by Rafael F. Capella, MD, FACS
Dr. Rafael F. Capella was a Clinical Assistant Professor of Surgery at the New Jersey Medical School of Newark, New Jersey, and a founding member of the American Society for Bariatric Surgery. He was a director of the Division of Bariatric Surgery at Hackensack University Medical Center at Hackensack, New Jersey, and Chief of Surgery at Tuxedo Memorial Hospital in Tuxedo, New York. One of his publications was among the 100 most cited articles in Bariatric Surgery. He was made honorary member of the bariatric surgical societies of Brazil, Mexico and Spain. Over the years, Dr. Capella taught his technique to many visiting surgeons from Europe and Latin America and operated abroad at multiple bariatric symposia. One of the highlights of Dr. Capella’s career was serving as the Honorary President of the fourth Latin American Congress of Bariatric and Metabolic Surgery in his native city of Cartagena, Colombia. Dr. Capella also likes to point out that his son Joseph shared the burden of an extremely busy practice for over nine years and assisted with many of his scientific contributions.
Bariatric Times. 2016;13(1):8–10.
This column is dedicated to telling the stories of leaders who have helped shape the field of bariatric surgery through their discoveries, teaching, and stewardship.
Column Editor: George L. Blackburn, MD, PhD, FACS
S. Daniel Abraham Professor of Nutrition; Associate Director, Division of Nutrition Harvard Medical School; Director, Center for the Study of Nutrition Medicine, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Column Editor: Daniel B. Jones, MD, MS, FACS
Professor of Surgery, Harvard Medical School, Vice Chair, Beth Israel Deaconess Medical Center, Boston, Massachusetts
A Message from the Column Editors
Dear Readers of Bariatric Times:
Bariatric surgery has many leaders who have shaped the field by their discoveries, teaching, and stewardship. In this column, we invite leaders to tell us about their most significant accomplishment(s). Here, we will hear from leaders about their visions, hurdles, collaborations, and, ultimately, what impact their accomplishments have had on the field of bariatric surgery. We will also learn how they set goals and have turned ideas into reality, as well as what was anticipated and what was not expected throughout their journeys.
We are very excited about this project and hope it will help to inspire the next generation of leaders as they evaluate new devices and technology and consider novel procedures and treatments in an era of cost containment. We hope you enjoy these stories.
Drs. George L. Blackburn and Daniel B. Jones
After practicing bariatric surgery for 38 years (the last nine in the company of my son Dr. Joseph F. Capella) and performing nearly 6,000 cases, I retired at the age 75 to take care of a cattle ranch that I inherited from my father in Cartagena, Colombia. This last endeavor has proven to be almost as challenging as my early experience with obesity surgery.
The large volume of cases that I was fortunate to have from the beginning of this long surgical journey was very helpful in detecting problems early and in developing a safer and more effective bariatric procedure. Nevertheless, over the decades I encountered many challenges and disappointments. At one point I was so discouraged that I suggested to my son, a general surgery resident at the time, that he consider training in a surgical subspecialty. The future of bariatric surgery looked very bleak at the time. Despite many setbacks, my bariatric experience was full of satisfaction. Looking back, seven years after my retirement, I consider obesity surgery to have been the most important and satisfying part of my surgical experience.
The Evolution of Vertical Banded Gastroplasty and Roux-en-y Gastric Bypass
My initial exposure to this discipline was in the late 70s with the transverse gastroplasty of Dr. Cesar Gomez. The procedure produced relatively poor weight loss results. In 1982, Dr. Edward Mason reported his experience with vertical banded gastroplasty (VBG). I followed Dr. Mason’s work closely and soon became busy performing his technique of gastroplasty. However, after performing 813 VBGs during the 1980s, I realized that the long-term weight loss achieved with VBG was less than desirable. In an effort to maintain some of the qualities of VBG but with the goal of improving weight loss, I began fusing gastric bypass with VBG. I called this operation VBG-gastric bypass or VBG-RGB. In 1989, I performed the operation on 69 VBG patients who had failed to lose sufficient weight, and by 1990, VBG-RGB became my primary procedure.
The VBG-RGB was first performed using the circular stapler instrument as in the classic VBG (Figure 1A). I soon learned that the pouch could be constructed with linear staplers exclusively, still maintaining the basic anatomy of VBG (Figure 1B). In the first 272 VBG-RGB cases, the pouch was stapled in continuity (Figure 1C). I soon learned that stapling the pouch in continuity eventually led to an unacceptable rate of staple disruptions. This complication also occurred in VBG but was completely asymptomatic and consequently usually unrecognized. This period of time was the lowest point of my bariatric experience. Patients were calling at all hours complaining of severe abdominal pain. Marginal ulcers were promptly recognized as the culprit. Fortunately, the first proton pump inhibitors were appearing on the market, providing me some time to resolve this problem. In the next 217 operations, the gastric segments were stapled and completely transected and the staple line of the stomach inverted with silk stitches (Figure 1D).[2,3] Complete transection of the gastric segments led to a drastic reduction in the incidence of staple disruption and gastro-gastric fistulas to 2.6 percent. (Figure 1D). I then reasoned that the gastro-gastric fistulas that were still occurring were the result of re-canalization between mucosal surfaces that came into contact despite the inversion of the staple line of the stomach. It was also well known at the time that a complication of gastric surgery in general are gastro-colic fistulas but not typically gastro-enteric fistulas. For reasons that are not entirely understood, the serosa of the small bowel must have qualities that resist the digestive action of gastric secretions. Based on this information, I interposed a limb of jejunum between the pouch and excluded stomach on the next 777 patients. This step essentially eliminated the problem of gastro-gastric fistulas and the resulting marginal ulcers (Figure 1E and Figure 2).
In reviewing my series, I found that a stapled gastro-jejunostomy was accompanied by a six-percent incidence of chronic or recurrent marginal ulcers (Figure 1E) Again, I rationalized that the incidence of ulcers was due to the disruption of the protective mucosa produced by the staple line at the gastrojejunostomy. The incidence of this type of marginal ulcers was reduced to 1.6 percent when we switched to a hand-sewn anastomosis of chromic and silk. When using only absorbable sutures, the ulcer rate dropped to 0.4 percent. (Figure 1F). This latest form of VBG-RGB, performed on 652 consecutive patients, was the final step in the evolution of my technique for gastric bypass. The procedure was called tubular banded Roux-en-Y gastric bypass (Figure 3).
Honing Technical Skills
Another complication to be addressed, unrelated to the gastro intestinal portion of the surgery, was the high rate of incisional hernias. As my technical expertise grew through the years, I performed the procedure through increasingly small incisions, resulting in less postoperative patient discomfort and a substantial reduction in the incidence of incisional hernias. The reduction in incision size was progressive year to year, and by 2006, the average size was 7cm in length. To perform the procedure through smaller incisions, it was necessary to make some changes in the technique to facilitate reaching the first portion of the jejunum. I realized that mobilizing and exteriorizing the greater omentum in these individuals with extreme obesity was unnecessary and, most of the time, impossible through these small incisions. The greater omentum was then left in place and a window was created through the thinnest portion of the gastrocolic omentum to reach the lesser sac. The greater abdominal cavity was entered by creating another window in the mesocolon. With two fingers, we identified the Treitz ligament and the proximal portion of the jejunum was exteriorized through the defects. The long and narrow pouch could in most cases be elevated to the skin level and easily anastomosed to the jejunum. The bowel was then reduced into the peritoneal cavity. At that time, we introduced several other changes including the use of large non- absorbable sutures to approximate the fascia, which may have also contributed to the reduction in the rate of incisional hernias. The main explication, however, can be attributed to a physical principle involving vessel radius and wall tension, La Place’s Law (Figure 4). The incidence of wound hernias was reduced from 9.2 percent in the year 2000 to one percent in 2005 with average incision lengths 22cm and 11cm, respectively. No incisional hernias were clinically identifiable in the last 102 cases performed in 2006 when the average incision length was 7cm (Figure 5).
Analyzing Bowel Obstruction after Open and Laparoscopic Gastric Bypass Surgery
During the latter part of my career, gastric bypass was increasingly being performed laparoscopically at the institution where I worked by several groups that were performing both open and laparoscopic bariatric surgery. It became evident that more patients were developing bowel obstruction following bariatric surgery, requiring re-operative intervention. We decided to analyze bowel obstruction following bariatric surgery at our institution. In the laparoscopic group, 68 of 697 patients (9%) were readmitted for bowel obstruction requiring reoperation. There were 14 additional recurrent obstructions. Total number of reoperations required was 82. Of the 68 patients requiring reoperations, three (4.4%) required bowel resection and eight (11.7%) had conversion to an open approach. Bowel resections were performed in two of the three patients with a second episode of bowel obstruction. There were no readmissions requiring operations for late bowel obstruction in the 735 patients in the open gastric bypass group. Our study suggested that the thin and loose adhesions characteristic of open laparotomies may play an important role in preventing bowel obstruction after gastric bypass surgery by stabilizing the small bowel. The lack of adhesions after laparoscopic gastric bypass surgery may allow for the free displacement of the small intestine into surgically created defects and for the possibility of internal herniation and closed loop obstructions.
Bariatric surgery has had phenomenal growth over the decades as a result of the dedication and collaboration of surgeons from around the world. The combined efforts of many has taken bariatric surgery from being an obscure and unappreciated surgical specialty to a discipline recognized for its ability to ameliorate or cure a vast array of diseases and to greatly improve the quality of life.
1. Capella RF, Capella JF, Mandac H, Nath P. Vertical banded gastroplasty-gastric bypass: preliminary report. Obes Surg. 199l;l:389–395.
2. Capella JF, Capella RF. The weight reduction operation of choice: vertical banded gastroplasty or gastric bypass? Am J Surg. 1996;171(1):74–79.
3. Capella RF, Capella JF. Reducing early technical complications in gastric bypass surgery. Obes Surg. 1997;7:149–157.
4. Capella JF, Capella RF. Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Obes Surg. 1999;9: 22–27
5. Capella JF, Capella RF. An assessment of vertical banded gastroplasty-Roux-en-Y gastric bypass for the treatment of morbid obesity. Am J Surg. 2002;183(2):117–123.
6. Capella RF, Iannace VA, Capella JF. Reducing the incidence of incisional hernias following open gastric bypass surgery. Obes Surg. 2007;17(4):438–444.
7. Capella RF, Iannace VA, Capella JF. Bowel obstruction after open and laparoscopic gastric bypass surgery for morbid obesity. J Am Coll Surg. 2006;203(3):328–335. Epub 2006 Jul 27.
FUNDING: No funding was provided.
FINANCIAL DISCLOSURES: The author reports no conflicts relevant to the content of this article.