The Rationale and Results of Gastroplasty/Distal Gastric Bypass

A recent review of the results of gastroplasties done at the University of Alberta Hospital showed that there was a high incidence of late weight loss failure. Therefore a new operation, gastroplasty/distal gastric bypass, has been performed on 263 patients. This operation results in a profound (mean greatest percentage excess weight loss of 87% at approximately 2 years) and lasting weight loss (mean final percentage excess weight loss of 78%) at 4 years, range 2-7.5 years post-operatively. Only 0.9% of patients failed to maintain at least a 40% excess weight loss. The operation achieves its effect through a moderate restriction that permits patients to eat normal table food from the time of discharge and with a mild malabsorption that is not ordinarily associated with diarrhea or notable deficiencies. Certain patients required debanding of the stoma and others developed staple-line eventration. Neither of these events after long-term follow-up resulted in weight loss failure nor in other serious side-effects. It is concluded that moderate failure of the gastroplasty stoma and staple line does not necessarily result in weight loss failure, because the malabsorptive portion of the operation remains intact. Low hemoglobin occurred in 16% of cases and deficiency of serum iron in 34%; a much smaller number of patients had chronic or intermittent deficiencies of these entities. Correction was easily achieved with oral replacement. Deficiencies in albumin, calcium, phosphorus and folate were rarely seen and minimal elevation of serum AST values occurred in just over 1% of patients. Chronic deficiencies or elevations were not seen in these patients. Stomal ulcer occurred in 6% of patients and bleeding associated with stomal ulcer in 1%. Half the patients with ulcer were managed with H₂ blockers, the other half with vagotomy. Both forms of treatment when individualized effectively prevent re-ulceration.     

Revisional Surgery for Severe Obesity with Fascia Banded Stoma Roux-en-Y Gastric Bypass

The fascia banded stoma Roux-en-Y gastric bypass (RYGBP) has been effective both as a primary and revision operation for severe obesity or failure of another operation. Since May 1984, 361 primary and 100 revisional fascia banded RYGBP operations have been reported. Weight loss achieved a mean body mass index of 30 for primary and 31 for revision patients at most recent follow-up of 3-6 years (mean 4.3 years) postoperatively. Mean overweight was 28% for primary, and 34% for revision patients. Eighty percent of primary and 79% of revision patients were within 50% of ideal weight. Revision rates for these patients were 0 for primary and 1% for revision patients. Operative mortality was 0 for primary and 1% for revision patients. Since morbidity and mortality, although low, are higher for revision than primary surgery, it is important to use an effective primary operation.     

The Effect of Gastric Bypass on Cholesterol,HDL, and the Risk of Coronary Heart Disease

A review of 150 charts revealed that 36 patients had pre-operative serum cholesterol greater than 200 mg% prior to Roux-Y gastric bypass. The average pre-operative weight was 266 lb (121 kg) and at 1 year post-operative 166 lb (75 kg), or 100 lb (45 kg) lost (77% excess weight loss). We compared the following pre- and post- operative data and found that: (1) cholesterol was decreased by 24% and triglycerides decreased by 40%; (2) post-operative cholesterol/HDL-C ratio of 3.31 put our patients in the half of average risk category for a clinical pathological coronary event according to the SmithKline Beecham Laboratories risk ratio chart. We conclude that Roux-Y gastric bypass and its ability to produce a significant weight loss and markedly affect cholesterol and triglyceride metabolism will also reduce a patient's risk of myocardial infarction.     

Use of a Calibration Balloon Tube to Size the Pouch and Channel in Gastroplasty Procedures

Gastroplasty is currently one of the most common surgical procedures performed on the morbidly obese for weight loss. An adequate result can be assured only if the pouch that is created is less than 30 ml and the channel that connects that pouch to the distal stomach is approximately 1 cm in diameter. The current method to size the pouch is to occlude the esophagus and the outlet of the pouch and to measure with a manometer through a naso-gastric tube. We contend this method is both time consuming and adds to the potential of complications. Through the use of a calibration balloon tube the size of the pouch can be quickly and safely estimated. It can also be used to size the channel between the pouch and the distal stomach and check for leaks. The technique of how this tube has been used over the past 6 years is described. By the use of a calibration balloon tube, three problem areas in gastric stapling surgery for morbid obesity are avoided, namely: inappropriate pouch size, inappropriate channel size and postoperative leaks.     

Obesity Surgery Poly-parametric Patient Auto-evaluation

A simple auto-evaluation sheet is presented for the proper assessment of the patient's condition after surgery. Stress is put not only on weight loss, but on other important factors as well.     

Cochlear implantation

Cochlear implants are the single greatest advancement of the late 20th century for the deaf and hearing impaired. Recent expanding guidelines as well as surgical techniques are discussed. Cochlear implantation is currently the only means to restoring partial hearing to patients with severe-to-profound sensorineural loss not aidable with conventional amplification.     

Obliteration of the frontal sinus with the pericranial flap

A host of autogenous and synthetic materials ranging from free fat, muscle, and bone to methylmethacrylate, hydroxyapatite cement, and glass beads have been used to obliterate the frontal sinus. These materials carry an increased risk of donor-site morbidity, as well as the risk of resorption, infection, and local inflammatory reactions. The pericranial flap is a local flap that can be used to obliterate small- and medium-sized frontal sinuses. This vascularized flap is easily and quickly harvested, and it avoids the morbidity associated with free-fat and cancellous bone grafts. Its ease of harvest, vascularity, and low complication rate make the pericranial flap an excellent alternative for frontal sinus obliteration.