Letters to the Editor
May 11, 1989 Dear Editor: I was very interested to see the article on the physiologic approaches to the control of obesity by Powers and Pappas in the March 1989 issue of Annals of Surgery. However I was very distressed to see the description of the gastric bypass given in the article from a paper that was 20 years old. The procedure as done now, is quite different from that which is described in the paper, and a review article on the subject should have reflected the more current procedure. At the present time, the stomach is no longer divided but is stapled instead. Furthermore the gastrojejunal anastomosis is much more narrow than that described by Drs. Powers and Pappas, usually in the range of 1 cm or less. In the article there is an accurate description of the vertical banded gastroplasty, but no mention of the complications. While complications are listed in the paragraph above on gastric bypass, this is not comparably mentioned in association with gastroplasty. This is quite inaccurate and complications for the latter operation are also relatively common, and are actually somewhat similar to those of the gastric bypass. I believe that omitting any mention of complications may imply that there are none. I think that this is an oversight. Furthermore, in terms of results in the several randomized studies between these two procedures, it appears that the gastric bypass is more effective in terms of weight loss. I think that in reviewing the subject as the authors did, it might have been appropriate to report these findings with accuracy. At any rate I do feel that the inaccurate description of current gastric bypass procedure is a major failing in this article. If this article had been published in a basic science or medical journal rather than a surgical one, and by physiologists or internists rather than by surgeons, one could possibly excuse this with the rationalization that the authors were unfamiliar with the literature and, considering the audience of the journal, it may not matter. However, when this article is published as the lead article of the most prestigious surgical journal, it is very distressing. It also makes me wonder whether this article was really reviewed before publication, and if so, how careful were the reviewers. It has been my experience that when I have submitted a paper to Annals ofSurgery, it is reviewed in great detail and depth. What went wrong in this case? At the least I think these authors should publish an addendum in a future issue of the journal that describes the current procedure of gastric bypass and lists the complications of the vertical banded gastroplasty procedure. NORMAN B. ACKERMAN, M.D., PHi.D. New York, New York
May 23, 1989 Dear Editor: We are pleased to have this opportunity to respond to several comments and criticisms that Dr. Norman Ackerman has concerning the article entitled "Physioloic-Approaches to the Control of Obesity" (Ann Surg 1989; 209:255-260). Apparently he misunderstood the major thrust of the manuscript in that he con-
siders it to be a comprehensive review of surgical techniques for morbid obesity. The purpose ofthe paper was actually to "discuss the physiologic mechanisms that affect satiety in animals and man." For that reason, the clinical aspects of surgery for obesity were relegated to one or two paragraphs in this manuscript. We acknowledge that devoting this small amount of the manuscript to surgery for morbid obesity did not allow a comprehensive review of techniques and complications. With those comments in mind, we would like to respond to Dr. Ackerman's specific criticisms. Dr. Ackerman is concerned that we quoted a 1969 paper on gastric bypass. It is the common practice to quote original manuscripts concerning techniques that were relatively new in their day. That is not to imply that these concepts or procedures have not been modified with time. The manuscript ofDrs. Mason and Ito was quoted because it was innovative in 1969 and still represents an important contribution in the gastric bypass literature. The use of the term "divide" implies anatomically divided, which can be done by physically dividing the stomach or stapling across it. We apologize if that was not made clear in the manuscript. The actual size of the anastomosis draining the small pouch varies among authors, but Dr. Ackerman is correct that the general trend has been toward smaller and smaller anastomoses. Not including the operative complications of vertical banded gastroplasty was not an oversight in this manuscript. The purpose was not to compare gastric bypass to vertical banded gastroplasty but was, instead, to present an overview suggesting that neither operation successfully treats all cases of obesity. The mention of complications in the section on gastric bypass was simply to highlight the fact that these are relatively complex operations on high-risk patients and are fraught with complications. It is true that the complication rate is similar for vertical banded gastroplasty, but as we stated earlier, our purpose was not to suggest that one operation was better than the other. Undoubtedly Dr. Ackerman feels that our article should serve as a reference for the complete description of the nuances of gastric bypass versus vertical banded gastroplasty. If this is the case, I am certain he will continue to be disappointed. If the readers of the Annals of Surgery are interested in a careful description of the current procedure for gastric bypass and a detailed list of complications ofvertical banded gastroplasty, they should not refer to our article, but should instead consult the many other studies in the literature whose intent is to review all clinical surgical aspects of intervention for morbid obesity. THEODORE N. PAPPAS, M.D. MARY A. POWERS, M.D. Durham, North Carolina April 5, 1989 Dear Editor: In a 24-hour ambulatory study, Eriksen et al.' failed to detect significant differences in the duodenal pH of healthy controls and patients with active duodenal ulcers and conclude that duodenal ulcer formation is not primarily due to exposure of the bulb mucosa to acid. We do not believe that this study can support the authors' conclusions.
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May 11, 1989 Dear Editor: I was very interested to see the article on the physiologic approaches to the control of obesity by Powers and Pappas in the March 1989 issue of Annals of Surgery. However I was very distressed to see the description of the gastric bypass given in the article from a paper that was 20 years old. The procedure as done now, is quite different from that which is described in the paper, and a review article on the subject should have reflected the more current procedure. At the present time, the stomach is no longer divided but is stapled instead. Furthermore the gastrojejunal anastomosis is much more narrow than that described by Drs. Powers and Pappas, usually in the range of 1 cm or less. In the article there is an accurate description of the vertical banded gastroplasty, but no mention of the complications. While complications are listed in the paragraph above on gastric bypass, this is not comparably mentioned in association with gastroplasty. This is quite inaccurate and complications for the latter operation are also relatively common, and are actually somewhat similar to those of the gastric bypass. I believe that omitting any mention of complications may imply that there are none. I think that this is an oversight. Furthermore, in terms of results in the several randomized studies between these two procedures, it appears that the gastric bypass is more effective in terms of weight loss. I think that in reviewing the subject as the authors did, it might have been appropriate to report these findings with accuracy. At any rate I do feel that the inaccurate description of current gastric bypass procedure is a major failing in this article. If this article had been published in a basic science or medical journal rather than a surgical one, and by physiologists or internists rather than by surgeons, one could possibly excuse this with the rationalization that the authors were unfamiliar with the literature and, considering the audience of the journal, it may not matter. However, when this article is published as the lead article of the most prestigious surgical journal, it is very distressing. It also makes me wonder whether this article was really reviewed before publication, and if so, how careful were the reviewers. It has been my experience that when I have submitted a paper to Annals ofSurgery, it is reviewed in great detail and depth. What went wrong in this case? At the least I think these authors should publish an addendum in a future issue of the journal that describes the current procedure of gastric bypass and lists the complications of the vertical banded gastroplasty procedure. NORMAN B. ACKERMAN, M.D., PHi.D. New York, New York
May 23, 1989 Dear Editor: We are pleased to have this opportunity to respond to several comments and criticisms that Dr. Norman Ackerman has concerning the article entitled "Physioloic-Approaches to the Control of Obesity" (Ann Surg 1989; 209:255-260). Apparently he misunderstood the major thrust of the manuscript in that he con-
siders it to be a comprehensive review of surgical techniques for morbid obesity. The purpose ofthe paper was actually to "discuss the physiologic mechanisms that affect satiety in animals and man." For that reason, the clinical aspects of surgery for obesity were relegated to one or two paragraphs in this manuscript. We acknowledge that devoting this small amount of the manuscript to surgery for morbid obesity did not allow a comprehensive review of techniques and complications. With those comments in mind, we would like to respond to Dr. Ackerman's specific criticisms. Dr. Ackerman is concerned that we quoted a 1969 paper on gastric bypass. It is the common practice to quote original manuscripts concerning techniques that were relatively new in their day. That is not to imply that these concepts or procedures have not been modified with time. The manuscript ofDrs. Mason and Ito was quoted because it was innovative in 1969 and still represents an important contribution in the gastric bypass literature. The use of the term "divide" implies anatomically divided, which can be done by physically dividing the stomach or stapling across it. We apologize if that was not made clear in the manuscript. The actual size of the anastomosis draining the small pouch varies among authors, but Dr. Ackerman is correct that the general trend has been toward smaller and smaller anastomoses. Not including the operative complications of vertical banded gastroplasty was not an oversight in this manuscript. The purpose was not to compare gastric bypass to vertical banded gastroplasty but was, instead, to present an overview suggesting that neither operation successfully treats all cases of obesity. The mention of complications in the section on gastric bypass was simply to highlight the fact that these are relatively complex operations on high-risk patients and are fraught with complications. It is true that the complication rate is similar for vertical banded gastroplasty, but as we stated earlier, our purpose was not to suggest that one operation was better than the other. Undoubtedly Dr. Ackerman feels that our article should serve as a reference for the complete description of the nuances of gastric bypass versus vertical banded gastroplasty. If this is the case, I am certain he will continue to be disappointed. If the readers of the Annals of Surgery are interested in a careful description of the current procedure for gastric bypass and a detailed list of complications ofvertical banded gastroplasty, they should not refer to our article, but should instead consult the many other studies in the literature whose intent is to review all clinical surgical aspects of intervention for morbid obesity. THEODORE N. PAPPAS, M.D. MARY A. POWERS, M.D. Durham, North Carolina April 5, 1989 Dear Editor: In a 24-hour ambulatory study, Eriksen et al.' failed to detect significant differences in the duodenal pH of healthy controls and patients with active duodenal ulcers and conclude that duodenal ulcer formation is not primarily due to exposure of the bulb mucosa to acid. We do not believe that this study can support the authors' conclusions.
107
