Gastric bypass proceedures - Forum

[Noro]

I'm curious as to how many surgeons are performing gastric stapling, and what their feelings are about the the optimum procedure as well as the resources needed (psychiatric, dietary, etc) to get a program off the ground. I seem to be seeing more and more morbidly obese patients, but I wonder if gastric bypass surgery is appropriate in a small community hospital.

Never done it and never will. It's bad medicine in my opinion. Trying to fix a neurochemical/psychological problem with the scalpel doesn't make sense.

[Avicenna]

I brought up this topic several months ago and was surprised I didn't get more responses like the above. Having been emboldened, I will state my opinion. It is: Ditto.

At the risk of repeating myself, I have not seen one patient more than five years out who is happy. Most are still obese, although usually less so, and despite being obese complain that they can't eat. If you ask them "well what did you expect" they say "well I knew I wouldn't be able to eat as much but I didn't think it would be like this" or something to that effect.

It was a completely different story in residency. We would see them back for two or three years, many close to ideal body weight, with resolution of their hypertension as promised by all the research that justifies bariatric surgery. I think that is why gastric bypass becomes popular in "waves," when one wave travels five years to wash up on shore (usually somebody else's beach) they become unpopular again.

I was recently surprised to find that hardly anyone in North Carolina does bariatric surgery. I had a patient ten years out from J-I bypass who was having problems referable to the bypass, and wanted to be converted to a GBP. I talked to the surgeons at Bowman-Gray, who told me they thought the only place in the state doing bariatric surgery was East Carolina. They do indeed have a program, but they (I think wisely) chose not to operate on this otherwise ideal candidate. Maybe patient selection is why their recent study looked so good.

I would be embarrased to have our society analyzed 10,000 years from now and try to explain why we did gastric bypasses. But not as embarrased as if I had to explain bags of silicone gel on the chest wall...

[Surgeon]

An internist colleague called me last week to report an unusual finding in a massively obese woman he'd just endoscoped. This woman had had a vertical banded gastroplasty about 10 years earlier by a very meticulous and competent surgeon. (My former partner--I assisted on the case). The internist found the band inside the stomach! He didn't recognize what it was until he pulled it out and discovered the marlex mesh. Incidentally, the patient is still massively obese.

[Loit]

Used to do it and quit because it is a medicolegal nightmare. A surgeon in our community runs a "full service" bariatric program including before and after calenders, support group and reduced portion restaurant deals. He is one of the most sued M.D.'s on our staff. It doesn't seem to bother him, however. I guess it's just the price of doing "business".

[StSt]

The finding of free-hanging marlex in the lumen of previously VBGed stomach has been occasionaly described. We had a similar case a few years ago.

As to obesity surgery in general my attitude resembles that of the rest of the discussants. The large published series (i.e Mason or Pories) report excellent results. The small unpublished series (our personal or around us) are much much less favorable. A while ago I re-operated on two post VBG patients who almost starved to death because of their too tight marlex band; follwoing their original procedure (by a surgeon who performed more than a thousand) they were included in his many times published series, obviously along the succesful cases.

Sure, we have seen the occasional patient who really enjoys and lives happily together with his VBG but...let somebody else do it!

[Schom]

I don't do them because:
1) I don't like the patients (from my residency experience)--too whiny, too demanding, too low a pain tolerance, they overeat (1 reported eating 6 hamburgers) causing their anastomoses to swell, then they vomit and have to have IV's and NG--our residency patients would come back to the ER a year after surgery at midnight with complaints that they related to their surgery--I was sure I would not have the personal tolerance to keep seeing them in the ER forever since I take almost all of my own call
2) Most malpractice carriers are very reluctant to cover you for this surgery
3) There are enough surgeons who do the operation--there are at least 2 in Iowa

[Avicenna]

I had some experience with gastric bypass as a resident, have never done one in private practice. I think that the modifications that have been made to the old JI bypass procedure such as the Scopinaro procedure or the duodenal switch have alot of potential. Patients can eat whatever they want (although they soon learn what they need to avoid), and they lose weight reliably. They don't have diarrhea, but their stools are foul smelling and gas can be a problem. I learned of the Scopinaro procedure (of all things) while on active duty during the Persian Gulf War, at Madigan Army Hospital in Tacoma, WA. The chief of surgery there has a large experience with them. Based on his recommendation, I performed the procedure once on a 350 lb. patient with symptomatic gallstones. She has done great. The nice thing about the procedure which differentiates it from gastric bypass or stapling, is that there is no "voodoo" involved with calibration of stomas; the operation is simply a hemigastrectomy with roux-en-y gastrojejunostomy that we all know how to do. The only difference is that you have to measure out the length of the various limbs of the bowel segments.

Finally, most patients are very interested in this procedure when you tell them that they can eat normal meals. It's not hard to imagine why a patient would reject an operation which prevents them from doing the one thing in life they love the most.

[Surgeon]

I must confess my ignorance - I have never heard of the Scopinaro procedure or the duodenal switch. Could you provide a brief description, and if it's not too much of a bother, some references to these procedures?

[Alalo]

I have learned about it in a different way. A young, 6 months pregnant lady presented with an acute abdomen a year after undergoing the Scopinaro operation. She lost weight and was in fact quite beutiful. However, the growing uterus changed somehow her new distorted GI anatomy, producing a closed-loop obstruction in the "excluded" duodenum-jejunum which were necrotic. She died. For me she was a case report.

[Sojer]

Of course your case report is dramatic and I can easily imagine why you wouldn't want to do them, but, as you say, it is only a case report. It in no way incriminates the procedure. I'm sure many of you are aware that morbid obesity is a bad disease, even if it is "self-induced." In spite of the short term successes of the various diets, medical treatment of obesity almost invariably fails. Surgery has been shown to be the ONLY successful treatment of obesity. Unfortunately surgery has its own risks and complications which must be considered. Surgery of morbid obesity is fraught with hazard, and should be undertaken only in intelligent well-informed patients. Especially since the patients are otherwise healthy and theoretically don't need an operation at all.

The Scopinaro procedure is basically a variation on the JI bypass. The JI bypass causes problems because there is a long defunctionalized segment of small bowel which is thought to develop bacterial overgrowth, leading to liver dysfunction and, in some patients, cirrhosis. The Scopinaro procedure is an attempt to avoid this problem by directing biliary and pancreatic secretions through the otherwise defunctionalized limb. A long roux-en-y limb is created, whereby gastric contents are sent through the other limb of the Y. The two limbs join about 50 cm. from the cecum, allowing partial digestion of the food. There is fairly good absorption of protein and carbohydrates, and relative malabsorption of fat. The operation also includes hemigastrectomy to prevent anastomotic ulcers, as well as cholecystectomy to prevent gallstone formation, which would otherwise occur in about 50% of patients.Patients must be maintained on additional vitamins and minerals for life. Most patients lose 80% of excess weight.

This was not meant to be a comprehensive explanation. I will find some references and post them here later.