Edward E. Mason

Gastric surgery for morbid obesity

Patients with 100 pounds of excess weight (BMI greater than 40) have sufficient risk of complications and impairment of function to warrant an operation. There is no operation that will bring all patients to a normal weight without risk. More complex operations may provide greater weight reduction, at least until compensatory changes occur that permit improved digestion and absorption of food. The more complicated the operation, the greater the risk of undesirable side effects. Vertical banded gastroplasty has evolved over the last 35 years as a simple, safe, and effective way to control excessive weight with a minimum risk. This simple operation will produce a normal weight in about 30% of patients and satisfactory weight control in 80% of patients, without need for revision surgery. Optimum results depend on intraoperative measurement of pouch volume and outlet reinforcement, education of patients in the care of their operation, and continual evaluation of the early and long-term effects of these operations.

Ilial Transposition and Enteroglucagon/GLP-1 in Obesity (and Diabetic?) Surgery

Background: This is a review of intestinal glucagon, which is released when undigested food is in the terminal ileum. Methods and Results: In the early 1980s, Koopmans and Sclafani showed in fat rats that the transposition of a short segment of ileum to the duodenum would decrease weight just as effectively as intestinal bypass. Sarson and coworkers found elevated enteroglucagon after biliopancreatic diversion (BPD). Scopinaro has observed that patients with diabetes who undergo BPD are cured of diabetes and do not experience a recurrence. Näslund and associates showed recently a high level of plasma glucagon-like peptide (GLP-1) 20 years after jejunoileal bypass. GLP-1 has been shown to be an effective medication for treatment of type 2 diabetes mellitus (DM). It must be given parenterally. It has been used only in short, well-controlled studies. Conclusions: It appears from all that is now known about GLP-1 that ileal transposition would be an ideal operation for treatment of type 2 DM. Release of enteroglucagon from the ileum has probably contributed to weight control in bypass operations for obesity, but the effect has been obscured by the associated malabsorption. The release of GLP-1 after meals has probably been beneficial to patients treated with gastric bypass who had type 2 DM. This is a recommendation for well-planned studies of ileal transposition in the treatment of type 2 DM and obesity. Ileal transposition is not recommended for general use until such studies have shown safety, efficacy, and the requirements for patient selection.

Starvation Injury after Gastric Reduction for Obesity

Abstract. Gastric reduction operations are designed to control body weight by establishing a small, meal-size juxtaesophageal, gastric pouch that empties into the jejunum (gastric bypass) or the larger portion of the stomach (gastroplasty). If the outlet of the pouch is too small, a patient may be limited to ingesting clear liquids. Vomiting then occurs if heavier liquids or normal foods are taken. An occasional patient has difficulty eating properly and vomits even though the pouch volume and outlet are of optimum size. For a patient who reports vomiting, a distinction must be made between episodic improper eating and uncontrolled starvation. Three types of starvation injury are described: (1) sudden death from protein malnutrition; (2) refeeding syndrome; and (3) Wernicke-Korsakoff syndrome. The mechanisms of the development, manifestations, prevention, and treatment of these complications are explained. Surgeons who treat severe obesity should be aware of these complications and be prepared to manage patients who have uncontrolled vomiting so that such complications either do not develop or are recognized and treated as early as possible before serious and irreversible injury occurs.

The Use of Pneumoperitoneum in the Repair of Giant Hernias

Preoperative pneumoperitoneum is used to re-establish the right of domain for abdominal viscera before repair of otherwise inoperable giant abdominal hernias. The aim of this study was to evaluate the use and safety of preoperative pneumoperitoneum in the repair of giant hernias in relation to surgical treatment of obesity. The medical records of patients who underwent preoperative pneumoperitoneum in the treatment of giant hernias between 1953-1993 were reviewed. There were 27 patients (11 males, 16 females; mean age: 56 years) whose mean preoperative weight was 99 kg (range: 69-183). Hernias were predominantly in the midline (17). Other locations were right lower quadrant (5), right upper quadrant (3) and groin (2). The mean duration of preoperative pneumoperitoneum was 28 days (3-100). Subcutaneous emphysema developed in three patients with no sequelae. Primary repair of the giant hernia without Marlex mesh was possible in 19 patients (70%). Marlex mesh was used in seven (26%). One patient had a fascia lata graft. Operative complications were one pulmonary embolus and one hematoma. There were no deaths. We conclude that preoperative pneumoperitoneum is a useful adjunct to giant hernia repair. Severe obesity should be corrected before preoperative pneumoperitoneum and hernia repair. Some patients may need mesh to replace insufficient abdominal wall or to reinforce repair.

Why the Operation I Prefer is Vertical Banded Gastroplasty 5.0

Vertical banded gastroplasty (VBG) is easy for the patient, requiring no nasal gastric tube, gastrostomy, feeding enterostomy, or central venous line. Clear liquids are begun the first morning and puréed foods the second day. VBG with a 5.0 cm collar and a 13 ml pouch provides sufficient weight control with minimal risk and side effects. Splenectomy risk is 0.3%, peritonitis from leak 0.6% and operative mortality 0.24%, VBG causes no malabsorption or bacterial overgrowth because there are no blind segments. VBG does not predispose to difficult to diagnose, lethal, closed segment obstruction because of the absence of exclusion. VBG minimizes risk of acid peptic disease by preserving normal feedback control of acid secretion. Revisions have been less than 2% per year. The first 250 patients to be followed for 5 years with VBG-5.0 showed an 80% success in achieving 25% of excess weight loss without revision. For these successful patients the average percentage excess weight loss was 60% for the morbid obese (MO 160 to 225% of ideal) and 52% for the super obese (SO over 225% of ideal). Absolute weight averages changed from 122 to 86 kg for MO and from 159 to 110 kg for SO.

Reoperation for Failed Gastric Bypass Procedures for Obesity

Reoperation is worthwhile when there is an obvious defect in the gastric reduction operation that has failed to control weight. Reoperation occasionally is necessary to correct a complication of gastric bypass. Vertical banded gastroplasty is the operation of choice for reoperations, as it provides weight control while eliminating the problems of bypass. Conversion of a horizontal to a vertical pouch is safe but requires careful attention to the technique to avoid injury to the other organs in the area and preservation of blood supply to the stomach. The gastrogastrostomy across the old horizontal staple line in the vertical pouch can be constructed in a way that will minimize the risk of obstruction. Vertical banded gastroplasty is now the only operation in use at UIHC for the treatment of obesity and is used not only as the primary operation but in all reoperations. Bypass of the stomach and duodenum is not necessary for weight control and adds some risk of malabsorption and duodenal and stomal ulcer plus a lifetime of inaccessibility of the excluded areas for diagnostic and therapeutic measures.

Gastric Bypass and Gastroplasty for Morbid Obesity

Gastric operations for the treatment of morbid obesity have been standardized. They require close adherence to specifications for success. The upper stomach volume should be measured intraoperatively and fashioned to a capacity of 50 ml at a pressure of 25 to 30 cm of saline. The outlet should be no larger than 12 mm in diameter. The necessity for bypassing the remainder of the stomach and duodenum has not been established. Early maintenance of gastric decompression and immediate supervision and education of patients regarding new eating habits are crucial in the prevention of gastric rupture. Long-term care is usually minimal, but patients should be followed at least at 6 weeks, 6 months, 1 year, and at yearly intervals thereafter. Increasing numbers of intestinal bypass operations are being replaced by gastric bypass or gastroplasty. Many surgeons who once used intestinal bypass have decided to use the stomach operations instead because of the much less complicated long-term care required after the gastric procedures.

Past, Present, and Future of Obesity Surgery

Background: At the meeting 1 year ago, Mary Lou Walen asked the author to provide a brief luncheon talk about the past, present, and future of obesity surgery for the Allied Health Sciences members who meet in conjunction with the annual meeting of the American Society for Bariatric Surgery. This led the author to examine the surgical treatment of severe obesity as it relates to our times and society. Edward O. Wilson has recommended that bariatric surgeons enlarge their view of the work they are engaged in, to include a more universal perspective. From this review, the following talk was presented.