Wieland et al should be applauded for the completeness of their follow-up of patients with jejunoileal bypass (94% of 84 patients for a mean of 4.5 years).1 It is not surprising that granulomas may appear and disappear despite continuation of the bypass state, as the list of causes for hepatic granulomata is quite extensive and includes a substantial idiopathic and drug-related group.2 In addition, the demonstration of granulomas on liver biopsy is frought with sampling effect.3 We agree, therefore, that reanastomosis should be reserved for patients with extensive hepatic necrosis or progressive fibrosis.The team approach advocated by Wieland et al (surgical, medical, and psychosocial) has been accompanied by a 7% mortality (3% in a more recent subset). However, one questions whether similar results are obtainable in an unsupervised setting. In addition to the surgically related deaths (at least three of six occurred in the
O'Reilly DJ, Clayman CB. Intestinal Bypass for Obesity-Reply. JAMA. 1982;247(15):2098. doi:10.1001/jama.1982.03320400018017
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