Symposium on Morbid Obesity
Gastric Bypass for Morbid Obesity Ward 0. Griffen, Jr., M.D., Ph.D.*
As experience with the long-term management of patients suffering from morbid obesity grows, a number of facts emerge. Morbid obesity in itself will decrease life expectancy. It is also associated with the early development of cardiopulmonary disorders, hypertension, and diabetes as well as a more accelerated course of these diseases. The nonoperative management of morbid obesity rarely leads to permanent weight reduction and, in fact, is often associated with intermittent increases and decreases in weight which may be more detrimental to health than maintaining the state of morbid obesity. While a variety of operative procedures have been recommended for the production of permanent weight loss in patients with morbid obesity, only two have withstood the test of time: the jejunoileal bypass operation, with its rationale of increasing caloric loss in the feces, and the gastric bypass procedure, with its rationale of decreasing caloric intake. This article will deal with the gastric bypass operations in distinction to the newer, and as yet incompletely tested, gastroplastic procedures. The gastric bypass operation is an exclusion procedure which was developed by Dr. Edward Mason of the University of Iowa in 1966. 9 1t produces weight loss by restricting caloric intake without interfering appreciably with the absorptive capacity of the bowel. Thus the adverse metabolic and nutritional effects of the small bowel bypass procedures are avoided. Three gastric bypass procedures will be described after which the surgical complications, metabolic complications, advantages and disadvantages of these operations will be discussed.
SELECTION OF PATIENTS The single most important criterion for consideration of an operative procedure for obesity is that the patient be morbidly obese. Morbid obesity has been variously defined by a number of authors reporting on the gastric bypass procedure, but the definitions are based on an absolute weight (50 *Professor and Chairman, Department of Surgery, University of Kentucky, Albert B. Chandler Medical Center, Lexington, Kentucky
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kg or 100 pounds over ideal body weight), or a relative definition of body weight (more than twice the ideal weight). While "ideal weight" itself has been obtained from tables provided by insurance statistics, Devine 4 has developed a formula for determining ideal weight which can be applied to all individuals and takes into account differences in weight according to sex: For females, ideal body= 45 kg+ 2.3 kg per inch over5feetin height; and for males, ideal body weight= 50 kg+ 2.3 kg per inch over 5feet. Most investigators also insist that their patients have participated in a weight control program and have shown some decrease in weight while on the program. Concomitant diseases are frequent and, of themselves, do not constitute a contraindication to the gastric bypass operation. In fact, some of these ailments, such as hypertension, diabetes, narcolepsy, and arthritis, are often improved by the weight loss resulting from the operation. Psychiatric evaluation of candidates for the operation has gone almost full circle. Since it is recognized that patients with morbid obesity suffer from some psychological problem, psychiatric screening was an essential part of the evaluation. This was felt to be particularly important for the gastric bypass operation since overeating seemed to be the mechanism whereby these individuals cope with stressful situations, and one of the assured effects of the gastric bypass operation was the inability to eat great quantities of food. However, with experience, the involvement of the psychiatrist in the screening of these patients preoperatively has dwindled. In our institution this has been a mutual decision because it has become apparent that it is not possible to predict a patient's psychological reaction to the operation even with the use of extensive psychological testing. While the operation will not reverse severe psychiatric illness, it only rarely worsens the situation.
OPERATIVE PROCEDURES The concept of the gastric bypass procedure was based on the observation that patients with peptic ulcer disease who underwent 75 to 80 per cent subtotal gastric resection often had difficulty maintaining weight. Several features are common to all the gastric bypass procedures: 1. The distal stomach is not resected, so that the operation is reversible if necessary. 2. The amount of stomach remaining in continuity with the rest of the gastrointestinal tract represents about 10 per cent of the stomach and perhaps is best measured by a standard volume determination as suggested by Alder and Terry. 2 A suggested volume of 50 dl capacity appears to be appropriate. 3. The anastomosis between the stomach and the jejunum is made no greater than 12 mm in diameter. Thus, the basic principles of the gastric bypass procedure are rapid filling and slow emptying which produce a prolonged feeling of satiety. The gastric bypass originally described by Mason and lto 9 involves a transection of the stomach so that the upper segment has a volume of approximately 60 dl. The distal cut end of the stomach is oversewn completely with Lembert sutures. The proximal cut end of the stomach is
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Figure 1. The gastric bypass originally described by Mason and Ito involved transection of the stomach. See text for details. (From Mason, E. E., and Ito, C.: Gastric bypass. Ann. Surg., 170:329, 1969, with permission.)
oversewn from the lesser curve side to within 1.2 em of the greater curve. A loop of jejunum is then brought up to this small opening through the transverse mesocolon and an end-to-side gastrojejunostomy performed. The stomach is then brought down and attached to the opening in the transverse mesocolon to prevent both internal hernia and twisting of the jejunal loop (Fig. 1). In 1977 Alden 1 described a different technique of gastric bypass in which he did not transect the stomach. Instead a complete staple line is placed across the stomach, again dividing it into a proximal segment with a volume of approximately 60 dl and a much larger distal segment. The jejunum is then brought up in antecolic fashion, and a 1.2 em side-to-side stapled anastomosis is made between the greater curvature ofthe stomach and the jejunum. This procedure avoids a transection of the stomach and its possible effect in interfering further with the blood supply at the anastomotic site, and also can be performed relatively quickly (Fig. 2). Between 1974 and 1977 we conducted a comparative study of the gastric bypass and jejunoileal bypass for morbid obesity. 5 At the beginning of that study the technique of Mason was used. However, bringing the stomach down below the transverse mesocolon seemed both difficult and hazardous. Thus, a Roux-en-Y type of reconstitution was used. In that study the majority of the patients who underwent gastric bypass had transection of the stomach as described by Mason, after which the
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Figure 2. In Alden's technique of gastric bypass, the stomach is not transected. See text for details. (From Alden, J. F.: Gastric and jejunoileal bypass. A comparison in the treatment of morbid obesity. Arch. Surg., 112:799, 1977. Copyright 1977, American Medical Association.)
jejunum was transected with a stapler 12 to 15 em beyond the ligament of Treitz. The distal cut end of the jejunum was then oversewn with interrupted 3-0 seromuscular sutures and brought through an opening in the transverse mesocolon, behind the distal stomach, and up to the cut edge of the proximal gastric pouch. This edge was then oversewn with interrupted 3-0 seromuscular sutures down to a point 1.2 em from the greater curvature and an end-to-side anastomosis then made between the stomach and the retrocolic jejunal limb. The limb was then tacked circumferentially to the opening in the mesocolon and an end-to-side jejunojejunostomy was constructed 35 em distal to the gastrojejunostomy (Fig. 3). More recently, this author has not transected the stomach but has simply placed a complete staple line across it similar to Alden's technique, but continues to use the Roux-en-Y anastomosis, making a side-to-side gastrojejunostomy on the greater curvature side of the stomach 2 em distal to the gastroesophageal junction.
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Figure 3. See text for details. (From Griffen, W. 0., Jr., Young, V. L., and Stevenson, C. C.: A prospective comparison of gastric and jejunoileal bypass procedures for morbid obesity. Ann. Surg., 186:500, 1977, with permission.)
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REPORTED RESULTS At a recent workshop, a total of 1585 patients were reported as having undergone gastric bypass. 3 • 6 • 7' 8 • 1 L 12 The weight loss following the gastric bypass procedures has been quite satisfactory in the majority of cases and in the two comparative studies, 3• 5 as good as the weight loss seen after jejunoileal bypass. Dr. Mason's original paper described satisfactory weight loss in 75 per cent of the patients, with a less than satisfactory weight loss in 25 per cent. In the total number of patients now reported to have undergone gastric bypass for morbid obesity, inadequate weight loss at the outset occurs in approximately 8 per cent. It is possible to overeat the pouch if the individual consumes foods of low volume and high caloric content. There are two types of patients with morbid obesity, the "snackers" and the "gorgers." The former group are more likely to be able to overeat the pouch than the latter. In general, the individuals who gorge themselves simply change their eating habits following the gastric bypass operation and do quite satisfactorily. On the other hand, unless the "snackers" watch their intake carefully, their weight reduction can be unsatisfactory. The average weight reduction reported in the total population of these series is 4 7.6 kg in one year. In no instance has excessive weight loss to a point below ideal body weight been reported following gastric bypass. The postoperative mortality in the 1585 patients is 1.6 per cent. Early complications include anastomotic leak, pulmonary embolism, wound infections, urinary tract infections, and other less common difficulties. The overall early complication rate is 22 per cent. Late complications include failure to lose weight satisfactorily (8 per cent), ventral hemia, persistent vomiting, hair loss, marginal ulcer, and other less common cited problems. The overall late complication rate is 1 7 per cent. Patient satisfaction is high, with 90 per cent of the patients showing no untoward effects or only minor problems such as occasional vomiting when they overeat. In patients followed for more than five years, late weight gain has occurred in less than 5 per cent. The psychological response to the operation, and its capability of producing a permanent weight reduction, has been positive in the majority of patients.
COMMENTS Certain features of the gastric bypass operation deserve special attention. First, almost all surgeons who have performed the gastric bypass operation for morbid obesity have found that there is a definite leaming curve in the procedure. The first patient in our own series lost less than 10 per cent of his body weight in the first six months following the operation. The meal capacity reported by this patient within three months of the operation clearly indicated that the remaining pouch was entirely too large. The pouch must be small, and while recommendations now are that the pouch be measured at a volume of 60 dl, the tendency is to make the pouch smaller than that because of the occasional patient who does not lose a sufficient amount of weight.
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The size of the anastomosis between the stomach and jejunum is also critical. Whether a loop jejunostomy or a Roux-en-Y reconstitution is used, a large anastomosis provides the pouch with an easy and sizable outflow, which permits the individual to consume more calories and thus lose an insufficient amount of weight. Thus, the entire concept of the gastric bypass operation is to provide a receptacle for food which is quite small and empties slowly. When these two features are properly met, the patients often comment on the fact that they feel full early after a meal and that the satiety lasts for a considerable period of time. Late weight gain has not been a particularly noticeable problem. Although during the first postoperative year, the patients do find that they can eat a greater quantity of food, they still become uncomfortable if they eat too much or too rapidly. Therefore, they continue to lose weight throughout the year, although at a slower rate than in the immediate postoperative period. Almost invariably, the 5 per cent ofthe patients who put on a considerable amount of weight after losing satisfactorily are those who have stretched a pouch, which was probably too large initially, and those who tend to snack rather than eat three meals a day. Inadequate weight loss, or regaining a large amount of weight, can be treated by revision of the gastric pouch, revision of the gastrojejunostomy, or both. This has produced good results as a secondary procedure and is preferred by the author to the addition of a jejunoileal bypass following a gastric bypass operation. Mini-dose heparin as a means oflessening deep vein thrombosis and preventing a postoperative pulmonary embolus seems to be a matter of the surgeon's choice. Printen 11 has indicated that these patients are at no greater risk to thromboembolic disease than the normal population, but many surgeons continue to use mini-dose heparin without experiencing any untoward effect in the intraoperative or postoperative period. It is also feasible to perform other procedures during the gastric bypass operation and such operations as cholecystectomy, tubal ligation, ventral and umbilical hernia repair, ovarian cystectomy, and even inferior vena caval interruption have been reported as accompanying procedures. There is no question that an anastomotic leak is the most serious complication of the gastric bypass procedure, the incidence being reported to be 4.4 per cent. It is the complication which is most likely to lead to a postoperative death, and that usually because of a delay in making the diagnosis. A temperature elevation of greater than 30.8° C (102° F) and, more importantly, a pulse rate of greater than 130 beats per minute in the early postoperative period, should make one suspicious of an anastomotic leak. It is then necessary to obtain a Gastrografin swallow in order to confirm such a leak and to proceed to the operating room for correction of the situation. Generally, the procedure needed for correction is identification of the leak and closure, adequate drainage of the left subphrenic space, and provision of a means of enteral nutrition for future use. There are several advantages of the Roux-en-Y anastomosis in patients in whom an anastomotic leak develops following gastric bypass. First, the material which goes into the left subphrenic space rarely contains bile or pancreatic juice, nor does a continuing leak contain such material. As far as can be ascertained, a leak occurring in a patient who
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has had a Roux-en-Y anastomosis has not resulted in a postoperative death; whereas leaks occurring following a loop gastrojejunostomy have. Second, the provision of a pathway for enteral nutrition following the closure of the leak can be accomplished simply by placing a standard gastrostomy into the distal bypassed stomach. Once peristalsis begins, feeding through the gastrostomy can be done and the need for a central venous line and its attendant complications can be avoided. In several long-term follow-up studies the incidence of nephrolithiasis following gastric bypass has been considerably less than that seen with jejunoileal bypass. While the mechanism of oxaluria and stone formation in patients with ileal dysfunction is not completely understood, it is apparent that high dietary oxalate and dietary fat malabsorption will increase urinary oxalate excretion considerably. Since ileal dysfunction is not seen in patients with gastric bypass, oxalate stone formation should be lower in patients following the gastric procedure. An additional factor may be one of dehydration which is not commonly recognized in gastric bypass patients, as compared to jejunoileal bypass patients. Thus, the incidence of stone formation following gastric bypass is of the magnitude of 1 per cent as compared to about 10 per cent in the jejunoileal group. An interesting feature of the nephrolithiasis seen after gastric bypass procedures is the high incidence of uric acid stones in these patients. There have been no reported instances of liver disease following gastric bypass operations. In the prospective study previously mentioned, serial liver biopsies were performed on patients undergoing gastric bypass. Almost invariably the liver biopsies done at the time of the bypass procedure showed fatty infiltration and occasionally some periportal inflammatory reaction. Percutaneous liver biopsies done one year following the procedure showed improvement in the histologic picture ofthe liver in 75 per cent of the cases and no change in the remainder. There were no instances in which the histologic pattern had worsened after the operation. In a few instances, the liver biopsy done one year postoperatively was actually interpreted by the pathologist, who knew nothing about the clinical history, as being a normal liver. This finding is undoubtedly related to the fact that the gastric bypass procedure is one which simply reduces caloric intake without interfering with absorptive processes. The psychological response to the operation has been quite gratifying. At first consideration of the operation, psychiatrists were concerned about the removal of the patient's coping mechanism and what effect it might have on patients who are psychologically impaired. Moreover, some surgeons contend that patients undergoing gastric bypass procedures are "food gorgers" and that patients have complained bitterly in the postoperative period about being unable to ingest a large quantity offood. 13 In the reports-on gastric bypass, as well as my own personal experience, that has been a minor difficulty. Once the patients have learned the proper method of eating, they fill the gastric pouch quickly, with a resultant feeling of satiety that only disappears slowly as the pouch empties. In fact, many patients expressed their great pleasure at being able to detect a weight loss on a weekly basis. In other words, for those patients who have consented to undergo the drastic step of having an operation to control their weight, loss of weight has become the primary motivating force in
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their lives. Thus it is not surprising that the psychological response to the operation is good, although it should be emphasized again that the operation is not designed to treat the psychological impairment of the individual. Several contraindications to the gastric bypass procedure have been suggested in the literature. Obviously, the patient must be a good operative risk in order to undergo such a major procedure. While Printen et al. 10 have published results on the gastric bypass procedure in patients over the age of 50 and indicated that this group does not respond as well as younger patients, age per se is not a contraindication to a gastric bypass procedure. Many older patients operated upon are suffering from severe disabling arthritis and some are even confined to a wheelchair because of an arthritic condition. Such patients do well even though their weight loss may not be as good as that seen with younger individuals. Eliminating the necessity for the weight-bearing joints to carry an additional 20 to 30 kg can remarkably ameliorate these symptoms. Duodenal ulcer disease and hiatal hernia have both been considered to be contraindications to the gastric bypass procedure. 7 Active ulcer disease probably is a contraindication, but patients who give a history of having had a duodenal ulcer in the past have undergone gastric bypass surgery without recognizable difficulty. While some authors have advocated performing a vagotomy and pyloroplasty in these patients at the time of gastric bypass surgery, others have simply performed the gastric bypass without vagotomy and have not reported any untoward effects. Marginal ulcer disease, which was commented upon when Mason presented the first report of gastric bypass, has not proved to be a serious postoperative problem, even in those patients undergoing a Roux-en-Y anastomosis. This is probably because the gastric pouch contains few parietal cells and cannot produce much hydrochloric acid. Hiatal hernia with reflux esophagitis is not a contraindication if a Roux-en-Y anastomosis is used. A loop gastrojejunostomy so close to the gastroesophageal junction may result in bile esophagitis if a hiatal hernia is present. However, the Roux-en-Y anastomosis eliminates bile reflux into the gastric pouch and has been done without any anti-reflux procedure in symptomatic patients with amelioration of the reflux esophagitis in all but a few patients and the disappearance of demonstrable esophagitis by endoscopy in all patients. The gastric bypass operation is an excellent procedure for a patient who has had a jejunoileal bypass and requires a takedown of the small bowel bypass because of untoward metabolic effects. It is well recognized that ifthejejunoileal bypass is simply taken down and the patient's small bowel reconstituted, weight gain is inevitable and the patient will once again become morbidly obese. Therefore, it is necessary to provide these individuals with a means of maintaining weight reduction. Addition of more small bowel into the nutrient stream has not proved successful. On the other hand, Taper et al. 14 have reported excellent results in four patients with conversion to gastric bypass, and this author has now had experience with 20 patients with most satisfactory results. The conversion of the jejunoileal bypass to a Roux-en-Y gastric bypass is an operation that can be accomplished in two hours and has been done with no
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mortality and minimal morbidity. Patient satisfaction with the conversion operation has been high.
SUMMARY The gastric bypass operation is designed to decrease the size of the food receptacle so that a limited number of calories can be ingested. All food ingested is absorbed normally, thus eliminating problems that may be associated with metabolic derangements. Although it is possible to overeat the gastric pouch, the overall result of gastric bypass, in terms of weight loss, is quite satisfactory, and the mortality rate ofless than 2 per cent and the morbidity rate of less than 20 per cent are also acceptable. Late complications following gastric bypass are low: specifically, nephrolithiasis is eight to 10 times less frequent than after jejunoileal bypass. Liver disease has not been seen following gastric bypass.
REFERENCES 1. Alden, J. F.: Gastric and jejunoileal bypass. A comparison in the treatment of morbid obesity. Arch. Surg., 112:799, 1977. 2. Alder, R. L., and Terry, B. E.: Measurement and standardization of the gastric pouch in gastric bypass. Surg. Gynecol. Obstet., 144:762, 1977. 3. Buckwalter, J. A.: A prospective comparison of the jejunoileal and gastric bypass operations for morbid obesity. World J. Surg., 1:757, 1977. 4. Devine, B. J.: Gentamicine therapy. Drug Intell. Clin. Pharm. 8:650, 1974. 5. Griffen, W. 0., Jr., Young, V. L., and Stevenson, C. C.: A prospective comparison of gastric and jejunoileal bypass procedures for morbid obesity. Ann. Surg., 186:500, 1977. 6. Griffen, W. 0., Jr.: Personal data. 7. Hermreck, A. S., Jewell, W. R., and Hardin, C. A.: Gastric bypass for morbid obesity: Results and complications. Surgery, 80:498, 1976. 8. Knecht, B. H.: Experience with gastric bypass for massive obesity. Am. Surgeon, 44:496, 1978. 9. Mason, E. E., and Ito, C.: Gastric bypass. Ann. Surg., 170:329, 1969. 10. Printen, K. J., and Mason, E. E.: Gastric bypass for morbid obesity in patients more than fifty years of age. Surg. Gynecol. Obstet., 144:192, 1977. 11. Printen, K. J., Miller, E. V., Mason, E. E., et al.: Venous thromboembolism in the morbidly obese. Surg. Gynecol. Obstet., 147:63, 1978. 12. Seay, J. E., III: Personal communication. 13. Stephenson, S. E., Jr.: Clinical trial of surgery for morbid obesity. Editorial comment. South. Med. J., 71:1370, 1978. 14. Tapper, D., Hunt, T. K., Allen, R. C., et al.: Conversion of jejunoileal bypass to gastric bypass to maintain weight loss. Surg. Gynecol. Obstet., 147:353, 1978. Department of Surgery Albert B. Chandler Medical Center Lexington, Kentucky 40536
Gastric Bypass for Morbid Obesity Ward 0. Griffen, Jr., M.D., Ph.D.*
As experience with the long-term management of patients suffering from morbid obesity grows, a number of facts emerge. Morbid obesity in itself will decrease life expectancy. It is also associated with the early development of cardiopulmonary disorders, hypertension, and diabetes as well as a more accelerated course of these diseases. The nonoperative management of morbid obesity rarely leads to permanent weight reduction and, in fact, is often associated with intermittent increases and decreases in weight which may be more detrimental to health than maintaining the state of morbid obesity. While a variety of operative procedures have been recommended for the production of permanent weight loss in patients with morbid obesity, only two have withstood the test of time: the jejunoileal bypass operation, with its rationale of increasing caloric loss in the feces, and the gastric bypass procedure, with its rationale of decreasing caloric intake. This article will deal with the gastric bypass operations in distinction to the newer, and as yet incompletely tested, gastroplastic procedures. The gastric bypass operation is an exclusion procedure which was developed by Dr. Edward Mason of the University of Iowa in 1966. 9 1t produces weight loss by restricting caloric intake without interfering appreciably with the absorptive capacity of the bowel. Thus the adverse metabolic and nutritional effects of the small bowel bypass procedures are avoided. Three gastric bypass procedures will be described after which the surgical complications, metabolic complications, advantages and disadvantages of these operations will be discussed.
SELECTION OF PATIENTS The single most important criterion for consideration of an operative procedure for obesity is that the patient be morbidly obese. Morbid obesity has been variously defined by a number of authors reporting on the gastric bypass procedure, but the definitions are based on an absolute weight (50 *Professor and Chairman, Department of Surgery, University of Kentucky, Albert B. Chandler Medical Center, Lexington, Kentucky
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kg or 100 pounds over ideal body weight), or a relative definition of body weight (more than twice the ideal weight). While "ideal weight" itself has been obtained from tables provided by insurance statistics, Devine 4 has developed a formula for determining ideal weight which can be applied to all individuals and takes into account differences in weight according to sex: For females, ideal body= 45 kg+ 2.3 kg per inch over5feetin height; and for males, ideal body weight= 50 kg+ 2.3 kg per inch over 5feet. Most investigators also insist that their patients have participated in a weight control program and have shown some decrease in weight while on the program. Concomitant diseases are frequent and, of themselves, do not constitute a contraindication to the gastric bypass operation. In fact, some of these ailments, such as hypertension, diabetes, narcolepsy, and arthritis, are often improved by the weight loss resulting from the operation. Psychiatric evaluation of candidates for the operation has gone almost full circle. Since it is recognized that patients with morbid obesity suffer from some psychological problem, psychiatric screening was an essential part of the evaluation. This was felt to be particularly important for the gastric bypass operation since overeating seemed to be the mechanism whereby these individuals cope with stressful situations, and one of the assured effects of the gastric bypass operation was the inability to eat great quantities of food. However, with experience, the involvement of the psychiatrist in the screening of these patients preoperatively has dwindled. In our institution this has been a mutual decision because it has become apparent that it is not possible to predict a patient's psychological reaction to the operation even with the use of extensive psychological testing. While the operation will not reverse severe psychiatric illness, it only rarely worsens the situation.
OPERATIVE PROCEDURES The concept of the gastric bypass procedure was based on the observation that patients with peptic ulcer disease who underwent 75 to 80 per cent subtotal gastric resection often had difficulty maintaining weight. Several features are common to all the gastric bypass procedures: 1. The distal stomach is not resected, so that the operation is reversible if necessary. 2. The amount of stomach remaining in continuity with the rest of the gastrointestinal tract represents about 10 per cent of the stomach and perhaps is best measured by a standard volume determination as suggested by Alder and Terry. 2 A suggested volume of 50 dl capacity appears to be appropriate. 3. The anastomosis between the stomach and the jejunum is made no greater than 12 mm in diameter. Thus, the basic principles of the gastric bypass procedure are rapid filling and slow emptying which produce a prolonged feeling of satiety. The gastric bypass originally described by Mason and lto 9 involves a transection of the stomach so that the upper segment has a volume of approximately 60 dl. The distal cut end of the stomach is oversewn completely with Lembert sutures. The proximal cut end of the stomach is
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Figure 1. The gastric bypass originally described by Mason and Ito involved transection of the stomach. See text for details. (From Mason, E. E., and Ito, C.: Gastric bypass. Ann. Surg., 170:329, 1969, with permission.)
oversewn from the lesser curve side to within 1.2 em of the greater curve. A loop of jejunum is then brought up to this small opening through the transverse mesocolon and an end-to-side gastrojejunostomy performed. The stomach is then brought down and attached to the opening in the transverse mesocolon to prevent both internal hernia and twisting of the jejunal loop (Fig. 1). In 1977 Alden 1 described a different technique of gastric bypass in which he did not transect the stomach. Instead a complete staple line is placed across the stomach, again dividing it into a proximal segment with a volume of approximately 60 dl and a much larger distal segment. The jejunum is then brought up in antecolic fashion, and a 1.2 em side-to-side stapled anastomosis is made between the greater curvature ofthe stomach and the jejunum. This procedure avoids a transection of the stomach and its possible effect in interfering further with the blood supply at the anastomotic site, and also can be performed relatively quickly (Fig. 2). Between 1974 and 1977 we conducted a comparative study of the gastric bypass and jejunoileal bypass for morbid obesity. 5 At the beginning of that study the technique of Mason was used. However, bringing the stomach down below the transverse mesocolon seemed both difficult and hazardous. Thus, a Roux-en-Y type of reconstitution was used. In that study the majority of the patients who underwent gastric bypass had transection of the stomach as described by Mason, after which the
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Figure 2. In Alden's technique of gastric bypass, the stomach is not transected. See text for details. (From Alden, J. F.: Gastric and jejunoileal bypass. A comparison in the treatment of morbid obesity. Arch. Surg., 112:799, 1977. Copyright 1977, American Medical Association.)
jejunum was transected with a stapler 12 to 15 em beyond the ligament of Treitz. The distal cut end of the jejunum was then oversewn with interrupted 3-0 seromuscular sutures and brought through an opening in the transverse mesocolon, behind the distal stomach, and up to the cut edge of the proximal gastric pouch. This edge was then oversewn with interrupted 3-0 seromuscular sutures down to a point 1.2 em from the greater curvature and an end-to-side anastomosis then made between the stomach and the retrocolic jejunal limb. The limb was then tacked circumferentially to the opening in the mesocolon and an end-to-side jejunojejunostomy was constructed 35 em distal to the gastrojejunostomy (Fig. 3). More recently, this author has not transected the stomach but has simply placed a complete staple line across it similar to Alden's technique, but continues to use the Roux-en-Y anastomosis, making a side-to-side gastrojejunostomy on the greater curvature side of the stomach 2 em distal to the gastroesophageal junction.
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Figure 3. See text for details. (From Griffen, W. 0., Jr., Young, V. L., and Stevenson, C. C.: A prospective comparison of gastric and jejunoileal bypass procedures for morbid obesity. Ann. Surg., 186:500, 1977, with permission.)
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REPORTED RESULTS At a recent workshop, a total of 1585 patients were reported as having undergone gastric bypass. 3 • 6 • 7' 8 • 1 L 12 The weight loss following the gastric bypass procedures has been quite satisfactory in the majority of cases and in the two comparative studies, 3• 5 as good as the weight loss seen after jejunoileal bypass. Dr. Mason's original paper described satisfactory weight loss in 75 per cent of the patients, with a less than satisfactory weight loss in 25 per cent. In the total number of patients now reported to have undergone gastric bypass for morbid obesity, inadequate weight loss at the outset occurs in approximately 8 per cent. It is possible to overeat the pouch if the individual consumes foods of low volume and high caloric content. There are two types of patients with morbid obesity, the "snackers" and the "gorgers." The former group are more likely to be able to overeat the pouch than the latter. In general, the individuals who gorge themselves simply change their eating habits following the gastric bypass operation and do quite satisfactorily. On the other hand, unless the "snackers" watch their intake carefully, their weight reduction can be unsatisfactory. The average weight reduction reported in the total population of these series is 4 7.6 kg in one year. In no instance has excessive weight loss to a point below ideal body weight been reported following gastric bypass. The postoperative mortality in the 1585 patients is 1.6 per cent. Early complications include anastomotic leak, pulmonary embolism, wound infections, urinary tract infections, and other less common difficulties. The overall early complication rate is 22 per cent. Late complications include failure to lose weight satisfactorily (8 per cent), ventral hemia, persistent vomiting, hair loss, marginal ulcer, and other less common cited problems. The overall late complication rate is 1 7 per cent. Patient satisfaction is high, with 90 per cent of the patients showing no untoward effects or only minor problems such as occasional vomiting when they overeat. In patients followed for more than five years, late weight gain has occurred in less than 5 per cent. The psychological response to the operation, and its capability of producing a permanent weight reduction, has been positive in the majority of patients.
COMMENTS Certain features of the gastric bypass operation deserve special attention. First, almost all surgeons who have performed the gastric bypass operation for morbid obesity have found that there is a definite leaming curve in the procedure. The first patient in our own series lost less than 10 per cent of his body weight in the first six months following the operation. The meal capacity reported by this patient within three months of the operation clearly indicated that the remaining pouch was entirely too large. The pouch must be small, and while recommendations now are that the pouch be measured at a volume of 60 dl, the tendency is to make the pouch smaller than that because of the occasional patient who does not lose a sufficient amount of weight.
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The size of the anastomosis between the stomach and jejunum is also critical. Whether a loop jejunostomy or a Roux-en-Y reconstitution is used, a large anastomosis provides the pouch with an easy and sizable outflow, which permits the individual to consume more calories and thus lose an insufficient amount of weight. Thus, the entire concept of the gastric bypass operation is to provide a receptacle for food which is quite small and empties slowly. When these two features are properly met, the patients often comment on the fact that they feel full early after a meal and that the satiety lasts for a considerable period of time. Late weight gain has not been a particularly noticeable problem. Although during the first postoperative year, the patients do find that they can eat a greater quantity of food, they still become uncomfortable if they eat too much or too rapidly. Therefore, they continue to lose weight throughout the year, although at a slower rate than in the immediate postoperative period. Almost invariably, the 5 per cent ofthe patients who put on a considerable amount of weight after losing satisfactorily are those who have stretched a pouch, which was probably too large initially, and those who tend to snack rather than eat three meals a day. Inadequate weight loss, or regaining a large amount of weight, can be treated by revision of the gastric pouch, revision of the gastrojejunostomy, or both. This has produced good results as a secondary procedure and is preferred by the author to the addition of a jejunoileal bypass following a gastric bypass operation. Mini-dose heparin as a means oflessening deep vein thrombosis and preventing a postoperative pulmonary embolus seems to be a matter of the surgeon's choice. Printen 11 has indicated that these patients are at no greater risk to thromboembolic disease than the normal population, but many surgeons continue to use mini-dose heparin without experiencing any untoward effect in the intraoperative or postoperative period. It is also feasible to perform other procedures during the gastric bypass operation and such operations as cholecystectomy, tubal ligation, ventral and umbilical hernia repair, ovarian cystectomy, and even inferior vena caval interruption have been reported as accompanying procedures. There is no question that an anastomotic leak is the most serious complication of the gastric bypass procedure, the incidence being reported to be 4.4 per cent. It is the complication which is most likely to lead to a postoperative death, and that usually because of a delay in making the diagnosis. A temperature elevation of greater than 30.8° C (102° F) and, more importantly, a pulse rate of greater than 130 beats per minute in the early postoperative period, should make one suspicious of an anastomotic leak. It is then necessary to obtain a Gastrografin swallow in order to confirm such a leak and to proceed to the operating room for correction of the situation. Generally, the procedure needed for correction is identification of the leak and closure, adequate drainage of the left subphrenic space, and provision of a means of enteral nutrition for future use. There are several advantages of the Roux-en-Y anastomosis in patients in whom an anastomotic leak develops following gastric bypass. First, the material which goes into the left subphrenic space rarely contains bile or pancreatic juice, nor does a continuing leak contain such material. As far as can be ascertained, a leak occurring in a patient who
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has had a Roux-en-Y anastomosis has not resulted in a postoperative death; whereas leaks occurring following a loop gastrojejunostomy have. Second, the provision of a pathway for enteral nutrition following the closure of the leak can be accomplished simply by placing a standard gastrostomy into the distal bypassed stomach. Once peristalsis begins, feeding through the gastrostomy can be done and the need for a central venous line and its attendant complications can be avoided. In several long-term follow-up studies the incidence of nephrolithiasis following gastric bypass has been considerably less than that seen with jejunoileal bypass. While the mechanism of oxaluria and stone formation in patients with ileal dysfunction is not completely understood, it is apparent that high dietary oxalate and dietary fat malabsorption will increase urinary oxalate excretion considerably. Since ileal dysfunction is not seen in patients with gastric bypass, oxalate stone formation should be lower in patients following the gastric procedure. An additional factor may be one of dehydration which is not commonly recognized in gastric bypass patients, as compared to jejunoileal bypass patients. Thus, the incidence of stone formation following gastric bypass is of the magnitude of 1 per cent as compared to about 10 per cent in the jejunoileal group. An interesting feature of the nephrolithiasis seen after gastric bypass procedures is the high incidence of uric acid stones in these patients. There have been no reported instances of liver disease following gastric bypass operations. In the prospective study previously mentioned, serial liver biopsies were performed on patients undergoing gastric bypass. Almost invariably the liver biopsies done at the time of the bypass procedure showed fatty infiltration and occasionally some periportal inflammatory reaction. Percutaneous liver biopsies done one year following the procedure showed improvement in the histologic picture ofthe liver in 75 per cent of the cases and no change in the remainder. There were no instances in which the histologic pattern had worsened after the operation. In a few instances, the liver biopsy done one year postoperatively was actually interpreted by the pathologist, who knew nothing about the clinical history, as being a normal liver. This finding is undoubtedly related to the fact that the gastric bypass procedure is one which simply reduces caloric intake without interfering with absorptive processes. The psychological response to the operation has been quite gratifying. At first consideration of the operation, psychiatrists were concerned about the removal of the patient's coping mechanism and what effect it might have on patients who are psychologically impaired. Moreover, some surgeons contend that patients undergoing gastric bypass procedures are "food gorgers" and that patients have complained bitterly in the postoperative period about being unable to ingest a large quantity offood. 13 In the reports-on gastric bypass, as well as my own personal experience, that has been a minor difficulty. Once the patients have learned the proper method of eating, they fill the gastric pouch quickly, with a resultant feeling of satiety that only disappears slowly as the pouch empties. In fact, many patients expressed their great pleasure at being able to detect a weight loss on a weekly basis. In other words, for those patients who have consented to undergo the drastic step of having an operation to control their weight, loss of weight has become the primary motivating force in
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their lives. Thus it is not surprising that the psychological response to the operation is good, although it should be emphasized again that the operation is not designed to treat the psychological impairment of the individual. Several contraindications to the gastric bypass procedure have been suggested in the literature. Obviously, the patient must be a good operative risk in order to undergo such a major procedure. While Printen et al. 10 have published results on the gastric bypass procedure in patients over the age of 50 and indicated that this group does not respond as well as younger patients, age per se is not a contraindication to a gastric bypass procedure. Many older patients operated upon are suffering from severe disabling arthritis and some are even confined to a wheelchair because of an arthritic condition. Such patients do well even though their weight loss may not be as good as that seen with younger individuals. Eliminating the necessity for the weight-bearing joints to carry an additional 20 to 30 kg can remarkably ameliorate these symptoms. Duodenal ulcer disease and hiatal hernia have both been considered to be contraindications to the gastric bypass procedure. 7 Active ulcer disease probably is a contraindication, but patients who give a history of having had a duodenal ulcer in the past have undergone gastric bypass surgery without recognizable difficulty. While some authors have advocated performing a vagotomy and pyloroplasty in these patients at the time of gastric bypass surgery, others have simply performed the gastric bypass without vagotomy and have not reported any untoward effects. Marginal ulcer disease, which was commented upon when Mason presented the first report of gastric bypass, has not proved to be a serious postoperative problem, even in those patients undergoing a Roux-en-Y anastomosis. This is probably because the gastric pouch contains few parietal cells and cannot produce much hydrochloric acid. Hiatal hernia with reflux esophagitis is not a contraindication if a Roux-en-Y anastomosis is used. A loop gastrojejunostomy so close to the gastroesophageal junction may result in bile esophagitis if a hiatal hernia is present. However, the Roux-en-Y anastomosis eliminates bile reflux into the gastric pouch and has been done without any anti-reflux procedure in symptomatic patients with amelioration of the reflux esophagitis in all but a few patients and the disappearance of demonstrable esophagitis by endoscopy in all patients. The gastric bypass operation is an excellent procedure for a patient who has had a jejunoileal bypass and requires a takedown of the small bowel bypass because of untoward metabolic effects. It is well recognized that ifthejejunoileal bypass is simply taken down and the patient's small bowel reconstituted, weight gain is inevitable and the patient will once again become morbidly obese. Therefore, it is necessary to provide these individuals with a means of maintaining weight reduction. Addition of more small bowel into the nutrient stream has not proved successful. On the other hand, Taper et al. 14 have reported excellent results in four patients with conversion to gastric bypass, and this author has now had experience with 20 patients with most satisfactory results. The conversion of the jejunoileal bypass to a Roux-en-Y gastric bypass is an operation that can be accomplished in two hours and has been done with no
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mortality and minimal morbidity. Patient satisfaction with the conversion operation has been high.
SUMMARY The gastric bypass operation is designed to decrease the size of the food receptacle so that a limited number of calories can be ingested. All food ingested is absorbed normally, thus eliminating problems that may be associated with metabolic derangements. Although it is possible to overeat the gastric pouch, the overall result of gastric bypass, in terms of weight loss, is quite satisfactory, and the mortality rate ofless than 2 per cent and the morbidity rate of less than 20 per cent are also acceptable. Late complications following gastric bypass are low: specifically, nephrolithiasis is eight to 10 times less frequent than after jejunoileal bypass. Liver disease has not been seen following gastric bypass.
REFERENCES 1. Alden, J. F.: Gastric and jejunoileal bypass. A comparison in the treatment of morbid obesity. Arch. Surg., 112:799, 1977. 2. Alder, R. L., and Terry, B. E.: Measurement and standardization of the gastric pouch in gastric bypass. Surg. Gynecol. Obstet., 144:762, 1977. 3. Buckwalter, J. A.: A prospective comparison of the jejunoileal and gastric bypass operations for morbid obesity. World J. Surg., 1:757, 1977. 4. Devine, B. J.: Gentamicine therapy. Drug Intell. Clin. Pharm. 8:650, 1974. 5. Griffen, W. 0., Jr., Young, V. L., and Stevenson, C. C.: A prospective comparison of gastric and jejunoileal bypass procedures for morbid obesity. Ann. Surg., 186:500, 1977. 6. Griffen, W. 0., Jr.: Personal data. 7. Hermreck, A. S., Jewell, W. R., and Hardin, C. A.: Gastric bypass for morbid obesity: Results and complications. Surgery, 80:498, 1976. 8. Knecht, B. H.: Experience with gastric bypass for massive obesity. Am. Surgeon, 44:496, 1978. 9. Mason, E. E., and Ito, C.: Gastric bypass. Ann. Surg., 170:329, 1969. 10. Printen, K. J., and Mason, E. E.: Gastric bypass for morbid obesity in patients more than fifty years of age. Surg. Gynecol. Obstet., 144:192, 1977. 11. Printen, K. J., Miller, E. V., Mason, E. E., et al.: Venous thromboembolism in the morbidly obese. Surg. Gynecol. Obstet., 147:63, 1978. 12. Seay, J. E., III: Personal communication. 13. Stephenson, S. E., Jr.: Clinical trial of surgery for morbid obesity. Editorial comment. South. Med. J., 71:1370, 1978. 14. Tapper, D., Hunt, T. K., Allen, R. C., et al.: Conversion of jejunoileal bypass to gastric bypass to maintain weight loss. Surg. Gynecol. Obstet., 147:353, 1978. Department of Surgery Albert B. Chandler Medical Center Lexington, Kentucky 40536
