Notes on the Surgical Treatment of Morbid Obesity

Fig. 23.1

Jejunoileal bypass . (With permission from Debora Gallegos Saliby)

Despite the popularity of these procedures in the 1960s and the good results regarding weight loss and resolution of comorbidities, serious complications occurred. The defunctionalized segment was responsible for bacterial overgrowth that generated arthralgia, distension, abdominal pain, and even liver failure. The occurrence of severe diarrhea was frequent. Many patients had protein depletion and vitamin deficiency. In the 1970s other less morbid procedures were developed, and the jejunoileal bypass was abandoned.

Malabsorptive Procedures

Biliopancreatic Diversion

Scopinaro et al. in 1979 [13] described an alternative to jejunoileal bypass and created the procedure known as biliopancreatic diversion (Fig. 23.2). This procedure consists of a partial distal gastrectomy with closure of the duodenal stump. The jejunum was divided 250 cm proximal to the ileocecal valve. The distal limb (Roux limb) was anastomosed to the stomach. The proximal limb (biliopancreatic limb) was anastomosed to the ileum 50 cm proximal to the ileocecal valve. This technique avoided blind-loop syndrome by maintaining pancreatic and biliary flow through the deviant bowel, and as there was contact between the food and the digestive fluids at 50 cm, the absorption was better than the jejunoileal bypass. This technique presented excellent results in regard to weight loss and resolution of comorbidities but was not free of complications. The most important were diarrhea, anemia, dumping stoma ulceration, protein deficiency, and calcium and vitamin D hypo-absorption.

../images/473262_1_En_23_Chapter/473262_1_En_23_Fig2_HTML.png — Fig. 23.2

Biliopancreatic diversion . (With permission from Debora Gallegos Saliby)

Duodenal Switch

In order to reduce the problems of biliopancreatic diversion, Douglas S. Hess and Douglas W. Hess [14] created in 1998 a variation of the biliopancreatic diversion – the duodenal switch (Fig. 23.3). The gastric restriction continued to be present through vertical partial gastrectomy along the greater curvature with resection of 70–80% of the stomach (sleeve gastrectomy). The duodenum was sectioned 3 cm distal to the pylorus. The small intestine was measured in its totality. Forty percent of this distance was calculated and measured retrograde from the ileocecal valve, the small intestine was sectioned at this point, and the distal limb was anastomosed to the duodenum, and the proximal limb was anastomosed to the ileum 75–100 cm proximal to the ileocecal valve.

../images/473262_1_En_23_Chapter/473262_1_En_23_Fig3_HTML.png — Fig. 23.3

Duodenal switch . (With permission from Debora Gallegos Saliby)

Pylorus preservation leads to slower gastric emptying and a lower incidence of dumping. The segment of duodenum present in intestinal transit decreased the incidence of stoma ulcers. In addition, due to this segment of duodenum in the alimentary transit, calcium and iron absorption improved greatly with lower incidence of anemia and calcium problems. The common alimentary channel of 75–100 cm was longer than the biliopancreatic diversion, therefore allowing better absorption of nutrients.

In 1995 Picard Marceau et al. [15] had already performed a similar procedure. They, however, did not transect the duodenum, only stapled it. The duodenal cross-stapling frequently permeated obviating the benefits of the operation.

Gastric Bypass

Restriction of the gastric capacity for the treatment of obesity was initiated by Edward Mason after observing weight loss in patients undergoing gastrectomy for the treatment of peptic ulcers. Mason and Ito [16], in 1967, sectioned the stomach horizontally, near the gastric fundus, creating a reservoir with about a 100 ml capacity, and gastrojejunostomy of 20 mm in the great curvature (Fig. 23.4). The rest of the stomach was left in the abdominal cavity. The results of weight loss were satisfactory with minimal side effects.

../images/473262_1_En_23_Chapter/473262_1_En_23_Fig4_HTML.png — Fig. 23.4

Gastric bypass Mason and Ito. (With permission from Debora Gallegos Saliby)

At first, authors were not concerned with the size of pouch or gastrojejunostomy. In 1977, Alder and Terry [17] stated that the larger the pouch, the greater the chance of its dilation, concluding that the ideal size of the pouch would be around 30 ml. In the same year, Alden [18] with the intention of minimizing leaks proposed not the section the stomach but only the horizontal stapling. However, this technique was soon abandoned due to frequent failure of staple lines and restoration of the gastric cavity completely with weight regain.

Mason et al. [19], in 1975, modified the procedure by proposing a narrower anastomosis, between 8 and 12 mm, postulating that the narrower anastomosis would increase weight loss. In the same study, they proposed to reduce the gastric reservoir to 60 ml.

Griffen et al. [20] in 1981 recommended the Roux-en-Y gastrojejunal anastomosis (Fig. 23.5). This modification reduced the tension in the gastrojejunal anastomosis, eliminated the alkaline reflux in the pouch, and added a poorly absorptive component, reducing the incidence of leaks, reducing the side effects of the procedure, and increasing weight loss.

../images/473262_1_En_23_Chapter/473262_1_En_23_Fig5_HTML.png — Fig. 23.5

Roux-en-Y gastric bypass . (With permission from Debora Gallegos Saliby)

Torres et al. [21] in 1983 started to use the lesser curvature of the stomach to make the pouch, since an anastomosis in the proximal portion of the stomach and along the great curvature was difficult in obese patients and the pouch dilates less when performed along the lesser curvature. They constructed a pouch based on the lesser curvature of the upper stomach with an approximate capacity of 35 ml, a gastrojejunostomy of 18 mm in diameter, and jejunojejunostomy in Roux-en-Y configuration at 90 cm from the gastric pouch.

Another modification was the use of prostheses in the terminal portion of the gastric pouch to prevent its dilation and to decrease the emptying of the stomach. Laws and Piantadosi [22] in 1981 and Linner [23] in 1986 used silicone rings for this purpose. Fobi and Flemming [24], in 1986, practiced a technique by constructing the gastric pouch along the lesser curvature and the jejunojejunostomy 100 cm from the gastroenterostomy applying a silicone ring above this anastomosis. Capella et al. [25], in 1991, described a similar procedure but with a smaller pouch with a capacity of only 15 ml, also with a silicone ring at the distal end of the pouch. Later, they replaced the silicone ring with a polypropylene mesh. They emphasized the idea to limiting gastric emptying in order to obtain better to weight loss.

In order to increase weight loss, Salmon [26] proposed that the Roux limb should be longer than 150 cm as compared to the traditional 100 cm length. Wittgrove et al. [27], in 1996, performed the first laparoscopic gastric bypass (Fig. 23.6).

../images/473262_1_En_23_Chapter/473262_1_En_23_Fig6_HTML.png — Fig. 23.6

Roux-en-Y gastric bypass . (With permission from Debora Gallegos Saliby)

Although the gastric bypass had an advantage over the biliopancreatic diversion and duodenal switch with less diarrhea and liver problems, weight loss was lower, and bypassing stomach and duodenum had the potential of leading to calcium and iron absorption problems in addition to vitamin B₁₂ deficiency.

Pure Restrictive Procedures

Gastroplasty

The first gastroplasty was proposed by Printen and Mason [28] in 1973 (Fig. 23.7). The procedure consisted of horizontal stapling of the gastric fundus, creating a proximal pouch with a stoma next to the great curvature that connected this small pouch with the remaining stomach. This operation was abandoned due to unsatisfactory weight loss, probably related to failure of the stapled line, dilation of the pouch, or enlargement of the communication channel. To avoid leaks of the stapling line, Gomes [29], in 1980, suggested two lines of stapling and reinforced the stoma with Mersilene mesh or polypropylene rings. These modifications were difficult to perform and caused fibrosis, erosions of the mesh into the stomach, and dilation of the pouch. Carey and Martin [30] proposed in 1981 stapling the stomach with two staple lines but with the outlet channel between the small proximal pouch and the rest of the stomach located midway between the lesser and greater curvature, with 1 cm diameter. Despite the efforts mentioned above, the problem of stapling leaks persisted, and gastric dilatation also occurred frequently.