Gastric Bypass H. Richard Hornberger, MD, Waterville, Maine
More than half a century of experience with total gastrectomy has taught us that the patients so treated do not gain weight. History has also indicated that few patients with high subtotal gastrectomy gain weight. In 1965, Mason of the University of Iowa reasoned that a 90 per cent gastric bypass could provide weight loss in morbidly obese patients without diarrhea, electrolyte imbalance, and hepatomegaly which complicate jejunoileal shunts. Since then, Mason’s group has performed over 400 gastric bypasses with a mortality of 3 per cent. The operation is considered in patients who are twice their normal weight, have demonstrated an inability to lose weight by dieting, have no major psychiatric, cardiopulmonary, or other problems, and are not more than fifty years of age. The age limit is waived in selected cases. Gastric bypass is performed through a midline incision from above the xiphoid to 1 inch above the umbilicus. After the greater curvature is freed, the fundus is transected just below the esophagogastric junction between two rows of staples. The distal gastric segment, left in place, is eventually sutured to the proximal segment to prevent torsion. A retrocolic Billroth II anastomosis no larger than 14 mm is carried out. A larger anastomosis permits too rapid emptying, allowing the patient to eat too often, if he is so inclined, as he usually is. Particularly important is a small proximal segment. Even with the pouch left after 75 per cent gastrectomy, the determined glutton can maintain his weight. The surgeon must overcome his natural instinct and leave a pouch with a capacity of no more than half a cup. More technical details are available in the report by Mason and Ito [I]. From the Department of Thoracic Surgery, Mid-Maine Medical Center, Waterville. Maine. Reprint requests should be addressed to H. Richard Hornberger. MD, 325 Kennedy Drive, Waterville. Maine 04901. Presented at the Fifty-Sixth Annual Meeting of the New England Surgical Society, Portsmouth, New Hampshire, September 25-27, 1975.
VohIaw 131, Apru lB78
Thirty-one gastric bypasses have been performed at Mid-Maine Medical Center with two deaths, a mortality of 6 per cent. One death was due to an acute respiratory distress syndrome. The other, in which autopsy was not obtained, was sudden and caused possibly by fatty acid toxicity induced by failure to provide glucose in intravenous fluids postoperatively [2]. The deaths in the Iowa series occurred early in the project and were related mostly to anastomotic leaks. The patients in the present series will be evaluated in terms of weight loss, surgical complications, and, most importantly, the true outcome. Table I lists the patients in the order in which they were operated on and shows their original weight, present weight, weight loss, and number of months since surgery. All of these patients demonstrated a significant weight loss. The first patient (350 pounds), in whom a jejunoileal shunt was converted to a gastric bypass because of various problems, maintains a weight level between 180 and 200 pounds. The second patient, who has had severe problems, nevertheless weighs 190 instead of his original 450 pounds. The third patient, a sixtyfive year old woman with hypertension, who was 5 feet tall and weighed 290 pounds, was crippled by obesity. Although the risk of surgery was extremely high, she survived a variety of complications and now weighs 130 pounds. Her entire life has been changed by this procedure. The fourth patient, a fifty-three year old widow with a fourteen year old son, also was incapacitated by obesity. She now weighs 170 pounds, has taken an LPN course, and is supporting both herself and her son. Weight loss in the first twenty patients was considered satisfactory except in patients 7,8, and 10. Patient 7, who weighed 240 pounds, has stabilized at about 170 pounds, but apparently will not lose any more. By her own admission, she lives on bread-and butter and soda and devotes most of her waking hours to eating and drinking. Patient 8,
415
Hornberger
TABLE
I Weight
Loss after Gastric
Bypass
Original
Present
Weight
Weight
Weight
Patient
(DOundS)
(pounds1
test (pounds)
1. NW
350 450 283 340 225 230 240 400 240 320 300 325 200 289 360 350
180 190 130 170 104 125 168 250 130 214 135 205 124 185 236 215 210 168 144 190 297 162 155 182 200 380 213 208
2. 3. 4. 5. 6. 7. 8. 9. 10.
11. 12. 13. 14. 15. 16. 17. 18.
BF” DD MS BT SF JBt RWt BB RHt DW GS ED* KV DP RH JP
RR 19. IP 20. LC 21. HEt 22. 23. 24. 25. 26. 27. 28.
GC* VW DW CR JH JVI MH
*Psychiatric tlnadequate
344 275 240 275 374 260 205 257 235 465 230 234
170 260 153 170 121 105 72 150 110 106 165 120 76 104 124 135 134 107 100 85 77 98 50 75 35 85 17 26
Months Since
60 48 38 34 32 25 23 23 21 19 19 16 15 14 14 12 10 11 10 9 9 7 7 5 1 3 2 2
problems. weight loss.
who probably weighed over 400 pounds, is stabilizing at 250 pounds, and although I consider this a less than satisfactory result, the patient is happier and usefully employed. Patient 10, who started at 320 pounds and is down to 214 pounds after nineteen months, will probably not lose much more. She has, however, been able to function more efficiently and is thoroughly satisfied with the procedure. The last eight. or nine patients cannot be evaluated completely at this time. Patient 21 has lost only 77 pounds in the first nine months. She has a hiatus hernia that may have been surgically induced and has difficulty with solid foods. She therefore consumes vast quantities of yogurt and I suspect that she will ultimately have a poor result. Table I indicates clearly that most patients will have satisfactory weight loss after surgery. The complications were as follows: necrosis of the wound in one patient (3 per cent), wound infections in six (15 per cent), pulmonary emboli in two (6 per cent), marginal ulcers in two (6 per cent), incisional hernias in two (6 per cent), pleural effusion in one (3 per cent), subphrenic abscess in
416
one (3 per cent), wound dehiscence in one (3 per cent), and a hiatus hernia in one (3 per cent) which may have been surgically induced. The overall complication rate was slightly greater than 50 per cent. Except for marginal ulcers, none of these complications was catastrophic although the subphrenic abscess and the pulmonary emboli obviously required prolonged hospitalization. In Mason’s series of 442 cases there were only three marginal ulcers; in the present series there were two. One healed after intensive medical treatment and prolonged hospitalization. The other created a fistula between proximal and distal segments and finally healed after distal gastrectomy and transthoracic vagotomy. The wound dehiscence occurred three days postoperatively in a muscular, active 465 pound man. The wound had been closed in layers, using the heaviest available Dacron@. The dehiscence was repaired with heavy unbraided wire placed through both fascia and peritoneum. A wound infection followed, but the wound held together and the patient returned to full time office work within three weeks from the day of the original surgery. We now come to the most significant evaluation of gastric bypass, that is, the true outcome, not only in terms of weight loss but also in terms of a healthy, happy, rehabilitated patient. At least five of the first twenty patients describe the results of the operation as “life-saving,” “a rebirth,” or “a chance to live again.” Five others fall just short of this degree of enthusiasm. Another tkn are healthier, generally happier, and more effective than before surgery, but are experiencing economic, psychiatric, or marital problems. Two patients, by any rational assessment, had severe psychiatric problems before and after surgery even though they have achieved the desired weight loss. Two or three others have had chronic psychosocial and economic problems, even though they have lost weight. All in all, no patient, including those with severe problems, has expressed regret at having had the operation. In fact, three of the happy patients were referred by one of those with disastrous results. This brings up the question of patient selection. I strongly disagree with many surgeons who believe that this kind of surgery has no place. There are two extremes of selection. A surgeon can operate on anyone who fits or comes close to fitting the criteria or he can limit his candidates to well adjusted, socially responsible, highly intelligent, 300 pound former homecoming queens. Reams have been written on the subject. Psychiatrists may be
The American Journal ol Surgery
Gastric Bypass
helpful in certain cases, but the surgeon must make the final evaluation. His selection will inevitably be influenced by his attitude towards the procedure, his accumulated experience, and his confidence or lack of it in his ability to perform the operation safely and effectively. After the first three months, follow-up care of these patients is relatively simple. Patients vary in their ability to shift from a 2 quart to a quarter pint receptacle, but nearly all seem to make the adjustment. Some remain compulsive eaters and therefore frequently avoid maximal desirable weight loss. There have been no long-term problems with diarrhea, electrolyte imbalance, or hepatomegaly. In this series there have been no cases of excessive weight loss. Summary
Gastric bypass in the very obese is a technically difficult and tedious procedure done in the attic of the peritoneal cavity. However, with careful attention to pre-, reasonably
intra-,
and postoperative
safe, effective,
unmanageable
and relatively
detail,
it is
free from
complications.
References 1. Mason EE, Ito C: Gastric by-pass in obesity. Surg Clin North Am 47: 1345.1967. 2. Mason EE, Gordy DD, Chernigoy FA, Printen.KJ: Fatty acid toxicity. Surg Gynecol Obstet 133: 992, 1971.
Discussion George Sager (Portland, ME): It sounds as if Doctors Hornberger and Mason have a reasonable answer to the bypass problem for massive obesity. Yet, a search of the “Index Medicus” on the subject of surgery for massive obesity from January 1970 to the present will show 122 articles, three of which are on gastric bypass, and all three are by Mason’s group in Iowa. Doctor Scott in Nashville and Doctor Woodward in Gainesville, both authorities in bypass surgery, have expressed lack of interest in gastric bypass. Considering the broader subject of surgery for massive obesity, we do not know why people have hyperphagia and become massively obese. Anorectic drugs for obesity are useless and in the long run medical treatment has a poor success rate. Doctor Chandler of the University of Virginia has set forth criteria for the ideal surgical candidate. The patient must be massively obese, two to three times his ideal weight, for a long time. They may have complications from obesity but should otherwise be in good health. They should have a realistic approach to life and be successful in almost all endeavors except that of losing weight. They must have
vabmm 151, Apa 1978
gained end lost many pounds of weight over the years, yet show a steady progressive weight gain. Very importantly, they must have established a relationship of trust with a physician who is willing to cooperate with the surgeon in overseeing his optimal health for a long time. The scale of acceptance of this operation varies from those who believe that it is never indicated, as represented by the Cleveland Clinic, and those who believe that anyone who is fat and wants the operation should have it. At the Maine Medical Center, a 500 bed hospital performing 12,000 operations a year, we have carried out five intestinal bypasses in three years, placing us well among the conservatives. According to published reports, gastric bypass produces the same results in weight loss as does intestinal bypass, while avoiding the complications of diarrhea with its inherent problems and of hepatic necrosis, which may be lethal. At the same time it is more difficult to perform. I think Doctor Hornberger will agree
that this is not a procedure to be performed by the occasional operator in a small community hospital. Martin E. Felder (Providence, RI): I have performed this operation in fifteen patients and so far am impressed with the results although the follow-up period is short. All of my patients have lost at least 20 per cent of their body weight during the first four month period, representing approximately 30 per cent of their excess weight. I have performed all but one of these operations in an antecolic rather than the retrocolic manner described by Doctor Mason. This is technically possible, especially when the entire greater curvature is freed all the way up to the esophagus. Unfortunately, a stoma1 ulcer has developed in one of my patients. Doctor Mason in his early reports indicated that there was always enough parietal cell mass in the bypassed segment to depress the antral production of gastrin successfully. In my patient with a stoma1 ulcer, serum gastric studies demonstrated that the gastrin level was about three times the normal. I have therefore begun to study gastrin levels but have no results to report at this date. If more stoma1 ulcers occur with this procedure, we may have to resect the segment that is now being bypassed. I have gone beyond the age limitation of fifty years and have three patients under the age of sixty who have had this operation primarily for medical indications, not obesity. Two had diabetes and the third, hypertension. They have all benefitted greatly from the procedure with a reduction in their previous medications. Rodger E. Weismann (Hanover, NH): My experience now is almost totally limited to jejunoileal bypass, which I reported on a couple of years ago. There are now about 360 cases in our series, and we have some idea of the problems in both selection and late complications as a result of this experience of more than eleven years.
417
Hornberger
The mortality rates for the two operations are fairly comparable. I have a feeling that the technical aspects of gastric bypass are considerably more complicated than are those of jejunoileal bypass. I would appreciate Doctor Hornberger’s comments on this. I think this is one reason I have not been interested in performing gastric bypass in massively obese patients. Another is that in Doctor Mason’s initial report, he thought that 25 per cent of his patients had not done satisfactorily in terms of weight loss and that jejunoileal bypass would probably eventually be necessary. I assume this has changed in his more recent reports. I would just like to state that the selection of patients, careful follow-up, study and identification with a single or a few persons who might be interested in their welfare are terribly important in the successful management of these patients. Moreover, the surgeon must keep a sense of humor and a sense of balance in order to deal with these patients. Frank J. Lepreair (Westport, MA): 1 have known of three patients who had remarkable results from having their teeth wired together. I wonder if Doctor Hornberger would comment.
418
H. Richard Hornberger (closing): Gastric bypass is technically more difficult than jejunoileal shunt. Once you have some experience with it, particularly in women, it is not all that difficult. In big men, like the 465 pound man I reported on, it is a gymnastic feat, no question about it. It is a deep hole, and if bleeding occurs there in the attic of the peritoneal cavity, unless you have a small intern you can lower into it, you are in trouble. If I can convince myself that the patients are not going to lose weight, and if they approximate the former homecoming queen, it is a reasonable procedure when the patients are just about twice their normal weight or even less. If you know that they are not going to lose weight, if they want an operation, and if they seem to be motivated, it becomes an easy thing to do when they weigh 235 or 240 pounds, much easier than when they weigh 300. A comment on marginal ulcer. Doctor Mason in some animal studies purported to show that the bypassed stomach and the excised stomach are equally effective in preventing marginal ulceration. He even hinted at the idea of using this procedure as a treatment for ulcer.
The American Journal of Surgery
More than half a century of experience with total gastrectomy has taught us that the patients so treated do not gain weight. History has also indicated that few patients with high subtotal gastrectomy gain weight. In 1965, Mason of the University of Iowa reasoned that a 90 per cent gastric bypass could provide weight loss in morbidly obese patients without diarrhea, electrolyte imbalance, and hepatomegaly which complicate jejunoileal shunts. Since then, Mason’s group has performed over 400 gastric bypasses with a mortality of 3 per cent. The operation is considered in patients who are twice their normal weight, have demonstrated an inability to lose weight by dieting, have no major psychiatric, cardiopulmonary, or other problems, and are not more than fifty years of age. The age limit is waived in selected cases. Gastric bypass is performed through a midline incision from above the xiphoid to 1 inch above the umbilicus. After the greater curvature is freed, the fundus is transected just below the esophagogastric junction between two rows of staples. The distal gastric segment, left in place, is eventually sutured to the proximal segment to prevent torsion. A retrocolic Billroth II anastomosis no larger than 14 mm is carried out. A larger anastomosis permits too rapid emptying, allowing the patient to eat too often, if he is so inclined, as he usually is. Particularly important is a small proximal segment. Even with the pouch left after 75 per cent gastrectomy, the determined glutton can maintain his weight. The surgeon must overcome his natural instinct and leave a pouch with a capacity of no more than half a cup. More technical details are available in the report by Mason and Ito [I]. From the Department of Thoracic Surgery, Mid-Maine Medical Center, Waterville. Maine. Reprint requests should be addressed to H. Richard Hornberger. MD, 325 Kennedy Drive, Waterville. Maine 04901. Presented at the Fifty-Sixth Annual Meeting of the New England Surgical Society, Portsmouth, New Hampshire, September 25-27, 1975.
VohIaw 131, Apru lB78
Thirty-one gastric bypasses have been performed at Mid-Maine Medical Center with two deaths, a mortality of 6 per cent. One death was due to an acute respiratory distress syndrome. The other, in which autopsy was not obtained, was sudden and caused possibly by fatty acid toxicity induced by failure to provide glucose in intravenous fluids postoperatively [2]. The deaths in the Iowa series occurred early in the project and were related mostly to anastomotic leaks. The patients in the present series will be evaluated in terms of weight loss, surgical complications, and, most importantly, the true outcome. Table I lists the patients in the order in which they were operated on and shows their original weight, present weight, weight loss, and number of months since surgery. All of these patients demonstrated a significant weight loss. The first patient (350 pounds), in whom a jejunoileal shunt was converted to a gastric bypass because of various problems, maintains a weight level between 180 and 200 pounds. The second patient, who has had severe problems, nevertheless weighs 190 instead of his original 450 pounds. The third patient, a sixtyfive year old woman with hypertension, who was 5 feet tall and weighed 290 pounds, was crippled by obesity. Although the risk of surgery was extremely high, she survived a variety of complications and now weighs 130 pounds. Her entire life has been changed by this procedure. The fourth patient, a fifty-three year old widow with a fourteen year old son, also was incapacitated by obesity. She now weighs 170 pounds, has taken an LPN course, and is supporting both herself and her son. Weight loss in the first twenty patients was considered satisfactory except in patients 7,8, and 10. Patient 7, who weighed 240 pounds, has stabilized at about 170 pounds, but apparently will not lose any more. By her own admission, she lives on bread-and butter and soda and devotes most of her waking hours to eating and drinking. Patient 8,
415
Hornberger
TABLE
I Weight
Loss after Gastric
Bypass
Original
Present
Weight
Weight
Weight
Patient
(DOundS)
(pounds1
test (pounds)
1. NW
350 450 283 340 225 230 240 400 240 320 300 325 200 289 360 350
180 190 130 170 104 125 168 250 130 214 135 205 124 185 236 215 210 168 144 190 297 162 155 182 200 380 213 208
2. 3. 4. 5. 6. 7. 8. 9. 10.
11. 12. 13. 14. 15. 16. 17. 18.
BF” DD MS BT SF JBt RWt BB RHt DW GS ED* KV DP RH JP
RR 19. IP 20. LC 21. HEt 22. 23. 24. 25. 26. 27. 28.
GC* VW DW CR JH JVI MH
*Psychiatric tlnadequate
344 275 240 275 374 260 205 257 235 465 230 234
170 260 153 170 121 105 72 150 110 106 165 120 76 104 124 135 134 107 100 85 77 98 50 75 35 85 17 26
Months Since
60 48 38 34 32 25 23 23 21 19 19 16 15 14 14 12 10 11 10 9 9 7 7 5 1 3 2 2
problems. weight loss.
who probably weighed over 400 pounds, is stabilizing at 250 pounds, and although I consider this a less than satisfactory result, the patient is happier and usefully employed. Patient 10, who started at 320 pounds and is down to 214 pounds after nineteen months, will probably not lose much more. She has, however, been able to function more efficiently and is thoroughly satisfied with the procedure. The last eight. or nine patients cannot be evaluated completely at this time. Patient 21 has lost only 77 pounds in the first nine months. She has a hiatus hernia that may have been surgically induced and has difficulty with solid foods. She therefore consumes vast quantities of yogurt and I suspect that she will ultimately have a poor result. Table I indicates clearly that most patients will have satisfactory weight loss after surgery. The complications were as follows: necrosis of the wound in one patient (3 per cent), wound infections in six (15 per cent), pulmonary emboli in two (6 per cent), marginal ulcers in two (6 per cent), incisional hernias in two (6 per cent), pleural effusion in one (3 per cent), subphrenic abscess in
416
one (3 per cent), wound dehiscence in one (3 per cent), and a hiatus hernia in one (3 per cent) which may have been surgically induced. The overall complication rate was slightly greater than 50 per cent. Except for marginal ulcers, none of these complications was catastrophic although the subphrenic abscess and the pulmonary emboli obviously required prolonged hospitalization. In Mason’s series of 442 cases there were only three marginal ulcers; in the present series there were two. One healed after intensive medical treatment and prolonged hospitalization. The other created a fistula between proximal and distal segments and finally healed after distal gastrectomy and transthoracic vagotomy. The wound dehiscence occurred three days postoperatively in a muscular, active 465 pound man. The wound had been closed in layers, using the heaviest available Dacron@. The dehiscence was repaired with heavy unbraided wire placed through both fascia and peritoneum. A wound infection followed, but the wound held together and the patient returned to full time office work within three weeks from the day of the original surgery. We now come to the most significant evaluation of gastric bypass, that is, the true outcome, not only in terms of weight loss but also in terms of a healthy, happy, rehabilitated patient. At least five of the first twenty patients describe the results of the operation as “life-saving,” “a rebirth,” or “a chance to live again.” Five others fall just short of this degree of enthusiasm. Another tkn are healthier, generally happier, and more effective than before surgery, but are experiencing economic, psychiatric, or marital problems. Two patients, by any rational assessment, had severe psychiatric problems before and after surgery even though they have achieved the desired weight loss. Two or three others have had chronic psychosocial and economic problems, even though they have lost weight. All in all, no patient, including those with severe problems, has expressed regret at having had the operation. In fact, three of the happy patients were referred by one of those with disastrous results. This brings up the question of patient selection. I strongly disagree with many surgeons who believe that this kind of surgery has no place. There are two extremes of selection. A surgeon can operate on anyone who fits or comes close to fitting the criteria or he can limit his candidates to well adjusted, socially responsible, highly intelligent, 300 pound former homecoming queens. Reams have been written on the subject. Psychiatrists may be
The American Journal ol Surgery
Gastric Bypass
helpful in certain cases, but the surgeon must make the final evaluation. His selection will inevitably be influenced by his attitude towards the procedure, his accumulated experience, and his confidence or lack of it in his ability to perform the operation safely and effectively. After the first three months, follow-up care of these patients is relatively simple. Patients vary in their ability to shift from a 2 quart to a quarter pint receptacle, but nearly all seem to make the adjustment. Some remain compulsive eaters and therefore frequently avoid maximal desirable weight loss. There have been no long-term problems with diarrhea, electrolyte imbalance, or hepatomegaly. In this series there have been no cases of excessive weight loss. Summary
Gastric bypass in the very obese is a technically difficult and tedious procedure done in the attic of the peritoneal cavity. However, with careful attention to pre-, reasonably
intra-,
and postoperative
safe, effective,
unmanageable
and relatively
detail,
it is
free from
complications.
References 1. Mason EE, Ito C: Gastric by-pass in obesity. Surg Clin North Am 47: 1345.1967. 2. Mason EE, Gordy DD, Chernigoy FA, Printen.KJ: Fatty acid toxicity. Surg Gynecol Obstet 133: 992, 1971.
Discussion George Sager (Portland, ME): It sounds as if Doctors Hornberger and Mason have a reasonable answer to the bypass problem for massive obesity. Yet, a search of the “Index Medicus” on the subject of surgery for massive obesity from January 1970 to the present will show 122 articles, three of which are on gastric bypass, and all three are by Mason’s group in Iowa. Doctor Scott in Nashville and Doctor Woodward in Gainesville, both authorities in bypass surgery, have expressed lack of interest in gastric bypass. Considering the broader subject of surgery for massive obesity, we do not know why people have hyperphagia and become massively obese. Anorectic drugs for obesity are useless and in the long run medical treatment has a poor success rate. Doctor Chandler of the University of Virginia has set forth criteria for the ideal surgical candidate. The patient must be massively obese, two to three times his ideal weight, for a long time. They may have complications from obesity but should otherwise be in good health. They should have a realistic approach to life and be successful in almost all endeavors except that of losing weight. They must have
vabmm 151, Apa 1978
gained end lost many pounds of weight over the years, yet show a steady progressive weight gain. Very importantly, they must have established a relationship of trust with a physician who is willing to cooperate with the surgeon in overseeing his optimal health for a long time. The scale of acceptance of this operation varies from those who believe that it is never indicated, as represented by the Cleveland Clinic, and those who believe that anyone who is fat and wants the operation should have it. At the Maine Medical Center, a 500 bed hospital performing 12,000 operations a year, we have carried out five intestinal bypasses in three years, placing us well among the conservatives. According to published reports, gastric bypass produces the same results in weight loss as does intestinal bypass, while avoiding the complications of diarrhea with its inherent problems and of hepatic necrosis, which may be lethal. At the same time it is more difficult to perform. I think Doctor Hornberger will agree
that this is not a procedure to be performed by the occasional operator in a small community hospital. Martin E. Felder (Providence, RI): I have performed this operation in fifteen patients and so far am impressed with the results although the follow-up period is short. All of my patients have lost at least 20 per cent of their body weight during the first four month period, representing approximately 30 per cent of their excess weight. I have performed all but one of these operations in an antecolic rather than the retrocolic manner described by Doctor Mason. This is technically possible, especially when the entire greater curvature is freed all the way up to the esophagus. Unfortunately, a stoma1 ulcer has developed in one of my patients. Doctor Mason in his early reports indicated that there was always enough parietal cell mass in the bypassed segment to depress the antral production of gastrin successfully. In my patient with a stoma1 ulcer, serum gastric studies demonstrated that the gastrin level was about three times the normal. I have therefore begun to study gastrin levels but have no results to report at this date. If more stoma1 ulcers occur with this procedure, we may have to resect the segment that is now being bypassed. I have gone beyond the age limitation of fifty years and have three patients under the age of sixty who have had this operation primarily for medical indications, not obesity. Two had diabetes and the third, hypertension. They have all benefitted greatly from the procedure with a reduction in their previous medications. Rodger E. Weismann (Hanover, NH): My experience now is almost totally limited to jejunoileal bypass, which I reported on a couple of years ago. There are now about 360 cases in our series, and we have some idea of the problems in both selection and late complications as a result of this experience of more than eleven years.
417
Hornberger
The mortality rates for the two operations are fairly comparable. I have a feeling that the technical aspects of gastric bypass are considerably more complicated than are those of jejunoileal bypass. I would appreciate Doctor Hornberger’s comments on this. I think this is one reason I have not been interested in performing gastric bypass in massively obese patients. Another is that in Doctor Mason’s initial report, he thought that 25 per cent of his patients had not done satisfactorily in terms of weight loss and that jejunoileal bypass would probably eventually be necessary. I assume this has changed in his more recent reports. I would just like to state that the selection of patients, careful follow-up, study and identification with a single or a few persons who might be interested in their welfare are terribly important in the successful management of these patients. Moreover, the surgeon must keep a sense of humor and a sense of balance in order to deal with these patients. Frank J. Lepreair (Westport, MA): 1 have known of three patients who had remarkable results from having their teeth wired together. I wonder if Doctor Hornberger would comment.
418
H. Richard Hornberger (closing): Gastric bypass is technically more difficult than jejunoileal shunt. Once you have some experience with it, particularly in women, it is not all that difficult. In big men, like the 465 pound man I reported on, it is a gymnastic feat, no question about it. It is a deep hole, and if bleeding occurs there in the attic of the peritoneal cavity, unless you have a small intern you can lower into it, you are in trouble. If I can convince myself that the patients are not going to lose weight, and if they approximate the former homecoming queen, it is a reasonable procedure when the patients are just about twice their normal weight or even less. If you know that they are not going to lose weight, if they want an operation, and if they seem to be motivated, it becomes an easy thing to do when they weigh 235 or 240 pounds, much easier than when they weigh 300. A comment on marginal ulcer. Doctor Mason in some animal studies purported to show that the bypassed stomach and the excised stomach are equally effective in preventing marginal ulceration. He even hinted at the idea of using this procedure as a treatment for ulcer.
The American Journal of Surgery
