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Even if the jejunoileal bypass has been definitely abandoned due to the high rate of hepatic complications, cases of liver injury after the new bariatric procedures are still reported. We aimed to review the available literature concerning liver damage associated with the older and newer types of bariatric surgeries.An extensive literature search of MEDLINE was performed using different combinations of the following terms: "bariatric surgery OR biliopancreatic diversion OR jejunoileal bypass OR roux-en-y gastric bypass OR vertical banded gastroplasty OR laparoscopic adjustable gastric banding" AND "hepatic/liver damage OR hepatic/liver impairment OR hepatic/liver failure".Although weight loss after bariatric surgery frequently induces an improvement of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis, and even the regression of hepatic fibrosis, bariatric procedures have been also associated with cases of acute liver failure or of chronic liver disease evolving until cirrhosis. After the jejunoileal bypass has been definitely abandoned, most of the recently described cases concern biliopancreatic diversion with/without duodenal switch, but liver damage has been reported after almost all types of bariatric surgeries. Protein-calorie malnutrition, bacterial overgrowth, lipotoxicity and genetic background are likely to play a central role in the physiopathology of hepatic injury.Understanding the inner mechanisms underlying acute or chronic liver injury after bariatric surgery can help in the prevention, early recognition and treatment of these rare but concrete cases.

According to the WHO, the worldwide prevalence of obesity body mass index (BMI) 30 kg/m² nearly doubled between 1980 and 2008, with 10% of men and 14% of women and a total of more than half a billion adults (aged20 years old) being classed as obese. At least 2.8 million people die each year worldwide as a result of being overweight or obese, usually from the inevitable related comorbidities. It has been reported that approximately 65% of the worlds population inhabits countries where overweight and obesity are responsible for higher mortality than underweight. The recently published Interdisciplinary European Guidelines on Metabolic and Bariatric Surgery note that despite the WHO stating that excess weight is considered the fifth leading risk for deaths worldwide, it has not yet been possible to successfully curb the obesity epidemic. Moreover, severe obesity (BMI35 kg/m²) represents a rapidly growing segment of the epidemic in which the negative effects on health and disability are especially marked. Excess weight drastically elevates a persons risk of developing a number of non-communicable diseases, such as diabetes, hypertension, stroke, dyslipidaemia, sleep apnoea, cancer, non-alcoholic steatohepatitis, and other serious comorbidities. The WHO emphasises that 44% of type 2 diabetes mellitus, 23% of ischaemic heart disease and around 741% of certain cancers are attributable to overweight and obesity. In the majority of European countries, overweight and obesity are responsible for about 80% of cases of type 2 diabetes, 35% of cases of ischaemic heart disease and 55% of cases of hypertensive disease among adults. Additionally, a range of debilitating conditions such as osteoarthritis, respiratory difficulties, gallbladder disease, infertility, and psychosocial problems, among others, which lead to reduced life expectancy, quality of life and disability, are extremely costly in terms of both absence from work and use of health resources. Noteworthy, the lifespan of severely obese individuals is decreased by an estimated 5-20 years depending on gender, age, and race. Weight loss and maintenance are the obvious aims of bariatric surgery. The ideal bariatric operation should be easy and quick to perform, with minimal perioperative and long-term complications. It should result in excellent weight loss and indefinite weight maintenance in the vast majority of operated patients, necessitating minimal follow-up care, and be equally suitable for all patients, independent of individual characteristics such as compliance, age, and different degrees of overweight. It is immediately apparent that such a surgical procedure does not exist, and therefore we must carefully evaluate all the different features and characteristics of each operation and of each patient to try to select the procedure that provides the greatest probability of long-term success for a particular patient, with the best cost/benefit ratio. Bariatric surgery has proven to be the most effective mode of treatment for morbidly obese patients, with recent long-term studies providing evidence of a substantial reduction of mortality in bariatric surgery patients, as well as a decreased risk of developing new health-related comorbidities. Furthermore, a reduction in the use of healthcare services and therefore a reduction in direct healthcare costs was also observed. Bariatric surgery is an established and integral part of the comprehensive management of morbidly obese patients.

Linee guida per la chirurgia bariatrica italiana elaborate dal gruppo di autori membri della Società Italiana di Chirugia dell'Obesità e delle Malattie Metaboliche (S.I.C.OB.), riunitesi in Consensus Conference a Praiano, 19-23 Ottobre 2007.

Alexithymia is the inability to express feelings with words and comprises a psychological construct frequently found in obese individuals. In eating disordered patients who show a tendency to lose control over food intake, personality traits with alexithymic characteristics have been demonstrated. The present cross-sectional study investigated the relationships between alexithymia and eating behaviour in severely obese patients.This study analysed 150 obese patients undergoing bariatric surgery and 132 subjects at more than 1 year after biliopancreatic diversion (BPD), when body weight has steadily normalised and any preoccupation with weight, food and diet has been completely abandoned. Obese and operated subjects completed the Toronto Alexithymia Scale (TAS), and eating behaviour was assessed via a semi-structured interview exploring binge eating disorder (BED), night eating and emotional eating, as well as by utilisation of the Three Factor Eating Questionnaire (TFEQ).Although alexithymic patients showed deranged eating behaviour, as evaluated by the TFEQ scores, the frequency of BED, night eating and emotional eating was similar in alexithymic (TAS60) and non-alexithymic patients. However, the prevalence of alexithymia was similar in obese and BPD subjects, whereas, in the operated subjects, TFEQ scores were lower (P0.005) than those in obese patients.These data suggest that, in severely obese patients, alexithymia does not influence eating behaviour; in severely obese patients, the tendency to lose control over food intake apparently represents a psychological construct that is substantially independent from alexithymia.

Background: The authors assessed the prevalence of diabetes, hypertension, dyslipidemia and metabolic syndrome in patients with a high degree of obesity. Methods: A retrospective investigation was planned in a cohort of obese patients with a wide range of body mass index (BMI) referred to a large University Hospital for weight loss. Results: An increase in prevalence of diabetes and hypertension with increase in the degree of obesity was observed, while the prevalence of dyslipidemia and metabolic syndrome appeared to be independent of the BMI values. Conclusion: In severely obese patients a still unknown factor which affects differently glucose and lipid metabolism cannot be excluded.

Recent advances in anesthetic and surgical techniques have increased the survival of patients after extensive bowel exclusions. This, in addition to the increased use of intestinal bypass for the treatment of obesity, has substantially increased the number of persons living with a short bowel. Proper management of these individuals is based on a thorough understanding of the pathophysiology of the shortened gastrointestinal tract.

An increasing number of women in childbearing age are submitted to surgical treatment of obesity; for this reason pregnancy represents a frequent event in operated patients.In this study pregnancy in patients with morbid obesity submitted to jejunoileal bypass (JIB) and gastric bypass (GB) are reviewed from the literature and the analysis of our experience with biliopancreatic diversion (BPD) is reported.In 113 pregnancies after JIB reviewed from the literature, the results seem to be debated either about the course of pregnancy or about maternal and neonatal status. The data of literature concerning the pregnancies following GB are less debated but rather slight. One hundred and fifty-two pregnancies after BPD have a complete documentation concerning maternal conditions, modality of outcome and neonatal situation.Pregnancy occurred in the obese women represents an increased maternal-fetal risk. The excess weight loss, the weight maintenance and the reduced weight changes during pregnancy are an advantage in the operate women who, in any case, need accurate controls of the nutritional status during the whole gestational period. Keeping these cautions pregnancy following surgical treatment of obesity represents an event not only possible but even with less problems than in pregnancy in obese women.

To investigate the influence of dieting and of body shape dissatisfaction on binge eating.Longitudinal study following billiopancreatic diversion (BPD), when the body shape has become normal or nearly normal, and any worries over weight, dieting and food have probably been abandoned completely.65 severely obese patients, evaluated by clinical semistructured interview for occurrence of binge eating episodes prior to, and at one and at two years following BPD.Whereas preoperative binge eating had been reported by 65% of the obese individuals, at two years following BPD binge eating occurred only in 9.2% of them.Weight stabilisation following BPD is associated with a sharp improvement in control over food intake, and this suggests the central role of dieting and/or of body dissatisfaction in causing binge eating episodes.

The relationships between the cognitive restraint and the tendency to disinhibition prior to gastric banding for obesity, as assessed by the Three Factor Eating Questionnaire, and the weight loss at one year following the operation were investigated. The amount of overall weight loss was correlated positively to the disinhibition and negatively to the cognitive restraint score. When the food consumption overtakes the proximal gastric pouch capacity, the patient feels a strong aversive stimulus, thus stopping eating. Therefore, more is the patient's tendency to lose the control on food intake more is the postoperative weight loss. On the contrary, the high restraint patient only seldom feels such an aversive stimulus, and only seldom stops eating, thus the weight loss is smaller. Except for the overeating due to the disinhibition, the aversive stimulus arising from the gastric restriction cannot influence by itself any other aspect of eating behavior.

Psychological traits of obese patients, assessed with the Eating Disorder Inventory (EDI), were compared to those of subjects in the long-term following biliopancreatic diversion for obesity (BPD), when body weight has been steadily normal for over 1 year and any preoccupation with dieting and weight has been completely abandoned. The overall results suggest that the stable body weight normalization on a completely free diet does confer considerable psychological benefit on obese individuals. On the basis of the EDI results, post-BPD subjects were divided into weight-preoccupied and not-weight-preoccupied individuals. In the not-weight-preoccupied subjects, the psychosocial status and emotional rectivity were closely similar to those observed in lean control persons, whereas the few weight-preoccupied subjects, in spite of completely normal body weight, showed residual body dissatisfaction and personality traits very similar to those of eating-disordered patients.

The relationships between the resting energy expenditure (REE), measured by indirect calorimetry, and eating behavior, assessed by the "Three Factor Eating Questionnaire" were evaluated. The study was carried out in a group of healthy never-obese subjects and in two groups of formerly obese people, who have maintained a normal weight for more than two years. The subjects of the first formerly obese group had brought their body weight to normal by dieting. The second one comprised subjects following biliopancreatic diversion for obesity (BPD) in the long term, who maintain a normal weight because of the intestinal malabsorption due to the operation regardless of food consumption. In comparison with the other subjects, significantly higher cognitive restraint score values were observed in the post-diet subjects. Furthermore, a negative significant correlation between cognitive restraint and REE was found in the non operated subjects, while such correlation was not present in the BPD subjects. Therefore, in normal people cognitive restraint has to be considered to be related to behavioral-cognitive factors rather than biologically driven by energy requirements.

Following gastric surgery for obesity, a satisfactory weight loss and, above all, long-term weight maintenance can only be achieved in patients who have succeeded in radically changing their preoperative eating habits. In this preliminary study gastric banding is associated with rehabilitative training which was carried out using similar methods to the programs used for eating disorders. One year after surgery the results were substantially the same as those reported in the literature, with an overall weight loss of approximately 50%. The lack of correlation between weight loss and the degree of gastric banding underlines, even after a short interval, the efficacy and importance of postoperative re-educational training. The utility of this integrated approach will only be more fully evaluated after a longer period.

Serum cholic and chenodeoxycholic acid conjugates were measured in fasting conditions and after meals in 14 patients with bile acid malabsorption due to ileal resection. Mean serum fasting levels of both primary bile acids did not differ from the controls. After meals, serum cholic acid peaks were lower in patients with ileal resection than in control subjects (p less than 0.001), while chenodeoxycholic acid peaks were reduced in colectomised patients (p less than 0.01). In the sera from patients with ileal resection, the glycine/glycine + taurine ratio for cholic and chenodeoxycholic acid increased (p less than 0.001) from morning to evening, and glycine/glycine + taurine ratio for chenodeoxycholic acid was significantly (p less than 0.01) different from the controls in the sera collected in the evening. The results are consistent with the concept of a better intestinal conservation of chenyl, mainly of the glycine conjugated from, than of cholylconjugates, in patients with ileal resection; this is probably because of passive absorption in the intestine. The postprandial peaks of serum cholic acid conjugates may therefore be regarded as a test of ileal dysfunction, while peaks of chenodeoxycholic acid conjugates suggest colonic impairment.

Bilio-pancreatic bypass is a new procedure that tries to obtain a maldigestion syndrome with selective malabsorption of the main high calorie foods. The operation consists of a gastric resection and division of the proximal jejunum just distal to the ligament of Treitz. A gastroentero-anastomosis is then constructed using the distal end of the transected jejunum, while the proximal jejunum is anastomosed to the side of the distal ileum. An experimental study carried out on 12 dogs confirmed that the operation causes a selective malabsorption with loss of weight and no complications. On the basis of this study it is suggested that this procedure has the following advantages over jejuno-ileal bypass: (a) normal absorption of bile salts, water and electrolytes; (b) slow recovery of absorption; (c) absence of a blind loop.

Biliopancreatic bypass for obesity entails a 2/3 distal gastrectomy with Roux-en-Y reconstruction, being the small bowel transected at its midpoint and the enteroenteroanastomosis placed 50 cm proximal to the ileocecal valve. Insulin and GIP fasting and meal-stimulated plasma concentrations were determined in 13 nonobese healthy volunteers, in 13 nonoperated obese patients, in 11 subjects within two months, in 12 subjects four to twelve months, and in 7 subjects fifteen to twenty months after operation. Insulin in the obese patients was significantly higher than in the control group. Postoperatively these patients showed a sharp reduction in basal and postprandial values. Plasma insulin levels, both basally and following the test meal, were very similar in the 15-20 month and the control group. Plasma GIP fasting level, meal-stimulated peak and integrated response in the obese group were higher than in control group. Due to the extreme variability among subjects in the obese group, the difference was significant only for the mean peak response. All values were greatly reduced after surgery. The mean fasting level in the 15-20 month group was very similar to that in the control group, and both peak and integrated responses were significantly lower than in the preoperative and control groups.

Cell mediated immunity was evaluated in vivo by means of the Multitest system in subjects at least one year after biliopancreatic bypass. Quantitative delayed hypersensitivity values were not significantly different between control, obese and partial biliopancreatic bypass subjects, while they were significantly (P less than 0.001) reduced in subjects who had total biliopancreatic bypass. The results demonstrate that cell-mediated immunity is not affected by partial biliopancreatic bypass, but that on the contrary, a severe immunosuppression follows total biliopancreatic bypass. A positive correlation between serum albumin concentration and Multitest score was found in all the operated patients.

Variations in body weight, behaviour of lipidaemic fractions proteinaemia, uricaemia and uricuria, and lipid and protein absorption were studied preoperatively and at varying times following operation in five subjects who had undergone jejuno-ileal bypass for obesity. The results showed high serous NEFA and a definite, early and persistent reduction in all lipidaemic fractions after operation. The post-operative levels of serous proteins, particularly albumin, which were reduced in all subjects, reached pathological levels in two patients where proteic malnutrition following on the operation was associated with serious liver disease. The results agree with reported data. The variations in lipidic and proteic malabsorption proved to be in agreement with weight drop and the serous parameters considered. The reduction in uricaemia encountered in the five patients studied failed to agree with data reported in the Anglo-Saxon literature. This may be explained by alimentary and racial differences between the two populations of patients.

Biliopancreatic bypass for obesity entails a 2/3 distal gastrectomy with Roux-en-y reconstruction, being the small bowel transected at its midpoint and the enteroenteroanastomosis placed 50 cm proximal to the ileocecal value. Pancreatic polypeptide (PP) and motilin fasting and meal-stimulated plasma concentrations were determined in 13 nonobese healthy volunteers, in 13 nonoperated obese patients, in 9 subjects within two months, in 12 subjects four to twelve months, and in 7 subjects fifteen to twenty months after operation. There were no significant differences in PP fasting levels between either the obese and control groups or between the postoperative groups and the preoperative group. Both meal-stimulated peak and integrated response values were similar in the obese and control groups, and were strikingly and progressively reduced postoperatively, with statistically significant difference between all postoperative groups and preoperative group. Mean plasma motilin fasting and peak values were higher in the obese group than in the control group, and significantly reduced in the 4-12 and 15-20 month group. Despite the huge variability among data, the integrated response in the 0-2 month group was significantly decreased in comparison with the preoperative group, while a subsequent progressive increase was shown by the 4-12 and 15-20 month groups.

The Multitest System, a new standardized method for evaluating delayed hypersensitivity and cell mediated immunity was carried out before surgery and throughout the postoperative care in subjects undergoing gastrointestinal surgery. In all patients significantly depressed cutaneous reactions were found in the first day after operation. Immunosuppression lasted more than four days when postoperative infection has set up, while in uneventful patients delayed hypersensitivity has returned to preoperative values from the fourth day. It would be suggested that Multitest System data in fourth postoperative day could identify subjects with uneventful recovery after surgery.

The treatment of obesity by intestinal bypass provides a unique model for the investigation of gut hormone release from the functionally deranged bowel. We have examined the postprandial response of eight circulating gut or pancreatic peptide hormones in 16 preoperative obese patients, 20 patients with jejunoileal bypass, 38 patients with biliopancreatic bypass and 13 age and sex-matched controls. Basal and post-meal hormone concentrations were determined by specific radioimmunoassay methods. Reductions of the upper small intestinal hormones, motilin and gastric inhibitory polypeptide were found in both types of surgery. Conversely, the ileal hormones neurotensin and enteroglucagon were elevated following surgery. This pattern is consistent with the known distribution of these hormones. Variations of response due to surgical differences were noted for gastrin and the enteropancreatic axis, which was more markedly disturbed after biliopancreatic bypass. The alterations of hormone release closely reflect the anatomical changes induced by each particular surgical technique.

Bone histomorphometry and vitamin D status were investigated in 41 patients studied 1-5 yr after partial or total biliopancreatic bypass. Metabolic bone disease, characterized by defective mineralization, decreased bone formation rate, and increased surface extent of resorption, was present in 30 patients (73%). Nine patients (22%) were hypocalcemic, but serum 25-hydroxyvitamin D concentrations were normal in all 41 patients. We conclude that metabolic bone disease is common after biliopancreatic bypass and usually occurs in the absence of simple vitamin D deficiency. The pathogenesis of the bone disease is unclear.

Delayed hypersensitivity was evaluated by means of Multitest System in 50 healthy Italian adults. Results were checked for homogeneity, comparability and reliability assays. Strict antigen and technique standardization warranted closely homogeneous results. Booster effect did not occur. Data evaluation was not depending on individual reader. Multitest System appears to be the most reliable method to evaluate delayed hypersensitivity and cellular immunity in man.

A critical review of the relevant literature is followed by the presentation of a new method for total hepatectomy in the dog. This is carried out in a single stage. Its main advantage is there is no temporary interruption of the portal or portocaval flow. A synthetic prosthesis is anastomosed end-to-end with the subhepatic vena cava and end-to-side with the supradiaphragmatic cava. Next, the portal vein is anastomosed side-to-side with the prosthesis and ligated upstream. Hepatectomy is then performed.

Biliopancreatic bypass for obesity entails a 2/3 distal gastrectomy with Roux-en-Y reconstruction, being the small bowel transected at its midpoint and the enteroenteroanastomosis place 50 cm proximal to the ileocecal valve. Neurotensin and enteroglucagon fasting and meal-stimulated plasma concentrations were determined in 13 nonobese healthy volunteers, in 13 nonoperated obese patients, in 11 subjects within two months, in 12 subjects four to twelve months and in 7 subjects fifteen to twenty months after operation. Basal plasma enteroglucagon was significantly higher in the obese group than in the controls. However, there was no difference in the peak response, and a decrease, though not statistically significant, was seen in the integrated response. All three values were strikingly augmented in the 0-2 month group, with a highly significant difference from the preoperative group. The 4-12 and 15-20 month groups, in comparison with the 0-2 month group, showed no changes in fasting levels, a clear-cut decreased peak response and a sharp progressive reduction in integrated response, mean value in the 15-20 month group being significantly lower than that of 0-2 month group. Neurotensin basal and meal-stimulated peak plasma concentrations in the obese group were significantly higher than in the control group, whilst the integrated response was almost identical in the two groups. In postoperative groups no substantial changes in fasting levels and an increase in the peak response were observed, with a considerable progressive rise in the integrated response.

Extracorporeal perfusion of pig liver lasting 4 hr, followed by isovolaemic exchange (6 litres in 1 hr) were employed in the management of coma in a case of acute virus hepatitis. Liver perfusion led to temporary regression of coma, whereas transfusion was followed by gradual improvement in the clinical picture; this was apparently not a direct consequence of the procedure adopted. Assessment of the degree of purification obtained with these two methods offers an explanation for the difference in their clinical effectiveness.

The nutritional status and total body composition of 33 patients with malnutrition after biliopancreatic bypass were studied. Body composition was evaluated directly by measurement of water and total sodium and indirectly by measurement of total body potassium. After nutrition with a parenteral nutritional support the conventional nutritional parameters were restored to the normal values (serum albumin and serum transferrin) and the parameters of body composition were markedly improved even though still altered with respect to healthy controls. Serum albumin and serum transferrin were shown to be very reliable indices of malnutrition but their normalization does not necessarily correspond to optimum body composition and thus to optimal normal nutrition.

The degree of hepatic steatosis and percentage total nitrogen content were evaluated simultaneously in a group of obese patients and after bypass surgery for obesity. The straight line relationship between sample weight and gas chromatographic response integrals shows that samples had the same water content. The higher concentration of total nitrogen in patients with higher levels of steatosis and the inverse correlation between degree of adipose infiltration and degree of total nitrogen, when water content is the same, suggest that the total liver parenchyma nitrogen concentration closely reflects the structural protein content.

Previous studies have demonstrated that changes in endoduodenal pressure may cause pancreatic alterations in biliary diseases. Anterior selective vagotomy of the duodenum was devised to reduce duodenal motility. An experimental study showed that such a surgical procedure is followed by a marked decrease in the overall duodenal kinesis, with disappearance of the highest pressure peaks.

Reference is made to 2 cases of fatal liver failure following jejuno-ileal by-pass for obesity, in which necropsy shown micronodular and the rarer fragmentary necrosis, in addition to serious steatosis. Liver alterations following by-pass are usually reversible and respond to the infusion of medicaments. The indication for surgical re-establishment of continuity, in which, if timely, leads to normalisation of liver shape and function, must be chosen without hesitation when changes, albeit reversible, appear to threaten life and resist treatment, and in all cases where biopsy points to progression towards irreversible sclerosis.

A 40 + 5 cm jejunoileal bypass was created as a means of treating a case of morbid obesity. Clinical, functional and morphological examinations were carried out prior to surgery and at various times for the following year. An initially rapid loss of weight was followed by an early halt around the 7th month and a subsequently steady state. While metabolic and cardiorespiratory benefits were obtained, considerable and progressive hyperchlorhydria and lithiasic cholecystitis were noted, along with minor, reversible complications.

Transit times were evaluated in 23 obese subjects before and 1,4 and 12 months after biliopancreatic by-pass. A modified version of the method of Hinton et al. was used to determine emptying of the stomach and partial and total transit times. Emptying of the stomach was normal preoperatively. After surgery, it was almost immediate, except in two subjects with stomitis. Both transit times were virtually unchanged. Since the segment between the stomach and the ileocaecal valve is only half as long as in the normal subject, the results show that the by-pass leads to a slowing of transit that concerns the small intestine only, is quickly established, and does not change in the course of time. Evaluation of the altered anatomical and functional situation, and the absence of a correlation between the long-term behaviour of transit times on one hand and of lipid malabsorption and weight loss on the other-hand, suggest that a slower transit time must not be regarded as a compensation mechanism, except insofar as it restricts the degree of malabsorption set up immediately after surgery. Preliminary studies of enterohormonal changes following the by-pass indicate that increased glucagon and decreased motiline values are mainly responsible for slower transit times.