Introduction
Jejunoileal bypass (JIB), the very first bariatric procedure, creates a short-bowel syndrome with approximately 35 cm of jejunum and 15 cm of ileum and a very long excluded small bowel blind loop. It was abandoned because of deleterious or lethal side effects [
1,
2]. Indications prompting JIB reversal include diarrhea, electrolyte abnormalities, malnutrition, organ failure, arthritis, and poor quality of life [
1‐
3]. JIB reversal is usually performed using a two-stage open approach [
3]: first, a jejunostomy feeding tube is placed in the excluded limb, and then, after 3–12 months, intestinal continuity is re-established.
Despite some small series [
1‐
10,
Supplementary Table], there is a lack of recommendations how to best implement (re)nutrition before JIB reversal. Previous reports provide no details on progression to half-strength nutrition, and refeeding intolerance of the excluded limb has been reported [
3,
4]. Here, we propose a refeeding protocol for the excluded limb prior to restauration of bowel continuity that has been successfully applied in two patients undergoing JIB reversal.
Discussion
These patients illustrate the well-known deleterious sequels after JIB and emphasize that reversal surgery should be considered to partially/completely correct the severe adverse effects and prevent further progression of organ failure [
5,
6].
To our knowledge, this is the first description of nutritional management of JIB patients before reversal. First, the nutritional status should be improved to reduce postoperative complications, through parenteral and/or enteral nutrition according to current local guidelines on severe malnutrition. Despite severe malabsorption after JIB, enteral feeding can be effective to improve nutritional status before surgery.
Timing and proper preparation for JIB reversal is crucial, mainly due to the size discrepancy between the excluded and the functional limb. This difference is caused by the atrophy of the enteral mucosa due to prolonged exclusion of nutrients from the intestinal lumen. The two patients presented here had JIB anastomoses at about 30 cm from the angle of Treitz and 15–20 cm from the cecum, and they underwent distinct jejunostomy placement procedures. In patient 2, the excluded limb was large enough to allow for direct placement of a Witzel jejunostomy at its proximal end, while it was too narrow in patient 1. In the latter, we performed a latero-lateral anastomosis between the proximal jejunum about 20 cm from the angle of Treitz. The jejunostomy was then placed a few centimeters proximally from this anastomosis, and the enterostomy passed 30–40 cm distally into the excluded loop. This approach places the jejunostomy on non-atrophic jejunum and allows refeeding of the excluded limb. The refeeding protocol was, however, identical, well-tolerated, and effective in both patients, permitting successful restauration of bowel continuity 4–6 months after jejunostomy, comparable to other reports in the literature [
3,
4].
We recommend progressive refeeding of the atrophic limb in five steps (Fig.
1). We believe that early enteral infusion of 5% glucose is safe for the extremely atrophic mucosa and is useful to test the patency of the loop after jejunostomy placement. The transition to an isocaloric formula was successful in both cases. The enteral flow rate should be gradually increased (10–20 ml/h/day) according to individual digestive tolerance. Nutrition, together with mechanical stimuli, allows to regain the integrity of the bowel after several months. The enteral absorption recovery was evident after JIB reversal in both patients who regained and stabilized their weight and corrected their micronutrient deficiencies. The two patients reported a progressive increase in their abdominal girth, although this could not be documented by objective measurements. This observation illustrates intestinal adaptation despite the extremely long mucosal inactivity.
Exclusion of the atrophic limb also affects pancreatic enzyme action resulting in steatorrhea (see Patient 1). In this case, semi-elemental formula, containing peptides and medium-chain triglycerides, should be tested. Moreover, hydration of the atrophic limb must be adapted to prevent digestive transit disorders.
In summary, this progressive refeeding protocol of the excluded limb via feeding enterostomy prior to surgery is an essential component for successful JIB reversal.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit
http://creativecommons.org/licenses/by/4.0/.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.