W h e n we initiated our efforts in the field of mor- munication between the gastric p o u c h and the bid obesity in 1971, we, like most bariatric sur- bypassed stomach necessary for the d e v e l o p m e n t geons, chose to p e r f o r m the jejunoileal bypass of a stomal ulcer? If the incidence of stomal ulcer because of its seemingly less d e m a n d i n g technical is different after a Roux-en-Ygastric bypass using a trouble in these large patients. After several years's vertical staple line a n d the lesser curvature portion experience we were discouraged by the multiple of the stomach for the pouch, or a Roux-en-Y l o n g t e r m sequellae observed in patients with a gastric bypass using a horizontal staple line and jejunoileal bypass in place. We decided to try the the cardia of the stomach for the pouch, is there gastric bypass operation described by Mason a n d an i n h e r e n t explanation for this finding? colleagues (1). At first we used the gastric bypass The answer to the first question is not clear. In with transection of the stomach a n d a loop gas- the article published in this issue of the Journal of trojejunostomy to drain the small gastric pouch. the American College of Surgeons (see pages 1-7), it Finding this operation difficult, particularly in the appears that c o m m u n i c a t i o n between the distal super obese patient, we m a d e two modifications: stomach and the gastric pouch, with resulting high double stapling rather than transecting the stom- acid exposure to the j e j u n u m , is required for ach and using a Roux-en-Y gastrojejunostomy to stomal ulceration. This conclusion is s u p p o r t e d by drain the gastric p o u c h as we u n d e r t o o k our ran- the finding of high acid and low p H in the p o u c h domized trial to compare the jejunoileal and gas- when a stomal ulcer and disrupted staple line was tric bypass procedures (2). T h e Roux-en-Y config- f o u n d and the decrease in acid after the commu- uration was u n d e r t a k e n with some concern nication between the p o u c h and the distal stom- because it left the j e j u n u m u n p r o t e c t e d from acid ach was repaired. O n the other hand, both Suger- by the usual neutralizing effects of bile and pan- m a n and associates and Hocking and coworkers creaticjuice. Stomal ulcer was seen infrequently in (5, 6) report stomal ulcers without staple line dis- our p a t i e n t s - - o n l y 3 in a review of 920 patients we ruption and an incidence of postoperative ulcer of r e p o r t e d on in 1988 (3). 13.3% and 8.2%, respectively. Pories reports that MacLean and coworkers have recorded in this he has observed a 3% stomal ulcer rate and a 16% issue (4) their experience with stomal ulcer after staple line disruption rate but has never seen the gastric bypass p r o c e d u r e as they p e r f o r m it. If stomal ulceration without staple line disruption the gastric p o u c h r e m a i n e d in continuity with the (WJ. Pories, personal communication, 1997). In bypassed distal stomach separated by staple lines the paper by J o r d a n and colleagues (6), high acid only (GB), the incidence of stomal ulcer was 16%. c o n t e n t was f o u n d in some patients without staple If the gastric p o u c h was isolated by transecting the line disruption b u t with a stomal ulcer. It appears stomach between staple lines so that the distal that exposure of the j e j u n u m to acid is the cause stomach was no longer attached to the pouch (IGB), of the postoperative stomal ulcers in these pa- the incidence of stomal ulcer was 2.9%, for an over- tients, but what is n o t resolved is whether the acid all incidence of postoperative stomal ulcer of 6.2%. is present because of a high parietal cell popula- Stomal ulcers occurred only if the patients devel- tion in the p o u c h or because of c o m m u n i c a t i o n oped a staple line disruption (GB) or a gastrogastric between the p o u c h and the distal stomach. fistula (IGB). Acid concentration in the p o u c h was This, then, leads to a consideration of the sec- high in all instances of stomal ulcer. o n d question. In 1934, Berger described the dis- These findings p r o m p t two questions. Is c o r n - tribution of parietal cells in the h u m a n stomach
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(7). While it is clear that the body of the stomach References
has a plentiful oxyntic cell count, it is equally apparent that the lesser curvature (the Magen- 1. Mason EE, and Ito C. Gastric bypass. Ann Surg 1969;170:329- 39. strasse?) of the stomach has a higher concentra- 2. Griffen WO Jr, Young VL, and Stevenson CC. A prospective tion of these cells than the cardia of the stomach, comparison of gastric and jejunoileal bypass procedures for which has few parietal cells. Because reports from morbid obesity. Ann Surg 1977;186:700-7. 3. Schwartz RW, Strodel WE, Simpson WS, and Griffen WO Jr. those surgeons who p e r f o r m Roux-en-Y gastric by- Gastric bypass revision: lessons learned from 920 cases. Sur- pass using a horizontal staple line and the cardiac gery 1988;104:806-12. portion of the stomach as the gastric p o u c h doc- 4. MacLean LD, Rhode BM, Nohr C, et al. Stomal Ulcer After Gastric Bypass. J Am Coll Surg 1997;185:1-7. u m e n t a lower postoperative stomal ulcer rate 5. Sugerman HJ, Kellum JM, Engle KM, et al. Gastric bypass for than those using a vertical staple line a n d the treating severe obesity. Am J Clin Nutr 1992;55:560s-566s. lesser curvature portion of the stomach for the 6. Jordan JH, Hocking MP, Rout WR, and Woodward ER. Mar- ginal ulcer following gastric bypass for morbid obesity. Am gastric pouch, it appears that the former proce- Surg 1991;57:286-88. dure is superior as far as the late complication of 7. Berger EH. The distribution of parietal cells in the stomach: a stomal ulcer is concerned. Probably the only way histopographic study. Am J Anat 1934;54:87-114. to resolve this would be for all bariatric surgeons to p e r f o r m periodic endoscopy and p o u c h acid studies on all their patients during l o n g t e r m followup--a rather tall order. In the meantime, we WARD O . GRIFFEN JR, MD, EACS will continue to' p e r f o r m the Roux-en-Y gastric University of Kentucky Medical Center bypass as originally described and await additional D e p a r t m e n t of Surgery studies on postoperative stomal u l c e r . Lexington, Kentucky