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Gastric bypass in morbid obesity1 Edward E. Mason,2 M.D., Ph.D., Kenneth Printen,3 J. M.D., Thomas J. Blommers,4 Ph.D., Jeffrey W. Lewis,5 M.D., and David H. Scott6 Morbid obesity has failed to respond to patient and the response pattern of such a diet, hypnosis, behavior modification, drugs, patient to the sudden reduction in stomach and group therapy. Surgeons have adopted size to 50 ml with a 12-mm diameter outlet. operations, which are used for other purposes, The advantage of intestinal bypass was sup- to the treatment of morbid obesity. Because posed to be in the ability of the patient to weight loss was an undesirable side effect of continue the art of good eating while losing these operations, a reorientation has beenweight. Some surgeons still believe that the required. Such is the case of Biliroth II gas- morbidly obese state can be controlled with trectomy, originally introduced in 1884 andcontinued bulimia. Actually, patients with Downloaded from www.ajcn.org by guest on May 13, 2011 previously the mainstay of the surgical treat- intestinal bypass also reduce their intake be- ment of acid peptic disease, which has beencause eating causes them to feel ill, pass foul- adapted to the treatment of morbid obesity. smelling flatus, and irritating liquid stool. When sufficient stomach was resected to pre-Morbidly obese patients, after gastric bypass, vent further ulceration, an intake deficiency are usually delighted to learn that half a cup was often an unwanted side effect. Further- of food will satisfy their desire to eat for a more, if any distal stomach was left, antral number of hours. The important item to com- gastrin was likely to cause stomal ulceration. prehend is that these patients must be pre- Intestinal bypass paved the way for oper- pared for their new small stomach. Even ative treatment of obesity. Even jejunocolic though these patients are not upset by the bypass seemed justifiable if the obesity werenew limitation in capacity, they must be in- sufficiently severe. Jejunoileal bypass was structed not to attempt over-indulgence once better tolerated and rapidly replaced jejuno- they begin to eat after the operation. Fortu- colic bypass. In 1966 an extensive exclusion nately, if they can be watched closely during of the stomach, patterned after Billroth II the first postoperative week, a surprising de- gastrectomy, was introduced as a possible gree of self-control is established with the treatment for morbid obesity. Preliminary help of newly found internal cues. studies by Mason and Ito (1) seemed to con- firm the thesis that, if sufficient acid secreting Evolution and standardization mucosa was kept in the excluded section of the stomach, antral gastrin would be sup- It has been said that experience is the pressed. The small upper stomach and greatest the teacher. In this light, perhaps a re- large excluded stomach would prevent over-counting of our trials and errors at The Uni- eating and the development of stomal ulcer.versity of Iowa during the last 12 years will The use of any exclusion operation for the spare other surgeons and patients the early surgical treatment of morbid obesity wascomplications, failures, and revisions that looked upon by surgeons with strong have at times made criti- our lives less pleasant, as cism; some advised the addition of vagotomy. we participated in the development of gastric For the most part, gastric bypass as a treat-operations for the treatment of obesity. ment for obesity was ignored. Those surgeons willing to treat morbidly obese patients were From the Department of Surgery, University of busy with intestinal bypass. The thought a of Iowa Professor Hospitals 2 and and Chairman Clinics, Iowa City, of General Iowa 52242. Surgery, Uni- near total gastrectomy analog in patients versity of Iowa College of Medicine. ‘ Professor of weighing up to 250 kg was not attractive. Surgery. Clinical Research Assistant in Sur- Another learning experience, still in proc- gery. Assistant Professor of Surgery. Clinical ‘ ess, involves the nature of the morbidly obese Research Clerk in Surgery. The American Journal of Clinical Nutrition 33: FEBRUARY 1980, pp. 395-405. Printed in U.S.A. 395 396 MASON ET AL. The first three operations (Fig. 1) weremortality decreased (Fig. 2). By the end of used in succession between 1966 and 1974,the year, however, it was apparent that weight inclusive. Although they all caused weight loss was less satisfactory than with gastric loss, each was supplanted by a subsequent bypass. Almost all of these patients needed modification because of dissatisfaction with revision, although to date, only 36% have one or more aspects of the procedure. been revised; all of these operations were In 1966, the drive to eat in the morbidly converted to a gastric bypass. Gastroplasty obese patient was not yet fully recognized, failed for the same reason that 23 to 30% of and although most patients lost weight with pre-1975 gastric bypass operations have re- a modified Billroth II operation, there were quired revision. There were no specifications too many failures. A small upper stomach for upper stomach size and no measurements was usually created, but the gastroenteros- of volume. In early 1971, there was concern tomy, formed over a 2-cm area at the greater about progressive stretching of the passage curvature, was too large. Many patients hadbetween the upper and lower stomach and dumping symptoms and this helped to reduce consequently, a gastrogastrostomy was used intake and to encourage avoidance of highwith the expectation that scarring would osmotic, high calorie intakes. Unfortunately, maintain a narrow passage. An inverted, su- there were too many patients who either didtured, narrow gastrogastrostomy was difficult Downloaded from www.ajcn.org by guest on May 13, 2011 not develop the dumping syndrome, or whose to control in size and early temporary ob- upper stomach was at times left much too struction was common. As a result, the use of large. As shown in Table 1, there was even- an anastomosis was abandoned and in its tually a 30% surgical revision rate. place, a channel of undivided stomach wall In 1971 gastroplasty was introduced. This was left along the greater curvature. This was a simpler procedure and the operative channel was 12 mm in diameter or less. Both A FIG. 1. Shows the variations in gastric operations for obesity used prior to 1975: A, 1966-1970, the stomach was divided and a short loop retrocolic gastroenterostomy was constructed; B, 1971, gastroplasty; C, 1972-1974, a longer greater curvature and a long narrow outlet. GASTRIC BYPASS IN MORBID OBESITY 397 TABLE 1 Compares the revision rate and weight loss at 1 year for the various gastric operations for morbid obesity at The University of Iowa through 1978 Bypass Gastroplasty Bypass Bypass Procedure years 1966-70 1971 1972-74 1975-78 Specifications Stoma None 12mm 12mm 12mm Pouch Small Small Small 50 ml Initial patients 64 56 273 216 % Revised 30 36 23 4 lyrlosskg 36 25 31 40 % Initial weight loss 24 17 21 29 % Excess weight loss 44 32 37 53 Patients followed 1 yr 60 49 243 138 8 control eating. Because the fundus was not Downloaded from www.ajcn.org by guest on May 13, 2011 mobilized and volume was not measured, 6 El Late Postoperative many patients could overeat. Some developed Death (1-6 years) the disconcerting combination of retention, putrefaction of the retained organic matter l2 0 Early Postoperative and vomiting, as well as the maintenance of Death (I 60 days) - excessive weight. They carried around a fuel 0-4 supply at all times and, in spite of periodic 8- vomiting caused by overeating, a slow, steady flow of calories into the intestine provided 6- more than was needed. In 1975, the importance of a small upper 4. stomach became even more obvious. Horn- 2- I to to R lOt 201 301 401 501 601 to to to to to berger he had observed patients (2) mobilized did not measure with gastric excellent pouch the fundus bypass, volume, weight completely; and although loss in his he assured he us that his upper stomach segment was smaller 00 200 300 400 500 600 700 than ours. Freeing up all of the fundus did No. of Patients not make the operation any easier, but it FIG. 2. Bar graph showing early % operative mor-seemed to be essential to the formation of a tality (shaded) and late unrelated mortality rate (clear). The decrease in early mortality 1 in the second 00 patients small pouch. Alden (3) described a small corresponds to the time when gastroplasty, a safer anterior pro- gastroenterostomy with stapling of cedure, was in use. Later changes have now reduced the stomach the in continuity below this, which risk of death in gastric bypass (see text). produced a relatively small upper stomach, and greatly reduced the operating time to the upper stomach and the stoma stretched close to 1 hr with an operative mortality of and weight loss was quite unsatisfactory zero. It has been learned since then that (Table 1). staples are not permanently effective in cc- In 1972, gastric bypass was resumed, butcluding the stomach in all patients. The staple with a longer greater curvature to allow forline should probably be reinforced in some easier placement of the gastroenterostomy way. A second set of staples a few mm from below the mesocolon. A 12-mm Hegar dilator the first set has been used by many of us after was used to calibrate the openings in the we became aware of one-application staple stomach and jejunum for the anastomosis. Afailures. long, narrow, windsock-shaped upper stom- Alder and Terry (4) describe the intraoper- ach with a small stoma was counted upon ative measurement to of the volume of the upper 398 MASON ET AL. stomach by injecting saline through the na- the remaining patients from an earlier era. At sogastric tube. They also recommended mea- The University of Iowa, a manometer has surement of the margins of the upper segment been attached to the nasogastric tube and the by placement of rubber bands at appropriate volume is measured at 25 to 30 cm saline of positions on the indweffing nasogastric tube. pressure above the level of the cricoid carti- The idea of measuring the volume of the lage when the operating table is level. A upper stomach had been a dream of gastric single-hole Ewald tube is used to measure the surgeons for as long as gastric resections had volume required to distend the upper stom- been in use, yet no one had thought of this ach. A Penrose drain around the esophagus simple solution to the problem. With Alder may be required to prevent esophageal reflux. and Terry’s technique, the surgeon could The measurement is made before the stomach know at the conclusion of the operation that is completely stapled, but while the stapling the specifications of an adequate operation apparatus is in place so that adjustments can had been met. Measurement of pouches be-be made if the pouch size is inappropriate. fore and after revision showed how far off During the period 1975 through 1978, there the initial estimate could be (Fig. 3). In the have been further attempts to modify the same manner, weight curves show how effec- operation. Figure 5 diagrams the three major tive the operation might be when specifica- variations currently being evaluated. Griffen Downloaded from www.ajcn.org by guest on May 13, 2011 tions are followed (Fig. 4). et a!. (5) made an early change from a loop During early 1975, the volume of the upper gastroenterostomy to a Roux-en-Y gastroen- stomach was progressively reduced and it was terostomy. Hermreck et al. (6) reported that not long before w 50 ml as specified as the they had used a Roux limb in 14 of their 75 requirement for an effective operation. Since patients subjected to gastric bypass after two then, revisions have nearly ceased except forpatients developed reflux esophagitis. They FIG. 3. Pre- and postrevision radiographic studies in the patient whose weight curve is shown in Figure 4. The volumes were measured during revision by filling the upper stomach with saline at 25 to 30 cm of water pressure. GASTRIC BYPASS IN MORBID OBESITY 399 also mention that a preoperative diagnosis of reflux esophagitis was considered to be a contraindication to gastric bypass. At The University of Iowa, a combined Nissen fun- doplication and gastric bypass was used in a Weight few patients who had reflux esophagitis, but (Kg) this combination cannot be recommended. These two procedures are antithetical in that the object of gastric bypass is a small upper stomach and a small outlet whereas fundo- plication requires a large upper stomach and Jan75 Jan76 Jan77 Jan78 ample emptying. Reflux responds well to Roux-en-Y gastroenterostomy and some of FIG. 4. Weight curve demonstrating failure of the initial operation due to excessive volume. With us a 50 ml have adopted this as a standard reconstruc- volume and 12 mm diameter stoma, the desired weighttion procedure for all patients. However, this was reached. makes the operation even more complex. Our Downloaded from www.ajcn.org by guest on May 13, 2011 D 1’ FIG. 5. Variations in use after D 1974: , anterior gastroenterostomy with the stomach stapled in continuity, described by Alden; E, as D but with Roux-en-Y reconstruction; F, and gastroplasty, same as recommended by Gomez, with stomach stapled, except for a greater curvature channel that is reinforced with a seromuscular 2-0 Prolene running suture and a second 3-0 running Lembert outside first. the Two of sets of staples should be used. 400 MASON ET AL. goa! is to reduce morbidity and mortality by cause, though, is likely to be acute dilatation simplifying the operation while achieving ad-of the stomach. This is clinically somewhat equate weight control. atypical because the upper stomach is so It may be that bypass of the stomach is not small. When the lower stomach is also dis- necessary. With rigid specifications for the tended with air, this can be corroborated with upper stomach volume and for a small outlet, an abdominal radiograph because it is a clin- gastrop!asty may provide weight control, es- ical situation of difficult diagnosis by physical pecially if the passage between the upper andexamination only, in morbidly obese patients. lower parts of the stomach can be maintained A pulse rate above 120/mm is usually present at a constant small diameter. Gomez is(7) if perforation occurs, but tachycardia may following a large number of patients with theeven be caused by distention alone. Over the stomach stapled in continuity and with years a we have learned to recognize more reinforced greater curvature passage. This quickly the signs and symptoms of perfora- procedure is under evaluation at The Univer- tion and appropriate management has been sity of Iowa and appears to be promising. developed. Consequently, patients die less Alden and Jewel! (private communication) frequently when leaks do occur. The drive are stapling the stomach completely after mo- for food in these patients has not been fully bilizing the fundus and then performing a appreciated. At times they are not aware of Downloaded from www.ajcn.org by guest on May 13, 2011 sutured anastomosis between the upper and what they eat and drink; at other times, they lower stomach. Pace et a!. (8) are using deliberately a sneak food and beverage. They simple procedure of removing staples from do not a always hear what they told; are for single cartridge of the TA9O so that the high some, there is no such thing as informed staple line leaves a passage that will just consent. accommodate a nasogastric tube. Because of The danger begins when the patient leaves the experience that we and others have hadthe operating room. Swallowed air in the with staples cutting through, it would seem presence of a poorly functioning nasogastric that this procedure may be too simple; two tube can rupture the stomach. Nasogastric sets of staples are needed as well as reinforce- tubes must be positioned so that half of the ment of the passage between the upper andopenings are in the upper stomach. The pa- lower stomach. These are technical details tient should not be allowed to drink before that are being studied by a number of differ- flatus has been passed. When oral intake is ent groups. No reports of the more recent begun it should be by the use of a medicine variations of gastroplasty have appeared inglass. Patients have attempted to drink from the literature and it would be best to wait pitcher, a from thesink in the room and from until these patients have been followed for at fountains in the hall, and have, in some in- least a year in centers where this procedure is stances, ruptured the stomach by such irra- being developed before recommending its tional behavior. widespread adoption. Once a patient has resumed oral intake and has begun to comprehend the limitations and Morbidity sensations of fullness and has had a few episodes of mild pain, nausea, or vomiting The major concern with gastric bypass has from overeating, then rupture of the stomach been perforation in the upper or lower stom- ceases to be a significant risk. There are some ach, which may cause peritonitis and death. patients who learn so readily that there is We have had such perforations in 5% never of a single vomiting episode. If patients patients; this rate has increased as the oper- are discharged too soon, there could be risk ation has become standardized with a 50-rn! of rupture even after discharge from the hos- volume and a 12-mm diameter outlet. Perfo- pital. A few days of practice are needed be- rations occur approximately as often in the fore the patient goes home and the training upper as in the lower stomach and are is facilitated as by preoperative practice with a common after gastroplasty as after gastric medicine glass and intense efforts at explain- bypass. Perforations occur in the immediate ing the limitations that will be imposed. A postoperative period, some being related to limited slow intake is most important. When operative techniques; the most frequent solid food is allowed it must be well chewed. GASTRIC BYPASS IN MORBID OBESITY 401 An interim period of blended food is a useful of bile in the gallbladder because there may part of early training and improves the intake be inadequate stimulation by cholecystoki- of protein and the necessary variety of food nm. Again, further study with bile composi- that supplies all essential nutrients. tion analysis is needed. Stomal ulcer has been another risk of gas- Knecht (12) has reported hair loss 50% in tric bypass. A small volume upper stomach of patients after gastric bypass. This problem, will not contain enough parietal cells to cause which is temporary, mild and not a cosmetic a stomal ulcer. However, to date, 2.7% problem, of has also been observed after intes- patients have developed stomal ulcers at The tinal bypass. It may be related to decreased University of Iowa after gastric bypass. This protein intake or decreased vitamin A. The is symptomatic of our failure to measure vol-extreme reduction in eating ability after gas- ume and to provide each patient with an tric bypass has led some patients to quit appropriately small upper stomach. The same eating entirely. If they do not return to the specifications that will assure adequate clinic in time, vitamin deficiencies and pe- weight loss will also prevent stomal ulcers. ripheral neuropathy may develop (6, 13). The Cimetidine and antacids are effective treat- neurologic changes respond to vitamins, jnent in some patients. When they fail, whicha should be part of the early manage- revision of the upper stomach to a 50 ment ml of all patients, and the eating deficiency Downloaded from www.ajcn.org by guest on May 13, 2011 volume is indicated and usually a trunca! responds to intravenous feedings followed by vagotomy is added. If there is evidence aof slow, supervised eating reeducation similar antral overactivity from an abnormally highto that of the early postoperative period. serum gastrin level, then the excluded stom- ach should be resected. This was seldom re- Results in weight loss quired unless the original division of the stomach had been so low that approached it Weight loss at 1 year follow-up in 138 an antra! exclusion. With intraoperative mea- patients operated on after 1974 at The Uni- surement of volume, this should never occur. versity of Iowa has been 40 15.5 kg, and ± Gallstones are frequent in the morbidly after 2 years, weight loss has been 44 ± 19.4 obese. Freeman et al. (9) found kg that of 238 in 66 patients. This represents 29 and 32% patients subjected to gastric bypass, 37% hadof initial weight, and 53 and 58% of excess had cholecystectomy. Twenty-eight patients weight, for the two different periods, respec- had prior, 54 coincident, and 6 subsequent, tively. The weight loss after a Roux-en-Y cholecystectomies. In a later study, Mabee reconstruction, et with a 50-nil upper stomach a!. (10) showed that gallbladder bile in the and small stoma at 6 months, is ±31 7.6 kg, morbidly obese is super-saturated with cho- 22% of initial weight and 39% of excess lesterol because of an excessive cholesterol weight. At 1 year (15 patients) weight loss secretion. This super-saturation persists even was 45 ± 11.4 kg, 31% of initial and52% of when patients are nourished by a constant excess weight. infusion of cholesterol-free formula. Theoret- Table 2 provides a comparison between the ically, the bile should become less lithogenic earliest operations in 1966 to 1970 and the after weight reduction after gastric bypass. operations performed since 1975. Early in There should not be any loss of the bile salt 1975 there were patients whose upper stom- pool. However, during the period of weight ach volume was either not measured, or was loss there may continue to be excessive cho-above 50 ml; consequently, some of these lesterol secretion in the bile and it might patients be required revisions. Not only has the desirable to treat such patients temporarily initial operation become more effective as it with chenodeoxycholic acid during the period has been standardized, but the revisions have of weight loss (11); this approach has not also become more effective. This can be ob- been tried yet. Further studies of bile com-served by comparing percent excess weight position are needed during and after weight lost (a parameter that standardizes patients loss after gastric bypass and gastroplasty according and to height, sex and initial weight) in when receiving treatment with chenodeoxy- the different groups. cholic acid. The Roux-en-Y type of gastroen- These data, as presented in Table 2, have terostomy may also be conducive to retention also demonstrated the predictive value of ob- 402 MASON ET AL. TABLE 2 Comparison of weight loss in kg, % of initial weight, and % of excess weight for patients operated during periods 1966 through 1970 and 1975 through 197S (revision can be considered as an indication of failure of the initial operation) Wt 10 SS, kg .. No. No. % Initial No. % Excess patients patients mean patients mean Mean SD 1966-70 Revision (initial 19 (151) 37 weight kg) Loss6mos 19 23 14 19 15 18 25 1 yr 18 33 23 18 20 17 33 2yr 18 32 24 18 20 17 32 3yr 18 33 28 18 21 17 34 Syr 15 35 32 15 21 14 34 1966-70 No revision (Initial 45 (140) 33 weight kg) Loss 6 mos 42 29 16 42 20 42 37 Downloaded from www.ajcn.org by guest on May 13, 2011 1 yr 42 37 21 42 26 42 48 2yr 38 41 23 38 28 38 51 3yr 35 39 24 35 27 35 49 5 yr 29 35 21 29 25 29 48 1975 Revision (initial weight 9 (129) 18 kg) Loss 6 mos 9 25 10 9 20 9 37 lyr 9 31 14 9 24 9 44 2yr 7 36 19 7 26 7 46 1975 No revision (initial 207 (137) 25 weight kg) Loss 6 mos 160 32 12 160 23 156 42 I yr 129 40 15 129 30 125 54 - 2yr 59 45 19 59 33 58 59 servations made at 6 months and 1 year. TABLE As 3 a result, early weight changes have been Weight ex- loss in kg/month for varying lengths of follow-up tremely helpful in deciding whether to con- tinue or abandon specific variations in the 6 Weeks 6 Months I Year operative technique. For example, our deci- 1966-70 6.6 4.5 3.0 sion to give up gastroplasty in 1971 was based SD/No. patients 4.3/ 59 2.6/ 61 1.8/ 60 upon the observation that at 6 months, excess 1971 5.9 3.5 2.1 weight lost averaged only 26%. SD/No. patients 5.1/ 53 2.7/ 54 1.6/ 49 Hermreck et a!. (6) have defmed a poor result as losing less than 2.3 kg/month/year, 1972-74 7.4 4.1 2.6 or two or more major complications. WithSD/No. patients 4.1/260 2.2/253 1.4/243 this criterion, they found that 17% of their 1975-78 patients had poor results after gastric bypass Measured 50 10.3 5.1 3.7 compared with 58% after intestinal bypass. In ml pouches our series, only the 1971 gastroplasty patients SD/No. patients 4.2/ 16 1.5/ 18 1.2/ 18 as a group failed to meet Hermreck’s criteria of success; since 1975, patients with a mea- sured 50 ml or less pouch have averaged 3.7 patients lose at a much faster rate during the kg loss per month by 1 year. As can be seen early postoperative period. in Table 3, this represents a marked improve- Hornberger (2) has reported a 60.8 kg av- ment; it should be noted, of course, that erage weight loss during the first year or GASTRIC BYPASS IN MORBID OBESITY 403 43.5% of initial weight. None of his 28 re- junoi!eal bypass. Of the total at the time of ported patients lost less than 2.7 kg/month the report, 58% either had life-threatening during the 1st year. His published estimate of complications, required reanastomosis, or capacity of the upper stomach, after gastric died. The patients tended to regain their lost bypass of no more than half a cup (180 weight nil) when the intestine was reanasto- is obviously estimated from postoperative mosed. Knowing this can be a strong deter- feeding. Intake capacity is always more even rent to having intestinal continuity restored. than the intraoperatively measured volume. Hitchcock et a!. (17), the first group to Sorrel (14), in an initial experience with 39report on the simultaneous performance of patients, reported four patients whose weight gastric bypass and reanastomosis of the small loss was unsatisfactory. Objective data of bowel, had a 29% rate of reanastomosis. pouch and stoma size were not collected and Seven patients had synchronous gastric by- radiographs were published illustrating anpass. They emphasized that all patients must excessively large upper stomach in one pa-be stable metabolically before they can un- tient, and a large stoma and adjacent jejunum dergo any operation, as was also stressed by in another patient. Knecht (12) reported an (18); if the patient us is extremely debilitated, initial experience averaging a 49 kg loss (47 the gastric bypass can be postponed. patients) at 1 year, 47 kg (23 patients) at 2 Tapper et a!. (19) have had only a 6% Downloaded from www.ajcn.org by guest on May 13, 2011 years, and 40 kg loss (10 patients) followed reanastomosis rate after intestinal bypass, but for 3 years. Five patients failed to lose at least they reported four synchronous gastric by- 25% of initial weight by 1 year; here again, passesjust a year after the report of Hitchcock intraoperative measurement of volume had et a!. (17). Tapper and associates observed not been used. that this option made it easier to obtain per- Alden (3) compared his first 100 patients mission for reanastomosis of the intestine with gastric bypass to his last 100 patients because patients were not confronted with with intestinal bypass. Gastric bypass pro- the prospect of regaining weight. They rec- duced a 1-year mean weight loss of 40.2 kg ommended a 150 ml volume for the upper or 36% of initial weight, while intestinal by-stomach that is, according to our experience, pass caused a loss of 40.6 kg or 31% of initial too large. weight. Rehospitalization rate during the 1st LaFave and Alden (20) have had experi- year was 12% for gastric and 32% for intes- ence with a significant number of patients tinal bypass. who have had synchronous reanastomosis of Two randomized prospective studies of the intestine and gastric bypass. They ob- gastric and intestinal bypass have been re- served that the staples are more likely to cut ported, one by Griffen et a!. (5) and the other through the stomach and allow reestablish- y buckwalter (15). One-year average weight ment of continuity from the upper to the loss for gastric bypass was 51 kg (Griffen, 18 lower gastric segment in patients who have patients) and 43 kg (Buckwalter, 6 patients) had intestinal bypass. This is probably related and for intestinal bypass, 58 kg (Griffen, 22 protein to depletion as mentioned earlier. The patients) and 31.5 kg (Buckwalter, 6 patients); staple line should be constructed with two follow-up to these studies continues. Griffen applications of the TA9O in all patients who et al. concluded that “once the technique of have had intestinal bypass and loss of body gastric bypass is learned, it would appear protein. to be superior tojejunoileal bypass in that it has Fifty-six patients have been referred to us the same weight loss capability, fewer long- because of problems of intestinal bypass; in term sequellae and no evidence of develop- 41 of them intestinal continuity was restored. ment of significant liver disease.” Buckwalter Gastric bypass, or gastroplasty, has been per- reached the same conclusion and is also con- formed later in 9, and synchronously in 12 tinuing to use gastric bypass, or gastroplasty, patients. The gastric procedures are easier to in preference to intestinal bypass. perform while the patient is at a lower weight. Rescue from intestinal bypass Ancillary benefits of weight loss Halverson et a!. (16) recently reported a Gastric bypass causes weight loss by reduc- 23% reanastomosis rate for patients with je- ing food intake. The same benefits that would 404 MASON ET AL. fo!!ow dietary weight loss are to be expected. provided it did not stifle innovation. Justifi- Mason et al. (21) have described the improve- cation for new operations and/or modifica- ment in diabetes as well as a reduction in tions must remain in the hands of each of the blood pressure for patients who are hyperten- surgeons who assumes final responsibility for sive. Cardiorespiratory function continues to the care of individual patients. There is a improve if preoperative weight loss was re- need for national registries and for well- quired because of the obesity hypoventilation planned clinical research studies, and all sur- syndrome. Varicose ulcers heal. Musculo- geons should be encouraged to continue their skeletal symptoms improve. There is also an reviews, audits, and reports to their peers. It improvement in employability, sex life, feel-would be a mistake, however, to think that ing of well-being, and other psychosocial fac-innovations in the use of operations can be tors. regulated. Neither intestinal nor gastric bypass are The societal problem new operations. Surgeons are trained in the Candidates for bariatric surgery are nu- scientific method and apply their training to merous. A waiting list, combined with clinical each patient. Changes are made in operative priorities, have been a means of dealing withprocedures according to the analysis of a the problem of patient overload, but specific this patient’s needs, experience, and in- Downloaded from www.ajcn.org by guest on May 13, 2011 approach may be a disservice to patients tercommunication who with other surgeons. It is are at a lower priority. Nevertheless, if sur- from dealing with the needs of individual geons defer too freely to the demand for this patients that a consensus evolves. New think- kind of surgery and attempt operate to upon ing supplants older attitudes when the time is too many patients, the nursing care required ripe. There can be no more effective criticism may exceed what can be properly provided. than that of professionals meeting together to Early discharge before patients have learned seek a better solution to a problem with which to cope with a greatly diminished gastric they all must deal on a daily basis. reservoir may also contribute to the devel- opment of leaks. Surgeons need to coordinate Summary their work with the hospital administration and colleagues in an effort to plan ahead and Gastric operations for the treatment of attempt only what is realistic. An ongoing morbid obesity have been standardized. They audit can be of great assistance. Some sur- require close adherence to specifications for geons are already participating in a national success. The upper stomach volume shouh registry, located at The University of Iowa, be measured intraoperatively and fashioned and keeping in touch with each other about to a capacity of 50 ml at a pressure of 25 to new developments; such communication 30 cm of saline. is The outlet should be no vitally important. larger than 12 mm in diameter. The necessity The urgency to reduce cost and to use for bypassing the remainder of the stomach hospital beds efficiently should not lead and to duodenum has not been established. premature operations upon patients who ac- Early maintenance of gastric decompression tually need weeks or months of hospital-su- and immediate supervision and education of pervised care to control obesity-induced car-patients regarding new eating habits are cru- diopulmonary insufficiency, and to prepare cial in the prevention of gastric rupture. them for a safe operation. On the other hand, Long-term care is usually minimal, but pa- cardiopulmonary insufficiency may be an tients should be followed at least at 6 weeks, added indication for gastric surgery to main- 6 months, 1 year, and at yearly intervals tain a lower weight, if the primary problem thereafter. Increasing numbers of intestinal is obesity. bypass operations are being replaced by gas- Finally, it is necessary to address the sub-tric bypass or gastroplasty. Many surgeons ject of surgical innovation and evaluation. who once used intestinal bypass have decided An “Institute of Health Care Assessment” as use the stomach to operations instead because suggested by Bunker et a!. (22) might haveof the much less complicated long-term care facilitated evaluation of these operations, required after the gastric procedures. U GASTRIC BYPASS IN MORBID OBESITY 405 References 12. KNECHT, B. H. Experience with gastric bypass for massive obesity. Am. Surg. 44: 496, 1978. 1. MASON, E. E., AND C. ITO. Gastric bypass in obesity. 13. PRINTEN, K. J., AND E. E. MASON. Peripheral neu- Surg. Chin. N. Am. 47: 1345, 1967. ropathy following gastric bypass for the treatment of 2. HORNBERGER, H. R. Gastric bypass. Am. J. Surg. morbid obesity. Obesity/Bariatric Med. 6: 185, 1977. 131: 415, 1976. 14. SORRELL, V. F. Bypass surgery for obesity. Aust. N. 3. ALDEN, J. F. Gastric and jejunoileal bypass. Arch. Z. J. Surg. 47: 656, 1977. Surg. 112: 799, 1977. 15. BUCKWALTER, J. A. A prospective comparison of the 4. ALDER, R. L., AND B. E. TERRY. Measurement and jejunoileal and gastric bypass operations for morbid standardization of the gastric pouch in gastric by- obesity. World J. Surg. 1: 757, 1977. pass. Gynecol. Surg. Obstet. 144: 762, 1977. 16. HALVERSON, J. D., K.GENTRY, L. WISE AND W. F. 5. GRIFFEN, W. 0., V. L. YOUNG AND C. C. STEVEN- BALLINGER. Reanastomosis after jejunoileal bypass. SON. A prospective comparison of gastric and jeju- Surgery 84: 241, 1978. noileal bypass procedures for morbid obesity. Am. 17. HITCHCOCK, C. T., W. R. JEWELL, C. A. HARDIN Surg. 186: 500, 1977. AND A. S. HERMRECK. Management of the morbidly 6. HERMRECK, A. S., W. R. JEWELL AND C. A. HARDIN. obese patient after small bowel bypass failure. Sur- Gastric bypass for morbid obesity: results and com- gery 82: 356, 1977. plications. Surgery 80: 498, 1976. 18. MASON, E. E., AND K. J. PRINTEN. Metabolic consid- 7. GOMEZ, C. A. Gastroplasty in the surgical treatment erations in reconstruction of the small intestine after of morbid obesity. Am. Chin. Nutr. J. 33: 406, 1980 jejunoileal bypass. Surg. Gynecol. Obstet. 142: 177, 8. PACE, W. G., E. W. MARTIN, JR., T. TETRICH, P. J. 1976. AND L. C. CAREY. Gastric partitioning for 19. TAPPER, D., T. K. HUNT, R. C. J. Downloaded from www.ajcn.org by guest on May 13, 2011 FABRI ALLEN AND morbid obesity. Ann. Surg. 190: 392, 1979. CAMPBELL. Conversion ofjejunoileal bypass to gas- 9. FREEMAN, J. B., P. D. MEYER, K. J. PRINTEN, E. E. tric bypass to maintain weight lost. Surg. Gynecol. MASON AND L. DENBESTEN. Analysis gallbladder of Obstet. 147: 353, 1978. bile in morbid obesity. Am. J. Surg. 129: 163, 1975.20. LAFAVE, J. W., AND J. F. ALDEN. Operative revisions 10. MABEE, T. M., P. MEYER, L. DENBE5TEN AND E. E. ofjejunoileal bypass. Arch. Surg. 114: 438, 1979. MASON. The mechanism of increased gallstones for- 21. MASON, E. E., K. . PRINTEN, J T. J. BLOMMERS AND mation in obese human subjects. Surgery 79: 460, D. H. Scorr. Gastric bypass for obesity after ten 1976. years experience. Intern. J. Obesity 2: 197, 1978. 11. HOFMANN, A. F., J. L. THISTLE, P. D. KLEIN, P. A. 22. BUNKER, J. P., D. HINKLEY AND W. V. MCDERMO1-r. SZCZEPANIK AND P. Y. S. Yu. Chemotherapy for Surgical innovation and its evaluation. 200: Science gallstone dissolution. J. Am. Med.Assoc. 239: 1138, 937, 1978. 1978.
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