Gastric Bypass for Obesity

Results of a Community Hospital Series

Kenneth Murphy, MD, Little Rock, Arkansas

John D. McCracken, MD, Little Rock, Arkansas

Kerry L. Ozment, MD, Little Rock, Arkansas

Nonoperative approaches to the treatment of morbid obesity are almost universally unsuccessful. Conse- quently, surgical procedures have become more im- portant in managing this health hazard. Intestinal bypass, popularized by Scott, Payne and others, in- duces sustained weight loss by promoting caloric malabsorption. However, the complications of jeju- noileal bypass make its morbidity and mortality substantial, and many investigators have become disenchanted with it.

Since its introduction by Mason in 1966, gastric bypass has become a very popular treatment for morbid obesity. The rationale of this operation is to promote weight loss by limiting the intake of food, while allowing normal digestion, absorption and as- similation of nutrients to take place. Increasing ex- perience with this newer procedure, plus numerous technical modifications, have enhanced the ease and safety of its use. Several large series have demon- strated that it is as effective as intestinal bypass and has a lower incidence of complications [1,2]. Some investigators, however, have proposed that gastric bypass be restricted to centers where investigational work is being carried out. The present report presents experience with gastric bypass at a community hos- pital. It reemphasizes the safety and efficacy of the procedure and stresses the critical points in its per- formance.

Material and Methods

The charts of all patients operated on by the authors for morbid obesity from March 1974 through July 1979 were reviewed. Data were gathered concerning each patient’s

From the Department of Surgery, Baptist Medical Center, Little Rock, Ar- kansas.

Requests for reprints should ba addressed to John D. McCracken, MD, Suite 1000, Medical Towers Building, 9601 Lile Drive, Little Rock, Arkansas 72205.

Presanted at the 32nd Annual Meeting of the Southwestern Surgical Congress, Colorado Springs, Colorado, May 5-8, 1980.

age, sex, height, weight and excess weight. The length of hospitalization for each patient was calculated. The type and number of operations coincident with gastric bypass and the incidence of early and late postoperative compli- cations were tabulated. Patient follow-up ranged from 1 to 63 months.

Seven hundred gastric bypasses were performed. One hundred twelve patients (16 percent) were male and 588 (84 percent) were female. Their average age was 35.0 years (range 13 to 65). The average weight was 259 pounds (range 171 to 580) and the average excess weight (using Metro- politan Life Insurance Co. tables) was 132 pounds (range 54 to 418). The average hospital stay was 8.6 days. All pa- tients received perioperative “mini-dose” heparin and prophylactic antibiotic coverage.

Operations were performed under general anesthesia through vertical upper midline incisions. After mobilization of the greater curvature of the stomach to the gastro- esophageal junction, the TA-90 Auto Suture@ stapler (U.S. Instruments, Stamford, Connecticut) was used to partition a gastric pouch holding approximately 50 to 60 ml. The GIA Auto Suture stapler was then used to construct an antecolic gastrojejunostomy (592 patients), a Roux-Y gaatrojejunostomy (47 patients) or a gastrogastrostomy (61 patients) to reestablish gastrointestinal continuity (Table I). In the majority of patients, decompression of the distal gastric pouch was accomplished by either gastrostomy (361 patients) or enteroenterostomy (150 patients). A naso- gastric tube positioned intraoperatively provided decom- pression of the proximal gastric pouch. A variety of con- comitant operative procedures was performed: 102 chole- cystectomies, 36 hiatal herniorrhaphies, 22 tubal ligations, 11 ventral herniorrhaphies, 10 umbilical herniorrhaphies and 52 other procedures.

Results

One hundred four patients (14.9 percent) had 169 complications related to gastric bypass. The opera- tive mortality was 0.4 percent (three patients). The complications included splenectomy in 34 patients (4.9 percent), staple dehiscence in 12 patients (1.7

Volume 140, December 1980 747

Murphy et al

TABLE I Distribution of Operative Procedures Used in 700 Patients Undergoing Gastric Bypass

Tvoe of Procedure No. Percent

Gastric stapling + gastrojejunostomy 86 12 Gastric stapling + gastrojejunostomy 356 51

+ gastrostomy Gastric stapling t gastrojejunostomy 150 21

+ jejunojejunostomy Gastric stapling + Roux-Y 47 7

gastrojejunostomy Gastric stapling + gastrogastrostomy 56 8 Gastric stapling + gastrogastrostomy 5 1

+ gastrostomy

Total 700 100

percent), incisional hernia in 10 patients (1.4 per- cent), wound infection in 9 patients (1.3 percent), alkaline reflux gastritis in 7 patients (1.0 percent), subphrenic abscess in 6 patients (0.9 percent), pul- monary embolus or infarction in 5 patients (0.7 per- cent), stoma1 obstruction, small bowel obstruction and pouch perforation in 4 patients (0.6 percent) each, and 71 other complications.

Sixty-six patients (9.4 percent) were hospitalized on 73 later occasions for problems possibly related to their initial surgery, including nausea and vomit- ing, dumping and alkaline reflux gastritis. Forty-six patients (6.6 percent) required 56 later operations including incisional hernia repair, panniculectomy, conversion of gastrojejunostomy to Roux-Y and re- vision of gastric bypass.

Dehiscence or separation of gastric staples without leakage occurred in 12 patients (1.7 percent); this allowed unrestricted intake of food and resulted in cessation or reversal of weight loss. Some of these patients have successfully undergone revision of gastric bypass. No marginal ulcers occurred in this series.

There were three operative deaths. A 29 year old

woman died on the fifth day after a 90 percent gastric bypass with gastrojejunostomy; the cause of death was vomiting and aspiration. A 57 year old woman died from pulmonary emboli and renal failure on the fifth day after 90 percent gastric bypass with gas- trojejunostomy. A 52 year old woman died from pulmonary emboli and perforated gastric ulcer on the second day after 90 percent gastric bypass with gas- trojejunostomy and jejunojejunostomy. In none of these patients was gastric pouch perforation the cause of death.

Perforation of the proximal and distal gastric pouches occurred in one and three patients, respec- tively (0.6 percent) All of these perforations were recognized and successfully treated.

Weight loss has been very satisfactory in the ma- jority of patients. At 3,6 and 12 months postopera- tively, the average weight loss was 41, 61 and 76 pounds, respectively (Figure 1). This represented a loss of 33,50 and 63 percent, respectively, of the pa- tients’ excess weight (Figure 2). By 18 to 24 months postoperatively, weight loss reached a plateau.

Comments

Increasing experiences with gastric bypass seem to document its safety and efficacy in the treatment of morbid obesity. The results reported in this series are comparable to others reported in the literature [l-3]. Although the procedure is still undergoing evolutionary changes, several points concerning gastric bypass should be stressed.

Patient selection: Careful patient selection is important. The ideal candidate for gastric bypass is one who has for at least 5 years exceeded his “ideal body weight” (based on life insurance tables) by at least 100 pounds and who has been unable to suc- cessfully lose weight on a physician-supervised pro- gram of nonoperative measures. The coexistence of

I 2 3 4 5 6 7 6 9 IO II 12 13 14 I6 24 30 36

POSTOPERATIVE MONTH

FIgwe 1. Weight loss after gas&k bypass. The numbers above the bars Indicate the number of patients In each fol- low-up group.

746 The American Journal 01 Surgery

Gastric Bypass for Obesity

diseases exacerbated by obesity (such as diabetes mellitus, hypertension and degenerative joint dis- ease) strengthens the indications for surgical therapy.

Preoperative evaluation: Preoperative evalua- tion should exclude serious organic disease as well as endocrine causes of obesity. The coexistence of obesity with diabetes mellitus, hepatic dysfunction, pulmonary disease and hyperlipidemia should be specifically searched for and these conditions treated if necessary. Any coexisting gastrointestinal disease should be discovered. Significant psychiatric illness should be ruled out. We do not consider routine for- mal psychiatric evaluation cost-effective or manda- tory. The routine we use is shown in Table II.

Technical considerations: Several technical surgical points are critical to a successful opera- tion:

Pouch size: Early in this series, a pouch size of approximately 75 to 100 ml was utilized. Subsequent follow-up revealed an unacceptable rate of weight loss. As pointed out by Mason et al [4], construction of a 50 ml gastric pouch is of paramount importance to a good surgical result. Consequently, all pouches are now constructed to hold approximately 50 ml.

Stoma diameter: Mason et al [4] demonstrated that a gastrojejunostomy stoma diameter of 12 mm is the maximum consistent with successful weight loss. During reoperation of several patients with gastric staple dehiscence, we noted marked dilatation of the original gastrojejunostomy. Consequently, other efforts in addition to the construction of a small stoma seem warranted to prevent stoma enlarge- ment. One of the authors (KLO) is currently using a Dacron@ wrap to reinforce all gastrojejunostomies; thus far there have been no complications. Longer follow-up will determine whether this method or others will be successful.

TABLE II Preoperative Evaluation of Morbidly Obese Patients

Laboratory Tests

Complete blood count, prothrombin time and partial thromboplastin time, platelet counts

Urinalysis Fasting and 2 hour postprandial blood glucose Glucose tolerance test (when indicated) Electrolytes, blood urea nitrogen, creatinine Liver function tests TSP, albumin, calcium, phosphate 8 A.M. and 8 P.M. plasma cortisol determinations T3-T4 Cholesterol, triglycerides Lipoprotein electrophoresis (when indicated)

Radiologic Tests

Chest roentgenography Upper gastrointestinal series Oral cholecystography Lumbar spine series

Other Tests

Arterial blood gases Spirometry Electrocardiography

Decompression: Adequate decompression of both the proximal and distal gastric pouches is an absolute necessity if a high incidence of perforation and leakage is to be avoided [5]. Positioning of the naso- gastric tube is critical and should be verified before abdominal closure. Unlike others, we do not place the tube through the gastrojejunostomy but instead place it entirely within the proximal pouch. We feel that additional decompression of the distal pouch pro- vides an independent safeguard. This can be ac- complished by either a distal pouch gastrostomy or a distal jejunojejunostomy. We have had no compli- cations from either approach. In the present series, four pouch perforations (0.6 percent) were reported; one was in the proximal pouch and three were in the

Figure 2. Percent of excess weight lost after gastric by- pass. The numbers above the bars Indicate the number of patients in each iollow-UD I 2 3 4 5 6 7 6 9 IO II 12 13 14 I7 24 30 36

grOl/p. POSTOPERATIVE MONTH

Volume 140, December 1990 749

Murphy et al

bypassed distal segment. This rate is considerably lower than has been reported in the literature to date.

We credit this result to the use of adequate gastric

decompression by the two abovementioned routes. We feel that the low incidence of wound infections

(1.3 percent) is at least partly due to the short oper- ating time (average of approximately 60 minutes) in these patients. This allows a shorter exposure of tissues to potential contamination.

Others have reported dehiscence or separation of

the gastric staple line. The exact cause of this com-

plication is unknown. In efforts to prevent this

complication, we, like others, are using two applica- tions of the TA-90 stapling device. The applications

should be no farther apart than the individual staple

lines. Finally, a significant number of patients have

postoperative nausea, vomiting and related gas- trointestinal symptoms which cannot be ascribed to

stoma1 ulceration, afferent loop syndrome, alkaline reflux gastritis or overeating. It is our impression that the incidence of these problems is much lower in

patients who undergo Roux-Y reconstruction of gastrointestinal continuity than those who receive

a traditional loop gastrojejunostomy. Consequently, we are presently using the Roux-Y technique in all

patients.

Summary

Seven hundred patients at a community hospital underwent gastric bypass for morbid obesity. Post- operative complications developed in 14.9 percent. The incidence of major complications was particu-

larly low. Both weight loss and the percentage of

excess weight lost in the postoperative period were

very satisfactory. The criteria for selecting patients for gastric bypass are presented and preoperative evaluation is reviewed. Major technical points in the operation are stressed. Roux-Y reconstruction of gastrointestinal continuity is the preferred technique in our hands. This report reemphasizes the safety and efficacy of gastric bypass as a treatment for morbid

obesity. When careful patient selection, preoperative evaluation and operative techniques are combined, excellent results can be expected in the community hospital.

References

1. Alden JF. Gastric and jejunoileal bypass: a comparis n in the treatment of morbid obesity. Arch Surg 1977; P 12:799- 806.

2. Giffen WO, Young VL, Stevenson CC. A prospective comparison of gastric and jejunoileal bypass procedures for morbid obe- sity. Ann Surg 1977;186:500-9.

3. Hermreck AS, Jewel1 WB, Hardin CA. Gastric bypass for morbid obesity: results and complications. Surgery 1976;80:498- 505.

4. Mason EE, Printen KJ. Hartford CE, Boyd WC. Optimizing results of gastric bypass. Ann Surg 1975;182:405-14.

5. Mason EE, Printen KJ, Barron P, Lewis JW, Kealey GP, Blommers TJ. Risk reduction in gastric operations for obesity. Ann Surg 1979;190:158-65.

Discussion Hugo V. Villar (Tucson, AZ): The authors have pre-

sented one of the largest series of surgically treated mor- bidly obese patients. The 5 percent rate of incidental splenectomy may be lowered by the use of mechanical re- traction. How many of the 700 patients actually lost weight? Only 240 weights were available in the first 3 months. At the University of Arizona Health Sciences Center, in about 200 patients who underwent gastric par- titioning, a variant of gastric bypass, we found that 20 percent were lost to follow-up and 30 percent failed to lose weight or reached a plateau too early, leaving only 50 per- cent in whom a satisfactory weight loss was achieved. In dealing with these patients there is a need for a strong counseling program. Surgery is only a partial answer to the difficult problems of the obese patient.

Edward W. Martin (Columbus, OH): How do you cal- ibrate the size of the stoma? What is your follow-up regi- men? On roentgenography 6 months to 1 year later the esophagus is dilated. Is reflux of food or food remaining in the distal esophagus a problem?

Gifford V. Eckhout (Denver, CO): Some disturbing features of gastric bypass are the inability to examine the distal stomach by noninvasive techniques along with the incidence of dumping syndrome, marginal ulcer and bleeding, sometimes massive bleeding, stomal obstruction, bilious gastritis, later enlargement of the stoma, acute gastric dilatation and blowout of the stomach, staple line failure, and inadequate weight loss in 5 to 20 percent of reported cases. Because of these problems, we began using a vertical stapled gastroplasty to see if we could eliminate some of the complications.

Including Dr. Daniel Fabito’s series in St. Louis and ours, we have a total of 320 patients to date who underwent vertical stapled gastroplasty, with no mortality, leaks, perforations, abscesses, obstructions or staple line failure. There was one splenectomy and a revision rate of 1.4 per- cent, for enlarged channel in 5 patients who did not have the no. 1 chromic suture placed around the channel. That is a very important suture. The average 12 month weight loss is 86 pounds.

Kenneth Murphy (closing): I certainly agree that close and frequent follow-up is indicated in all of these patients. Surgical therapy for morbid obesity only attacks the result and not the primary cause of the patient’s problem. We do not measure the volume of the pouch. It is an estimate. We construct the gastrojejunostomy with the GIA stapler set at 2 cm. Our patients are discharged on a solid diet with restrictions on carbohydrates and fluids. Problems in the distal esophagus may prove to be the most common long- term complication of this operation, particularly alkaline reflux gastritis. We are now doing Roux-Y reconstruction. The final word is not in on gastric bypass.

750 The American Journal of Surgery