Chapter 13

The main reason for failure of medical therapy of obesity in obtaining a stable body weight normalization is the reluctance of obese patients to permanently change their lifestyle and eating habits. These changes are temporarily easy to obtain by means of food-limitation surgical procedure, but when, in the long run, the patients are left with the original problem, the majority of them will not be able to maintain the changes indefinitely.

Forty years of worldwide experience with surgical treatment of obesity have demonstrated that the more the success of a procedure depends on patient's cooperation, the poorer the results are. This is the reason why malabsorptive methods, which require minimal patient's compliance, have always been the most effective obesity operations. The reduction of nutrient absorption was actually the first approach to surgical treatment of obesity. The fact that a new way had been opened and the early weight loss results with jejunoileal bypass (JIB) led to more than 100,000 of these operations performed in the United States through the years 1960s and 1970s. However, the analysis of late results and complications of JIB caused a drastic coolness of the initial enthusiasm. In addition to its complications, essentially due to indiscriminate malabsorption and the harmful effects of the long blind loop, the main problem with JIB is its narrow “therapeutic interval.” In fact, the total length of the small bowel left in continuity is restrained within the range of 40–60 cm, a shorter or longer bypass resulting in life-threatening malabsorption or no weight reduction, respectively. On the other hand, the massive intestinal adaptation phenomena cause an increased absorptive surface leading out of the upper limits of the above range, with ensuing substantial recovery of energy absorption capacity.1 This, in addition to the frequent need of restoration for major complications, ends in a high rate of failure with weight regain.2,3 The high complication rate and the overall unsatisfactory weight loss results of JIB during the years around 1980 led to the general abandoning of malabsorption approach for obesity surgery, the gastric restriction procedures becoming those most frequently used.

Because of the absence of a blind loop and of the malabsorption essentially selective for fat and starch, biliopancreatic diversion (BPD) is free of the complications pertaining to JIB.4,5 Moreover, BPD has a very wide “therapeutic interval” because by varying the length of the intestinal limbs, any degree of fat, starch, and protein malabsorption can be created, thereby adapting the procedure to the population's or even the patient's characteristics, to obtain the best possible weight loss results with the minimum of complications.6 Finally, the selective energy malabsorption, in conjunction with this extreme flexibility, makes it easy to neutralize the consequences of intestinal adaptive phenomena, which, on the other hand, are little effective in BPD. In fact, since the absorption of protein and the other essential nutrients occurs in the alimentary limb (AL), the common limb can be ...

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