Abstract
Gastric bypass is an extensive exclusion operation which was developed in 1966 and has been used in over 600 patients for the treatment of morbid obesity. Stomal ulceration has developed in 2% of patients and has usually occurred because the stomach was transected at too low a level. To determine the effect of varying levels of transection and exclusion of the stomach, graded gastric bypass was studied in 2 peptic ulcer models in dogs. With histamine-in-beeswax, stomal ulcers occurred whenever there was more than 63% of the stomach located above the gastroenterostomy. With common duct ligation, stomal ulcers were not observed in dogs with 44% or less of the stomach excluded, but when more than 44% of the stomach emptied through the duodenum, duodenal ulcers developed. Stomal ulceration occurred as a result of excessive acid production from large fundic segments stimulated by histamine. Duodenal ulcers resulted from a deficiency in buffering of acid when sufficient stomach was excluded and when an adequate volume of acid entered the duodenum where bile was excluded. These experiments add further emphasis to the importance of high transection of the stomach in gastric bypass, but also suggest that the occurrence of common duct obstruction will introduce the risk of duodenal ulcer in patients who have had gastric bypass for the treatment of obesity.
Résumé
Le bypass gastrique est une opération d'exclusion importante qui, depuis 1966, a été pratiquée chez plus de 600 malades atteints d'obésité pathologique. Un ulcère peptique est apparu dans 2% des cas, en général lorsque l'estomac avait été sectionné trop distalement. Pour préciser les effets du niveau de transsection gastrique et d'exclusion de l'estomac, nous avons étudié, chez le chien et sur 2 modèles d'ulcère peptique expérimental, les effets d'exclusions gastriques d'importance variable. Dans le modèle à l'histamine incluse en cire d'abeille, des ulcères peptiques se développent lorsque l'on laisse, au-dessus de la gastroentérostomie, plus de 63% de l'estomac. Dans l'autre modèle, à ligature du cholédoque, il n'y a pas d'ulcère peptique lorsque l'exclusion gastrique est inférieure ou égale à 44%; mais lorsqu'elle dépasse ces 44% et que l'estomac se draine dans le duodénum, des ulcères duodénaux apparaissent. Ces ulcères duodénaux sont dus à une insuffisance de neutralisation de la sécrétion acide, lorsque le segment d'estomac exclu est suffisamment grand et que des quantités importantes d'acide s'écoulent dans un duodénum privé de bile. Ces résultats expérimentaux soulignent l'importance d'une section haute de l'estomac dans le bypass gastrique; ils suggèrent, de plus, qu'une obstruction de la voie biliare principale entraîne un risque d'ulcère duodénal chez le patient opéré de bypass gastrique pour obésité.
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Mason, E.E., Ito, C. Graded gastric bypass. World J. Surg. 2, 341–347 (1978). https://doi.org/10.1007/BF01561513
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DOI: https://doi.org/10.1007/BF01561513