PROCEEDINGS oJ tM th A·N·N·U·A·L ariatri surgery colloquium I I i ! . 1 I 1 i ! PROCEEDINGS OF THE 5TH ANNUAL BARIATRIC SURGERY COLLOQUIUM EDITED BY THOMAS J. BLOMMERS, PH.D. I I j I I Presented June 3-4, 1982 I Iowa City, Iowa Under the Auspices of I THE UNIVERSITY OF IOWA I Department of Surgery I . ! I Transcription by Patricia L. Piper , . "'. ':' .., © Copyright 1983 by The University of Iowa All Rights Reseryed Printed in the United States of America CONTRIBUTORS John F. Alden, M.D. Kathye Gentry, M.S., PAC Professor, Surgery Washington University University of Minnesota School of Medicine Medical School 4960 Audubon Avenue Minneapolis, Minnesota St. Louis, Missouri Thomas J. Blommers, Ph.D. D. Michael Grace, M.D. Clinical Research, Surgery Associate Professor, General and Colloquium Coordinator Surgery, Western Ontario University The University of Iowa 339 Windermer Road Iowa City, Iowa london, Ontario, Canada Joseph A. Buckwalter, M.D. John D. Halverson, M.D. Professor, Surgery Associate Professor, Surgery University of North Carolina Washington University School School of Medicine of Medicine Chapel Hill, North Carolina 4960 Audubon Avenue St. louis, Missouri Marilyn l. Bukoff, R.D., M.A. Dietitian, Dietary Services James P. Hayes, J.D. The University of Iowa Meardon, Sueppel, Downer and Hayes Iowa City, Iowa 122 South linn Street Iowa Ci ty, Iowa Luigi M. Delucia, M.D. Private Practice, Surgery Charles A. Herbst, M.D. 10738 Riverside Drive Associate Professor, Surgery North Hollywood, California University of North Carolina School of Medicine C. Gregory Doherty Chapel Hill, North Carolina 19 Gateview Court San Francisco, California Darwin K. Holian, M.D. Private Practice, Surgery Cornelius Doherty, M.D. 5333 Hollister Avenue Private Practice, Surgery Santa Barbara, California 490 Post Street San Francisco, California l. Michael Howell, M.D. Private Practice, Surgery Gifford V. Eckhout, M.D. Fargo Clinic Private Practice, Surgery 737 Broadway, Box 2067 2045 Franklin, Suite 714 Fargo, North Dakota Denver, Colorado Ben H. Knecht, M.D. Martin E. Felder, M.D. Clinical Instructor, Surgery Assistant Professor, Surgery University of Washington Brown University 820 North Chelan Avenue Providence, Rhode Island Wenatchee, Washington Cheri L. Florance, Ph.D. John M. Kroyer, M.D. Director, Communications Private Practice, Surgery Disorders Institute 1741 Pacific Avenue 1450 Hawthorne Avenue Long Beach, California Columbus, Ohio iii Henry L. Laws, M.D. Paul W. Moen, M.D. Associate Professor, Surgery Private Practice, Surgery University of Alabama 1504 Seventh Street Birmingham, Alabama Moline, Illinois Jeffrey W. Lewis, M.D. Cathy M. Mojzisik, R.N. Assistant Professor, Surgery Ohio State University The University of Iowa Schobl of Medicine Iowa Ci ty, Iowa 410 West Tenth Avenue Columbus, Ohio Richard I. MacArthur, M.D. Assistant Professor, Surgery J. Patrick O'Leary, M.D. University of Kansas Professor, Surgery Medical Center Vanderbilt University 39th and Rainbow Boulevards School of Medicine Kansas City, Kansas Chief, Surgical Service Veterans Administration Edward W. Martin, M.D. Medical Center Assistant Professor, Surgery Nashville, Tennessee Ohio State University College of Medicine Kenneth J. Printen, M.D. 410 West Tenth Avenue Professor, Surgery Columbus, Ohio The University of Iowa Iowa Ci ty, Iowa Edward E. Mason, M.D. Professor and Chairman, Sheldon M. Solochek, M.D. Division of General Surgery Private Practice, Surgery The University of Iowa 1218 West Kilbourn Avenue Iowa Ci ty, Iowa Milwaukee, Wisconsin David K. "Miller, M.D. Jose C. Torres, M.D. Clinical Instructor, Surgery Clinical Instructor, Surgery University of Utah University of Louisville School of Medicine Louisville, Kentucky Salt Lake City, Utah iv TABLE OF CONTENTS Page WEI.C<::f.1E •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 1 Edward E. Mason,' M.D. Bn.IOPAN'~IC BYPASS ••••••••••••••••••••••••••••••••••••••••••••••••••••••• 2 Darwin K. Holian, M. D. RCl.J}{-m-Y GASTRIC BYPASS ••••••••••••••••••••••••••••••••••••••••••••••••••••• 5 David K. Miller, M.D. HORIZCNrAL BANDED GASTROPLASTY ............................................... 8 JOM M. Kroyer, M.D. GASTROPLASTY WITH MESH REINFORCEMENT 11 D. Michael Grace, M.D. EVOLUTlOO OF GASTRIC PARI'ITICNING ........................................... 14 Edward w. Martin, M.D. GASTRC:XiASTROS'ra."\1Y •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 18 Richard I. MacArthur, M.D. CrnPARISON OF GASTRIC BYPASS AND VERrICAL BANDED GASTROPLASTY 22 Edward E. Mason, Ph.D., M.D. COMPARISON OF GASTRIC BYPASS AND GASTRC:XiASTROSTCMY 25 L. Michael Howell, M. D. CCMPARISON OF GASTRIC BYPASS AND LESSER CURVATURE GASTROPLASTY 29 Jose C. Torres, M.D. CLASSIC GASTRIC BYPASS, SHOUID WE CHANGE? 31 Ben H. Knecht, M.D. DISCUSSION OF VARIATICNS OF TECHNIQUE AND TECHNICAL PROBLEMS ••••••••••••••••• 34 John F. Alden, M.D., Cornelius Doherty, M.D., Henry L. Laws, M.D., and Jeffrey W. Lewis, M.D. OBESITY SURGERY IN THE OLDER AGE PATIENT 41 Martin E. Felder, M.D. A COMPtJrER INFORl'lIATION SYSTEM FOR VERI'ICAL BANDED GASTROPLASTY 42 C. Gregory Doherty RADICX:;RAPHIC STUDIES IN GASTRIC REDUcrION PROCEDURES 45 Luigi M. DeLucia, M.D. EFFECl'S ON INSULIN-DEPENDENT DIABErICS 47 Charles A. Herbst, M.D. BLEEDING FRCM THE BYPASSED ST(I.IlACH ........................................... 55 John F. Alden, M.D. v GAI...I.BI.ADDER DISEA.SE ••••••.•••••••..•••••••••..••••••.•...•..•••.••...•••••••. 58 Sheldon M. Solochek, M.D. IMPROVEMENT IN OXYGEN CONSUMPTION 64 Donald Zavala, M.D. DISCUSSICN OF BARIATRIC SURGERY'S OVERALL EFFECl' ON PATIENTS................. 67 John D. Halverson, M.D., Paul W. Moen, M.D., J. Patrick O'leary, M.D., and Kenneth J. Printen, M.D. lrJlPROV'ING S~Irn CRITER.I.A. ••••••••••••••••••••••••••••••••••••••••••••••••• 70 Marilyn L. Bukoff, R.D., M.A. MEASUREMENT OF JMPACr ON LIFE 72 Cheri L. Florance, Ph.D. PREADMISSION PATIENT EDUCATICN ••••••••••••••••••••••••• 0 ••••••••••••••••••••• 75 Cathy M. Mojzisik, R.N. PREOPERATIVE AND POSTOPERATIVE PSYCHIATRIC STUDY 77 Kathye Gentry, M.S., PAC DISCUSSICN OF MALPRACTICE AND BARIATRIC SURGERY •••••••••••••••••••••••••••••• 82 James P. Hayes, J.D., Edward E. Mason, Ph.D., M.D., and J. Patrick O· Ieary, M.D. S~TlOO AND .ADJ"O~ ••••••••••••••••••••••••••••••••••••• "............... 87 Edward E. Mason, Ph.D., M.D. vi 1 WELCOME Edward E. Mason, M.D. This is the lOOth year since Darwin's death and a number of us have used the word evolution in talking about these operations for morbid obesity. This Colloquium is really an opportunity to look at the progress of that evolution. We appreciate greatly that all of you have come, some from across the street, and others from long distances. In addition to those from the United States, surgeons from Australia, Canada, Denmark, Italy and Norway are also attending this meeting. I want to call your attention to the arrangements that have been made by Ken Printen, Tom Blommers, Bob Davis and the people here at the Conference Center and the excellent job that they have done in planning and organizing this year's Colloquium. 2 BILIOPANCREATIC BYPASS Darwin K. Holian~ M.D. I realize that I am probably the only surgeon doing the biliopancreatic bypass in the United States. My aim is to convince you, from clinical experience, about four things: 1) the procedure is well founded and physiological; 2) it is not too technically difficult; 3) it is almost without failure or side effects; and 4) patient acceptance is excellent. My practice is located in a relatively small southern California city. Competition is fierce and one has to liv~ with his patients. Encouraged by patient demand on the one hand and a new TA90 stapler on the other, I began gastric stapling procedures of varying types about four years ago. My results were so bad and patient acceptance so poor, that I was convinced there had to be a better way. At this same conference two years ago, I became intrigued with Dr. Scopinaro's thoughts and studies on what has been labeled the biliopancreatic bypass. I elected to do his Type 4 procedure because at that time it appeared to have the best results. The operation consists of a two-thirds gastrectomy done only to reduce acid secretion. I close the duodenum with a TA55 ® stapler. I put the TA90 stapler across the stomach and fold it in as everybody recommends with interrupted serosa-to-serosa sutures. Then I divide the small intestine in half and I suture the distal half of the intestine to the stomach. I suture the proximal end of the intestine to the terminal ileum 20 inches from the ileocecal valve. Scopinaro claims that, for the excessively obese, a 150~cm alimentary tract is successful in almost 100% of patients. I think a 50-cm common ileoconduit is very important. This creates a selective malabsorption syndrome allowing absorption of simple sugars, adequate protein, vitamins and bile salts, but does not allow digestion of fats or starchs. No diarrhea results. After the third postoperative week the patients are completely free of dietary restrictions. This makes them extremely happy. Technically, the most difficult part of the procedure to perform is the retrocolic gastroileostomy. However, since the introduction of the curved disposable #25 EEA stapler, I have cut operating time by one hour and I am finally assured of a good anastomosis. I remove all vessels from the distal 5 cm of the greater curvature of the stomacn using 2-0 Prolene sutures in that area and around the end of the small intestine. The EEA is introduced through an enterotomy about 4 inches from the cut end of the ileum. It is necessary to keep the gastroileostomy far enough away from the gastric closure so that the turned in stomach, particularly the corner, will not cover the stoma and cause obstruction. After firing the stapler, I leave it closed. At that point it becomes an internal retractor. I pull the anast9mosis below the transverse mesocolon and suture the 3 edge of the rent in the mesocolon to the serosa of the stomach. Only then is the stapler opened and removed. The enterotomy is closed and the Roux-en-Y enteroenterostomy to the terminal ileum is completed.