Biliointestinal bypass shares similarities with jejunoileal bypass: An operation to avoid?

The biliointestinal bypass (BIB) proposed by Hallberg in 1979, continues to be one of the leading procedures in Italian bariatric surgery, and given the positive literature on the technique and the weight loss associated with it, it is often employed by our center as well. However, despite the promising early results, it is not without complications. Since postsurgery malabsorption in BIB is often comparable to what can be found in short-bowel syndrome after extensive intestinal removal, we would like to ask a provocative question: should BIB be abandoned? We studied 38 BIB patients operated on from 1999 to 2005, and observed no perioperative mortality and morbidity; however, only 24 patients, of whom 15 were women, were available at 1-year follow- up. For these 24, preoperative mean age was 37.25±8.80 years, mean body weight 147±37 kg, mean body mass index (BMI; kg/m2) 50.7±7.8, mean percentage of excess weight (%EW) 108.8±29%. After 1 year, mean body weight loss was 56 kg (147±37.2 kg vs. 90±19 kg), decrease in mean BMI around 20 (BMI 50.7±7.8 vs. 30.5±5) and mean percentage of excess weight loss (%EWL) 50%. Late morbidity occurred in 100% of the follow-up sample: 100% suffered hypokalemia; 29%, protein energy malnutrition (PEM); 87%, vitamin B1 and A deficiency syndrome; and 37%, acute relapsing hemorrhoidal disease. Tc-99m HIDA cholescintigraphy showed a stenosis of biliointestinal anastomosis in 29%. PEM was worse when the jejunal tract was shorter than 40 cm and when a biliointestinal anastomosis stenosis occurred. This new condition unfortunately led to a state like that suffered with the obsolete jejunoileal bypass (JIB). Despite this, BIB can play a role in those patients in whom rapid weight loss is required, due to severe obesity-related comorbidities, and who do not accept gastrectomy (e.g., in biliopancreatic diversion), or who refuse bariatric restrictive surgery. © SINPE-GASAPE.