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Mason gastric bypass
Mason Gastric Bypass Long-Term Follow-up and Comparison With Other Gastric Procedures
Ben H. Knecht, MD, FACS, Wenatchee, Washington
The failure of nonoperative methods to control massive obesity [1] led surgeons to investigate operative methods [2]. The surgical approaches to massive obesity have consisted of intestinal bypass, gastric bypass, and an array of gastroplasties. Due to the short- and long-term complications associated with intestinal bypass, it should no longer be recommended [3-51. The success of gastric procedures has made massive obesity surgically correctable [VI. Since the introduction of the gastric bypass by Mason [8] in 1966, various gastric procedures to control weight have been introduced. Gastroplasty (gastric stapling) techniques are still new and are undergoing revisions. Comparison of the Mason gastric bypass with other current obesity procedures may help determine its place in the surgical treatment of obesity. Material and Methods In this 8 year series, 171 patients underwent a Mason gastric bypass procedure and have been followed for at least 1 year. With three exceptions, the patients were twice their ideal weight based on the Metropolitan Life Insurance Company weight table data for people with a medium frame. All patients had been obese for at least 5 years and were less than 50 years of age [9]. Preoperatively, extensive outpatient evaluation was carried out [IO]; formal psychiatric testing and interviewing were not. Pickwickian, Prader-Willi, or Cushing’s syndrome was not found in any patient. The age range was 17 to 49 years (average 35 years). There were 150 women and 21 men. Details of the operative technique were taught to me by Dr. Edward Mason and were reported earlier [IO]. It be-
From the Department of Surgery, Wenatchee Valley Clinic, Wenatchee. Washington. Requests for reprints should be addressed to Ben H. Knecht, MD, P.O. Box 489, Wenatchee, Washington 98801. Presented at the 69th Annual Meeting of the North Pacific Surgical Association, Spokane, Washington, November 12 and 13, 1982.
604
came evident in late 1975 that a smaller pouch than previously constructed could be formed by taking down all of the short gastric vessels. This dissection resulted in a tube effect from the gastroesophageal junction into the upper stomach. The stomach’s greater curvature area, attached to the medial tip of the spleen, became the area of anastomosis. The proximal pouch was not measured exactly; however, it was about thumb size (6 by 2 by 2 cm) with a 1 to 1.2 cm anastomosis. Operative time was under 2 hours. The patients were returned to a nursing area specially designated for the care of the obese surgical patient. Additional procedures were tubal ligation in 16 patients, splenectomy in 7, ovarian resection for large cysts in 4, cholecystectomy in 19, liver biopsy in 2, hysterectomy in 3, and dilatation and curettage in 1. The average length of stay was 7 days. All patients were discharged with a chewable multivitamin containing minerals and iron. Results Weight loss results were separated into two groups: the 26 patients operated on before 1976 who did not have the fundus completely mobilized and the 145 patients operated on after 1976 who had a small pouch (Table I). Weight loss plateaued 1 year postoperatively. A procedure was considered a failure if 25 percent of initial weight was not lost and if lost, was not maintained over time [II]. Using this criteria, 17 of the 26 patients operated on before 1976 and 9 of the 145 patients operated on after 1976 were considered treatment failures. Patient follow-up was frequent during the first postoperative year. Thereafter, follow-up was usually carried out by mail or telephone. Some patients could not be found and were considered lost to follow-up. Revisions were performed on three patients due to failure to lose weight, bile gastritis, and nonspecific gastric bleeding (one patient each). The major complication categories of Peltier et al [12] were used (Table II). One patient had a leak at the greater curvature of the proximal pouch on the second postoperative day. This patient died suddenly
The American
Journal of Surgery
Mason Gastric
TABLE I
Bypass
Weight Loss Results in 171 Patients With Mason Gastric Bypass: Collective and 50 Pound Groups (19731982) Ideal
Large pouch Mean Weight (lb) Patients operated(n) Patients followed (n) Total weight loss (%) Excess weight loss (%) Small pouch Mean weight (lb) Patients operated (n) Patients followed (II) Total weight loss (%) Excess weight loss (%) 200-250 lb group Large pouch (lb) Patients (n) Small pouch (lb) Patients (n) 250-300 lb group Large pouch (lb) Patients (n) Small pouch (lb) Patients (n) 300-350 lb group Large pouch (lb) Patients (n) Small pouch (lb) Patients (n) 350-475 lb group Large pouch (lb) Patients (n) Small pouch (lb) Patients (n)
125
. . . . . . 126
Preooerative
289 26 26
... ... 296 145 145
1 Year
2 Year
3 Year
4 Year
5 Year
6 Year
7 Year
8 Year
199 26 26 31 55
194 26 24 33 58
199 26 22 31 55
204 26 22 29 52
215 26 21 28 45
212 26 10 27 47
213 21 17 26 46
180 10 8 38 66
162 109 99 44 76
170 75 68 43 74
170 46 37 43 74
171 33 29 43 74
182 10 8 39 67
.. . .. ... ...
... ... ... . ... 146 1
... ..
. ...
175 144 138 41 71
114 7 114 22
240 7 238 22
170 7 139 22
169 6 134 20
167 6 133 12
172 6 137 10
172 6 137 5
175 3 169 1
184 3
124 12 121 71
278 12 274 71
188 12 160 69
182 12 161 49
189 11 169 37
191 10 168 20
210 9 174 17
218 5 181 6
205 8
180 2
.. ..
..
131 5 133 31
324 5 326 31
246 4 200 29
253 4 191 19
277 3 190 10
257 4 197 4
268 4 183 4
262 2 200 1
220 4
214 3
... ...
. ...
147 2 147 21
439 2 386 21
247 2 235 18
215 2 207 11
234 2 200 9
257 2 197 6
259 2 189 5
. . .
278 2
... ... ... .
..
at home 35 days after discharge from an autopsyproved pulmonary embolism. The two leaks were in the area where the transverse colon mesentery was sutured to the greater curvature of the proximal pouch. The only postoperative subphrenic abscesses developed in two patients who underwent splenectomy. Anastomotic revision was performed in five patients: the anastomoses failed to open postoperatively in 3 patients, one closed after functioning satisfactorily in another patient, and one patient could not tolerate any solids. When the proximal gastric pouch was pulled further through the transverse colon mesentery, anastomotic problems were alleviated. In the first few postoperative months, the pouch filled with one to three teaspoons of formed food. This gradually increased to the volume of half a sandwich after 1 year. Peripheral neuropathy developed in two patients, but resolved with vitamin B complex shots and thiamine. During the first postoperative year, loss of hair (telogen effluvium) was noted in the majority of patients, beginning 2 to 5 months after surgery and ending at 10 to 12 months [13]. An acute gastrointestinal bleeding episode occurred in one patient secondary to intussusception
Volume 145, May 1983
.
... ...
. . . .
.
of the transected greater curve corner of the distal stomach through the pylorus. This complication could have been prevented by suturing the greater curve corner of the proximal pouch. Comments Gastric bypass has remained a demanding undertaking [14]. A gastric leak is still the most feared complication of surgery for obesity. Mason [8] has emphasized its cause and diagnosis. Additional leaks in my patients have been prevented with recognition of the thin muscular wall of the fundic portion of the stomach; sutures can penetrate the thin wall of the stomach and introduce a small amount of contamination [15]. This could account for the one spontaneous intraabdominal abscess that occurred. The no. 12 F. Levin nasogastric tube should be positioned just inside the gastroesophageal junction to prevent the tube-associated leaks described by Mason [8]. The patient’s general status and abdomen must be examined twice a day to diagnose a leak. The diagnostic criteria for an acute abdomen (usually described for patients of normal weight) tend to be obscured by the thick subcutaneous tissue in obese patients. A liquid-soluble contrast swallow should be carried out
605
Knecht
TABLE II
Major Complications in 171 Patients With Mason Gastric Bypass (1973-1982) Patients
Complication
14 (8%) 1 2 3 7 2 1 1
Surgical Wound infection Wound dehiscence Wound hernia Splenectomy Subphrenic abscess lntraabdominal abscess Pancreatitis Pulmonary embolus Stoma and pouch Obstruction Operated Ulceration Operated Nonoperated Leakage Bile gastritis Hemorrhage Duodenal ulcer Readmit. vomiting (psychological) lntussusception Metabolic Neuropathy Anemia Death
2: (13%) 5 1 1 2 1 4 2 6 : (4%) 2 5 1(0.6%)
if there is any concern about a leak. When interpreting the roentgenograms, the distal gastric staple line may be interpreted as an extraluminal contrast leak. When Mason [S] created a small pouch (50 ml), the incidence of stomal ulcer was reduced from 3.8 to 0.98 percent. The two stoma1 ulcers noted in my series of patients were associated with the large proximal pouch. The creation of a small proximal pouch required complete dissection of the upper fundus with ablation of the angle of His. The blood supply to this small pouch from the left inferior phrenic vessels and the left gastric vessels must be preserved. The total ligation of the short gastric vessels did not result in pouch necrosis in my patients. Peltier et al [12] compared a small group of retrocolic loop gastrojejunostomies and Roux-Y loop
TABLE Ill
gastrojejunostomies and noted no difference in the occurrence of bile gastritis. I concur with Halverson et al [16] and Linner [17] in attributing the absence of bile emesis to a consistently small (1.0 cm) anastomosis. The Bilroth II retrocolic loop gastrojejunostomy allows examination of the afferent limb, pylorus, and distal stomach with a pediatric endoscope. Many of my patients related symptoms attributable to dumping. Both Linner [17] and I have independently concluded that one of the reasons longterm weight loss is maintained is that the persistence of these symptoms act to restrict intake of concentrated carbohydrates. MacLean et al [ll ] measured body composition in nine of their gastroplasty patients who lost 105 pounds in 12 months. All of their patients had a loss of fat with a minor decrease in body cell mass without evidence of malnutrition. I have stressed the importance of walking a mile a day to my patients, as walking seems to assist in weight loss by burning fat stores and ketones, but it does not increase the breakdown of muscle protein [la]. Halmi et al [19] studied the symptoms of weakness and fatigue in the same patients while they were dieting and after gastric bypass surgery. They found that weakness and fatigue occur with about the same frequency with both methods of weight loss. Mason [8] noted that gastric bypass did cause a mild iron deficiency anemia in some patients. Empirically, I noted that iron-deficient patients who had undergone a gastric bypass required liquid iron for better iron absorption. Comparison: There are four popular types of gastric procedures to control obesity (Figure I). There is great similarity between the Alden and Mason gastric bypasses. Table III lists the weight loss and major complications associated with each type of gastric procedure. The number of surgical complications associated with the Mason gastric bypass is high because included among them are Mason’s early pioneering results. Those surgeons who compared results in their gastroplasty and gastric bypass patients all favored gastric bypass [17,21,22]. Gastroplasty may not be a long-term solution to obesity; the
Comparison of Four Malor Types of Gastric Procedures for Surgical Complications and Weight Loss’ Gastric Bypass Mason 18, 121
Alden [5,8, 17,21,22,30]
Horizonal Gastroplasties Come2 Ohio [ 17,22,23] [17,241
Complications (%) Surgical Stoma and pouch Death
22 14 3
10 5 2
Average weight loss (lb) Total weight loss (%)
74 25
90 33
75 28
72 24
811
612
246
48
Patients,(n) l
606
8 9 0.2
3 7 0.2
Results have been taken from each author’s report and averaged with similar reported patients.
The American Journal of Surgery
Mason Gastric Bypass
Figure 1. Gastric procedures for weight loss: Mason and Alden gastric bypasses (top ieff and righf, respectively), and Gomez and Ohb ho&o&a/ gastropiasties (bottom left and right, respectively). F = fundus; S = stomach.
gastroplasty lumen must be supported or it will expand [I 71. Staple disruption has also been known to occur. Attempts to reinforce the staple line with a variety of methods have failed to solve the problem of the gastric mucosa not healing between the staples [Z&-27]. The transected stomach of a Mason gastric bypass, when reinforced with sutures, did not have disruption problems. The small tubular shape of the proximal pouch as it enters the anastomosis seems to maintain a small anastomosis. Gastroplasty tends to have the same number of complications as a gastric bypass when performed by the same surgeon [22]. I believe it is important to avoid the tendency to blame the failure of the surgery on the patient’s weak character and continued overeating. Summary The Mason gastric bypass as performed over 8 years on 171 patients for the treatment of massive exogenous obesity. The first 26 patients had a large pouch constructed, and poor long-term weight loss occurred. In the last 6 years, 145 patients had a smaller pouch with a 5.5 percent immediate postoperative complications rate. One early death re-
Volume145,May1993
sulted. Late complications and revisions were few. In the last 145 patients there were only 9 who did not maintain a weight loss of greater than 25 percent of their total weight. This group of 145 patients have lost an average of 42 percent of their total weight (121 pounds) and 72 percent of their excess weight. The stapled Alden gastric bypass and horizontal gastroplasties, when compared with the Mason gastric bypass, have similar complications with the potential for poor weight loss after long-term follow-up due to channel enlargement or staple-line leakage. The Mason gastric bypass is an excellent surgical method of weight loss. References 1. Vanltallie TB. “Morbid” obesity: hazardous disorder that resists conservative treatment. Am J Clin Nutr 1980;33:358-63. 2. Buckwald H, Rucker RD. The history of metabolic surgery for morbid obesity and a commentary. World J Surg 1981;5: 781-7. 3. Halverson JD. Obesity surgery in perspective. Surg 1980;87: 119-27. 4. Garrison RN, Waterman NG, Sanders GB, et al. A communitywide experience with jejunoileal bypass for obesity surgery. Am J Surg 1977;133:675-80. 5. Alden JF. Gastric and jejunoileal bypass. Arch Surg 1977;
607
Knecht
112:799-606. 6. Renfield JR, Bray GA. Is obesity a surgical disease? West J Med 1975; 123:396-8. 7. The Danish obesity patient: randomized trial of jejunoileal bypass versus medical treatment in morbid obesity. Lancet 1979;2:1255-7. 6. Mason EE. Surgical treatment of obesity. Philadelphia: WB Saunders, 1981:152-215. 9. Printen KJ, Mason EE. Gastric bypass for morbid obesity in patients more than 50 years of age. Surg Gynecol Obstet 1977;144:192-4. 10. Knecht BH. Experience with gastric bypass of massive obesity. Am Surg 1978;44:496-504. 11. MacLean LD, Rhode BM, Shizgal HM. Gastroplasty for obesity. Surg Gynecol Obstet 1981; 153: l-9. 12. Peltier G, Hermreck AS, Moffat RE, Hardin CA, Jewel1 WR. Complications following gastric bypass procedures for morbid obesity. Surgery 1979;86:648-54. 13. Goette DK, Ddom RB. Aploecia in crash dieters. JAMA 1976;235:2622-3. 14. Hermreck AS, Jewel1 WR, Hardin CA. Gastric bypass for morbid obesity: results and complications. Surgery 1976;80: 498-505. 15. Bushkin FL, Neustein CL, Parker TH, Woodward ER. Nissen fundoplication for reflux peptic esophagitis. Ann Surg 1977;185:672-7. 16. Halverson JD, Zuckerman GR, Koehler RE, Gentry K, Michael HEB, DeSchryver-Kecskemeti K. Gastric bypass for morbid obesity. Ann Surg 1981;194:152-60. 17. Linner JH. Comparative effectiveness of gastric bypass and
608
gastroplasty. Arch Surg 1982; 117:695-700. 18. Drenick EJ, Fisler JS, Johnson DG, McGhee G. The effect of exercise on substitutes and hormones during prolonged fastina. Intern J Obesitv 1977:1:49-61. 19. Halmi KA, Stunkard AJ, -Mason. EE. Emotional response to weight reduction by three methods: gastric bypass, jejunoileal bypass, diet. Am J Clin Nutr 1980;33:446-51. 20. Murphy K, McCracken JD, Ozment KL. Gastric bypass for obesity. Am J Surg 1980;140:747-50. 21. Lechner GW, Callendar AK. Subtotal gastric exclusion and gastric partitioning: a randomized prospective comparison of one hundred patients. Surgery 1981;90:637-44. 22. Freeman JB, Burchett HJ. A comparison of gastric bypass and gastroplasty for morbid obesity. Surgery 1980;88:43344. 23. Gomez CA. Gastroplasty in the treatment of morbid obesity. Am J Clin Nutr 1980;33:406-15. 24. Pace WG, Martin ER Jr, Tetirick T, Fabri PJ, Carey LC. Gastric partitioning for morbid obesity. Ann Surg 1979;190:392400. 25. Mason EE, in discussion of Freeman JB, Burchett HJ. A comparison of gastric bypass and gastroplasty for morbid obesity. Surgery 1980;88:433-44. 26. Brolin RE, Ravitch MM. Experimental evaluation of techniques of gastric partitioning for morbid obesity. Surg Gynecol Obstet 1981;153:877-82. 27. Printen KJ, in discussion of Ellison EC, Martin EF, Laschinger J, et al. Prevention of early failure of stapled gastric partitions in treatment of morbid obesity. Arch Surg 1980; 115:52833.
The American Journal of Surgery
Ben H. Knecht, MD, FACS, Wenatchee, Washington
The failure of nonoperative methods to control massive obesity [1] led surgeons to investigate operative methods [2]. The surgical approaches to massive obesity have consisted of intestinal bypass, gastric bypass, and an array of gastroplasties. Due to the short- and long-term complications associated with intestinal bypass, it should no longer be recommended [3-51. The success of gastric procedures has made massive obesity surgically correctable [VI. Since the introduction of the gastric bypass by Mason [8] in 1966, various gastric procedures to control weight have been introduced. Gastroplasty (gastric stapling) techniques are still new and are undergoing revisions. Comparison of the Mason gastric bypass with other current obesity procedures may help determine its place in the surgical treatment of obesity. Material and Methods In this 8 year series, 171 patients underwent a Mason gastric bypass procedure and have been followed for at least 1 year. With three exceptions, the patients were twice their ideal weight based on the Metropolitan Life Insurance Company weight table data for people with a medium frame. All patients had been obese for at least 5 years and were less than 50 years of age [9]. Preoperatively, extensive outpatient evaluation was carried out [IO]; formal psychiatric testing and interviewing were not. Pickwickian, Prader-Willi, or Cushing’s syndrome was not found in any patient. The age range was 17 to 49 years (average 35 years). There were 150 women and 21 men. Details of the operative technique were taught to me by Dr. Edward Mason and were reported earlier [IO]. It be-
From the Department of Surgery, Wenatchee Valley Clinic, Wenatchee. Washington. Requests for reprints should be addressed to Ben H. Knecht, MD, P.O. Box 489, Wenatchee, Washington 98801. Presented at the 69th Annual Meeting of the North Pacific Surgical Association, Spokane, Washington, November 12 and 13, 1982.
604
came evident in late 1975 that a smaller pouch than previously constructed could be formed by taking down all of the short gastric vessels. This dissection resulted in a tube effect from the gastroesophageal junction into the upper stomach. The stomach’s greater curvature area, attached to the medial tip of the spleen, became the area of anastomosis. The proximal pouch was not measured exactly; however, it was about thumb size (6 by 2 by 2 cm) with a 1 to 1.2 cm anastomosis. Operative time was under 2 hours. The patients were returned to a nursing area specially designated for the care of the obese surgical patient. Additional procedures were tubal ligation in 16 patients, splenectomy in 7, ovarian resection for large cysts in 4, cholecystectomy in 19, liver biopsy in 2, hysterectomy in 3, and dilatation and curettage in 1. The average length of stay was 7 days. All patients were discharged with a chewable multivitamin containing minerals and iron. Results Weight loss results were separated into two groups: the 26 patients operated on before 1976 who did not have the fundus completely mobilized and the 145 patients operated on after 1976 who had a small pouch (Table I). Weight loss plateaued 1 year postoperatively. A procedure was considered a failure if 25 percent of initial weight was not lost and if lost, was not maintained over time [II]. Using this criteria, 17 of the 26 patients operated on before 1976 and 9 of the 145 patients operated on after 1976 were considered treatment failures. Patient follow-up was frequent during the first postoperative year. Thereafter, follow-up was usually carried out by mail or telephone. Some patients could not be found and were considered lost to follow-up. Revisions were performed on three patients due to failure to lose weight, bile gastritis, and nonspecific gastric bleeding (one patient each). The major complication categories of Peltier et al [12] were used (Table II). One patient had a leak at the greater curvature of the proximal pouch on the second postoperative day. This patient died suddenly
The American
Journal of Surgery
Mason Gastric
TABLE I
Bypass
Weight Loss Results in 171 Patients With Mason Gastric Bypass: Collective and 50 Pound Groups (19731982) Ideal
Large pouch Mean Weight (lb) Patients operated(n) Patients followed (n) Total weight loss (%) Excess weight loss (%) Small pouch Mean weight (lb) Patients operated (n) Patients followed (II) Total weight loss (%) Excess weight loss (%) 200-250 lb group Large pouch (lb) Patients (n) Small pouch (lb) Patients (n) 250-300 lb group Large pouch (lb) Patients (n) Small pouch (lb) Patients (n) 300-350 lb group Large pouch (lb) Patients (n) Small pouch (lb) Patients (n) 350-475 lb group Large pouch (lb) Patients (n) Small pouch (lb) Patients (n)
125
. . . . . . 126
Preooerative
289 26 26
... ... 296 145 145
1 Year
2 Year
3 Year
4 Year
5 Year
6 Year
7 Year
8 Year
199 26 26 31 55
194 26 24 33 58
199 26 22 31 55
204 26 22 29 52
215 26 21 28 45
212 26 10 27 47
213 21 17 26 46
180 10 8 38 66
162 109 99 44 76
170 75 68 43 74
170 46 37 43 74
171 33 29 43 74
182 10 8 39 67
.. . .. ... ...
... ... ... . ... 146 1
... ..
. ...
175 144 138 41 71
114 7 114 22
240 7 238 22
170 7 139 22
169 6 134 20
167 6 133 12
172 6 137 10
172 6 137 5
175 3 169 1
184 3
124 12 121 71
278 12 274 71
188 12 160 69
182 12 161 49
189 11 169 37
191 10 168 20
210 9 174 17
218 5 181 6
205 8
180 2
.. ..
..
131 5 133 31
324 5 326 31
246 4 200 29
253 4 191 19
277 3 190 10
257 4 197 4
268 4 183 4
262 2 200 1
220 4
214 3
... ...
. ...
147 2 147 21
439 2 386 21
247 2 235 18
215 2 207 11
234 2 200 9
257 2 197 6
259 2 189 5
. . .
278 2
... ... ... .
..
at home 35 days after discharge from an autopsyproved pulmonary embolism. The two leaks were in the area where the transverse colon mesentery was sutured to the greater curvature of the proximal pouch. The only postoperative subphrenic abscesses developed in two patients who underwent splenectomy. Anastomotic revision was performed in five patients: the anastomoses failed to open postoperatively in 3 patients, one closed after functioning satisfactorily in another patient, and one patient could not tolerate any solids. When the proximal gastric pouch was pulled further through the transverse colon mesentery, anastomotic problems were alleviated. In the first few postoperative months, the pouch filled with one to three teaspoons of formed food. This gradually increased to the volume of half a sandwich after 1 year. Peripheral neuropathy developed in two patients, but resolved with vitamin B complex shots and thiamine. During the first postoperative year, loss of hair (telogen effluvium) was noted in the majority of patients, beginning 2 to 5 months after surgery and ending at 10 to 12 months [13]. An acute gastrointestinal bleeding episode occurred in one patient secondary to intussusception
Volume 145, May 1983
.
... ...
. . . .
.
of the transected greater curve corner of the distal stomach through the pylorus. This complication could have been prevented by suturing the greater curve corner of the proximal pouch. Comments Gastric bypass has remained a demanding undertaking [14]. A gastric leak is still the most feared complication of surgery for obesity. Mason [8] has emphasized its cause and diagnosis. Additional leaks in my patients have been prevented with recognition of the thin muscular wall of the fundic portion of the stomach; sutures can penetrate the thin wall of the stomach and introduce a small amount of contamination [15]. This could account for the one spontaneous intraabdominal abscess that occurred. The no. 12 F. Levin nasogastric tube should be positioned just inside the gastroesophageal junction to prevent the tube-associated leaks described by Mason [8]. The patient’s general status and abdomen must be examined twice a day to diagnose a leak. The diagnostic criteria for an acute abdomen (usually described for patients of normal weight) tend to be obscured by the thick subcutaneous tissue in obese patients. A liquid-soluble contrast swallow should be carried out
605
Knecht
TABLE II
Major Complications in 171 Patients With Mason Gastric Bypass (1973-1982) Patients
Complication
14 (8%) 1 2 3 7 2 1 1
Surgical Wound infection Wound dehiscence Wound hernia Splenectomy Subphrenic abscess lntraabdominal abscess Pancreatitis Pulmonary embolus Stoma and pouch Obstruction Operated Ulceration Operated Nonoperated Leakage Bile gastritis Hemorrhage Duodenal ulcer Readmit. vomiting (psychological) lntussusception Metabolic Neuropathy Anemia Death
2: (13%) 5 1 1 2 1 4 2 6 : (4%) 2 5 1(0.6%)
if there is any concern about a leak. When interpreting the roentgenograms, the distal gastric staple line may be interpreted as an extraluminal contrast leak. When Mason [S] created a small pouch (50 ml), the incidence of stomal ulcer was reduced from 3.8 to 0.98 percent. The two stoma1 ulcers noted in my series of patients were associated with the large proximal pouch. The creation of a small proximal pouch required complete dissection of the upper fundus with ablation of the angle of His. The blood supply to this small pouch from the left inferior phrenic vessels and the left gastric vessels must be preserved. The total ligation of the short gastric vessels did not result in pouch necrosis in my patients. Peltier et al [12] compared a small group of retrocolic loop gastrojejunostomies and Roux-Y loop
TABLE Ill
gastrojejunostomies and noted no difference in the occurrence of bile gastritis. I concur with Halverson et al [16] and Linner [17] in attributing the absence of bile emesis to a consistently small (1.0 cm) anastomosis. The Bilroth II retrocolic loop gastrojejunostomy allows examination of the afferent limb, pylorus, and distal stomach with a pediatric endoscope. Many of my patients related symptoms attributable to dumping. Both Linner [17] and I have independently concluded that one of the reasons longterm weight loss is maintained is that the persistence of these symptoms act to restrict intake of concentrated carbohydrates. MacLean et al [ll ] measured body composition in nine of their gastroplasty patients who lost 105 pounds in 12 months. All of their patients had a loss of fat with a minor decrease in body cell mass without evidence of malnutrition. I have stressed the importance of walking a mile a day to my patients, as walking seems to assist in weight loss by burning fat stores and ketones, but it does not increase the breakdown of muscle protein [la]. Halmi et al [19] studied the symptoms of weakness and fatigue in the same patients while they were dieting and after gastric bypass surgery. They found that weakness and fatigue occur with about the same frequency with both methods of weight loss. Mason [8] noted that gastric bypass did cause a mild iron deficiency anemia in some patients. Empirically, I noted that iron-deficient patients who had undergone a gastric bypass required liquid iron for better iron absorption. Comparison: There are four popular types of gastric procedures to control obesity (Figure I). There is great similarity between the Alden and Mason gastric bypasses. Table III lists the weight loss and major complications associated with each type of gastric procedure. The number of surgical complications associated with the Mason gastric bypass is high because included among them are Mason’s early pioneering results. Those surgeons who compared results in their gastroplasty and gastric bypass patients all favored gastric bypass [17,21,22]. Gastroplasty may not be a long-term solution to obesity; the
Comparison of Four Malor Types of Gastric Procedures for Surgical Complications and Weight Loss’ Gastric Bypass Mason 18, 121
Alden [5,8, 17,21,22,30]
Horizonal Gastroplasties Come2 Ohio [ 17,22,23] [17,241
Complications (%) Surgical Stoma and pouch Death
22 14 3
10 5 2
Average weight loss (lb) Total weight loss (%)
74 25
90 33
75 28
72 24
811
612
246
48
Patients,(n) l
606
8 9 0.2
3 7 0.2
Results have been taken from each author’s report and averaged with similar reported patients.
The American Journal of Surgery
Mason Gastric Bypass
Figure 1. Gastric procedures for weight loss: Mason and Alden gastric bypasses (top ieff and righf, respectively), and Gomez and Ohb ho&o&a/ gastropiasties (bottom left and right, respectively). F = fundus; S = stomach.
gastroplasty lumen must be supported or it will expand [I 71. Staple disruption has also been known to occur. Attempts to reinforce the staple line with a variety of methods have failed to solve the problem of the gastric mucosa not healing between the staples [Z&-27]. The transected stomach of a Mason gastric bypass, when reinforced with sutures, did not have disruption problems. The small tubular shape of the proximal pouch as it enters the anastomosis seems to maintain a small anastomosis. Gastroplasty tends to have the same number of complications as a gastric bypass when performed by the same surgeon [22]. I believe it is important to avoid the tendency to blame the failure of the surgery on the patient’s weak character and continued overeating. Summary The Mason gastric bypass as performed over 8 years on 171 patients for the treatment of massive exogenous obesity. The first 26 patients had a large pouch constructed, and poor long-term weight loss occurred. In the last 6 years, 145 patients had a smaller pouch with a 5.5 percent immediate postoperative complications rate. One early death re-
Volume145,May1993
sulted. Late complications and revisions were few. In the last 145 patients there were only 9 who did not maintain a weight loss of greater than 25 percent of their total weight. This group of 145 patients have lost an average of 42 percent of their total weight (121 pounds) and 72 percent of their excess weight. The stapled Alden gastric bypass and horizontal gastroplasties, when compared with the Mason gastric bypass, have similar complications with the potential for poor weight loss after long-term follow-up due to channel enlargement or staple-line leakage. The Mason gastric bypass is an excellent surgical method of weight loss. References 1. Vanltallie TB. “Morbid” obesity: hazardous disorder that resists conservative treatment. Am J Clin Nutr 1980;33:358-63. 2. Buckwald H, Rucker RD. The history of metabolic surgery for morbid obesity and a commentary. World J Surg 1981;5: 781-7. 3. Halverson JD. Obesity surgery in perspective. Surg 1980;87: 119-27. 4. Garrison RN, Waterman NG, Sanders GB, et al. A communitywide experience with jejunoileal bypass for obesity surgery. Am J Surg 1977;133:675-80. 5. Alden JF. Gastric and jejunoileal bypass. Arch Surg 1977;
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Knecht
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