ARTICLE IN PRESS International Journal of Surgery Open ■■ (2016) ■■–■■ Contents lists available at ScienceDirect International Journal of Surgery Open journal homepage: www.elsevier.com/locate/ijso 1 Review Article 2 3 Overview of gastric bypass surgery 4 5 Q1 Elroy Patrick Weledji * 6 Department of Surgery, Faculty of Health Sciences, University of Buea, Cameroon 7 8 9 ARTICLE INFO ABSTRACT 10 1211 Article history: Gastric bypass surgery is indicated for several clinical reasons including benign and malignant upper gas- 1413 Received 7 June 2016 trointestinal tract pathologies. Any gastric resection or bypass procedure interferes with gastric emptying 1615 Received in revised form 17 September and the aim of reconstruction is to minimize the disturbance to the upper gastrointestinal physiology. 17 2016 18 Gastric bypass procedures induce early satiety, with or without concomitant impaired absorption of nu- 19 Accepted 19 September 2016 20 trients, and offer the best solution for morbid obesity. The long-term health benefits of gastric bypass 21 Available online 22 surgery for morbid obesity must be found to outweigh the operative risks and side-effects of gastric bypass 23 24 and thus patient selection is fundamental. The aim of the study was to review the indications, compli- 25 Keywords: 2726 Gastric bypass cations, sequelae and outcome of gastric bypass procedures. 2928 Indications © 2016 Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article 3130 Complications under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 32 Sequelae 33 34 1. Introduction 2. Gastrojejunostomy 65 35 66 36 The history of gastric bypass surgery began in 1880 when the By diverting gastric acid away from the duodenum, anastomo- 67 37 Polish surgeon Ludwik Rydygier performed a gastroenterostomy for sis of the stomach to a loop of jejunum was once used to treat 68 38 peptic ulcer disease [1]. In 1885, the Austrian surgeon Theodor duodenal ulcer but carried a high recurrence (50%) rate [12]. Gas- 69 39 Billroth (Fig. 1) performed a first-stage gastrojejunostomy to alle- trojejunostomy was then used as a drainage procedure following 70 40 viate the symptoms of an obstructing large pyloric tumour followed truncal vagotomy for peptic ulcer disease but has fallen into disuse 71 41 by a second-stage resection of the tumour with restoration of gas- since the advent of effective medical treatment to suppress gastric 72 42 troduodenal continuity [1,2]. Most modern forms of gastrectomy with acid output and antral helicobacter pylori invasion [13,14]. Lapa- 73 43 gastrojejunal anastomosis (Billroth II) are modelled on this oper- roscopic gastrojejunostomy (LGJ) has been proposed as the technique 74 44 ation and described for the treatment of peptic ulcer disease in 1911 preferred over open gastrojejunostomy for relieving gastric outlet 75 45 [2–4]. With the success of antral Helicobacter pylori eradication triple obstruction (GOO) due to malignant and benign disease with im- 76 46 therapy for peptic ulcer disease which includes antibiotics and a re- proved outcome and an acceptable complication rate [15]. 77 47 versible chemical vagotomy with H2 receptor antagonist or proton Gastrojejunostomy would also bypass congenital pre-ampullary du- 78 48 pump inhibitor, surgery is now indicated only for the emergency odenal obstruction from a duodenal web/atresia/stenosis and an 79 49 complications of perforation, severe vomiting from pyloric steno- annular pancreas, with no or minimal early or long term compli- 80 50 sis and haemorrhage [5]. It was also well recognized that Billroth cations including malnutrition [16]. Although resection of a primary 81 51 II (partial) gastrectomy is associated with weight loss and several gastric tumour provides better palliation than bypass surgery pro- 82 52 variations of this procedure have been used effectively in the sur- vided the patient’s general health will allow this, patients with 83 53 gical treatment of morbid obesity with benefit lasting for up to 10 unresectable distal gastric tumours may benefit from a high antecolic 84 54 years [4,6–11]. The restriction of volume of ingested food togeth- gastrojejunostomy [17–19]. The control of the rate of delivery of the 85 55 er with altered absorption of nutrients, especially fat contributes gastric contents to the small intestine that allows adequate mixing 86 56 to achieving the weight loss and the malabsorptive procedures alter with bile and pancreatic juices and avoids overwhelming the di- 87 57 the digestive process in different ways [8–11]. The aim of this review gestive and absorptive capacity of the small intestine requires an 88 58 was to evaluate the common gastric bypass procedures with regard intact and innervated pylorus. The importance of attempting to pre- 89 59 to their indications, sequelae and outcome. serve normal gastric emptying in gastric bypass procedures without 90 compromising oncological results is seen with the more physio- 91 60 logical post-operative digestive function of the pylorus – preserving 92 partial pancreaticoduodenectomy for pancreatic head cancer than 93 61 with the partial stomach resection of the classical Kausch–Whipple 94 62 Q2 * Department of Surgery, Faculty of Health Sciences, University of Buea, PO Box 126, 63 Limbe, S. W. Region, Cameroon. procedure [20]. The Whipple’s procedure is also occasionally indi- 95 64 E-mail address: [email protected]. cated in cases of duodenal or pancreatic head trauma. Following a 96 http://dx.doi.org/10.1016/j.ijso.2016.09.004 2405-8572/© 2016 Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Elroy Patrick Weledji, Overview of gastric bypass surgery, International Journal of Surgery Open (2016), doi: 10.1016/j.ijso.2016.09.004 ARTICLE IN PRESS 2 E.P. Weledji / International Journal of Surgery Open ■■ (2016) ■■–■■ tomy) (Fig. 1) [2–4]. The Polya gastrectomy with retrocolic end-to- 145 side gastrojejunostomy has become a commonly performed 146 modification of the Billroth II procedure [2]. Franz von Hofmeister 147 described a partial gastrectomy with a retrocolic gastrojejunos- 148 tomy involving the greater curvature [2,28]. Reconstruction following 149 partial gastrectomy may be simple or difficult depending partly on 150 the build of the patient and partly on the extent and nature of the 151 disease process. Thus Billroth II gastrectomy is usually used for an 152 emergency perforated large duodenal ulcer not suitable for simple 153 omental patch closure and when a duodenal anastomosis (Billroth 154 1) cannot easily be made [29]. A Billroth I gastrectomy is not a bypass 155 procedure and is suitable for a resistant benign gastric ulcer after 156 excluding malignancy [14,27]. The Billroth II is associated with prob- 157 lems of bile reflux into the gastric remnant and oesophagus, and a 158 higher risk of stomal ulceration. Thus, approximately two-thirds of 159 stomach should be resected to avoid repeated antral exposure to 160 bile [6,14]. For the theoretical benefits of delaying gastric emptying 161 97Q10 Q13 Fig. 1. Diagram of Billroth II gastrectomy. and preventing reflux of duodenal contents into the stomach, a 162 98 Hofmeister ‘valve’ can often be fashioned by reducing the stoma length 163 to around 5 cm through closing part of the opening in the gastric 164 99 retroperitoneal duodenal injury, options for duodenal repair may stump and the rest being used for the actual anastomosis [28]. 165 100 include a pyloric exclusion effected through a gastrostomy. The pyloric 166 101 ring is closed with a continuous suture or stapling which breaks down 3.1. Complications 167 102 after several weeks. The procedure is combined with a gastrojeju- 168 103 nostomy and the addition of octreotide and intravenous acid Billroth II gastrectomy was favoured for many years for its rel- 169 104 suppression may improve duodenal healing and decrease stomach atively low peptic ulcer recurrence rate (less than 5%) [2,4,6]. 170 105 ulceration. Roux-en-Y loop (Roux-en-Y duodenojejunostomy) drain- However, it has a high mortality and complication rate [6,14]. Leakage 171 106 age of the defect from significant tissue loss in the second part of may occur from either the duodenal stump or from the anastomo- 172 107 the duodenum is the procedure of choice in the stable patient [21]. sis. Leakage from the duodenal stump is usually due to afferent loop 173 108 Both the duodenum and the bile duct are triply bypassed with a obstruction. This risk is reduced by the formation of a Roux-en-Y 174 109 gastroenterostomy, and a retrocolic Roux-en-Y hepatico-jejunostomy reconstruction. If there is controlled leak without sepsis or gener- 175 110 for a duodenal obstructive, locally-advanced pancreatic head car- alized peritonitis conservative treatment is indicated with parenteral 176 111 cinoma [22]. However a prophylactic gastrojejunostomy may suffice nutrition. Otherwise exploration is required to drain any sepsis and 177 112 for an obstructive unresectable periampullary carcinoma [23]. to establish drainage of the afferent loop. A useful technique for the 178 113 latter is to insert a T tube into the duodenum and, therefore, es- 179 114 2.1. Complications tablish a controlled fistula, and to decompress the afferent loo 180 115 obstruction [6,30,31]. It is unlikely that direct suture of a leak will 181 116 Early technical complications from a gastrojejunostomy would be feasible. Treatment of a gastrojejunal leak is problematic. More 182 117 include: (a) haemorrhage which is usually from the gastric side of commonly the leak is delayed, occurring 7–14 days postopera- 183 118 the anastomosis and usually only starts when the clamps are re- tively.