Surgery for morbid obesity. Appraisal of old and new techniques

Morbid obesity is a serious and sometimes lethal disease of unknown etiology. Nonsurgical treatment has not been successful in producing permanent weight loss. Surgical treatment does reliably result in weight loss but is not a cure and is not indicated for all morbidly obese patients. Jejunoileal bypass, the first operation devised for morbid obesity, usually produces excellent weight loss but has high rates of morbidity and mortality. For this reason, it is not currently advised by most surgeons. Gastric bypass reduces morbidity and mortality without compromising weight loss; however, it is technically more difficult than jejunoileal bypass. The newest operations for morbid obesity are variations of gastroplasty. If correctly performed, they will produce satisfactory weight loss with the lowest morbidity rates of all the operations for morbid obesity. However, long-term results for these procedures are not yet available. Therefore, the ideal operative procedure for morbid obesity has yet to be identified.     

Is it feasible to reach the bypassed stomach after Roux-en-Y gastric bypass for morbid obesity? The use of the double-balloon enteroscope

BACKGROUND AND STUDY AIMS: Endoscopic evaluation of the excluded stomach after Roux-en-Y gastric bypass surgery for morbid obesity is a challenge, and the pathological changes that take place in the bypassed stomach are unclear. A new double-balloon method of evaluating the bypassed stomach after Roux-en-Y gastric bypass surgery for morbid obesity is described here. PATIENTS AND METHODS: This new enteroscope uses two balloons, one attached to the tip of the endoscope and the other to the distal end of the soft overtube. The procedures were carried out in six patients using the retrograde route, through the end-to-side jejunal anastomosis via the duodenobiliopancreatic limb up to the bypassed stomach. RESULTS: The bypassed stomach was reached in five of six patients (83.3 %). An endoscopic appearance of atrophic gastritis was found in three patients, mild in two cases and severe in one case with intestinal metaplasia. Erosive and hemorrhagic gastritis was found in two patients. CONCLUSIONS: Endoscopic evaluation of the bypassed stomach via the retrograde route after Roux-en-Y gastric bypass for morbid obesity is feasible using the double-balloon enteroscope.     

Postoperative nursing care of gastric bypass patients.

The incidence of morbid obesity is increasing epidemically in the United States. Multiple factors affect the disease process. Numerous methods have been used to treat morbid obesity. The current gold standard operation, Roux-en-Y gastric bypass, has gained popularity. Because a variety of surgical procedures for weight loss are being performed and new procedures are being introduced, the delivery of specialized nursing care has come to the forefront. Nurses' application of current nursing literature and standards of care for postoperative gastric bypass patients puts nurses in a pivotal position to affect both early and late outcomes of these patients after surgery. Morbid obesity is defined, and current treatment trends and postoperative complications are discussed. Recognition and identification of unique nursing considerations and use of critical thinking skills to best meet the needs of postoperative gastric bypass patients, including how obesity affects hemodynamic parameters and airway management, are highlighted.     

Hypocalcemia as a complication of jejunoileal bypass for morbid obesity.

Hypocalcemia following jejunoileal bypass for morbid obesity is not an uncommon occurrence. Three cases of severe hypocalcemia after bypass operation are presented with emphasis on the altered physiology of calcium homeostasis. Recognition and treatment of bypass hypocalcemia can avert a potentially serious complication.     

Que faire en cas de reflux gastro-oesophagien compliquant la sleeve gastrectomie ? Cas clinique et revue de la littérature

Bariatric surgery is currently the treatment of choice for morbid obesity. Sleeve gastrectomy (SG) is a straightforward technique without intestinal bypass, therefore maintaining endoscopic access to the gastric tube. These advantages make this technique the most common procedure in France. However, longer follow-up after SG reveals an increasing rate of gastro-esophageal reflux disease (GERD), which can be a concerning long-term complication. We present the case of a patient with invalidating GERD, five years after undergoing a SG procedure for morbid obesity and discuss its surgical treatment.     

Radiologic assessment of the distal stomach and duodenum after gastric bypass: Percutaneous CT-guided transcatheter technique

Following some types of gastric bypass surgery for morbid obesity the conventional barium examination fails to opacify the bypassed segments of distal stomach and duodenum. The authors describe a technique for visualization of these segments by injection of contrast material through a percutaneously inserted catheter.     

Indications for surgery for morbid obesity and effectiveness of bariatric surgery

In this paper we describe a history and technical aspects of bariatric surgery. And surgical techniques of Divided Vertical Banded Gastroplasty and perioperative management are presented. Our indications for surgery for morbid obesity are almost equal to the guidelines for obesity surgery adopted by the American Society for Bariatric Surgery October 1986. From 1982 to 2000, 64 bariatric surgical procedures were performed at the author's institution. Vertical banded gastroplasty was performed in 45 patients, Horizontal gastric partitioning in 8 patients, Gastric bypass in 10 patients, and Divided vertical banded gastroplasty in 1 patient. The average weight loss one year after Vertical banded gastroplasty is 1/3 of the patient weight. Most of the preexisting comorbid conditions related to the obesity showed improvement or were completely resolved after surgery. No major complications were observed postoperatively. We concluded that surgical procedures for morbid obesity are very effective therapy.     

Intussesception after jejunoileal bypass as diagnosed by ultrasound

Eighty patients who had undergone jejunoileal bypass for morbid obesity were examined by ultrasound at their routine follow-up visits to the clinic. Ultrasonographic evidence of intestinal intussusception was found in 15 patients (19%). Two of these patients were asymptomatic. Ultrasonographic findings were confirmed by operation in 6 patients (5 with intussusception, 1 negative).     

Gastroplasty in morbid obesity: observations in 300 patients

Morbid obesity is associated with a number of life-threatening complications. Medical treatment of morbid obesity is rarely successful. Gastric reduction has replaced intestinal bypass as the surgical treatment of choice. Indications for operation are fairly standardized, and complications and results are similar in most large series. In our series of 300 gastroplasties done during the past four years, weight loss compares favorably with that in other reported series. Our hospital complication rate has been low because of short operating time and early ambulation. Postoperative vomiting has been reduced by enlarging the stoma. Revision rate was between 1% and 2% per year. The surgical treatment of morbid obesity requires a great deal of personal contact between surgeon and patient in the preoperative and postoperative periods. Because these patients tend not to comply with the dietary restrictions of the operation, close follow-up care is required.     

Surgery for morbid obesity. Selecting the patient and procedure

Every physician strives for a treatment that is 100% effective. Although operations for morbid obesity are not perfect, their 80% success rate in helping patients maintain a loss of at least 20% of their original weight is far better than the less-than-10% success rate of nonsurgical treatments. Of the procedures available, intestinal bypass should be avoided, as side effects are numerous. Roux-en-Y gastric bypass is generally successful, as is banded gastroplasty. Surgical candidates need to be selected carefully, and patients must be educated to stay involved in treatment, that is, "use" their operation to ensure a successful outcome.     

The frequency of respiratory failure in patients with morbid obesity undergoing gastric bypass

Morbid obesity is associated with multiple metabolic and mechanical abnormalities that increase morbidity and mortality after major abdominal surgery. It is unclear whether patients undergoing bariatric surgery have increased pulmonary complications postoperatively. We performed a retrospective chart review of 207 patients who underwent elective gastric bypass surgery during a recent 2-year period. Body mass index (BMI = kg/m2) of more than 35 was used to define morbid obesity. The purpose of this study was to determine the frequency of respiratory failure, defined as intubation for 24 hours or more and/or reintubation, in these patients. We also evaluated differences in the frequency of respiratory failure between patients with a BMI of 43 or less and those with a BMI of more than 43. Patients with morbid obesity undergoing elective weight loss surgery had few respiratory or other perioperative complications with our experienced team. The rates of respiratory failure and total postoperative complications were 8% in the group with a BMI of 43 or less and 14% in the group with a BMI of more than 43. Skillful anesthetic care allows patients with significant comorbid conditions to benefit from bariatric surgery with reasonable risk in terms of postoperative complications.     

The role of additives in allergic vasculitis during intravenous hyperalimentation.

A 39-year-old woman who had previously undergone a jejunoileal bypass for morbid obesity was receiving intravenous hyperalimentation. The patient developed allergic vasculitis while receiving fluid which contained a multi-vitamin solution. Rechallenge with this preparation resulted in an exacerbation of her skin lesions. The possible role of such additives in the development of unusual hypersensitivity reactions is discussed.     

Minimally invasive surgery for morbid obesity--evidence or fashion?

In the last decades surgical treatment for morbid obesity has emerged from being the interest of only few surgeons to a well recognized surgical specialty. This development was promoted by the dramatic increase of prevalence of obesity and the development of laparoscopic surgical techniques. In 1996 the NIH consensus conference stated that bariatric surgery is the most effective therapy to treat obesity and type 2 diabetes, whereas conservative treatment strategies failed in the long-term. Only few studies have compared the different operative strategies. It has been shown that the bypass procedure is better than gastric banding with respect to weight loss and the decrease of comorbidities, but suffers from more short-term morbidity. In recent years, randomized trials have been published comparing laparoscopic with open procedures. These studies show an advantage for the laparoscopic techniques. This paper gives a critical overview on bariatric surgery and summarizes the current literature in this speciality.     

Renal complications of jejuno-ileal bypass for obesity

Jejuno-ileal bypass has until recently been an accepted treatment for refractory morbid obesity. Although hyperoxaluria causing renal tract calculi is a well-recognized complication, we describe eight patients who developed significant renal failure attributable to hyperoxaluria resulting from this procedure, three requiring renal replacement therapy. We review the literature, describing 18 other cases with renal failure, the mechanisms of hyperoxaluria and its treatment. Because reversal of the bypass may result in stabilization or partial improvement of renal function, these patients require long-term follow-up of renal function.     

Gastric cancer after mini‐gastric bypass surgery: A case report and literature review

Gastric cancer in the stomach after Roux‐en‐Y gastric bypass or mini‐gastric bypass is rare, but a few cases have been reported since 1991, when the first case emerged. According to the literature, the interval between bypass surgery and the diagnosis of cancer ranged from 1 to 22 years. Given the difficulty of monitoring a bypassed stomach, the potential for gastric cancer must be considered, especially in countries with high incidence of this cancer. The literature reported the first case in the Asia–Pacific region – a woman developed advanced gastric cancer in her stomach 9 years after laparoscopic mini‐gastric bypass for morbid obesity.     

Imaging of morbid obesity procedures and their complications

Surgery for morbid obesity has become commonplace in the United States. Any radiologist who reads abdominal films, body CT, or does gastrointestinal fluoroscopy should be familiar with the surgical procedures and their imaging. Included in this update will be discussions of the vertical banded gastroplasty, Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and biliopancreatic diversion with duodenal switch.     

Minimally invasive surgery for morbid obesity

In patients with morbid obesity, surgery is the only treatment known to produce sustained weight loss and to reduce comorbidities. Traditional (open) gastric bypass surgery is associated with postoperative complications that include wound infection, pulmonary embolism, and pneumonia. Laparoscopic techniques achieve similar long-term results as does open surgery, with fewer postoperative complications.     

Effects of surgical therapy of extreme obesity on physical and psychological outcome]

More than 400 patients with morbid obesity were treated surgically in our unit over the past 18 years. Three different methods (intestinal bypass, bilio-intestinal shunt and vertical banded gastroplasty) were used. In order to assess any postoperative increase in life quality and to compare the three different techniques, 25 matched patients from each group were followed up and the findings compared with a group of non-operated morbidly obese persons. Psychological tests were also supplied. Irrespective of the technique performed a significant increase in quality of life was obtained in 75% of the cases.     

Adverse psychologic reactions to ileal bypass surgery.

Of 33 patients who underwent ileal bypass surgery for morbid obesity and were followed up with psychiatric interviews and consultation postsurgery, five appear to have had adverse psychologic sequelae related to the procedure. The emotional problems of these five patients were in part related to or precipitated by their drastic weight loss after ileal bypass. In most cases, the patients generally had depressive symptoms and, in dynamic terms, were dependent individuals with lifelong problems in object relations. The coping styles demonstrated, while not rigorously classified as psychiatric illness, appeared to predispose them for certain difficulties even when weight had been lost. Ileal bypass surgery apparently is not psychologically innocuous as previously thought, and psychiatric follow-up of patients is indicated.     

Evaluation of a faecal dysbiosis test for irritable bowel syndrome in subjects with and without obesity

Biomarkers for irritable bowel syndrome (IBS) are demanded. An altered faecal microbiome has been reported in subjects with IBS and could be a valuable biomarker. This study evaluated the diagnostic properties of a new test for faecal dysbiosis, designed to distinguish IBS from healthy volunteers and compared the prevalence rates of dysbiosis related to IBS and morbid obesity. Subjects with and without morbid obesity and IBS were included. The faecal microbiota was assessed with GA-map^TM Dysbiosis Test (Genetic Analysis AS, Oslo, Norway). The test result was given as dysbiosis (yes/no). Comparisons were made between four groups: subjects with IBS and morbid obesity (IBS+/MO+); subjects without IBS and with morbid obesity (IBS?/MO+); subjects with IBS and without morbid obesity (IBS+/MO?); and healthy volunteers (IBS?/MO?).The prevalence rates of dysbiosis in the groups IBS+/MO+, IBS-/MO+, IBS+/MO- and IBS-/MO- were 18/28 (64%), 45/71 (63%), 31/63 (49%) and 38/91 (42%). Dysbiosis was more prevalent in subjects with morbid obesity, both in those with and without IBS, than in healthy volunteers (p values .04 and .006). Used as a diagnostic test for IBS in subjects without morbid obesity, the positive and negative likelihood ratios (LR) were 1.18 (0.83–1.67) and 0.87 (0.65–1.18), respectively, and in subjects with morbid obesity the LR were 1.01 (95% CI: 0.73–1.41) and 0.98 (0.54–1.75) respectively. The dysbiosis test was unsuitable as a diagnostic test for IBS. Dysbiosis was statistically significantly associated with morbid obesity, but not with IBS.