Management of the morbidly obese patient after small bowel bypass failure.

Fourteen patients underwent small bowel bypass (SBB) takedown for complications such as chronic nausea and vomiting, excessive flatus, intractable diarrhea, liver dysfunction, electrolyte imbalance, hyperoxaluria with renal stones, and arthritis. The average weight loss in these 14 patients after SBB was 93 pounds (34% of initial weight), with a mean follow-up of 23 months. Four of the 14 patients had SBB takedown only and gained an average of 36 pounds over the ensuing 14 months. Similarly, three patients had SBB takedown with delayed (asynchronous) gastric bypass (GB) and gained an average of 55 pounds during the 14 months prior to GB. Following GB these three patients lost only an additional 8 pounds over a 12 month period, leaving them 47 pounds heavier than at the time of SBB takedown. In contrast, seven patients treated with SBB takedown and synchronous GB not only maintained the weight reduction obtained with SBB, but, in addition, had further modest weight reductions (average, 18 pounds), for a mean follow-up of 8 months. There were no serious operative or late complications with any of the above operations. In addition, the complications leading to SBB takedown resolved in each case. It is concluded that synchronous GB is an effective means of maintaining the weight reduction in the morbidly obese patient after SBB takedown.