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Revision of gastric bypass
Revision of Gastric Bypass
Richard I. MacArthur, MD, Kansas City, Kansas David E. Smith, MD, Kansas City, Kansas Arlo S. Hermreck, MD, Kansas City, Kansas William Ft. Jewell, MD, Kansas City, Kansas Creighton A. Hardin, MD, Kansas City, Kansas
Gastric bypass is an accepted method of weight control in the morbidly obese patient [I-3]. The average weight loss after bypass is 30 to 40 percent of the preoperative weight [I$?]. However, 8 to 25 percent of patients in whom gastric bypass is performed fail to lose a satisfactory amount of weight [2,4,5]. These patients apparently “overeat” the bypass or develop a mechanical problem that results in inadequate weight loss. This review reports experience at the University of Kansas Medical Center with revision of gastric bypass in patients with mechanical abnormalities resulting in inadequate weight loss. Material
and Methods
Between November 1973 and October 1979,630 gastric bypasses were performed at the University of Kansas Medical Center. The criteria for patient selection were as follows: the patient had to be at least 100 pounds over ideal weight, have no psychological or medical contraindication, and must have made serious attempts at weight loss before undergoing gastric bypass. Three types of gastric bypass have been performed: gastric division with retrocolic gastrojejunostomy, gastric partition with antecolic gastrojejunostomy, and gastric partition with gastrogastrostomy. Major technical considerations during gastric bypass were creation of a small proximal gastric pouch and a small anastomosis. As the program evolved, both pouch size and anastomosis diameter decreased. At present, a 50 ml pouch and an anastomosis of 1.0 to 1.2 cm are created and four parallel rows of staples are used to partition the stomach. All operations were performed by the attending staff or From the Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas. Reouests for reorints should be addressed to Richard I. MacArthur. MD. Depaiment of Surgery. Universlty of Kansas Medical Center, 39th and Rainbow Boulevard. Kansas City, Kansas 66103. Presented at the 32nd Annual Meeting of the Southwestern Surgical Congress, Colorado Springs, Colorado, May 5-6, 1960.
Volume 140, Deoemfwr 1960
by the resident staff under the direct supervision of the attending staff. The criteria for unsatisfactory weight loss were failure to lose an average of 6 pounds per month for 1 year or weight gain after early weight loss. Before reoperation all patients’ eating habits were analyzed and in patients whose history was not consistent with overeating, upper gastrointestinal roentgenography was performed. The size of the proximal pouch, the size of the anastomosis and the condition of the staple line were evaluated. An increase in the size of the gastric pouch or the anastomosis, or both, were. considered indications for reoperation. Dehiscence of the gastric staple line was also considered an indication for revision. A statistical analysis of weight loss using Student’s t test was performed for each patient, using the patient as his own control. Results Fifty-three patients underwent 56 revisions of gastric bypass procedures. Three patients underwent two revisions. Fifty-two of the patients were females. The average time from the original gastric bypass to revision was 18.5 months (range 4 to 36). Weight loss before revision averaged 12.5 percent of the original weight. Twenty-three patients (41 percent) were gaining weight at the time of reoperation. Failure of the original operation was attributed to an enlarged proximal pouch in 24 patients (42.8 percent), to an anastomosis greater than 1.2 cm in 14 patients (25 percent), and to both in 13 patients (23.2 percent). Five patients (8.9 percent) had had dehiscence of the gastric staple line. The average weight loss after revision in patients followed up for at least 6 months was 16.5 percent of the prerevision weight. A statistical analysis comparing each patient’s weight with his prerevision weight showed a significant (p >O.Ol) weight loss in
751
al
MacArthur
et
TABLE I
Gastric Bypasses and Revisions From 1973 to 1979
Year
No. of Gastric Bypasses Performed
Bypasses Subsequently Revised No. %
1973 1974 1975 1976 1977 1978 1979 (through September)
2 26 98 121 131 142 110
0 5 13 12 11 12 0
0 19.2 13.3 9.9 a.4 a.4 0
Total
630
53
a.4
48 (90.4 percent) of the patients (Figure 1). The combined weight loss after the original gastric bypass and the revision was 29.7 percent of the original weight. The average original weight was 213 percent of ideal weight, the average prerevision weight 175 percent of ideal, and the average weight after reoperation 146 percent of ideal weight (Figure 2). Five patients (9.4 percent) failed to lose weight after revision of the original gastric bypass. Two patients gained weight after revision. Three patients underwent a second revision. The indications for the second revision were enlarged proximal pouch in one patient, enlarged anastomosis in one patient, and enlarged pouch and anastomosis in one patient. Two
360 350340 330 320 310 300 290 260 270 260 250 240 230 220 210 200 I90 160 !70160 I50 140 130 120II0 -
loo’
PRE- SMALL
ORIGINAL
PRE-REVISION
2nd REVISION
FINAL
BOWEL BYPASS
752
The American Journalof Surgery
Revision of Gastric Bypass
of the three second-revision patients had satisfactory weight loss. With experience, the failure rate has decreased. In 1974 there were 5 failures in 26 gastric bypasses (19.2 percent). In 1975 the failure rate was 13.3 percent. In 1976 the failure rate was 9.9 percent, and in 1977 and 1978 it was 8.4 percent. There have been no failures to date in the operations performed in 1979 (Table Il. A variety of surgical procedures has been used to correct the flaw in the original operation. The gastric pouch may be reduced by excising part of the remaining fundus or by applying new staple lines to the existing pouch. In most instances the anastomosis is completely revised, and at present we are converting all gastrojejunostomies to gastrogastrostomies.
360
There were 12 early complications after 56 revisions of gastric bypass. Atelectasis developed in two patients, phlebitis in one, postoperative wound infection in two and prolonged ileus in one. Three patients had splenectomy secondary to operative trauma, and subphrenic abscess developed in two of them. One patient had a minor pancreatic injury during splenectomy. There were three late complications. One patient developed paresthesia that resolved with vitamin therapy. One patient developed a stoma1 ulcer that was treated with transthoracic vagotomy. A third patient developed a small bowel obstruction that responded rapidly to nasogastric suction and intravenous administration of fluids. There were no operative deaths in the series.
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350 340
-
330 320 310 300
-
290
-
280
-
270 260
-
250
-
240
-
230
-
220
-
210 200
-
190 180 170 160 150 I40 130 120I10 -
Figure 2. Weight expressed as percentage of /deal wetght.
volume 140, December 1980
loo ’
PRE-SMALL 8OWEL BYPASS
ORIGINAL
PRE-REVISKIN
2nd REVISION
FINAL
753
MacArthur et al
Comments Some patients who are morbidly obese have significant weight loss after gastric bypass, whereas others fail to lose a satisfactory amount of weight. Our experience indicates that a vast majority of the patients in whom a mechanical reason for failure of the original bypass can be determined can achieve additional weight loss by correction of the mechanical fault. In addition, revision can be performed safely with acceptable morbidity, and to date we have had no mortality associated with these operations. During the course of gastric bypass for morbid obesity, it is essential that the key elements of the operation, namely a small proximal gastric pouch and a small anastomosis, be performed with strict attention to detail, especially when the operator is learning the operative procedure. The proximal gastric pouch can be measured intraoperatively either by the method described by Mason et al (51 or Alder and Terry [S]. In addition, we agree with Mason et al [5] and Hornberger [ 71 that the creation of a small proximal gastric pouch is facilitated by complete mobilization of the fundus of the stomach. The anastomosis may either be measured directly for the correct size or performed over a bougie or dilator. We feel that two applications of the stapler, which creates four parallel rows of staples, will reduce the incidence of staple line dehiscence. At the time of revision it is necessary to determine the exact cause of the failure of the original gastric bypass. Revision should then be based on correcting’ the flaw in the original procedure. At present we are converting patients with previous gastrojejunostomies to gastrogastrostomies at the time of revision, if technically feasible. If the failure of the original operation is due to overeating, then attempts at behavior modification and other psychological counseling should be obtained and revision avoided. It remains to be determined whether a noncompliant patient can enlarge the pouch or the anastomosis or disrupt a staple line. Revisions should be reserved for patients who appear to have an oversized pouch or anastomosis or a staple line separation and should not be performed in noncompliant patients.
After proper evaluation of the patient, revision of a gastric bypass may be undertaken with the expectation of a satisfactory result and an acceptable rate of complications. References 1.
MasonEE, Printen KJ, Paulk SC. Optimizing the results of gastric
bypass. Ann Surg 1975;182:465-14. _ 2. Hermreck AS. Jewel1 WR. Hardin CA. Gastric bypass for morbid obesity. Surgery 1976180:498-505. _. 3. Griffin WO. Gastric bypass for morbid obesity. Surg Clin North Am 1979;59:1103-12. 4. Mason EE, Ito C. Gastric bypass. Ann Surg 1969;170:329. 5. Mason EE. Printen KJ, Blommers TJ, Lewis JW, Scott DH. Gastric bypass in morbid obesity. Am J Clin Nutr 1980;33:395405. 6. Alder RL, Terry BE. Measurement and standardization of the gastric pouch in gastric bypass. Surg Gynecol Obstet 1977; 1441762-3. 7. Hornberger HR. Gastric bypass. Am J Surg 1976;131:415.
Discussion Lawrence H. Wilkinson (Albuquerque, NM): A 20 year old woman underwent gastric bypass in April 1978. I first saw her 3 months later. She had had distressing vomiting. Roentgenography revealed severe reflux, and conservative management failed to stop the vomiting. Following Ed Mason’s advice, the efferent limb was divided proximal to the gastroenterostomy and a Roux-Y performed 40 cm distal. The outlet stoma of the stomach could not be found. The stomach was opened proximal to the anastomosis and the jejunum distal to the anastomosis was opened, and the stoma had completely healed. We constructed a larger than desirable outlet. Until we learn more about human physiology and its relation to emotional states, surgery offers the most reliable solution to morbid obesity. G. Simon Bachir (Kansas City, KS): Concerning the stoma1 ulcer that was treated by vagotomy, what evidence was there that it was acid-induced and not bile-induced? Ward 0. Griffen (Lexington, KY): We have performed 500 gastric bypasses with a Roux-Y technique and have yet to see the first dilated esophagus after that type of anastomosis. We have performed revision in 18 of the 500 patients. The causes for revision are the same: too big a pouch, too big an anastomosis or both, and staple line disruption in three patients.
In this series, 90.6 percent of the patients who had revision of their original gastric bypass for failure to lose satisfactory weight had a significant additional
Richard I. MacArthur (closing): We are at an early stage in determining the correct operation for morbid obesity. If the gastric pouch is too large, we reduce it by using additional staple lines to create a smaller reservoir. If the anastomosis is too large, then in almost all cases we revise the anastomosis, and at present we are converting all patients with a previous gastrojejunostomy to a gastrogastrostomy. We are now performing gastric partition
weight loss. The postoperative complication rate was 21.4 percent, and there were no postoperative deaths.
with gastrosto~y exclusively. we have nithad the-problem with dilatation of the esophagus.
Summary
754
The American Journal of Sqery
Richard I. MacArthur, MD, Kansas City, Kansas David E. Smith, MD, Kansas City, Kansas Arlo S. Hermreck, MD, Kansas City, Kansas William Ft. Jewell, MD, Kansas City, Kansas Creighton A. Hardin, MD, Kansas City, Kansas
Gastric bypass is an accepted method of weight control in the morbidly obese patient [I-3]. The average weight loss after bypass is 30 to 40 percent of the preoperative weight [I$?]. However, 8 to 25 percent of patients in whom gastric bypass is performed fail to lose a satisfactory amount of weight [2,4,5]. These patients apparently “overeat” the bypass or develop a mechanical problem that results in inadequate weight loss. This review reports experience at the University of Kansas Medical Center with revision of gastric bypass in patients with mechanical abnormalities resulting in inadequate weight loss. Material
and Methods
Between November 1973 and October 1979,630 gastric bypasses were performed at the University of Kansas Medical Center. The criteria for patient selection were as follows: the patient had to be at least 100 pounds over ideal weight, have no psychological or medical contraindication, and must have made serious attempts at weight loss before undergoing gastric bypass. Three types of gastric bypass have been performed: gastric division with retrocolic gastrojejunostomy, gastric partition with antecolic gastrojejunostomy, and gastric partition with gastrogastrostomy. Major technical considerations during gastric bypass were creation of a small proximal gastric pouch and a small anastomosis. As the program evolved, both pouch size and anastomosis diameter decreased. At present, a 50 ml pouch and an anastomosis of 1.0 to 1.2 cm are created and four parallel rows of staples are used to partition the stomach. All operations were performed by the attending staff or From the Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas. Reouests for reorints should be addressed to Richard I. MacArthur. MD. Depaiment of Surgery. Universlty of Kansas Medical Center, 39th and Rainbow Boulevard. Kansas City, Kansas 66103. Presented at the 32nd Annual Meeting of the Southwestern Surgical Congress, Colorado Springs, Colorado, May 5-6, 1960.
Volume 140, Deoemfwr 1960
by the resident staff under the direct supervision of the attending staff. The criteria for unsatisfactory weight loss were failure to lose an average of 6 pounds per month for 1 year or weight gain after early weight loss. Before reoperation all patients’ eating habits were analyzed and in patients whose history was not consistent with overeating, upper gastrointestinal roentgenography was performed. The size of the proximal pouch, the size of the anastomosis and the condition of the staple line were evaluated. An increase in the size of the gastric pouch or the anastomosis, or both, were. considered indications for reoperation. Dehiscence of the gastric staple line was also considered an indication for revision. A statistical analysis of weight loss using Student’s t test was performed for each patient, using the patient as his own control. Results Fifty-three patients underwent 56 revisions of gastric bypass procedures. Three patients underwent two revisions. Fifty-two of the patients were females. The average time from the original gastric bypass to revision was 18.5 months (range 4 to 36). Weight loss before revision averaged 12.5 percent of the original weight. Twenty-three patients (41 percent) were gaining weight at the time of reoperation. Failure of the original operation was attributed to an enlarged proximal pouch in 24 patients (42.8 percent), to an anastomosis greater than 1.2 cm in 14 patients (25 percent), and to both in 13 patients (23.2 percent). Five patients (8.9 percent) had had dehiscence of the gastric staple line. The average weight loss after revision in patients followed up for at least 6 months was 16.5 percent of the prerevision weight. A statistical analysis comparing each patient’s weight with his prerevision weight showed a significant (p >O.Ol) weight loss in
751
al
MacArthur
et
TABLE I
Gastric Bypasses and Revisions From 1973 to 1979
Year
No. of Gastric Bypasses Performed
Bypasses Subsequently Revised No. %
1973 1974 1975 1976 1977 1978 1979 (through September)
2 26 98 121 131 142 110
0 5 13 12 11 12 0
0 19.2 13.3 9.9 a.4 a.4 0
Total
630
53
a.4
48 (90.4 percent) of the patients (Figure 1). The combined weight loss after the original gastric bypass and the revision was 29.7 percent of the original weight. The average original weight was 213 percent of ideal weight, the average prerevision weight 175 percent of ideal, and the average weight after reoperation 146 percent of ideal weight (Figure 2). Five patients (9.4 percent) failed to lose weight after revision of the original gastric bypass. Two patients gained weight after revision. Three patients underwent a second revision. The indications for the second revision were enlarged proximal pouch in one patient, enlarged anastomosis in one patient, and enlarged pouch and anastomosis in one patient. Two
360 350340 330 320 310 300 290 260 270 260 250 240 230 220 210 200 I90 160 !70160 I50 140 130 120II0 -
loo’
PRE- SMALL
ORIGINAL
PRE-REVISION
2nd REVISION
FINAL
BOWEL BYPASS
752
The American Journalof Surgery
Revision of Gastric Bypass
of the three second-revision patients had satisfactory weight loss. With experience, the failure rate has decreased. In 1974 there were 5 failures in 26 gastric bypasses (19.2 percent). In 1975 the failure rate was 13.3 percent. In 1976 the failure rate was 9.9 percent, and in 1977 and 1978 it was 8.4 percent. There have been no failures to date in the operations performed in 1979 (Table Il. A variety of surgical procedures has been used to correct the flaw in the original operation. The gastric pouch may be reduced by excising part of the remaining fundus or by applying new staple lines to the existing pouch. In most instances the anastomosis is completely revised, and at present we are converting all gastrojejunostomies to gastrogastrostomies.
360
There were 12 early complications after 56 revisions of gastric bypass. Atelectasis developed in two patients, phlebitis in one, postoperative wound infection in two and prolonged ileus in one. Three patients had splenectomy secondary to operative trauma, and subphrenic abscess developed in two of them. One patient had a minor pancreatic injury during splenectomy. There were three late complications. One patient developed paresthesia that resolved with vitamin therapy. One patient developed a stoma1 ulcer that was treated with transthoracic vagotomy. A third patient developed a small bowel obstruction that responded rapidly to nasogastric suction and intravenous administration of fluids. There were no operative deaths in the series.
-
350 340
-
330 320 310 300
-
290
-
280
-
270 260
-
250
-
240
-
230
-
220
-
210 200
-
190 180 170 160 150 I40 130 120I10 -
Figure 2. Weight expressed as percentage of /deal wetght.
volume 140, December 1980
loo ’
PRE-SMALL 8OWEL BYPASS
ORIGINAL
PRE-REVISKIN
2nd REVISION
FINAL
753
MacArthur et al
Comments Some patients who are morbidly obese have significant weight loss after gastric bypass, whereas others fail to lose a satisfactory amount of weight. Our experience indicates that a vast majority of the patients in whom a mechanical reason for failure of the original bypass can be determined can achieve additional weight loss by correction of the mechanical fault. In addition, revision can be performed safely with acceptable morbidity, and to date we have had no mortality associated with these operations. During the course of gastric bypass for morbid obesity, it is essential that the key elements of the operation, namely a small proximal gastric pouch and a small anastomosis, be performed with strict attention to detail, especially when the operator is learning the operative procedure. The proximal gastric pouch can be measured intraoperatively either by the method described by Mason et al (51 or Alder and Terry [S]. In addition, we agree with Mason et al [5] and Hornberger [ 71 that the creation of a small proximal gastric pouch is facilitated by complete mobilization of the fundus of the stomach. The anastomosis may either be measured directly for the correct size or performed over a bougie or dilator. We feel that two applications of the stapler, which creates four parallel rows of staples, will reduce the incidence of staple line dehiscence. At the time of revision it is necessary to determine the exact cause of the failure of the original gastric bypass. Revision should then be based on correcting’ the flaw in the original procedure. At present we are converting patients with previous gastrojejunostomies to gastrogastrostomies at the time of revision, if technically feasible. If the failure of the original operation is due to overeating, then attempts at behavior modification and other psychological counseling should be obtained and revision avoided. It remains to be determined whether a noncompliant patient can enlarge the pouch or the anastomosis or disrupt a staple line. Revisions should be reserved for patients who appear to have an oversized pouch or anastomosis or a staple line separation and should not be performed in noncompliant patients.
After proper evaluation of the patient, revision of a gastric bypass may be undertaken with the expectation of a satisfactory result and an acceptable rate of complications. References 1.
MasonEE, Printen KJ, Paulk SC. Optimizing the results of gastric
bypass. Ann Surg 1975;182:465-14. _ 2. Hermreck AS. Jewel1 WR. Hardin CA. Gastric bypass for morbid obesity. Surgery 1976180:498-505. _. 3. Griffin WO. Gastric bypass for morbid obesity. Surg Clin North Am 1979;59:1103-12. 4. Mason EE, Ito C. Gastric bypass. Ann Surg 1969;170:329. 5. Mason EE. Printen KJ, Blommers TJ, Lewis JW, Scott DH. Gastric bypass in morbid obesity. Am J Clin Nutr 1980;33:395405. 6. Alder RL, Terry BE. Measurement and standardization of the gastric pouch in gastric bypass. Surg Gynecol Obstet 1977; 1441762-3. 7. Hornberger HR. Gastric bypass. Am J Surg 1976;131:415.
Discussion Lawrence H. Wilkinson (Albuquerque, NM): A 20 year old woman underwent gastric bypass in April 1978. I first saw her 3 months later. She had had distressing vomiting. Roentgenography revealed severe reflux, and conservative management failed to stop the vomiting. Following Ed Mason’s advice, the efferent limb was divided proximal to the gastroenterostomy and a Roux-Y performed 40 cm distal. The outlet stoma of the stomach could not be found. The stomach was opened proximal to the anastomosis and the jejunum distal to the anastomosis was opened, and the stoma had completely healed. We constructed a larger than desirable outlet. Until we learn more about human physiology and its relation to emotional states, surgery offers the most reliable solution to morbid obesity. G. Simon Bachir (Kansas City, KS): Concerning the stoma1 ulcer that was treated by vagotomy, what evidence was there that it was acid-induced and not bile-induced? Ward 0. Griffen (Lexington, KY): We have performed 500 gastric bypasses with a Roux-Y technique and have yet to see the first dilated esophagus after that type of anastomosis. We have performed revision in 18 of the 500 patients. The causes for revision are the same: too big a pouch, too big an anastomosis or both, and staple line disruption in three patients.
In this series, 90.6 percent of the patients who had revision of their original gastric bypass for failure to lose satisfactory weight had a significant additional
Richard I. MacArthur (closing): We are at an early stage in determining the correct operation for morbid obesity. If the gastric pouch is too large, we reduce it by using additional staple lines to create a smaller reservoir. If the anastomosis is too large, then in almost all cases we revise the anastomosis, and at present we are converting all patients with a previous gastrojejunostomy to a gastrogastrostomy. We are now performing gastric partition
weight loss. The postoperative complication rate was 21.4 percent, and there were no postoperative deaths.
with gastrosto~y exclusively. we have nithad the-problem with dilatation of the esophagus.
Summary
754
The American Journal of Sqery