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Gastric bypass in morbid obesity1

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Gastric bypass in morbid obesity1 Powered By Docstoc
					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




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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




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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




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                                                                                                    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




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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




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                             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




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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




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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




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        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%




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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-




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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

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                                                                                                                 massive       obesity. Am.     Surg. 44: 496, 1978.
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     morbid       obesity.         Ann.       Surg.       190: 392,          1979.                        CAMPBELL.            Conversion            ofjejunoileal             bypass         to gas-
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     MASON        AND L. DENBESTEN.                    Analysis           gallbladder
                                                                         of                              Obstet.          147: 353,        1978.
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