No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
The Magenstrasse and Mill Operation for Morbid Obesity
Abstract
Our aim was to evolve a simpler, more physiological type of gastroplasty that would dispense with implanted foreign material such as bands and reservoirs. The Magenstrasse, or "street of the stomach", is a long narrow tube fashioned from the lesser curvature, which conveys food from the esophagus to the antral Mill. Normal antral grinding of solid food and antro-pyloro-duodenal regulation of gastric emptying and secretion are preserved.
100 patients with morbid obesity (83M, 17F, mean age 40 years) were treated by the Magenstrasse and Mill procedure and followed-up for 1-5 years. Mean preoperative BMI was 46.3 kg/m2, and mean excess weight was 106%.
Operative mortality was 0. Major complications occurred in 4% of patients. There were few side-effects, although mild heartburn was fairly common. Mean weight loss was 38 kg (+/- 14 kg), equivalent to 60% of excess weight, achieved within 1 year of operation, after which no further significant gain or loss of weight occurred.
The Magenstrasse and Mill procedure is the simplest and most physiological gastroplasty yet described. Many of the drawbacks of vertical banded gastroplasty, adjustable banding and gastric bypass are avoided. It is safe, has few side-effects and leads to major and durable weight losses, similar to those produced by other types of gastroplasty.
... Literatûros duomenimis, neseniai ádiegta ir pastaruoju metu atliekama tik keliolikoje pasaulio klinikø, Magenstrasse ir Mill gastrorestrikcinë operacija yra saugi, fiziologiðka ir efektyvi [1][2][3][4]. Tai patvirtino, mûsø duomenimis, pirmà kartà Lietuvoje atlikta ði operacija. ...
... Po ðiø operacijø pacientas turi riboti maisto kieká, laikytis dietos. Po restrikciniø operacijø numetama 50-60% svorio pertekliaus [1][2][3][4]. Tokiø operacijø trûkumai yra ðie: implantuojami svetimkûniai, kartais sutrikdomas normalus maisto slinkimas pro prievarèio þiedà ir tai sukelia dempingo sindromà; be to, po ðiø operacijø praëjus kuriam laikui, skrandis iðsitempa iki pradiniø matmenø ir, gráþus prie þalingø mitybos áproèiø, svorio vël priaugama. ...
... Magenstrasse ir Mill operacija priklauso restrikciniø operacijø grupei. Literatûroje ji vadinama ávairiai: verikalioji gastrektomija, parietalinë gastrektomija, "rankovës" gastrektomija, didþiosios kreivës gastrektomija [1][2][3][4]. Ði svorio maþinimo operacija pradëta dar visai neseniai ir atliekama tiktai keliolikoje pasaulio klinikø. ...
Eugenijus Stratilovas, Povilas Miliauskas, Giedrė Rudinskaitė
Vilniaus universiteto Onkologijos instituto Abdominalinės ir bendrosios chirurgijos
ir onkologijos skyrius, Santariškių g. 1, LT-08660 Vilnius
El paštas: grudinsk@yahoo.com
Antsvoris yra plintanti žmonijos problema, sukelianti rimtų sveikatos sutrikimų. Išleidžiamos milžiniškos lėšos antsvorio sukeliamoms ligoms gydyti. Nutukimas didina riziką susirgti vėžiu ir mirtingumą. Vienas iš veiksmingiausių šios problemos sprendimo būdų yra svorio mažinimo operacijos. Magenstrasse ir Mill operacija priklauso restrikcinių svorio mažinimo operacijų grupei. Literatūroje ši operacija yra vadinama įvairiai: vertikalioji gastrektomija, parietalinė gastrektomija, rankovės gastrektomija, didžiosios kreivės gastrektomija. Iki šiol tai viena iš paprasčiausių ir fiziologiškiausių gastroplastikų. Ją atliekant išvengiama svetimkūnių (gastroplastikos žiedų, talpyklų). Po šios operacijos nepasireiškia daugelis kitoms skrandžio restrikcinėms (žiedu) ir malabsorbcinėms operacijoms būdingų funkcinių sutrikimų ir komplikacijų. Straipsnyje aprašyta, mūsų duomenimis, pirmoji Lietuvoje atlikta Magenstrasse ir Mill operacija. Jos rezultatai ir peržvelgti užsienio literatūros duomenys leidžia teigti, kad operacija yra fiziologiška, efektyvi ir saugi pacientui, techniškai paprasta ir patikima chirurgui. Kaip ir kitos gastroplastikos, ji lemia didelį ir ilgalaikį svorio kritimą.
Pagrindiniai žodžiai: Magenstrasse ir Mill operacija, nutukimas, svorį mažinančios operacijos
Magenstrasse & Mill operation
Eugenijus Stratilovas, Povilas Miliauskas, Giedrė Rudinskaitė
Department of Abdominal and General Surgery and Oncology, Institute of Oncology,
Vilnius University, Santariškių str. 1, LT-08660 Vilnius, Lithuania
E-mail: grudinsk@yahoo.com
Obesity is pervasive problem of humanity which causes serious health problems. The huge sum of money is spent on the treatment of obesity induced diseases. Obesity increased risk of cancer and mortality too. Bariatric operation is one of the most effective methods to manage this problem. Magenstrasse & Mill operation is one of restrictive bariatric operations. This is one of the simplest and most physiological gastroplasty yet described. The implanted foreign material (gastric bands, reservoirs) is avoided. Many of the drawbacks of restrictive and malabsorbtive bariatric operations are avoided. We present the first, as we know, case of Magenstrasse & Mill operation in Lithuania. Our results and data of literature confirm that this is physiological, effective and save operation for the patient, furthermore it is technically simple and secure operation for the surgeon.
Keywords: Magenstrasse ir Mill operation, obesity, bariatric operations
... The search for the ideal procedure leads us to re-evaluate Magenstrasse and Mill (M&M) procedure (Fig. 1). M&M was first described in 1987 by Johnston et al. [11]. In this method, a long narrow gastric tube is fashioned by a stapling along the lesser curvature (Magenstrasse) which drain into the antrum (Mill), avoiding gastric resection. ...
... Weight loss reports of M&M procedure consisted mainly of the studies of the original series. Johnston et al. [11] reported a series of 100 patients operated between 1992 and 1998. Their study reported EWL of 60% at 1 year after M&M, the weight being unchanged over the second and third year. ...
Background
The Magenstrasse and Mill gastroplasty (M&M) is a gastric restrictive procedure without band or stomach resection. Short-term evaluation of the laparoscopic procedure showed low morbidity and satisfactory results on weight loss. Evidence of the validity of the technique in the longer term is scarce.
Methods
Data from patients who underwent M&M procedure from May 2012 to September 2015 were retrospectively reviewed. Preoperative clinical characteristics and data up to 4 years after operation were analyzed.
Results
A total of 132 patients were included in this study with a mean age of 46 ± 13.4 years. The mean body mass index (BMI) at the time of procedure was 43 ± 4.5 kg/m². Mean percentage of excess weight loss (%EWL) was 67, 67, 58, and 57% at 1, 2, 3, and 4 years, respectively. The remission rate for diabetes was 36%. About half of the insulin-dependent patients could stop their insulin treatment. Hypertension was resolved in 33.8% of the patients after 4 years. Incidence of vitamin and mineral deficiency was low throughout the study period, less than or equal to 3% for vitamin B12 and 1% for ferritin. Incidence of gastroesophageal reflux did not exceed 15% during the study. Over 75% of the patients reported a good or very good quality of life following the surgery.
Conclusion
These results confirm the validity of M&M as a bariatric procedure. The low incidence of vitamin deficiencies and gastroesophageal reflux might be the important asset of M&M over other existing techniques.
... In this operation, a long narrow stomach tube (namely, the Magenstrasse) is formed around a bougie, and the stomach is stapled and divided from the incisura angularis to the angle of His. Unlike the previous techniques, it does not leave foreign material within the abdomen (21). It was generally shown that this procedure achieves acceptable weight loss, while preserving gastric emptying mechanisms and thus minimizing possible side-effects, such as vomiting, dumping and diarrhea (22). ...
The purpose of this article is to present a well-known physician and highlight his contribution into an essential, but neglected anatomical feature. George Sclavunos (1869-1954) was a 20th century Greek physician, whose scientific work was a significant milestone in global medical knowledge. In word that means "stomach road". It is a ribbon-like path that extends along the lesser curvature of the stomach from the gastric cardia to the antrum and releases the gastric content directly into the small intestine. Its importance is confirmed by its association not only with drug delivery, but also with anti-obesity surgical techniques. The old German term has come back into common medical usage in view of the commonly performed Magenstrasse and Mill procedure , a form of bariatric surgery. Conclusion: Sclavunos G. managed to observe an anatomical structure that has remained of great importance until today.
... In 1979, Scopinaro performed biliopancreatic diversion (BPD) [7], and in 1986, Kuzmak invented the silastic ring, based on which adjustable gastric banding was described [8]. In 1987, Johnston introduced gastric sleeve resection, the operation that is currently performed most frequently [9]. Originally it was a part of BPD-duodenal switch. ...
Obesity belongs to the most serious metabolic diseases affecting human health due to its pandemic character and significant impact on the risk of cardiovascular and other obesity-related health complications. The treatment is complex and requires multidisciplinary approach. Currently, bariatric-metabolic surgery (BMS) represents the most effective therapy with long-term effect, leading to significant changes in body composition. BMS procedures not only assure weight loss but also positively affect various metabolic and cardiovascular illnesses. As such, the patient may benefit from improvement of several concomitant diseases after mini-invasive BMS intervention. Standardized BMS procedures most frequently used in the world nowadays include sleeve gastrectomy, Roux-en-Y gastric bypass, one anastomosis gastric bypass, and single anastomosis duodeno-lileal bypass with sleeve. The innovative concept is represented by single anastomosis sleeve ileal bypass. Multidisciplinary assessment helps to select patients suitable for BMS and determine the best type of surgical intervention. Endoscopic procedures may serve as a bridge to surgery for polymorbid high-risk patients. Provided the postoperative regimen is strictly adhered to, the results of BMS are excellent. Sustainable weight loss followed by the improvement of associated obesity-related comorbidities results in a significant increase in the overall quality of life.
... In 1988, Hess and Hess (USA) [6] first added the sleeve gatrectomy, and simultaneously the duodenal switch (DS), as a modification to the biliary pancreatic diversion (BPD) to improve clinical outcomes. However, in 1993 Marceau (Canada) [7] first described in Leeds (England) in 1995 [8], is performed using a similar technique to that used for vertical banded gastroplasty (VBG). Major benefits of the M & M procedure include the preservation of the gastric emptying [9], avoidance of foreign materials, and reduced gastrointestinal symptoms such as diarrhea, dumping and vomiting [10]. ...
Background: Laparoscopic sleeve gastrectomy is becoming one of the most common procedures performed for the treatment of morbidly obese patients in the last few years until now.Objectives: This type of surgery needs to be evaluated regarding the various techniques used and the possible post-operative complications with the exact methods of treating them.Patients and methods: A retrospective study was conducted on 240 consecutive morbidly obese patients over a period of 3 years (Feb 2011- Mar 2013) in the Saint Raphael Centre of morbid obesity with an average patient body mass index of 45 (35 - 61). They all underwent LSG, and the decreased weight resulting from surgery was analyzed regarding early and late complications. In 40 of the 240 patients, the gastric band was removed 4 weeks prior to the sleeve operation.Results: Intraoperative difficulties (difficult endotracheal intubation in 7 patients, difficult ports insertion in 6 patients, opening of the staple line in one patient and a bleeding from short gastric vessels in 2 patients). Only 5 patients developed primary haemorrhages (within the first 24 hours post operatively) from the staple line three of them were treated conservatively and the other 2 patients were returned to the theater, no anastomotic leakage or stricture, and no mortality. During a median follow up of 10.6 months (range of 1-3 months), the excess BMI lost reached 52+-23%, and the BMI decreased from 45 +-5 to 33 +- 5 kg/m2. Patient satisfaction scores (1-4) at least one year after surgery was 3.5 +- 0.7.Conclusion: The early results achieved by following the above outlined surgical steps in 240 consecutive patients who underwent LSG indicates show that this type of morbid obesity surgery is an effective, safe and worthwhile choice for morbidly obese patients as a first treatment option, although long-term results are still pending.
... Sleeve gastrectomy may be seen as an extension of the Magenstrasse and Mill procedure [16], with the first open sleeve gastrectomy performed by Doug Hess in 1998 [17] followed 2 years later by the first laparoscopic sleeve gastrectomy by Gagner et al. [1] as part of a DS procedure, they subsequently also reported sleeve gastrectomy after biliopancreatic diversion with DS as a salvage procedure for poor weight loss. [18] Regan et al. reported sleeve gastrectomy as a first step for sufficient weight loss prior to performing a more definite procedure such consumption, NSAID use, metabolic factors such as liver disease (including nonalcoholic fatty liver), coagulopathy, hypertension, and super-obesity. ...
Background
Laparoscopic sleeve gastrectomy has become a standalone procedure for the treatment of severe obesity with excellent short- and mid-term outcome. Staple-line leak is one of the most dreaded complications of this procedure. Following a standardized sequence of critical steps can help decrease the incidence of leaks. In this review, we examine the etiopathogenesis of leaks after laparoscopic sleeve gastrectomy and important implicated technical considerations.
Materials and Methods
A comprehensive literature search of various databases was performed with relevant keywords. The published scientific literature was critically appraised.
Results
Patient-, surgery-, and surgeon-related risk factors should be recognized and modifiable risk factors should be addressed. There are anatomical, physiological, and technical considerations that contribute to the pathogenesis of leaks, based on which a multitude of precautions need to be taken to prevent staple-line leak.
Conclusion
The correct bougie size, distance from the pylorus, stapler size, orientation of staple line, and distance from angle of His and an intraoperative leak test are some of the crucial aspects for a successful outcome after sleeve gastrectomy. Staple size less than that of 1.5 mm should not be used on the stomach, stapling should be initiated at least 5 cm from pylorus and calibrated on a bougie that should not be <32 Fr size. Reinforcing the staple line reduces the incidence of hemorrhage, and current evidence indicates the incidence of leak. Performing a leak test, though offers less sensitivity to predict a leak, does help in detecting the immediate mechanical failure of staple line.
... The isolated form of the SG was described for the first time in 1993, by Johnson et al. and published in 2003. [1] Initially Laparoscopic Sleeve Gastrectomy (LSG) proposed as a first-step procedure in high-risk patients followed by second-step laparoscopic biliopancreatic diversion and duodenal switch or laparoscopic Roux-en-Y gastric bypass, LSG, with the minimally invasive techniques and an increase in surgical experience, become widely considered as a primary restrictive bariatric procedure. The early findings from prospective and retrospective studies have been encouraging, and the potential advantages include excellent weight loss outcomes, co-morbidity resolution, the relative ease of the technique, the avoidance of a foreign body or adjustments, a shortened operating time, and immediate restriction of caloric intake. ...
... [15] The studies reported by Johnston et al., and Sarela et al., have shown an EWL from 61 to 68% after long-term follow-up of 5 years. [16,17] The studies comparing results of resolution of type 2 diabetes mellitus after sleeve gastrectomy, duodenal switch and gastric bypass have shown no significant difference in resolution of diabetes, fasting blood glucose level, and insulin levels. [18] A number of studies have shown resolution of hypertension from 62 to 70% of patients, [19,20] which is comparable to results after gastric bypass and BPD/duodenal switch. ...
... It was converted to a unique and sole technique by Johnston et al. [10] and a minimally invasive alternative had been established afterwards [11] . It had gained popularity since that time as a complete bariatric surgical technique [12] . ...
Background: Obesity is considered as an epidemic globally, which associated with gastroesophageal reflux disease (GERD). Bariatrics surgery tends to reduce GERD manifestations. However, some reports noticed development of GERD after bariatric surgery; the problem which not addressed well in our community. Aim of the work: To estimate incidence of postoperative GERD after laparoscopic sleeve gastrectomy (SG) in patients with no history of GERD symptoms prior to surgery. Patients and Methods: Fifty morbidly obese patients who were scheduled for laparoscopic SG with no history of preoperative symptoms suggesting GERD and normal upper gastrointestinal endoscopy were included. All were assessed clinically and radiologically and followed-up for clinical or endoscopic GERD manifestations. Results: Females were predominant (76.0%). Weight, body mass index and waist/hip ratio were significantly reduced after SG. Postoperative complications were leak (2.0%), wound infection (2.0%), bleeding (2.0%), stricture (4.0%) with overall rate of 8.0%. Incidence of GERD was 22.0% (11 patients; 4 grade A, 5 grade B and 2 grade C). There was significant increase of Waist/hip ratio (both pre-and postoperatively) in patients who developed GERD when compared to those who did not develop GERD. In addition, there was significant increase of sleep related problems and stricture in patients who developed GERD when compared to those did not develop GERD (63.6%, 18.2% vs 17.9%, 0.0% respectively).Conclusion: the incidence of GERD after SG was 22.0%. It was of mild or moderate nature, which denotes safety of SG. The procedure is also associated with marked weight reduction.
... cedure in 1993 by Johnston et al. [2] with a minimally invasive alternative developed in 1999. SG is now considered as a newer stand-alone operation being performed with increasing frequency. ...
... Johnston and colleagues from Leeds, United Kingdom, developed a simpler "Magenstrasse and Mill" (M & M) procedure that would avoid the use of implanted foreign material such as bands and reservoirs and overcome the disappointing results of the VBG procedure and the morbidity of the gastric bypass (6). At first, a 40-French bougie was used, but because of unsatisfactory weight loss, the size was reduced gradually, and they found that a 32-French bougie resulted in a 63% excess weight loss at 3 years. ...
... Intestinal obstruction can cause an increase in intra-gastric pressure and weight loss [166][167][168]. Other surgical procedures, in which the stomach fundus is removed, such as Nissen fundoplication, proximal gastrectomy, magenstrasse and mill and gastric sleeve plication all lead to weight loss and likely increased intra-gastric pressure [169][170][171][172][173]. Resection of the stretchable portion of the rat stomach (forestomach) partially reproduces weight loss effects of VSG in rats, possibly due to reduced compliance and capacity of stomach to distend and accommodate gas pressure [174]. ...
Roux-en-Y gastric bypass (RYGB) surgery is one of the most effective treatments for obesity and type II diabetes. RYGB was originally believed to work by mechanically restricting caloric intake or causing macronutrient malabsorption. However, such mechanical effects play no role in the remarkable efficacy of gastric bypass. Instead, mounting evidence shows that altered neuroendocrine signaling is responsible for the weight reducing effects of RYGB. The exact mechanism of this surgical response is still a mystery. Here, we propose that RYGB leads to weight loss primarily by inducing a functional shift in the gut microbiome, manifested by a relative expansion of aerobic bacteria numbers in the colon. We point to compelling evidence that gastric bypass changes the function of the microbiome by disrupting intestinal gas homeostasis, causing excessive transit of swallowed air (oxygen) into the colon.
... Indiquée initialement chez les patients ayant un BMI supérieur à 60 kg/m 2 avec des co-morbidites sévères, le DS était pratiqué en deux temps: le premier était une chirurgie réductrice réalisant le manchon gastrique dans le but de réduire le poids et l´impact des comorbidités ; puis, 6 mois plus tard, le deuxième temps est une chirurgie de malabsorption. Constatant que la SG réduisait rapidement et significativement le poids de ces patients Johnston et al. [4] ont proposé en 1993 la SG comme une technique propre non suivie par le court-circuit intestinal. ...
... Sleeve patients also report a significant incidence of reflux (10-20%) [4] which may adversely affect the quality of life resulting in long-term medical therapy, or conversion to a gastric bypass. The gastric clip is a new device used to create a tubular gastric pouch similar to the sleeve gastrectomy and to the Magenstrasse and Mill (M&M) procedure [5,6], resulting in similar early 2-year results (Fig. 9), but without stapling, cutting, and without changing the anatomy. It is interesting to note that the M&M procedure showed stable weight loss results up to 5 years of 60%. ...
Background:
Morbid obesity remains one of society's significant medical dilemmas. It is rapidly worsening and expected to affect 35% of the US population by the year 2020. Common current bariatric procedures exist and include, but not limited to, the adjustable gastric band, gastric bypass, and the sleeve gastrectomy. Although beneficial to morbidly obese patients, they also alter the patient's anatomy and involve resections, or require maintenance. The goal of the trial is to show a new minimally invasive vertical gastric clip technique that produces significant weight loss but requires no resection, no change in anatomy, and is reversible.
Methods:
From November 2012 to February 2016, prospective collected data from 117 patients was included in the gastric clip trial. The clip consists of a silicone-covered titanium backbone with an inferior hinged opening that separates a medial lumen from an excluded lateral gastric pouch. The inferior opening allows the gastric juices to empty from the fundus and the body of the stomach into the distal antrum.
Results:
Weight loss and comorbidities were evaluated among 117 patients over a 39-month period. 66.7% excess weight loss was seen with minimal adverse events. Average length of surgery was 69 min. Average length of stay was 1.3 days. Fifteen of the originally implanted clips were electively removed based on the original protocol, and the other two were removed for displacement of the device.
Conclusion:
The vertical, gastric clip trial has shown that excellent weight loss can be achieved without some of the complications seen with historical bariatric procedures. This clip is placed without requiring stapling, resection, malabsorption, change in anatomy, or maintenance. It is also easily reversible.
... The reported initial weight loss after SG spans a wide range, between 33 and 83 % [13,14]. In a prospective study of 100 patients, Johnston et al. presented a %EWL of 60 % after 5 years [15]. That study group achieved a %EWL of 60.3 % after 12 months and 63.8 % after 24 months. ...
Abstract Background The aim of this systematic study was to investigate patient outcomes and nutritional deficiencies following sleeve gastrectomy (SG) during a median follow-up of two years. Methods Over a period of 56 months, all consecutive patients who underwent SG were documented in this prospective, single-center, observational study. The study endpoints included complication rates, nutritional deficiencies and percentage of excess weight loss (%EWL). Results From September 26, 2005 to May 28, 2009, 100 patients (female: male = 59:41) with a mean age of 43.6 years (range: 22–64) and a preoperative BMI of 52.3 kg/² (range: 36–77) underwent SG. The mean operative time was 86.4 min (range: 35–275). Major complications were observed in 8.0 % of the patients. During the follow-up period, 25 patients (25.0 %) underwent a second bariatric intervention (22 DS and 3 RYGBP). Out of the total 100 patients, 48 % were supplemented with iron, 33 % with zinc, 34 % with a combination of calcium carbonate and cholecalciferol, 24 % with vitamin D, 42 % with vitamin B12 and 40 % with folic acid. The patients who received only a SG (n = 75) had %EWL of 53.6, 65.8 and 62.6 % after 6, 12 and 24 months, respectively. Conclusions SG is a highly effective bariatric intervention for morbidly obese patients. Nutritional deficiencies resulting from the procedure can be detected by routine nutritional screening. Results of the study show that Vitamin B12 supplementation should suggested routinely.
... Symptomatic biliary reflux, gastritis, and esophagitis have been reported after minigastric bypass (MGB) as well [1,9,13]; however, the longer, lesser curvature-based gastric pouch is believed to reduce reflux to a greater extent compared with the Mason loop gastric bypass [5,14,15]. The long pouch has some resemblance with the Magenstrasse-Mill operation [16] but is more effective due to the added bypass. Nevertheless, concerns have been raised about chronic alkaline reflux and the risk for gastric cancer in the long term [6,13,17,18]. ...
Introduction Roux-en-y gastric bypass is a successful weight loss surgery together with a great impact on metabolic syndrome. Laparoscopic minigastric bypass is a new emerging bariatric surgery procedure with current debates on its efficacy and safety. Objectives The aim of this study was to evaluate the effect of laparoscopic minigastric bypass on weight loss, safety, and associated metabolic diseases. Patients and methods The study was performed in Menoufia University Hospital and other private hospitals in Kuwait. All patients underwent laparoscopic minigastric bypass and were followed up for 18 months. Its impact on BMI, %excess weight loss (%EWL), and associated metabolic diseases were reported and analyzed at 6, 12, and 18 months. Results A total of 80 patients were included in this study, of whom 49 were female. A total of 58 patients were diabetic, 62 patients were hypertensive, and 69 patients were dyslipidemic. The mean operative time was 92 ± 11.73 min. The mean %EWL was 77.3 ± 9.8%. The mean hospital length of stay was 3 days. One patient had anastomotic leak and two patients had biliary gastritis and were managed with Roux-en-Y gastric bypass. One patient showed marginal ulcer. A total of 47 patients with type 2 diabetes returned to normal glucose level. A total of 51 hypertensive patients became normotensives. A total of 59 patients showed complete improvement in lipid profile after 18 months. Conclusion Minigastric bypass is provisionally effective as other standard bariatric surgery procedures, with good impact on associated metabolic diseases.
Sleeve gastrectomy has rapidly gained recognition as an effective and safe treatment for obesity and related diseases. With minimal anatomical changes, sleeve gastrectomy leads to substantial weight loss through a combination of mechanical restriction and a shift in gut hormone regulation. Thanks to its safety and technical simplicity, it has also proven beneficial for high-risk patients with severe comorbidities. Adequate perioperative management, careful patient selection, expertise in surgical techniques, and knowledge of potential pitfalls play crucial roles in ensuring successful outcomes.
Although the duodenal switch makes up less than 1% of bariatric procedures performed today, it is recognized to be the most effective weight loss procedure for the super morbidly obese population. Roux-en-Y gastric bypass remains the procedure of choice for bariatric patients suffering from severe gastroesophageal reflux disease; however, the duodenal switch offers a reasonable alternative in the morbidly obese patient with a BMI ≥50 kg/m2 and mild symptomatic reflux.
Duodenal switch is currently the most powerful bariatric operation. The bases of its functioning is the perfect mixture of a restrictive but also metabolic procedure, the sleeve gastrectomy, together with a hypo-absorptive intestinal bypass, which preserves the pylorus and eliminates the whole jejunum from the alimentary route. Long-term results offer a maintained weight loss greater than 30% of total weight loss, and a remission of the metabolic disease in more than 80% of the cases. Quality of life can be jeopardized with a wrong selection of the patient, an insufficient supplementation, or if the patient is lost to follow-up. A thorough preoperative study and an adequate length of the limbs for each patient can warrant a low rate of complications or secondary effects.KeywordsDuodenal switchSleeve gastrectomyPylorusMalabsorption
Surgery for severe obesity started in the 1950s. The development of different operations including variants of jejunoileal bypass, gastric bypass, gastric restrictive surgery, and biliopancreatic diversion are discussed in this chapter. The development of endoscopic procedures such as endoscopic sleeve gastroplasty and alternative approaches including neuromodulation are also presented.
The sleeve gastrectomy (SG) procedure was evolved from the biliopancreatic diversion- duodenal switch procedure in order to reduce complication rates and improve outcomes for patients. The complications can be categorised as early, medium, and long-term. A common mid-late complication that is encountered in patients post-SG is gastro-oesophageal reflux disease (GERD). GERD is a prominent complication that patients will often complain about, and symptoms include chest pain, dysphagia, heartburn, regurgitation, chronic cough, and laryngitis. With the rise in obesity, and the already high prevalence of GERD in these populations, this is a significant cause of morbidity in western populations and is likely set to worsen. In this chapter, we will cover the pathophysiology of GERD, as well as management options for patients presenting with it post sleeve.
Purpose of review:
Current bariatric surgical practice has developed from early procedures, some of which are no longer routinely performed. This review highlights how surgical practice in this area has developed over time.
Recent findings:
This review outlines early procedures including jejuno-colic and jejuno-ileal bypass, initial experience with gastric bypass, vertical banded gastroplasty and biliopancreatic diversion with or without duodenal switch. The role laparoscopy has played in the widespread utilization of surgery for treatment of obesity will be described, as will the development of procedures which form the mainstay of current bariatric surgical practice including gastric bypass, sleeve gastrectomy and adjustable gastric banding. Endoscopic therapies for the treatment of obesity will be described. By outlining how bariatric surgical practice has developed over time, this review will help practicing surgeons understand how individual procedures have evolved and also provide insight into potential future developments in this field.
Background: Laparoscopic sleeve gastrectomy (LSG) is a recent bariatric procedure emerging from duodenal switch that itself emerged from the standard biliopancreatic diversion. In this chapter, I chronologically address each step and development leading to laparoscopic sleeve gastrectomy. Conclusion: It has been 20 years since the use of laparoscopic technique to construct a sleeve gastrectomy, and the development has been rapid and short and has spread worldwide.
Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the world, accounting for more than 50% of all bariatric procedures (Ponce J, DeMaria EJ, Nguyen NT, Surg Obes Relat Dis 12:1637–1639, 2016). LSG is a safe and effective primary bariatric procedure with durable weight loss. We believe LSG should not be called “easy” and should be performed only by surgeons trained in bariatric surgery. The highlights of a safer SG systematization are based in minimum 36Fr bougie calibration, starting 2–5 cm from the pylorus, keeping about 1 cm distance from esophagus and using some kind of staple line reinforcement.
During the last 20 years, morbid obesity has reached epidemic proportions around the world. More than one in two adults and one in six children are overweight or obese. It is estimated that there are 671 million people who are obese (BMI > 30) in the world.
Aim:
Bariatric surgery is an important option when life-style modification, diet, and medical treatment are inadequate in lose weight. Bariatric surgical methods have gained popularity in recent years. In this paper, we compared the Magenstrasse and Mill(M&M) technique, with performing a simpler and more physiological type of gastroplasty without implanted foreign material such as band and reservoir, to the Sleeve Gastrectomy (SG) technique. This study aimed to determine the effects of the M&M for obesity on the rabbits in comparison with the SG, which is accepted as a standard bariatric technique with creating a gastric tube.
Material and methods:
The study was approved by the University of Van Yuzuncu Yıl Regional Committee of Ethics (Institutional Animal Care and Use Committee). 20New Zealand Rabbits underwent operations. After prestudy with 2 rabbits, the remaining 18 rabbits were divided into 2 groups; Group 1 (SG) and Group 2 (M&M).
Results:
Group 1 rabbits were observed to lose weight in all, while Group 2 rabbits; 2 of them died, 5 of them lost weight, 2 of them gained weight. When the pre and post-operative weight of the rabbits were compared; preoperative median weight values of 9 rabbits in Group 1 were significantly higher than postoperative values. On the other hand, there was no significant change in the mean weight of Group 2 of 7 rabbits (living up to 8weeks). The mean weight of rabbits undergoing standard SG was significantly lower than the M&M technique.
Conclusion:
We believe that this animal experimental study, which we conducted intending to compare M&M and SG techniques, will contribute to the literature as a pilot study and determine the survey of M&M technique as a pioneer in other studies.
Key words:
Bariatric surgery, Magenstrasse and Mill gastroplasty, Sleeve gastrectomy.
The renewed interest in surgery for morbid obesity happened not only due to increase in the prevalence of obesity, but also due to key changes and improvement in surgical technique that led to more efficient, safer, and less morbid operations. The knowledge of the history of bariatric surgery is thus essential to perform the most adequate technique to treat a very high prevalent disease. This chapter reviews the history of bariatric surgery.
The surgical treatment of morbid obesity and the numerous medical conditions associated with obesity have evolved over the past 58 years since the first operation specifically designed to create weight loss was performed and reported. Many different procedures and innumerable variations of procedures have since come and gone. The transition to laparoscopic procedures has dramatically improved recovery time, discomfort, cosmesis, and many complications. Lessons learned during the evolution of bariatric and metabolic surgery are important to remember in order to continue to improve safety and efficacy.
It is becoming more common for surgeons to manage obese patients in the acute setting with non-bariatric surgical emergencies. Obesity presents a diagnostic challenge for the acute care surgeon. Given the emergent need for intervention and the subsequently minimized opportunity for preoperative selection and optimization, obese patients requiring emergency surgery represent a complex patient population at high risk for perioperative morbidity. There is nothing unique about perforations of the upper gastrointestinal tract in the obese population versus other patients but there are specific additional considerations that the acute care surgeon should be aware of. It is particularly important that obese patients requiring emergency surgery are managed by an anesthetist experienced in the care of the obese along with an experienced surgeon in order to minimize the operative time and the risk of complications. Bariatric surgical expertise seems to favorably impact hospital length of stay and the application of more minimally invasive approaches in cases not routinely done laparoscopically.
The continuous rise in the incidence and prevalence of obesity along with its associated devastating economic burden has been a serious threat to global public health. Over the last few decades, unsatisfactory results with conservative treatment of obesity such as diets, behavior modification, pharmacologic therapy, alone or in combination, have left bariatric surgery as the only, most effective option for treatment of obesity and its related comorbid diseases. Surgeons have been constantly looking for safer, more effective, and more persistent bariatric procedures, to aid in the rapid growth and advancement of this relatively young surgical branch. The introduction of minimally invasive techniques in the bariatric field can be regarded as the turning point in the history of this practice. The advantages offered by laparoscopic bariatric procedures compared to open surgeries were so pronounced that a massive increase in patient demand and number of surgeries performed worldwide ensued.
Graphene oxide nanoparticles/polythreonine polymer as a nano-coating on AZ91E Mg alloy was considered as a new temporary implant for gastrectomy applications. This coating as a novel one is decomposable and has bio-viability possessions. Various electrochemical measurements were utilized for corrosion performance estimation of Mg alloy in peritoneal fluid with time of dipping. It was recognized that the nano-coating is fixed for 20 days giving unexpected high corrosion resistance. All experimental outcomes were verified by scanning electron microscope (SEM) and Energy dispersive X-ray (EDX) techniques. Moreover, in vitro antibacterial, and cytotoxicity of metal with and/or without coating utilizing MTT assay for cell viability analysis were achieved.
Surgery of obesity (bariatric surgery) as a separate area of medical science dates back its history from the middle of the previous century. The foundation for its development was based on the ideas of physiology of digestion, the causes and mechanisms of its disturbances that had been formed at that time. An important role was played by achievements in related areas of medicine: anesthesiology, transfusiology. Before that effective antibacterial drugs have already been created. Rich experience in various fields was brought for medicine by the Second World War. The return of society to pre-war cultural values became the impetus for bariatric surgery genesis. For two first decades, the main method of surgical treatment of overweight was shunting operations in the small intestine, aimed at reducing absorption of nutrients (malabsorption techniques). However, a significant number of negative side effects gradually forced to abandon this group of procedures and were the basis for the search for other options in surgical interventions. Since the late 60-es of the 20th century for two decades, methods have been actively developed that limited the flow of nutrients (restrictive approach). The main idea in the development of this group of operations was to reduce the volume of the stomach. At the same time, attempts were made to combine both malabsorptive and restrictive mechanisms in one technique. By the beginning of the 90-es, practically all the available variants of surgical interventions have been proposed and introduced into clinical practice. At the same time, minimally invasive surgical technologies began to be actively introduced into this area of medicine. By the beginning of the 21st century almost all surgical techniques have been adapted to endovideo- (laparoscopic-) surgery. Over the past decade, intraluminal (endoscopic) methods for reducing stomach volume and reducing nutrient absorption have been developed.
Bariatric surgery exists for more than 60 years and has been growing extensively ever since, along with the obesity epidemic. If bariatric surgeons fail to embrace the current morbidly obese population, surgical strategies are questioned because multiple variations and evolutions have been described, while mishaps and tough discussions occurred. For the time being, the most popular procedures are performed through the laparoscopic approach: Roux-en-Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric adjustable banding (LAGB). The laparoscopic sleeve gastrectomy, now a stand-alone intervention, was originally suggested as a first step of the gastrointestinal anastomosis with duodenal switch, which is still performed as either a second step or a primary operation. Other new interventions such as gastric plication and one-anastomosis types of gastric bypass have insufficient backup evidence at this moment. Solid evidence exists in favour of global efficacy, long-term weight loss maintenance, acceptable rate of side effects, cost-effectiveness and improvements of associated diseases, especially type 2 diabetes and metabolic syndrome.
From a symbol of beauty and wealth to a burden for negative stigma, the perception of overweight and severe obesity has transformed over the years, until our current times; it is now recognized as a multifactorial and potentially dangerous disease.
Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure in the United States, accounting for more than half of all bariatric procedures. There are several factors that have led to its rapid traction since its inception. Firstly, in comparison to the laparoscopic adjustable gastric banding, which was still popular at the time, the sleeve was a simple yet a metabolic operation, activating significant hormonal pathways that lead to changes in eating behavior, glycemic control, and gut functions, all without the need for an implant. Secondly, in contrast to Roux-en-Y gastric bypass (RYGB), LSG is less technically complex and therefore more appealing to patients. Being limited to the stomach makes it simpler and evades the risk of internal hernias and malabsorption complications such as micronutrient and protein deficiency. Yet, if needed, it could always be converted to a malabsorptive operation by simply performing the intestinal part of these operations.
Bariatric surgery is a medical specialty dedicated to the treatment of obesity and its comorbidities through surgical procedures. We present a detailed collection on the history and evolution of laparoscopic sleeve gastrectomy over the course of 20 years. The gastric sleeve induces weight loss by several mechanisms. It significantly reduces gastric chamber size and decreases the secretion of the hormone called ghrelin, thus promoting quicker satiety and decreasing appetite. Karamankos S.N. found a greater percentage of excess-weight loss with gastric sleeve than with bypass in a 1-year follow-up (69,7% ± 14,6% versus 60,5% ± 10,7%). A 2011 meta-analysis by Padwal R. et al. concluded that there is a greater decrease in body mass index in patients undergoing sleeve gastrectomy than with gastric bypass, -10,1 kg/m2 and -9 kg/m2, respectively.
Obesity and diabetes mellitus are becoming 2 of the most leading risk factors that threaten public health worldwide. Obesity is a very strong but preventable risk factor for getting type 2 diabetes. Laparoscopic sleeve gastrectomy (LSG) has been a main approach to the surgical management of morbid obesity and type 2 diabetes but its role remains undefined. Here, we overviewed the clinical outcomes and regulatory mechanisms of LSG, aiming at providing thorough theoretical supports and effective technical guidance to the pathogenesis, prognosis, treatment and prevention of type 2 diabetes with obesity. Futher more, the prospectives and main drawbacks (such as considerable heterogeneity and unicity, little comparability and relevance) of LSG are also discussed.
Obesity has been a problem for centuries and it has increased to a worldwide epidemic with severe implications on individual and public health. The history of bariatric surgery was born out of observations leading to investigation and advancement. Many dedicated surgeons searched for an ideal procedure to treat the rapidly growing epidemic of morbid obesity and alleviate the burden of comorbid conditions. Treating obesity has been challenging and advancements in surgery have led to increased success and durable results. Early operations were plagued by high morbidity and mortality. The ideal procedure must have low complication risk, both in short and long term, as well as durable and lasting results. Several techniques have been developed in the last 70 years benefiting from the advent of laparoscopy. Minimally invasive techniques created a revolution in bariatric surgery and have improved safety profiles leading to increased popularity and application. Although complex bariatric procedures can be performed with mortality rates similar to cholecystectomy, postoperative complications resulting from the altered anatomy and physiology must be considered. Advancements in techniques and quality monitoring from national and international societies have improved and standardized the delivery of bariatric surgery worldwide. The effects on metabolic conditions have widened the breadth of minimal invasive bariatric surgery into the field of metabolic surgery.
Die laparoskopische Sleeve-Gastrektomie ist die bariatrische Operation mit der aktuell am schnellsten ansteigenden Fallzahl weltweit. Die relativ kurze Operationszeit, ein vermeintlich technisch einfacher operativer Eingriff sowie die beeindruckenden Effekte im postoperativen Verlauf sind die treibende Kraft in der raschen Weiterentwicklung dieser Operationsmethode. Gerade in der Beliebtheit der operativen Methode liegt die Gefahr, die potentiellen frühen und späten postoperativen Komplikationen zu unterschätzen. Das Kapitel soll helfen, das tiefere Verständnis für die Methode und einen funktionierenden operativen Standard für das eigene Zentrum zu entwickeln.
Introduction. Obesity is a disease whose incidence is increasing in our population, including the young. The different surgical options offer good results, when the procedure is individualized according to the characteristics of the patient, but there are associated morbidity and mortality and high costs determined by the use of mechanical sutures. Materials and methods. We report 100 patients that underwent a new restrictive surgical procedure, an original laparoscopic operation that we have called the Sales´gastric surset. Analysis of this series was performed through review of the clinical records, follow-up examinations, and telephone intervieat. Results. One hundred patients were operated on during the period August 2006 and August 2007. There were 56 women and 44 men, with ages ranging from 15 to 64 years, and body mass index ranging from 32 to 45 kg/m2. Mean weight loss was 26.44 kg, corresponding to e mean of 69.61% Discussion. This new original procedure represents a valid alternative in bariatric surgery, is easy to perform, and is associated with lesser morbimortality rates. Because it is performed as an ambulatory operation and does not require the use of mechanical sutures, costs and hospital stay are minimized. It can be easily offered in our hospitals and augments the possibility of bariatric surgery, especially in low income persons.
Obesity has been a problem since medieval times, but only in the latter 20 years it has been recognized as a worldwide epidemic. Treating obesity is challenging and difficult, but surgery has led to an increased success and novel insights on the pathophysiology of obesity. Several surgical techniques have been developed during the last 50 years and the advent of laparoscopic surgery has increased its safety, efficacy and demand from the population. Nowadays, the ever increasing and successful use of novel techniques have been responsible for several changes in the established treatment paradigms.
The surgical treatment of morbid obesity and the numerous medical conditions associated with obesity has evolved over the past 58 years since the first operation specifically designed to create weight loss was performed and reported. Many different procedures and innumerable variations of procedures have since come and gone. The transition to laparoscopic procedures has dramatically improved recovery time, discomfort, cosmesis, and many complications. Lessons learned during the evolution of bariatric and metabolic surgery are important to remember in order to continue to improve safety and efficacy.
In light of the epidemic of obesity impacting our society, the treatment of morbid obesity with surgery has obtained mainstream status. In fact, for many patients and their physicians, bariatric surgery is recognized as the preferred course of action. Coding for the most commonly performed procedures remains a relatively straightforward process. Although, at times, obtaining approval by payors can prove problematic, the benefits of bariatric surgery have become clear. Less commonly performed procedures including revisional operations necessitate a broader understanding of coding to determine which options are best. This chapter will review the coding for initial, commonly performed procedures and introduce the reader to options for more complex bariatric surgical procedures.
Laparoscopic sleeve gastrectomy is a bariatric surgical procedure created for long-term weight loss and improvement of metabolic syndrome abnormalities in morbidly obese patients. It has been shown to demonstrate durable results compared with other bariatric procedures. This article aims to describe the surgical technique and perioperative care for patients undergoing laparoscopic sleeve gastrectomy based on current scientific literature and best standard practices.
Obesity is now one of our major public health problems. Effective and acceptable treatment options are needed. The Lap-Band system is placed laparoscopically and allows adjustment of the level of gastric restriction.
A prospective study of 709 severely obese patients was conducted over a 6-year period at a university-based multidisciplinary referral center. After extensive preoperative evaluation, patients with a body mass index > 35 were treated by Lap-Band placement. Close follow-up with progressive adjustment of gastric restriction continued permanently. Medical co-morbidities were monitored as part of comprehensive prospective data collection.
There have been no deaths perioperatively or during follow-up. Significant perioperative adverse events occurred in 1.2% only. Reoperation has been needed for prolapse (slippage) in 12.5%, erosion of the band into the stomach in 2.8% and for tubing breaks in 3.6%. A steady progression of weight loss has occurred through the duration of the study with 52 +/- 19% EWL at 24 months (n = 333), 53 +/- 22% EWL at 36 months (n = 264), 52 +/- 24% EWL at 48 months (n = 108), 54 +/- 24% EWL at 60 months (n = 30), and 57 +/- 15% EWL at 72 months (n = 10). Major improvements have occurred in diabetes, asthma, gastroesophageal reflux, dyslipidemia, sleep apnea and depression. Quality of life as measured by Rand SF-36 shows highly significant improvement.
Placement of the Lap-Band system provides safe and effective control of severe obesity. The effect on weight loss is durable and is associated with major improvement in health and quality of life. It has the potential to provide a broadly acceptable option for this common and serious disease.
This study investigated effects of the Magenstrasse and Mill gastric restrictive procedure for obesity on weight loss and risk of coronary heart disease (CHD). Eleven patients who were defined as high risk by the Framingham Heart Study risk score underwent surgery and were followed up for three years. Large reductions in weight, blood pressure and CHD risk were obtained.
Background:Stomal ulcer is a serious complication of gastrogastric fistula following Roux-en-Y gastric bypass for obesity.Study Design:A 1–8 year continuous followup of 499 patients with gastric bypass in continuity (GB) and isolated gastric bypass (IGB) documented the incidence of fistula formation, development of stomal ulcer, stimulation of acid production within the gastric pouch, and response to treatment.Results:In 123 GB patients, staple line disruption occurred in 36 (29%) and stomal ulcer occurred in 20 (16%). Gastrogastric fistula with stomal ulcer was significantly lower in 376 patients who underwent IGB, (ie, 11 patients [3%]). Significantly larger amounts of acid, a lower pH, and a greater time with a pH less than 2 were found in the gastric pouches of patients who developed stomal ulcer after Roux-en-Y gastric bypass. All patients had a perforated staple line. Successful closure of the staple line significantly decreased acid production and pH in the gastric pouch when tested before and after remedial operation with healing of stomal ulcers.Conclusions:Stomal ulcer after gastric bypass is the result of acid production in the bypassed stomach in the presence of a gastrogastric fistula. Separation of the gastric pouch from the main stomach decreases the incidence of fistula formation and stomal ulcer but does not eliminate it. Interposition of a well vascularized organ, the jejunum between the pouch and main stomach, is an attractive solution for patients who require remedial operations on the stomach and possibly for primary operations as well.
The safety and lifelong success of vertical banded gastroplasty in treatment of severe obesity is highly dependent upon the technique of the operation. Intra-operative spatial orientation, standardized measurement of the pouch, external outlet calibration and stabilization with polypropylene mesh are all important components of quality control.Copyright © 1997 S. Karger AG, Basel
Objective:
This report documents that the gastric bypass operation provides long-term control for obesity and diabetes.
Summary background data:
Obesity and diabetes, both notoriously resistant to medical therapy, continue to be two of our most common and serious diseases.
Methods:
Over the last 14 years, 608 morbidly obese patients underwent gastric bypass, an operation that restricts caloric intake by (1) reducing the functional stomach to approximately 30 mL, (2) delaying gastric emptying with a c. 0.8 to 1.0 cm gastric outlet, and (3) excluding foregut with a 40 to 60 cm Roux-en-Y gastrojejunostomy. Even though many of the patients were seriously ill, the operation was performed with a perioperative mortality and complication rate of 1.5% and 8.5%, respectively. Seventeen of the 608 patients (< 3%) were lost to follow-up.
Results:
Gastric bypass provides durable weight control. Weights fell from a preoperative mean of 304.4 lb (range, 198 to 615 lb) to 192.2 lb (range, 104 to 466) by 1 year and were maintained at 205.4 lb (range, 107 to 512 lb) at 5 years, 206.5 lb (130 to 388 lb) at 10 years, and 204.7 lb (158 to 270 lb) at 14 years. The operation provides long-term control of non-insulin-dependent diabetes mellitus (NIDDM). In those patients with adequate follow-up, 121 of 146 patients (82.9%) with NIDDM and 150 of 152 patients (98.7%) with glucose impairment maintained normal levels of plasma glucose, glycosylated hemoglobin, and insulin. These antidiabetic effects appear to be due primarily to a reduction in caloric intake, suggesting that insulin resistance is a secondary protective effect rather than the initial lesion. In addition to the control of weight and NIDDM, gastric bypass also corrected or alleviated a number of other comorbidities of obesity, including hypertension, sleep apnea, cardiopulmonary failure, arthritis, and infertility. Gastric bypass is now established as an effective and safe therapy for morbid obesity and its associated morbidities. No other therapy has produced such durable and complete control of diabetes mellitus.
The efficacy of gastric surgery for morbid obesity has often been questioned because of incomplete long-term patient follow-up. Between 1977 and 1984, 537 consecutive patients received either a gastric bypass with a Roux-en-Y gastrojejunostomy, an unbanded gastrogastrostomy, or a vertical banded gastroplasty. The follow-up period was 5 years for all patients who underwent Roux-en-Y gastrojejunostomy and unbanded gastrogastrostomy and 3 years for all patients who underwent vertical banded gastroplasty. Only 5.8% of all patients were unavailable for this late follow-up. The unbanded gastrogastrostomy was not an effective weight-control operation. Both the Roux-en-Y gastrojejunostomy and vertical banded gastroplasty provided effective long-term weight control. Although the Roux-en-Y gastrojejunostomy gave slightly better weight control than the vertical banded gastroplasty, the more simple, safe, and physiological vertical banded gastroplasty is the procedure of choice for most patients with morbid obesity.
Vertical banded gastroplasty has evolved from gastric bypass and earlier forms of gastroplasty as a safe and effective gastric reduction procedure for the treatment of morbid obesity. This article provides a step-by-step description of the technique. Spatial orientation by use of landmarks such as an Ewald tube in the esophagus, the angle of His, and a Penrose drain around the esophagus is important in avoiding injury to adjacent structures. Careful measurement of the pouch volume at a pressure of 70 cm H2O is necessary. For patients between 170 and 225 per cent of ideal weight, a 5.0 cm circumference collar is used around the outlet. For heavier patients, a 4.5 cm collar is used. Bypass is not necessary because weight control depends on a small pouch and stoma.
Since 1966 a total of 130 gastric bypasses and 56 gastroplasties were performed for control of severe exogenous obesity. Gastric bypass excludes the distal 90% of stomach and establishes gastrointestinal continuity through short-limb retrocolic gastroenterostomy. Gastroplasty maintains continuity of stomach through greater curvature tube 1.0 to 1.5 cm in diameter. Both provide extremely small proximal stomach pouches as reservoir, which empties slowly through a snug outlet into distal gastrointestinal tract. Gastric bypass provides added deterent of dumping when excessive carbohydrate-rich foods are ingested.
While both were effective in producing weight loss, gastric bypass was associated with more progressive and sustained weight reduction. Overall mortality was 4.6% for gastric bypass and 2% for gastroplasty. This mortality occurred in the first three years of this six-year experience. Both operations can now be performed within acceptable limits of mortality and morbidity, and neither has been followed by long-term complications associated with various intestinal short-circuiting procedures.
Consistent weight reduction by gastroplasty requires precise construction of an appropriately sized stoma that will not dilate. The technique described constructs such a stoma around a 32 French Hurst dilator with an external ring of Silastic tubing over polypropylene suture.
With the operative modifications and dietary guidelines described in this report, death and complications from gastric bypass were minimal, and weight loss was marked. Ninety per cent of a group of 69 patients lost more than half of their excess weight within the first two years after operation. Stringent preselection of patients for operation was crucial to the success of the operation, and marked alterations of eating behavior was necessary to achieve the weight loss. Mild electrolyte deficiencies and hypovitaminosis occurred in up to one-fourth of the patients. While none of these abnormalities was harmful to the patients, and all were easily corrected, their occurrence demonstrates the importance of long-term follow-up after the operation. We conclude that gastric bypass, with a 50-60 cc pouch and a small (1-1.2 cm) gastrojejunostomy, remains the operation of choice for morbid obesity.
Prospective evaluation of 114 obese patients (96 women, 18 men) undergoing vertical banded gastroplasty over a 5-year period was undertaken. The age range was 17-58 (median 37) years, median weight 119.3 (range 79-216) kg, mean(s.d.) proportion of excess body-weight 104.1 (34.9) per cent and median body mass index (BMI) 44.8 (range 33.2-77.7) kg/m2. Three gastric outlet stoma circumferences were used: 5.5 cm (31 patients), 5.0 cm (28) and 4.75 cm (55). A total of 109 patients (95.6 per cent) were available for follow-up. At 1 year after operation, 54 patients (59 per cent) had lost greater than 50 per cent of excess body-weight. No patient lost less than 25 per cent of excess body-weight, and the median BMI was 32.5 (range 21.3-47.8) kg/m2. The operative mortality rate was zero, but three patients (2.6 per cent) with gastric leakage required surgical revision. Vertical banded gastroplasty is a relatively safe and simple procedure that produces significant and sustained weight reduction in the majority of morbidly obese patients.
To present our experience with a group of obese patients treated by vertical banded gastroplasty.
Open prospective study.
Teaching hospital, Sweden.
198 Morbidly obese patients operated on between 1986 and April 1994.
Modified Mason vertical banded gastroplasty.
Weight loss, mortality, early and late morbidity, and reoperation.
The mean (SEM) age was 40 (0.7) and 149 of the 198 were women (75%). 22 Patients (11%) were lost to follow-up. Five patients died (3%), one soon after operation. Mean (SEM) body mass index (BMI) was 44.4 (0.5) preoperatively and this decreased to 32.6 (0.6) after four years (n = 99) and 33.8 (1.3) after seven years (n = 20). 21 patients developed 24 early postoperative complications, and 31 patients were reoperated on 41 times for late complications.
All patients lost weight after vertical banded gastroplasty, and their weight continued to decrease during a seven-year follow-up. This was somewhat offset by the high rate of reoperations required.
Stomal ulcer is a serious complication of gastrogastric fistula following Roux-en-Y gastric bypass for obesity.
A 1-8 year continuous followup of 499 patients with gastric bypass in continuity (GB) and isolated gastric bypass (IGB) documented the incidence of fistula formation, development of stomal ulcer, stimulation of acid production within the gastric pouch, and response to treatment.
In 123 GB patients, staple line disruption occurred in 36 (29%) and stomal ulcer occurred in 20 (16%). Gastrogastric fistula with stomal ulcer was significantly lower in 376 patients who underwent IGB, (ie, 11 patients [3%]). Significantly larger amounts of acid, a lower pH, and a greater time with a pH less than 2 were found in the gastric pouches of patients who developed stomal ulcer after Roux-en-Y gastric bypass. All patients had a perforated staple line. Successful closure of the staple line significantly decreased acid production and pH in the gastric pouch when tested before and after remedial operation with healing of stomal ulcers.
Stomal ulcer after gastric bypass is the result of acid production in the bypassed stomach in the presence of a gastrogastric fistula. Separation of the gastric pouch from the main stomach decreases the incidence of fistula formation and stomal ulcer but does not eliminate it. Interposition of a well vascularized organ, the jejunum between the pouch and main stomach, is an attractive solution for patients who require remedial operations on the stomach and possibly for primary operations as well.
Optimal evaluation of the results of surgery for morbid obesity requires a long-term follow-up for at least 5 years.
One hundred patients were operated by vertical banded gastroplasty (VBG) and revised with a follow-up of no less than 5 years. Sixty patients were morbidly obese with a body mass index (BMI) of between 40 and 50 kg/m2, and 40 were super-obese with a BMI of >50 kg/m2. Follow-up included 93 patients (93%).
Initial surgical mortality was nil. Twenty-five patients required surgery for complications related to the technique (25%) and one patient died due to pulmonary embolism after a re-stapling operation. The percentage excess weight loss was 54.3%, and the BMI was 33 kg/m2 for the 84 patients followed to 5 years post VBG. Only 40 out of 92 patients (43.5%), obtained the weight loss benefit due to the operation. None of them is able to eat a regular diet, and the quality of food intake has been severely affected in some of them.
VBG is, in our experience, a safe and technically simple operation, but the long-term results are questionable. The reoperation rate was high, and weight loss and quality of life are superior with other operations.
The incidence of complications following gastric bypass surgery has decreased markedly over the last 30 years; nevertheless, significant morbidity and mortality is still associated with this procedure. Much of the improved risk of this technique can be attributed to the numerous modifications that have taken place in its evolution.
We compared our series of 640 primary cases of vertical banded gastroplasty-Roux-en-Y gastric bypass (VBG-RGB), a form of gastric bypass, with gastric bypass series reported in the literature from 1966 to 1996. Incidences considered were those of subphrenic abscess, gastrointestinal leaks, obstruction of the excluded segment of gastrointestinal tract, splenectomy and death.
The overall trend during the last 30 years has been a reduction in the rate of major complications. In our series, we had one major complication, a subphrenic abscess. This compares favorably with the incidence of major complications reported in the literature.
The gastric bypass is a significantly safer operation today than three decades ago. We believe that the relatively low complication rate of VBG-RGB results from: (1) the anatomic location of the gastric pouch; (2) the type of stapling device used in its construction; (3) a pouch outlet restricted by a prosthetic band rather than a narrow anastomosis; and (4) the construction of a retrocolic, retrogastric Roux-en-Y gastrojejunal anastomosis.
The Annual Scientific Meeting of the Association of Surgeons of Great Britain and Ireland was held in Brighton on 5–7 May 1999 under the Presidency of Professor R. C. N. Williamson. The abstracts of the oral and poster presentations of the original work presented at the meeting have been published in a BJS Supplement that accompanied the June 1999 issue of the Journal. The articles that follow in the present issue describe work presented at the Brighton meeting that have been accepted for publication after peer review by the Journal's referees. Other papers from this meeting will appear in subsequent issues. © 1999 British Journal of Surgery Society Ltd
Varieties of gastric surgery have increasingly been used in the management of morbid obesity. Generally, however, research and commentary in this area have related to surgical technique, with weight loss or morbidity being regarded as the most important dependent measures. In the context of the publication of several papers relating to the effects of surgery in the long-term, we believe that it is timely for surgeons to examine their criteria for success. In this paper, we argue that weight loss is inadequate as a primary criterion for success in this context, and that the value of the intervention should be measured against a multidimensional concept of success.
BACKGROUND: A prospective, randomized trial comparing vertical banded gastroplasty (VBG) and gastric bypass (GB) was performed on 106 patients between 1987 and 1990. METHODS AND RESULTS: Failures of these two operations (manifested by failure to lose weight, late weight gain or intolerance of adequate oral intake) were treated by means of a third operation, isolated gastric bypass (IGB), in which the small gastric pouch was isolated from the gastric fundus. The latter operation was significantly better than VBG or GB and achieved a 63% success rate, i.e. body mass index (BMI) < 35 kg m(2) and less than 50% excess weight. During the year following this trial an additional 54 patients underwent IGB. When this operation was performed for morbid obesity and was the Initial procedure, 96% of the patients achieved a successful result. If IGB was performed as a revision procedure or for super obesity (BMI > 50 kg m(2)), the success rate was 63% with 100% follow-up at 40 months. Major morbidity occurred in six of the 160 patients who underwent 195 operations (the trial period and subsequent year). There were no deaths and follow-up was 98%. CONCLUSIONS: The ideal gastric operation based on this study emphasizes the following requirements: a small pouch (< 15 ml) totally separated from the stomach, a pouch not dependent on staples, placed in the dependent position to prevent stasis, constructed without foreign material and with an anastomosis which permits ingestion of solid food.
The effect of transecting vs. stapling the stomach in continuity in the banded gastric bypass (GBP) operation was studied.
50 patients, 25 in each group, were enrolled into a prospective study to determine if transecting the stomach vs. stapling it in continuity in performing GBP for obesity decreases the incidence of gastro-gastric fistula formation without increased morbidity.
The patient profiles in the 2 groups were very similar. The peri-operative complications included 1 splenic capsular injury in each group, controlled without a splenectomy. There was 1 anastomotic leak in the stapled and 1 bleeding from the cut edge of the bypassed stomach in the transected group, both requiring re-operations in the immediate postoperative period. There was no peri-operative mortality. The percent follow-up after 6 years was 80% and 88% in the stapled and transected groups respectively. The incidence of late complications of solid food intolerance, ventral incisional hernia, cholelithiasis and small bowel obstruction was similar in both groups. There were 8 gastro-gastric fistulas in the stapled group and 1 in the transected group. The reduction in body mass index and percent excess weight loss (66%) were similar in both groups.
The incidence of gastro-gastric fistula may be reduced in GBP procedures by transecting the stomach as opposed to stapling it in continuity, without an increase in morbidity or mortality or any loss in the effectiveness of the operation.
The Magenstrasse and Mill (M&M) procedure for obesity is designed to preserve normal gastric emptying mechanisms. The hypothesis investigated in this study was that gastric emptying would be normal after the M&M gastroplasty. Gastric emptying studies were performed using both liquid and solid test meals, in ten morbidly obese patients (MO group) and in 13 patients after the M&M procedure (MM group). Seven people of normal weight served as controls and were matched for age, sex and height to the M&M and MO groups. Three years after the M&M procedure, mean (SD) weight loss was 42 (19) kg, with a mean loss of excess weight of 58% (20%). Gastric emptying half-times (t 1/2) are expressed in minutes, as median values (25th and 75th percentiles). The t 1/2 for solids was 97 (85-110) min in the control group, 140 (86-220) min in the MO group and 79 (46-150) min in the MM group. Median gastric emptying for solids was 0.7% (0.6%-0.8%) per minute in the control group, 0.5% (0.3%-0.8%) in the MO group and 0.9% (0.4%-1.4%) in the M&M group. There were no statistically significant differences in the emptying times of the three groups. It is concluded that the M&M procedure achieves acceptable weight loss, while preserving gastric emptying mechanisms and thus minimising possible side-effects such as vomiting, dumping and diarrhoea, which are common complications of gastric bypass procedures.
The authors assessed the quality of life (QOL) of patients after the Magenstrasse and Mill (M-M) procedure for morbid obesity (MO) and compared this with the QOL of MO patients and non-obese controls.
Personal, postal and telephone questionnaire survey was completed by 82 patients after the M-M procedure, 35 MO patients and 20 normal controls. QOL was assessed by Short Form 36 (SF-36), Hospital Anxiety and Depression (HAD) scale, and obesity surgery related questionnaire.
Physical, social and psychological well-being of patients was substantially better after the M-M compared with their MO counterparts. After the M-M procedure, patients were significantly less depressed but remained anxious when compared with morbidly obese patients. The majority of patients (88%) were pleased with the result of surgery.
This study provides empirical evidence that the M-M procedure for MO leads to a substantially better QOL.
The association between insulin resistance (IR) and obesity and its causal relationship with type 2 diabetes is well recognized. The possibility of an association, causal or otherwise, with other obesity-related co-morbidities warrants consideration.
IR was calculated pre-operatively in 80 patients undergoing gastric bypass surgery for severe obesity, using the homeostasis model assessment (HOMA) method, and again in 70 patients on at least one occasion post-operatively within 12 months. Correlations with weight parameters and pre-existing co-morbidities including diabetes, hypertension, dyslipidemia and hepatic steatosis were made.
78/80 patients had IR pre-operatively which did not correlate with pre-operative weight or BMI. As expected, there were positive correlations between pre-operative IR and abnormal glucose tolerance and diabetes. A positive correlation was also found between IR and hepatic steatosis, but no correlation was noted between IR and hypertension or fasting levels of cholesterol, triglycerides or Chol/HDL cholesterol ratios. Improvement in IR was uniformly seen after gastric bypass, sooner than would be accounted for by weight loss alone. The degree of pre-operative IR was not a predictor of weight loss after gastric bypass in these patients.
While IR is an almost universal accompaniment of severe obesity, it does not correlate with the degree of obesity in this group of patients. A number of important co-morbidities show a clear association with IR, and improvement in these after gastric bypass may well be related to striking and rapid changes in IR.
Metabolic bone disease is a well-documented long-term complication of obesity surgery. It is often undiagnosed, or misdiagnosed, because of lack of physician and patient awareness. Abnormalities in calcium and vitamin D metabolism begin shortly after gastrointestinal bypass operations; however, clinical and biochemical evidence of metabolic bone disease may not be detected until many years later.
A 57-year-old woman presented with severe hypocalcemia, vitamin D deficiency, and radiographic evidence of osteomalacia, 17 years after vertical banded gastroplasty and Roux-en-Y gastric bypass. Following these operations, she was diagnosed with a variety of medical disorders based on symptoms that, in retrospect, could have been attributed to metabolic bone disease. Additionally, she had serum metabolic abnormalities that were consistent with metabolic bone disease years before this presentation. Radiographic evidence of osteomalacia at the time of presentation suggests that her condition was advanced, and went undiagnosed for many years. These symptoms and laboratory and radiographic abnormalities most likely were a result of the long-term malabsorptive effects of gastric bypass, food intake restriction, or a combination of the two.
This case illustrates not only the importance of informed consent in patients undergoing obesity operations, but also the importance of adequate follow-up for patients who have undergone these procedures. A thorough history and physical examination, a high index of clinical suspicion, and careful long-term follow-up, with specific laboratory testing, are needed to detect early metabolic bone disease in these patients.
Clinical and costeffectiveness of surgery for people with morbid obesity. 2001, Southampton Health Technology Assessments Centre on behalf of The National Institute for Clinical Excellence
- A Clegg
- E Loveman
- P Royle
Clegg A, Loveman E, Royle P et al. Clinical and costeffectiveness of surgery for people with morbid obesity. 2001, Southampton Health Technology Assessments Centre on behalf of The National Institute for
Clinical Excellence, UK.
Metropolitan Height and Weight tables
Metropolitan Height and Weight tables. Stat
Bull Metrop Insur Co 1983; 64: 2-9.
Vertical ring gastroplasty for morbid obesity
- G V Eckhout
- O L Willbanks
- J T Moore
Eckhout GV, Willbanks OL, Moore JT. Vertical ring
gastroplasty for morbid obesity. Am J Surg 1986; 152:
713-6.
Vertical stapling: a new type of gastroplasty
- L L Tretbar
- E C Sifers
Tretbar LL, Sifers EC. Vertical stapling: a new type of
gastroplasty. Int J Obes 1981; 5: 538.