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World J. Surg. 22, 925-935, 1998 Gastric Bypass Operation for Obesity · Mathias A.L.
Fobi, M.D.,1,2,3 · Hoil Lee, M.D.,1,2,3 · Ronald Holness, M.D.,2,3 · DeGaulle
Cabinda. M.D.,3 2. 3. Center for Surgical Treatment of Obesity, Abstract. Gastric bypass is considered by many to be the gold standard for surgical treatment of obesity. Gastric bypass was a natural evolution from gastric operations that were used for the treatment of peptic ulcer disease. Gastric bypass, first described in 1967, has undergone many modifications. It presently exists as a hybrid operation. Gastric bypass operation has been extensively scrutinized and evaluated against other operations for the treatment of obesity. Co-morbidities due to severe obesity are usually ameliorated or arrested after the weight loss from gastric bypass. Gastric bypass operation is now being performed with a perioperative morbidity of less than 10%. The average percentage excess weight loss with gastric bypass is 70%. The success rate, defined as 5o% excess weight loss after at least 2 years of follow-up, is 85%. The metabolic deficiencies of gastric bypass are controllable with supplemental intake. This report with special references to the Fobi Pouch Gastric Bypass operation. a modification of gastric bypass done by the author, presents the evolution, modifications, risks, outcome, and future trends of gastric bypass for treatment of obesity. This chapter discusses exclusively the gastric bypass (GBP) operation for obesity. The evolution of the GBP, the modifications that have been made, the complications, weight loss outcome, and the future of the GBP are examined. Because GBP exists as a hybrid operation, the Fobi Pouch Gastric Bypass operation for obesity (FPO), a modification of the GBP, is referred to more specifically because it is the procedure used by the author. Indications for obesity surgery and other aspects of obesity that relate to all other obesity operations are not discussed in detail but are mentioned where necessary to complement the text. Evolution of Gastric Bypass Operation for Treatment of ObesityMason and Ito [1, 2] after extensive laboratory investigation reported their use of GBP in humans in 1967 for the treatment of obesity. The operation has undergone a host of modifications by their originators and others [3-14]. The prototype was the Billroth 11 gastric operation but without removal of the distal stomach (Fig. I ). The stomach was transacted horizontally across the upper fundus, totally separating the distal stomach from the proximal gastric pouch, which was anastomosed to a loop of jejunum. Correspondence to: M.A.L. Fobi, M.D.Center for Surgical Treatment of Obesity Suture technique was used. Alden [3]
introduced use of the staple instrument to obesity surgery to provide an
in-continuity division between the upper pouch and the distal stomach. This
change simplified the operation and made it technically less involved and
safer (Fig. 2). Griffen et al. [4] used a Roux-en-Y gastrojejunostomy instead
of a loop (Figs. 3, 4), which decreased the incidence of troublesome bile
reflux. Initially the pouch size was about 100 cc, and the gastric stoma or
outlet was 2 cm wide; but over time both pouch and stomach a became smaller.
The present range of the pouch size is 10 to 30 cc and the stoma diameter 12
mm. Torres et al. [5] in 1980 started using the lesser curvature vertical
pouch for GBP (Fig. 5). Influenced by the works of Scopinaro et al. [6] from
Mechanism of Functioning of the GBP The GBP causes weight loss by decreasing caloric intake. This is accomplished by inducing anorexia, decreasing the capacity of the stomach, restricting the rate of emptying of the pouch, inducing a feeling of satiety even with minimal caloric intake, prohibiting the intake of certain high osmolar foods (which cause the dumping syndrome), and finally causing selective malabsorption of fat. Anorexia Patients who undergo GBP report loss of the desire to
eat. They forget to eat. They also complain of nausea at the sight, smell, or
taste of food during the first 3 to 8 months after the operation. These
symptoms vary in intensity and duration with the patient. The exact reasons
for these desirable, but in some cases troubling, side effects are not clear.
Gastrointestinal physiologists hypothesize that connecting the pouch directly
to the small bowel enables salivary secretions going into the small bowel to
release gut hormones (enterokinins), which inhibit the brain appetite center
and stimulate the center that causes the feeling of nausea. This explanation
is logical, but scientific studies to validate this hypothesis are needed in
light of the increasing awareness of the significance of obesity as one of
the major causes of morbidity and mortality in the Small Gastric PouchDecreasing the capacity of the stomach is the basic mechanism of all the restrictive operations for obesity. Many have referred to the restricting capacity of the pouch as forced behavior modification. The 10- to 30-cc pouch of GBP results in the patient experiencing discomfort or regurgitation whenever an inordinate amount of fluids or food is consumed. It was this decrease in the capacity to ingest food (reported by patients with the Billroth 11 operation for peptic ulcers who failed to regain or maintain their weight) that stimulated Mason to consider using GBP to treat obesity.
Narrow Stoma The size of the gastric pouch outlet is a significant determinant of the
weight loss and maintenance after GBP. The size of the stoma controls the
rate of emptying of the pouch and hence the rate of caloric intake. Stomal
calibration and re Satiety Patients report satiety with little oral intake after GBP. This is due to the release of gut peptides (cholecystokinin, pancreatic glucagon, and bombesin-like peptides) by the pancreas and small bowel as the food empties directly from the pouch into the small bowel. These gut hormones appear to curb the appetite feedback effect on the brain.
Dumping Syndrome The dumping syndrome is a side effect of GBP that causes weight loss because it limits the ability of the patient to ingest certain high osmolar and thus calorie-dense foods. Rapid transit of food through the gastrointestinal tract due to the dumping syndrome is also implicated in the malabsorption and thus weight loss characteristic of GBP. Fat Malabsorption Selective malabsorption of fat without interfering with the absorption of protein and carbohydrates is one of the main contributors to the effectiveness of GBP for causing weight loss. The altered anatomy in GBP does not allow normal sequential mixing of food with bile and pancreatic secretions, which results in inadequate digestion of fats and other fat-soluble nutrients and consequently in decreased absorption of fats and significantly decreased caloric absorption. Evolution of the Transected Silastic Ring Gastric Bypass (Fobi Pouch Gastric Bypass Operation for Obesity) At this time there is no overwhelming evidence to support the unequivocal recommendation of any one modification of GBP, which accounts for the profusion of variations of GBP described in the literature. The operation we currently use evolved over a 15-year period. We began in 1978 with the Griffen/Alden modification of the Mason GBP, the horizontally stapled pouch with a retrocolic Roux-en-Y gastrojejunostomy (Fig. 4) followed in 1980 by the LaFave-Alden gastrogastrostomy [24], in 1982 by the Mason vertical banded gastroplasty (VBG) [25], and in 1984 by the Henry Laws Silastic ring vertical gastroplasty (SRVG) [26]. In 1986 we introduced the distal Roux-en-Y gastric bypass (DRYGBP) (Fig. 6) as a revision operation for the failed gastroplasty and gastric bypass operations [8]. It was a GBP with a 2-ft efferent Roux limb and 5-ft common limb. Influenced by the works of Scopinaro and Holian, we started using the DRYGBP in all our super-obese patients and some of our selected morbidly obese patients. From 1985 to 1989 we revised about one-third of our VBGs and SRVGs to GBP because of inadequate weight loss or weight loss but progressive weight regain. In some of the revisions the band was left in place, and the gastroenterostomy was made distal to the band. In so doing a new operation evolved: the banded pouch gastric bypass (BPGBP) [14]. Weight loss with this modification appeared better than with SRVG, VBG, or the standard modified Mason GBP. We called it the SRVGBP [15, 161 and subsequently used it routinely from 1989 through 1991.
In 1991, in an effort to address the problem of staple line breakdown, the pouch in this SRVGBP was transacted. This gave birth to the TSRVGBP [16]. The efferent limb of the Roux-en-Y is interposed between the transacted pouch and the distal bypassed stomach and is used as a serosal patch to the cut edge of the proximal pouch to reduce the incidence of leaks, intra-abdominal abscess, and gastrogastric fistula. We use a gastrostomy tube routinely to decompress the distal stomach to prevent the syndrome of acute gastric dilatation and to provide an alternate route for hydration or feeding if the need does arise. A radiopaque ring marker is routinely placed around the gastrostomy site to facilitate future percutaneous access to the distal stomach. This composite operation, with the TSRVGBP, the interposed jejunal limb covering the cut edge of the pouch, the gastrostomy tube, and the gastrostomy site marker is called the "Fobi Pouch Gastric Bypass operation for obesity" (FPO) (Fig. I 1). We have used this technique from 1991 hence. It may not remain our final choice in such a rapidly changing field, but we will not change until another modification of the GBP proves to be superior over at least a 5-year follow-up period. The surgical technique of the FPO involves a Roux-en-Y limb about 2 ft
long and a biliopancreatic limb about 2 ft from the ligament of Treitz (Fig.
12). The enteroenterostomy is side to side using the stapled triangulation
method. The mesenteric gap is closed to prevent internal herniation. The
proximal gastric pouch is then formed by transacting the stomach vertically
just left of the gastroesophageal (GE) junction down across to a point 7 to 8
cm from the GE junction on the lesser curvature, avoiding the neurovascular
structures on the lesser curvature (Fig. 13A-D). This technique enables
adequate direct visualization and thus objective evaluation of the anterior
and posterior aspects of the pouch and distal stomach for tears, leaks,
bleeding, and visual estimation of the pouch size. The cut edge of the
proximal pouch and the distal stomach are re
Patients usually undergo bowel preparation the day before the operation and are admitted the morning of the operation, placed on a prophylactic antibiotic, and given prophylactic her) subcutaneously. Teds' stockings or sequential compression antiphlebotic devices (or both) are used regularly. The hospital stay is usually 4 days. The essence of this GBP operation is the small pouch, interposed jejunal limb, narrow stoma, stomal support, gastrostomy tube for decompression and feeding, distal stomach marker for percutaneous access, and the Roux-en-Y limb. Perioperative Complications of the GBP Despite the most carefully planned and executed operation, complications occasionally occur, and it is of vital importance that the surgeon maintain a high index of suspicion during the entire perioperative period. Preoperative problems associated with GBP include nonspecific complications, such as idiosyncratic reactions to medications used preoperatively. Intraoperative complications may include reactions to medications, problems with intubation and other anesthesia-related complications such as aspiration, cardiac arrhythmias, hyperthermia, hypotension, hypertension, and orotracheal injuries.
Fig. 15. Gastrostomy tube insertion and gastrostomy site marker to facilitate future percutaneous access to the bypass distal stomach of the FPO. Postoperative nonspecific complications may include all of the above plus thrombophlebitis, pulmonary embolism, atelectasis, pneumonia, bleeding, intra-abdominal infections, wound infections, and wound dehiscence. Acute small bowel obstruction, acute cholecystitis, and enterocolitis have also been described after GBP. Complications related to the GBP procedure include splenic, esophageal, vagus nerve, pancreatic, liver, and colon injuries. A leak from the pouch, the anastomosis, or the distal stomach is the most lethal complication after GBP if it is not recognized and treated promptly. Tachycardia (rapid pulse; heart rate >120 bpm) [27] in a postoperative GBP patient is highly suggestive of leakage. Should this finding be present, hypovolemia should be corrected. A chest radiograph should be obtained to exclude pneumonitis or atelectasis. Lower lobe atelectasis, especially involving the left lower lobe, or a left-sided pleural effusion can be the result of a leak and subphrenic collection particularly if associated with a left shoulder strap pain. We have had 29 (3%) leaks in 944 patients (Table 1); 9 (1.3%) leaks occurred in 705 primary patients. Five were contained leaks within the jejunal wrap that resolved with antibiotic treatment. Four patients required surgical intervention; two of the four died, and the other two had unremarkable recoveries. Among the 239 patients who had the FPO as a revision operation, 20 (8.4%) developed leaks. Only two of this group required surgical intervention; they developed their leaks after discharge from the hospital and after the drains and gastrostomy tubes had been removed. The routine use of drains for all revision operations enabled spontaneous drainage of the other leaks without further surgical intervention. Acute gastric dilatation is the other potentially lethal complication that can occur after GBP. It is usually due to afferent loop obstruction from either intraluminal bleeding at the enteroenterostomy site, a kink at the same site, internal herniation., or volvulus. Acute gastric dilatation can also occur as a consequence of gastric ileus due to normal operative trauma without mechanical obstruction. Gastritis and marginal ulceration, each with or without hemorrhage, have also been described after GBP [28-34]. We had one patient who developed massive hemorrhage that drained via the gastrostomy tube, but the bleeding stopped spontaneously. Perioperative mortality after GBP has declined from the high 4% in Mason and Ho's [2] original report to a low 0 to 1% in many recent series [10, 11, 33, 34]. There were 5 (0.5%) perioperative deaths among 944 patients after the FPO, three due to leaks and two due to pulmonary embolism. Three (0.4%) deaths occurred in the primary group and two (0.8%) in the revision group.
Primary: patient shaving the FPO as their initial obesity operation; secondary: patients having the FPO as a revision operation after another surgery. Late Complications after GBP The reported complications in the literature after GBP comprises a long list, but the incidence of most is low with the exception of iron deficiency anemia, vitamin B,, deficiency, and fat-soluble vitamin A, D, and E deficiencies. Late complications after GBP can be summarized as weight loss failures, outlet problems, peptic ulcer disease, nutritional deficiencies, post-GBP side effects, cholelithiasis, ventral hernias, psychiatric problems, and late deaths. Weight Loss Failure Weight loss of less than 50% of the patient's excess weight or lack of maintenance of more than 50% excess weight loss over the time period of the study is considered weight loss failure. Some consider any significant weight regain with return of significant co-morbidities as weight loss failure. The causes of weight loss failure after the GBP operation for obesity include an initial large pouch (> 30 cc), an initial large stoma (> 14 mm), a dilated pouch, dilated stoma, staple line disruption or gastrogastric fistula, super-obesity, and the patient factor. The failure rate of GBP in series followed for more than 5 years range from 5% to 40% (average 15%) [34-37]. In our series of 944 patients with the FPO, only 12 of the 516 patients (2.3%) eligible for 2-year follow-up have been documented to have lost less than 50% of the excess weight. None of the 47 patients who have been followed for more than 5 years falls into the weight failure category. This is because the FPO operation addresses the causes of weight failure after GBP, such as a small vertically placed pouch that dilates minimally over time, an outlet 12 mm in diameter with the external support of the Silastic ring band that is not dilatable, and no stapling in continuity, the most common cause for weight regain with other GBP operations [17-23]. We have had 19 (2.3%) gastrogastric fistulas (Table 2), all of them associated with documented leaks. There were 5 (0.7%) gastrogastric fistulas in 705 patients who underwent primary FPO, and 14 (5.9%) in those who had a secondary FPO. Eighteen patients have required reoperation for revision, and one patient is awaiting approval for her reoperation. This last patient is one of the 12 who lost less than 40% excess weight. Three super-obese patients have required revision to the DRYGBP with good results.
Primary: patients having the FPO as their initial obesity operation; secondary: patients having the FPO as a revision operation after another surgery. Outlet Problems Three types of outlet problems are seen after GBP: (1) functional outlet obstruction or stenosis; (2) bezoar obstruction; and (3) anatomic stenosis or obstruction due to band migration or hypertrophic scar formation. Functional outlet obstruction or stenosis is the most common outlet problem encountered after GBP. It is characterized by radiologically and endoscopically normal-appearing outlet in a patient with all the clinical symptoms of stenosis or obstruction, such as vomiting, dehydration, and excessive weight loss; occasionally even electrolyte imbalance or protein malnutrition is present. Of the 944 FPO patients operated between 1991 and 1996, only 72 fell into this category. Altogether 41 patients were managed by outpatient counseling and monitoring of their nutritional and fluid intake along with blood chemistries; 12 were readmitted for in-hospital hydration, counseling, and monitoring of their blood chemistries; 19 had percutaneous gastrostomy tubes inserted as outpatients and were managed with gastrostomy enteral feedings for periods ranging from 1 week to 3 months; and 4 subsequently required laparotomy for removal of the band and intraoperative dilatation of the stoma. Bezoar obstruction requiring endoscopic retrieval or management has been documented in 17 of the 944 patients with the FPO. One patient has had three bezoar obstructions, and two other patients have had two obstruction episodes each. Anatomic obstruction due to band migration or stenosed outlet has been documented in 32 patients (3.4%). Altogether 19 patients have had revision operations with removal of the band and stoma dilatation; 14 of the 19 also had gastrogastric fistulas. The other 13 have been treated expectantly with oral or gastrostomy feedings and have spontaneously extruded the band and required no further surgical intervention. Capella and Capella reported a similar incidence of obstruction and stenosis [18, 19]. Peptic Ulcer Disease We have not documented any gastric or duodenal ulcers in our 944 FPO patients, although marginal or stomal ulcers have been documented in 28 (3%). Twenty-six of these ulcers were associated with band migration or a gastrogastric fistula. These were managed operatively with the associated medical problems. The two patients who had isolated marginal ulcers responded to nonsurgical management. Most other series of GBP report the rare occurrence of gastric or duodenal ulcers [28, 29]. The incidence of marginal or stoma ulcers in other GBP studies ranges from 1% to 25% [28-32]. Marginal ulcers in GBP patients are almost always the result of the pouch being too large, band erosion, or the coexistence of staple line breakdown or a gastrogastric fistula [11, 17, 23, 30, 31]. Small Bowel Obstruction Late bowel obstruction has been documented in 44 (4.7%) of our -FPO patients. These have been found to be due to adhesive Pobands usually involving the enteroenterostomy site or volvulus due to internal herniation at the enteroenterostomy site or around the Roux-en-Y limb, whether antecolic or retrocolic. Such defects must be closed at the time of the primary operation to avoid these complications. Obstruction due to intussusception has been documented in two patients: One patient had three such episodes and died from complications after the third episode. There was also one death from a closed segment obstruction that was not diagnosed until the patient developed hypovolemic shock and sepsis. Disproportionate abdominal pain in a GBP patient without peritonitis or leukocytosis or fever is highly suggestive of ischemic pain due to a biliopancreatic limb obstruction [38]. Ventral Hernia Ventral incisional hernias have been documented in 44 (4.7%) of the 944 patients after the FPO. Ventral hernias occur in about 5% after the GBP. Until a time when the fiscal intermediaries recognize loose and sagging skin in post-GBP patients as a significant medical problem the occurrence of incisional hernias is a desirable side effect of the GBP operation. Approval for an incisional hernia repair enables the surgeon to excise the excess skin and sagging soft tissues that result from the massive weight loss.
SLD: staple line disruption; GGF: gastrogastric fistula. a. Upper gastrointestinal radiographs done in 10 days and at 1 and 2 years. b. l % GGF in primary operation; 6% GGF in revision operation.
From Fobi [23].
From Fobi [23]. Nutritional Deficiencies Iron, vitamin B12, folic acid, and fat-soluble vitamin A, D, and E deficiencies occur in most GBP patients if they do not take the appropriate supplements [34, 38-42]. We routinely prescribe these supplements to all our FPO patients. Calcium and thiamine supplements are also prescribed routinely. Trinsicon is a combination of iron, folic acid, and vitamin B-complex vitamins that we have found useful for preventing the deficiency syndromes in GBP patients. Protein malnutrition (PMN) has been seen rarely and transiently after GBP, usually as a result of another complication (i.e., outlet stenosis or obstruction) rather than as a primary side effect. One modification of the GBP, the DRYGBP, is associated with a significant incidence of PMN [8 -40, 4 1 ]. PMN has been an occasional finding in FPO patients, usually due to outlet problems, and has been adequately managed by oral protein intake supplements or percutaneous gastrostomy supplements. Cholelithiasis Cholelithiasis is a recognized complication of massive weight loss. Of the 944 patients who underwent FPO, 24 (2.5%) developed cholelithiasis. The incidence of cholelithiasis after GBP ranges from 2% to 73% [11, 30]. Some surgeons perform routine cholecystectomy with GBP. Post-GBP Side Effect Nausea, vomiting or postprandial regurgitation, dumping syndrome, diarrhea, and hypoglycemia may occur after gastric bypass. The number of these side effects, their frequency of occurrence, and their severity varies from patient to patient. Rarely is any treatment necessary for any of them. Most patients with or without counseling learn to overcome these side effects if no other cause is found. Psychiatric Problems Exacerbation of depression has been noted after GBP, and increased anxiety state and identity crises have been reported [11]. These problems are probably due to the weight loss, inability to accept the new eating patterns, and unrealistic patient expectations after the operation, rather than a specific complication of the GBP. Marital maladjustment is the most common psychiatric diagnosis after weight loss. The obvious changes in body image, differences in peer relationships, and awakening of sexuality, as well as the new assertiveness experienced by these patients, demand frequent and compassionate support, especially during the first year. We have found support groups to be more helpful to patients with post-GBP psychiatric problems than referral to a psychiatrist or psychologist. Late Death Late death seldom bears any relation to the operation, although one of the ten late deaths in our series was due to a delayed diagnosis of a closed segment obstruction and the another was due to the delayed diagnosis of intussusception. These two deaths were the result of "managed care" restriction of access to appropriate, timely medical care. Weight Loss Results Among 944 patients, there were 705 with a primary FPO and 239 with a secondary FPO (Table 1). Of this group, 516 qualified for a 2-year follow-up at the time of this writing. Among this subgroup only 12 patients have been documented to have lost less than 50% of their excess weight. Our 2-year weight loss experience with the four modifications of the GBP we have used (Table 3) is consistent with other published results [ 19 -23, 33, 34, 35, 36, 44, 45]. Most GBP operations result in an average 70% excess weight loss [35-37, 44-50]. In 1992 a total of 25 patients with an FPO were entered into a randomized prospective evaluation with 25 patients with the SRVGBP; 24 of the FPO patients and 21 of the SRVGBP patients have been followed for 4 years (Tables 4, 5). All the FPO patients, including the one with the band removed, have had excellent weight loss with an average excess weight loss of 75%. It is significant to note that at 4 years of follow-up in this small series there is no tendency to regain weight or for a decrease in the percentage excess weight loss seen in other series with similar follow-up [20-23, 32, 33, 34-36, 44, 45]. If this observation persists at 10 years of follow-up, we will be able to say that we have developed an operation that adequately controls severe obesity. Future of the GBP The GBP procedure has undergone more scrutiny than any other obesity operation. It has been evaluated against the jejunoileal bypass, gastrogastrostomy, horizontal gastroplasty, vertical banded gastroplasty, and gastric banding [3, 4, 32, 35-37, 43-49, 49, 50]. In all the published evaluations GBP, no matter what modification was used, has proved to be the more effective weight loss operation [35-37, 43-49], which is why the GBP has been called the gold standard of obesity operations. Modifications to the GBP now are, as before, aimed at addressing the problem of slow but progressive weight regain that starts 2 years after GBP. The inadequate weight loss or the weight regain due to large t)ouches or large stomas (or both) have been adequately addressed by making pouches < 30 cc and stomas < 12 mm. The weight regain due to staple line breakdown is being adequately addressed by gastric transaction, which can be done more safely now than at the time Mason described the operation. The weight regain due to stomal dilation is being addressed by either increasing the degree of malabsorption [8-10, 43] or adding external support to the stoma [11-16, 18, 19, 30]. Having used both methods, we prefer the latter because of the severe metabolic sequela of the former (i.e., protein malnutrition, calcium deficiency, kidney problems, and nonspecific enteritis). Modifications of GBP should be carried out with due consideration to the risk/benefit ratio of more weight loss and the side effects of the operation. Wittgrove and Clark [50] reported 27 cases of GBP done laparoscopically with excellent results at 3 to 18 months of follow-up. It will not be long before all GBP modifications are done laparoscopically. Hopefully in the not too distant future the need for the surgical approach to obesity will be obsolete. In the meantime GBP offers the morbidly obese effective surgical control. Resume Le by-pass gastrique est considere par beaucoup comme le << gold standard >> pour le traitement chirurgical de l'obesite. Le by-pass gastrique est une consequence de l'evolution naturelle des interventions utilisees pour le traitement de la maladie ulcereuse. Depuis sa description initiale en 1967, cette intervention a subit plusieurs modifications, et, a present, peut etre consid6r6c comme une varitable intervention hybride. On I'a evaluee extensivement par rapport a d'autres interventions pour le traitement de l'obesite. Les etats co-morbides en rapport avec l'obesite morbide sont habituellement ameliorees on disparaissent apres la perte postoperatoire de poids. A I'heure actuelle, la morbidite perioperatoire est inf6rieure A 10%. Grace A l'intervention, la perte de surpoids realisee est de 70% en moyenne. Le succes est defini lorsqu'une perte de poids de 50% est atteint apres au moins deux ans; ceci s'observe chez 85% des patients. Les deficits mdtaboliques en rapport avec cette chirurgie se corrigent bien avec un apport supplementaire. Dans cc rapport, en faisant reference A l'intervention de la poche de Fobi, une modification personnelle de I'auteur, on presente 1'evolution, les modifications, les risques, les resultats et les tendances futures du by-pass gastrique dans le traitement de l'obesite morbide. Resumen El "bypass"
gdstrico es considerado por muchos como el patron oro en el tratamiento
quirergico de la obesidad. El procedimiento resulte de la evolucien natural
de las operaciones gdstricas que han sido utilizadas en el tratamiento de la
enfermedad ulceropeptica. El "bypass" gastrico, descrito por
primera vez en 1967, ha sufrido muchas modificaciones y actualmente se
practica como una operaci6n hibrida. Ha sido escudrifiado y ampliamente
evatuado frente a otras operaciones que se utilizan en el trata miento de la
obesidad. Con el "bypass" gdstrico se mejora o se controla la
comorbilidad de la obesidad severa. En la actualidad el procedimiento se
ejecuta con una morbilidad perioperatoria menor al 10%; se logra un promedio
de reducci6n del exceso de peso del orden del 70% y una tasa de 6xito a 5
afios del 85%, definido dste como una perdida del 50% de peso a los dos afios
de seguimiento. Las deficiencies metabelicas del "bypass" gastrico
son controlables mediante ingesta suplementaria. El presente | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
