In this issue (see p 643), Tustin et al have described three patients in whom fungal infections developed after jejunoileal bypass; two of the patients did sufficiently poorly to require reanastomosis. While the increased incidence (2%) of fungal infection in this group of patients is important, the report points out the fundamental paradox of jejunoileal bypass surgery—patients with the "best result" (most weight loss) are the most likely to experience serious complications.
Patients who are considered for obesity surgery of any kind should be morbidly obese (at least twice their ideal weight). In most cases, the excess weight represents fat without a commensurate increase in lean body mass. When weight loss occurs after intestinal bypass, two distinct groups of patients can be identified: (1) those whose weight loss is primarily from fat stores, and (2) those whose lean body mass is depleted in addition to fat stores.1 Patients from