Ulcerogenesis in Surgery for
Obesity
Edward Eaton Mason MD
NBSR NEWSLETTER, WINTER 1995 Volume
10, Number 4
Important relationships exist between the body of
the stomach, antrum, and duodenum that protect both
duodenal and stomal mucosa from ulceration. Operative
disturbance of these relationships may lead to stomal
and/or duodenal ulcers unless some counteracting
measure(s) are taken. Devine(1) in Melbourn, Australia
used antral exclusion in the treatment of large
duodenal ulcers in 1928. Antral exclusion rapidly
gained a world-wide reputation for producing stomal
ulcers. Before gastric bypass was used in man, the
operation was studied in laboratory animals to make
certain that stomal ulcers would not result.(2)
Gastric bypass included enough acid secreting mucosa
to suppress gastrin secretion,(3) which was the cause
of stomal ulcers after the antral exclusion operation
of Devine.
Scopinaro's biliopancreatic diversion (BPD),(4) for
treating obesity, is a Mann-Williamson(5) preparation
in which bile and pancreatic juices are diverted into
the ileum. Scopinaro includes resection of the distal
stomach which removes both the gastrin secreting
antrum and a portion of the acid secreting parietal
cell mass. Others are using BPD without removing the
excluded stomach. An interesting modification of
Scopinaro's biliopancreatic diversion is now in
use.(6) This operation uses two measures to reduce the
risk of stomal ulceration. One is DeMeester's duodenal
switch(7) and the other is Wangensteens's sleeve
resection of most of the parietal cell mass.(8)
DeMeester demonstrated that when the stomach was
separated from the duodenum, the stomal ulceration
rate was 86% after anastomosis of duodenum to ileum
and 100% if anastomosed to jejunum. Acid secretory
inhibition, from acid washing over the duodenum, no
longer occurred. DeMeester then showed that if the
duodenum was divided just above the entry of the bile
and pancreatic ducts, the risk of stomal ulceration
was reduced to 29% and 10% respectively. Acid
secretory inhibition was preserved by maintaining
continuity between the stomach and the first part of
the duodenum.
A number of surgeons have combined a modification
of vertical banded gastroplasty with a Roux-en-Y
gastric resection, using varying lengths of intestinal
bypass in the limbs of the intestinal reconstruction.
To the extent that the bile and pancreatic juice are
shunted into lower reaches of the small bowel, this
simulates a Mann-Williamson preparation. When
excessive acid secretion is added to the equation, as
in bypass operations for obesity, the site of
ulceration depends in part upon where the most acid
leaves the stomach.(9) An extensive gastric exclusion
protects the stoma, but at the risk of duodenal
ulceration. A large pouch increases the risk of stomal
ulceration while protecting the duodenum. It must be
remembered, however, that if the exclusion is antral
without sufficient parietal cell mass, uninhibited
gastrin secretion causes stomal ulceration.
When direct communications develop between the
pouch and the excluded stomach following staple line
disruption after gastric bypass, this becomes an
ulcerogenic preparation requiring operative
correction.(10) If the pouch is too large, stomal
ulcers are seen. If most of the stomach is excluded,
duodenal ulceration may occur.
Surgeons should avoid ulcerogenic anatomy in their
efforts to reduce all patients to a normal weight.
Much can be accomplished by operations that restrict
food intake but do not interfere with the normal
relationships between the acid secreting portion of
the stomach, the gastrin secreting antrum, and the
duodenum. It is interesting to observe the repetition
of learning that continues in the use of stomach
operations. Operations to reduce acid have been
replaced by treatment of infection with Helicobacter
pylori.
Stomach operations for obesity were originally
modifications of operations designed for the treatment
of acid peptic disease. Now, operations for obesity
performed on the stomach must be designed to avoid the
production of acid peptic disease. Gastric surgery for
ulcer has been lost, but the lessons learned remain of
great value.
History does repeat. It is possible that operations
on the stomach for obesity will also be replaced by
specific medical treatment as we learn more about the
etiology (DNA) of severe obesity. In the meantime,
severe obesity continues to be morbid and lethal and
operations remain the only effective means of
treatment. Even a small increase in risk of ulcer is
to be avoided because of the long life that most of
these patients have. We are now seeing occasional
duodenal bleeding and stomal ulcers in patients who
had a gastric bypass many years ago. Severe bleeding
leads to operations that in turn become complicated,
or the bleeding may even be lethal before a diagnosis
and appropriate treatment can be applied. Surgeons
today must avoid the production of peptic ulcer when
they are treating obesity.
It took two million years of DNA evolution to
assemble the upper gastrointestinal tract of humans
and related mammals. As time goes on and we examine
the evidence through follow-up, we find that "keep it
simple surgeon" (KISS) is usually best. Let's dedicate
our efforts toward a better, and international
N(I)BSR. The practical way to do this is to assemble
lists of consecutive patients who are five, ten, etc.
years beyond operation and find out what really
happened. This is doable because it can be done one
patient at a time, as we find and devote a little of
our time to following these patients long term. It is
nature's way. It must be the surgeon's way to evolve
better methods of treating the obese. Nule nocere
for now and for each patient's lifetime.
1. Devine, HB. Gastric exclusion.
SURGERY GYNECOLOGY AND OBSTETRICS. 1928, 47:239-243.
2. Mason EE, Ito C. Gastric bypass.
SURGICAL CLINICS OF NORTH AMERICA. 1967; 47:
1345-1351.
3. Mason EE, Munns JR, Kealey GP, Wangler R,
Clarke WR, Cheng HF, Printen KJ. Effect of
gastric bypass on gastric secretion. AMERICAN
JOURNAL OF SURGERY. 1976; 13s1:162-168.
4. Scopinaro NBSR, Gianetta E, Friedman D,
Traveerso E, Adami GF, Vitalie B, Mariner G, Cuneo
S, Ballari F, Colombinin M, Bachi V.
Biliopancreatic diversion for obesity. PROBLEMS
IN GENERAL SURGERY. 1992;9:362-379.
5. Mann FC, Williamson CS. The experimental
production of peptic ulcer. ANNALS OF SURGERY.
1923;77: 409-422.
6. Marceau P, Biron S, Bourque R-A, Potvin M,
Hould F-S, Simard S. Biliopancreatic diversion
with a new type of gastrectomy. OBESITY SURGERY.
1993;3:29-35.
7. DeMeester TR, Fuchs KH, Ball CS, Alburtucci
M, Smyrk TC , Marcus JN. Experimental and
clinical results with proximal end to end
duodenojejunostomy for pathologic duodenogastric
reflux. ANNALS OF SURGERY. 1987;206:414-426.
8. Wagensteen OH. Evolution and evaluation
of an acceptable operation for peptic ulcer,
including description of the technique of tubular
gastric resection with transverse gastroplasty and
extrapleural sternotomy for operations in the attic
of the abdomen. The REVIEW OF GASTROENTEROLOGY.
1953;20:611-626.
9. Mason EE, Ito C. Graded gastric bypass.
WORLD JOURNAL OF SURGERY 1978;2:341-349.
10. Jordan JH, Hocking MP, Rout WR, Woodward
ER. Marginal ulcer following gastric bypass for
morbid obesity. AMERICAN SURGEON.
1991;57:286-288.
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