Obesity Surgery

, Volume 21, Issue 12, pp 1879–1886 | Cite as

Gastric By-pass with Fixed 230-cm-Long Common Limb and Variable Alimentary and Biliopancreatic Limbs in Morbid Obesity

  • José Hernández-Martínez
  • Miguel Ángel Calvo-Ros
Clinical Research

Abstract

Background

Morbid obesity is a disease of increasing prevalence. Diet and exercise are not effective for excess weight loss (EWL) in most patients; therefore, different bariatric surgery procedures based in restriction or malabsorption, or a combination of both, i.e., the Roux-en-Y gastric by-pass (RYGBP) hybrid operation, have been established. Here, we report the outcome of a modified RYGBP operation in 565 obese patients.

Methods

Our modified RYGBP operation consisted of a pouch smaller than 25 cc, a fixed common limb of 230 cm, and the rest of the small bowel redistributed among the alimentary channel (60%) and the biliopancreatic channel (40%).

Results

A large variation in the whole length of small bowel was observed (380–820 cm). EWL was gradually increasing from month 1 after surgery (20.1%) to month 12 (70.1%); this value was maintained in the 2–8-year follow-up period. No differences in fecal protein and carbohydrate loss, before and after surgery, were seen; in contrast, three- to tenfold-higher lipid loss was produced after surgery. Long-term complications were scarce (28 patients with chronic anemia, 3 patients with flatulence, and 8 patients with mild diarrhea).

Conclusions

Gastric pouch smaller than 25 cc and measurement of the entire small bowel length during RYGBP surgery, leaving a 230-cm length of common limb and redistributing the remaining 60% in the alimentary channel and 40% in the biliopancreatic channel produced sustained EWL with few secondary nutrient deficits along an 8-year follow-up period.

Keywords

Bariatric surgery RYGBP Measured limbs Gastric by-pass 

References

  1. 1.
    Calle EE, Thun MJ, Petrelli JM, et al. Body-mass index and mortality in a prospective cohort of U.S. adults. N Engl J Med. 1999;341:1097–105.PubMedCrossRefGoogle Scholar
  2. 2.
    WHO, Obesity: preventing and managing the global epidemic, in Report on a World Health Organization Consultation on Obesity 1998: Geneva.Google Scholar
  3. 3.
    Deitel M, Shikora SA. The development of the surgical treatment of morbid obesity. J Am Coll Nutr. 2002;21:365–71.PubMedGoogle Scholar
  4. 4.
    Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am. 1967;47:1345–51.PubMedGoogle Scholar
  5. 5.
    Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995;222:339–50. discussion 350–2.PubMedCrossRefGoogle Scholar
  6. 6.
    Fobi MA. Vertical banded gastroplasty vs gastric bypass: 10 years follow-up. Obes Surg. 1993;3:161–4.PubMedCrossRefGoogle Scholar
  7. 7.
    Jones Jr KB. Experience with the Roux-en-Y gastric bypass, and commentary on current trends. Obes Surg. 2000;10:183–5.PubMedCrossRefGoogle Scholar
  8. 8.
    MacLean LD, Rhode BM, Nohr CW. Late outcome of isolated gastric bypass. Ann Surg. 2000;231:524–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Sugerman HJ, Kellum JM, DeMaria EJ. Conversion of proximal to distal gastric bypass for failed gastric bypass for superobesity. J Gastrointest Surg. 1997;1:517–24. discussion 524–6.PubMedCrossRefGoogle Scholar
  10. 10.
    Fobi MA, Lee H, Igwe Jr D, et al. Revision of failed gastric bypass to distal Roux-en-Y gastric bypass: a review of 65 cases. Obes Surg. 2001;11:190–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Brolin RE, Kenler HA, Gorman JH, et al. Long-limb gastric bypass in the superobese. A prospective randomizeed study. Ann Surg. 1992;215:387–95.PubMedCrossRefGoogle Scholar
  12. 12.
    Torres JC. Gastric bypass distal Roux-en-Y with jejunal interposition. Obes Surg. 1993;3:191–5.PubMedCrossRefGoogle Scholar
  13. 13.
    Choban PS, Flancbaum L. The effect of Roux limb lengths on outcome after Roux-en-Y gastric bypass: a prospective, randomized clinical trial. Obes Surg. 2002;12:540–5.PubMedCrossRefGoogle Scholar
  14. 14.
    Scopinaro N, Gianetta E, Adami GF, et al. Biliopancreatic diversion for obesity at eighteen years. Surgery. 1996;119:261–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Kim JJ, Tarnoff ME, Shikora SA. Surgical treatment for extreme obesity: evolution of a rapidly growing field. Nutr Clin Pract. 2003;18:109–23.PubMedCrossRefGoogle Scholar
  16. 16.
    Biron S, Hould FS, Lebel S, et al. Twenty years of biliopancreatic diversion: what is the goal of the surgery? Obes Surg. 2004;14:160–4.PubMedCrossRefGoogle Scholar
  17. 17.
    Rabkin RA, Rabkin JM, Metcalf B, et al. Nutritional markers following duodenal switch for morbid obesity. Obes Surg. 2004;14:84–90.PubMedCrossRefGoogle Scholar
  18. 18.
    Sugerman HJ, Londrey GL, Kellum JM, et al. Weight loss with vertical banded gastroplasty and Roux-Y gastric bypass for morbid obesity with selective versus random assignment. Am J Surg. 1989;157:93–102.PubMedCrossRefGoogle Scholar
  19. 19.
    Leifsson BG, Gislason HG. Laparoscopic Roux-en-Y gastric bypass with 2-metre long biliopancreatic limb for morbid obesity: technique and experience with the first 150 patients. Obes Surg. 2005;15:35–42.PubMedCrossRefGoogle Scholar
  20. 20.
    Freeman JB, Kotlarewsky M, Phoenix C. Weight loss after extended gastric bypass. Obes Surg. 1997;7:337–44.PubMedCrossRefGoogle Scholar
  21. 21.
    MacLean LD, Rhode BM, Nohr CW. Long- or short-limb gastric bypass? J Gastrointest Surg. 2001;5:525–30.PubMedCrossRefGoogle Scholar
  22. 22.
    Feng JJ, Gagner M, Pomp A, et al. Effect of standard vs extended Roux limb length on weight loss outcomes after laparoscopic Roux-en-Y gastric bypass. Surg Endosc. 2003;17:1055–60.PubMedCrossRefGoogle Scholar
  23. 23.
    Inabnet WB, Quinn T, Gagner M, et al. Laparoscopic Roux-en-Y gastric bypass in patients with BMI <50: a prospective randomized trial comparing short and long limb lengths. Obes Surg. 2005;15:51–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Underhill BM. Intestinal length in man. Br Med J. 1955;2:1243–6.PubMedCrossRefGoogle Scholar
  25. 25.
    Ahrens Jr EH, Blankenhorn DH, Hirsch J. Measurement of the human intestinal length in vivo and some causes of variation. Gastroenterology. 1956;31:274–84.PubMedGoogle Scholar
  26. 26.
    Fanucci A, Cerro P, Fraracci L, et al. Small bowel length measured by radiography. Gastrointest Radiol. 1984;9:349–51.PubMedCrossRefGoogle Scholar
  27. 27.
    Kjeldahl JA. A new method for the determination of nitrogen in organic matter. Zeitschreft fur Analytische Chemie. 1883;22:366–82.CrossRefGoogle Scholar
  28. 28.
    Van der Kamer JH, Ten Bokkel HH, Weyers H. Rapid method for the determination of fat in feces. J Biol Chem. 1949;177:347–55.Google Scholar
  29. 29.
    Clegg KM. The application of the anthrone reagent to the estimation of starch in cereals. J Sci Food Agric. 1956;7:40.CrossRefGoogle Scholar
  30. 30.
    Brolin RE, Kenler HA, Gorman RC, et al. The dilemma of outcome assessment after operations for morbid obesity. Surgery. 1989;105:337–46.PubMedGoogle Scholar
  31. 31.
    Flancbaum L. Mechanisms of weight loss after surgery for clinically severe obesity. Obes Surg. 1999;9:516–23.PubMedCrossRefGoogle Scholar
  32. 32.
    Fobi MA, Lee H, Holness R, et al. Gastric bypass operation for obesity. World J Surg. 1998;22:925–35.PubMedCrossRefGoogle Scholar
  33. 33.
    Murr MM, Balsiger BM, Kennedy FP, et al. Malabsorptive procedures for severe obesity: comparison of pancreaticobiliary bypass and very very long limb Roux-en-Y gastric bypass. J Gastrointest Surg. 1999;3:607–12.PubMedCrossRefGoogle Scholar
  34. 34.
    Sarr MG. Motility and absorption in the transplanted gut. Transplant Proc. 1996;28:2535–8.PubMedGoogle Scholar
  35. 35.
    Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y- 500 patients: technique and results, with 3–60 month follow-up. Obes Surg. 2000;10:233–9.PubMedCrossRefGoogle Scholar
  36. 36.
    Date Y, Kojima M, Hosoda H, et al. Ghrelin, a novel growth hormone-releasing acylated peptide, is synthesized in a distinct endocrine cell type in the gastrointestinal tracts of rats and humans. Endocrinology. 2000;141:4255–61.PubMedCrossRefGoogle Scholar
  37. 37.
    Fruhbeck G, Diez-Caballero A, Gil MJ, et al. The decrease in plasma ghrelin concentrations following bariatric surgery depends on the functional integrity of the fundus. Obes Surg. 2004;14:606–12.PubMedCrossRefGoogle Scholar
  38. 38.
    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;346:1623–30.PubMedCrossRefGoogle Scholar
  39. 39.
    Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;232:515–29.PubMedCrossRefGoogle Scholar
  40. 40.
    Higa KD, Ho T, Boone KB. Laparoscopic Roux-en-Y gastric bypass: technique and 3-year follow-up. J Laparoendosc Adv Surg Tech A. 2001;11:377–82.PubMedCrossRefGoogle Scholar
  41. 41.
    Nguyen NT, Rivers R, Wolfe BM. Factors associated with operative outcomes in laparoscopic gastric bypass. J Am Coll Surg. 2003;197:548–55. discussion 555–7.PubMedCrossRefGoogle Scholar
  42. 42.
    Gould JC, Needleman BJ, Ellison EC, et al. Evolution of minimally invasive bariatric surgery. Surgery. 2002;132:565–71. discussion 571–2.PubMedCrossRefGoogle Scholar
  43. 43.
    DeMaria EJ, Sugerman HJ, Kellum JM, et al. Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity. Ann Surg. 2002;235:640–5. discussion 645–7.PubMedCrossRefGoogle Scholar
  44. 44.
    del Val Díez, Martínez-Blázquez IC, Valencia-Cortejoso J, et al. Bypass gástrico. Cir Esp. 2004;75:244–50.Google Scholar
  45. 45.
    Biertho L, Steffen R, Ricklin T, et al. Laparoscopic gastric bypass versus laparoscopic adjustable gastric banding: a comparative study of 1,200 cases. J Am Coll Surg. 2003;197:536–44. discussion 544–5.PubMedCrossRefGoogle Scholar
  46. 46.
    Olbers T, Lonroth H, Fagevik-Olsen M, et al. Laparoscopic gastric bypass: development of technique, respiratory function, and long-term outcome. Obes Surg. 2003;13:364–70.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science + Business Media, LLC 2011

Authors and Affiliations

  • José Hernández-Martínez
    • 1
  • Miguel Ángel Calvo-Ros
    • 2
  1. 1.Hospital de Yecla General surgery Hospital Mesa del Castillo Obesity Surgery UnitMurciaSpain
  2. 2.Hospital de BasurtoBilbaoSpain

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