 months after bariatric surgery due to multiple-organ dysfunction syndrome and metastatic esophageal squamous carcinoma, respectively. One patient with hepatitis C required a reversal of the RYGB because of malnutrition and an inability to tolerate oral intake. Four of the 7 patients had type 2 diabetes mellitus (T2DM), 4 had hypertension, and 6 patients had dyslipidemia. All patients were on immunosuppressive medications, but only 4 were on corticosteroids. Glycemic control was improved in all surviving patients with T2DM. The mean BMI was 34.27 ± 5.51 kg/m2 before OLT and 44.34 ± 6.08 kg/m2 before RYGB; it declined to 26.47 ± 5.53 kg/m2 after RYGB. In conclusion, in this case series of patients undergoing RYGB after OLT, we observed therapeutic weight loss, improved glycemic control, and improved high-density lipoprotein levels in the presence of continued dyslipidemia. RYGB may have contributed to the death of 1 patient due to multiple-organ dysfunction syndrome. Liver Transpl 19:1324–1329, 2013. © 2013 AASLD.