Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction.

BACKGROUND: Gastro-gastric fistulas and marginal ulcers are frequent and serious complications of gastric compartmentalization procedures for obesity. METHODS: The authors analyzed 810 patients after 911 operations for gastro-gastric fistulas and marginal ulcers over an 8-year period. All patients underwent a form of gastric bypass, in which a pouch is constructed along the lesser curvature of the stomach. The outlet of the pouch was restricted with a prosthetic band. In the first 189 patients (Group I), the pouch and stomach were stapled in continuity or partially divided. In the next 222 patients (Group II), segments were stapled and separated by transection. In the remaining 492 cases (Group III), in addition to transection of the stomach, a limb of jejunum was interposed between the pouch and excluded stomach. Stapled anastomoses were done in Group I and II patients and a portion of Group III patients. The remaining patients underwent hand-sewn anastomosis. RESULTS: Gastro-gastric fistulas occurred in 49% of the patients in Group I, 2.6% of those in Group II, and 0% of those in Group III. In stapled anastomosis, the incidence of marginal ulceration in Groups I, II, and III were 8.5%, 5.4%, and 5.1%, respectively. In a subset of Group III patients, in whom a two-layer, hand-sewn anastomosis was done, the incidence was 1.6% when the outer layer was not absorbable and 0% when both layers were absorbable. CONCLUSIONS: Gastro-gastric fistulas and marginal ulcerations are likely the result of breakdown of the mucosa resulting from migrating staples and other foreign material. Lack of integrity of the gastric lining facilitates the action of the gastric digestive process. Transection of gastric segments with interposition of jejunum prevents gastro-gastric fistula formation. An intact serosa appears to block the digestion of bowel wall by gastric enzymes. Our early data suggest that the use of absorbable sutures at the gastrojejunostomy significantly decreases the incidence of marginal ulceration.

Converting vertical banded gastroplasty to a lesser curvature gastric bypass: technical considerations.

BACKGROUND: Vertical banded gastroplasty (VBG) is occasionally followed by poor weight loss or complications requiring reoperation. Several studies have analyzed the morbidity and mortality associated with conversions of VBG to gastric bypass, but few have described the actual technique. The most frequent complications related to this type of reoperation are gastrointestinal leaks. MATERIALS AND METHODS: The authors analyzed 60 consecutive conversions from VBG to lesser curvature gastric bypass, performed on 60 patients. The cases were analyzed for surgical technique, complications and weight loss. In all the cases the operation was limited to the lesser curvature of the stomach, and certain technical maneuvers were done to facilitate the creation of the pouch and anastomosis. RESULTS: There were three major complications, and two patients required reoperation. There were no gastrointestinal leaks or mortality. Percentage weight loss at 5 years was similar to primary gastric bypasses. CONCLUSION: Converting failed or complicated VBGs to lesser curvature gastric bypasses are safe and effective weight loss operations. By performing several specific technical maneuvers and limiting the operation to the highly vascular lesser curvature, complications can be reduced to a minimum.

Reducing early technical complications in gastric bypass surgery.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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 weight reduction operation of choice: vertical banded gastroplasty or gastric bypass?

BACKGROUND: Despite important advances in the field of bariatric surgery over the last 40 years, no single operation has clearly emerged as the optimum procedure. Over the last decade, however, attention has focused on vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RGB). PATIENTS AND METHODS: We compared 329 VBG procedures consecutively performed in 328 patients, and 623 VBG-RGB operations in 560 patients for mortality, early and late complications requiring reoperation, and for weight loss up to 5 years. In 272 VBG-RGB operations, the gastric segments were stapled in continuity, and in 351 cases, the gastric segments were stapled and completely separated. RESULTS: Early complications were few for both procedures. Unsatisfactory weight loss was the most frequent late complication among VBG patients, whereas revision for staple-line disruption was the most common cause for late reoperation in the VBG-RGB group. The incidence of stapleline disruption was 22% for VBG-RGB patients when gastric segments were stapled in continuity and 2% when gastric segments were completely divided (P < 0.0001). Weight loss for the VBG patients and VBG-RGB patients at 5 years was 47% and 62%, respectively (P < 0.0001). CONCLUSION: Our data suggest, as others have shown, that RGB is a better weight-loss operation than VBG. A lesser curvature vertical pouch stapled in continuity with the excluded stomach can be associated with a high rate of staple-line disruption in RGB. Separation of gastric segments appears to significantly diminish this complication (P < 0.0001). Late complications now are fewer, and VBG-RGB is our weight-reduction procedure of choice.