Ask the Experts: Dilemmas in Bariatric Surgery

| June 16, 2010

This month’s dilemma:

This month’s expert:
Alberto Salinas, MD
Dr. Salinas is from the Hospital de Clínicas Caracas, Venezuela;

Bariatric Times. 2010;7(6):32

The Dilemma
A 36-year-old woman presented to The Bariatric and Metabolic Institute of the Cleveland Clinic Florida, Weston, Florida, with complaints of intractable nausea and vomiting. The patient was three years post-gastric bypass and malnourished with a body mass index (BMI) of 18kg/m[2]. She had undergone extensive workup in an outside institution, including esophagogastroduodenoscopy (EGD), revealing “surgical fragments” on her gastric pouch. EGD performed by the staff at Cleveland Clinic Florida revealed the presence of an eroded preanastomotic gastric ring. The patient had no knowledge of the ring being placed at the time of her original operation. The patient underwent laparoscopy with removal of the ring. Postoperative upper gastrointestinal series revealed unobstructed passage of contrast. The patient was discharged pain free and able to tolerate food.

Expert Commentary
by Alberto Salinas, MD
Fobi[1] and Capella[2] advocated a vertical gastric bypass reinforcing the gastric pouch outlet with a silastic ring or Marlex mesh, first stapling and later transecting the stomach.[3,4] We began performing a silastic ring vertical gastric bypass (SRVGB) in 1990.5 Since 1994, we completely transected the gastric pouch parallel to the lesser curve and interposed the one meter of a Roux-en-Y limb, retrocolic and retrogastric, between the transected pouch and the bypassed stomach. A silastic ring was placed 1.5 to 2cm above the gastrojejunostomy.[5]

We believe that the construction of a vertical pouch results in less distention and excludes the ingested nutrients from the Ghrelin-producing tissue.[6] The silastic ring controls emptying of the gastric pouch and enhances long-term effectiveness of the restrictive component, thus contributing to long-term weight loss.[7] This surgery also facilitates the delivery of ingested nutrients to the hindgut, increasing postpandrial levels of peptide YY (PYY), glucagon-like peptide-1 (GLP), and oxyntomodulin. These incretins suppress gastrointestinal motility, gastric emptying, small intestinal transit, and food intake, producing late satiety.[8]

We began using a silastic ring with a 5.5cm circumference guided by the first report from the original vertical banded gastroplasty by Mason.[9] The five-percent rate of surgical ring removal due to solid intolerance despite an appropriate caliber of the gastrojejunal anastomosis led us to increase the circumference of the ring to 6cm. This appears to be well tolerated by 99 percent of these patients.[5] Currently, we use a 6.5cm silastic ring in patients 50 years or older.

We initially reported a one-percent rate of silastic ring migration to the lumen. All of those cases had a totally hand-sewn gastrojejunal anastomosis and all the rings were removed endoscopically. With our current technique—stapled side-to-side gastrojejunostomy with hand-sewn closure of the common opening used for the staple application, placing the ring well above of the anastomosis—we reduced the migration rate to nearly zero in primary cases.[5] We speculate that ring migration occurs through the upper angle of the gastrojejunal anastomosis. It is noteworthy that we had migration of the ring only in the totally hand-sewn group and none in the stapled ones.

We have a recent study of revisional bariatric surgery10 in which we found a 3.6-percent rate of ring migration after conversions from restrictive procedures to gastric bypass. Also, all patients with gastro-gastric fistula had migration of the band. The main complaint is epigastric pain and food intolerance. Some patients refuse to return to the office for fear that having the rings removed might result in weight reegain. Eventually, the patients’ poor nutritional statuses forces them to come in for endoscopic removal of the ring. The patient that came to Cleveland Clinic should have been informed about the details of the procedure, including the use of a ring above the gastrojejunal anastomosis. This knowledge would have allowed the endoscopist to remove the ring with confidence, which, in our experience, has solved all the symptoms in all of our cases, avoiding a laparoscopic exploration.

Weight loss results appear to be improved in gastric bypass procedures with a band compared to those without one.[3,11] We reported a 72-percent excess weight loss (EWL)[12] after 10 years follow up and 83-percent EWL in a 5-year follow up cohort study.[14]

In conclusion, a 6 to 6.5cm circumference SRVGB is well tolerated in the majority of the patients, promoting lasting weight loss with low incidence of therapeutic failure.[13]

1.    Fobi Mal. Why the operation I prefer is a silastic ring vertical gastric bypass. Obes Surg. 1991;1:423–426.
2.    Capella R, Capella JF, Mandac H, Nath P. Vertical banded gastroplasty—gastric bypass: preliminary report. Obes Surg. 1991;1:389–395.
3.    Capella JF, Capella R. The weight reduction operation of choice: vertical banded gastroplasty on gastric bypass? Am J Surg. 1996;171:74–79.
4.    Fobi Mal, Lee H, Holness R, Cabinda D. Gastric bypass operation for obesity. World J Surg. 1998;22:925–935.
5.    Salinas A, Santiago E, Yegüez J, et al. Silastic ring vertical gastric bypass: evolution of an open surgical technique and review of 1,588 cases. Obes Surg. 2005;15:1403–1407.
6.    Cummings DE, Weigle DS, Frayo RS, et al. Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery. N Engl J Med. 2002;346:1623–630.
7.    Fobi Mal. Banded gastric bypass: combining two principles. Surg Obes Relat Dis. 2005;1:304–309.
8.    Batterham RL, Cowley MA, Small CJ, et al. Gut hormone PYY(3-36) physiologically inhibits food intake. Nature. 2002;418:650–654.
9.    Mason EE. Vertical banded gastroplasty for obesity. Arch Surg. 1982;117:701–706.
10.    Salinas A, Acosta G, García W, et al. Revisional bariatric surgery: 266 open cases. Accepted to plenary session at the 15th International Federation for the Surgery of Obesity and Metabolic Disorders Congress, September 3–7, 2010, Long Beach, Los Angeles, California, USA.
11.    Fobi Mal, Lee H, Felahy B, et al. Choosing an operation for weight control and the transected banded gastric bypass. Obes Surg. 2005;15:114–121.
12.    Salinas A. Silastic ring vertical gastric bypass with gastric transection and jejunal interposition: ten years follow up. Presented at The 11th International Federation for the Surgery of Obesity Congress, August 30–September 2, 2006; Sydney, Australia.
13.    Salinas A, Salinas H, Santiago E, et al. Silastic ring vertical gastric bypass: cohort study with 83% rate of 5-year follow-up. Surg Obes Relat Dis. 2009;5:455–458.

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