Chapter 21

The gastric bypass operation was described by Mason in 19691 and has evolved, with many variations, since the original loop technique. Many investigators, including Dr. Henry Buchwald, abandoned the loop technique because of many complications, such as alkaline gastritis and esophagitis, and the Roux-en-Y technique was brought forward and refined. The Roux en-Y has been the standard for the “hybrid” of bariatric operations for over three decades understanding that the Roux limb needed to be at least 60 cm to eliminate the reflux but many aspects of the operation remained unproven. It has been felt that the size of the gastric pouch, the restriction at the level of the gastroenterostomy, and the maintenance of an adequate length of common channel (to maintain absorption) are important in this operation.

As the laparoscopic era developed in bariatric surgery, three different ways to perform the gastroenterostomy emerged. The circular stapler was first used by me, as the primary author of this chapter, and Dr Champion2 and Dr Higa3 spearheaded the linear stapling and hand-sewn techniques, respectively, which will be discussed in other chapters.

In 1993, we developed the laparoscopic gastric bypass, and in 1994 the technique was first reported with results.4 In this operation, the gastroenterostomy was created with a 21-mm circular stapling device. The first technique of circular stapler anvil placement involved pulling the anvil down from the mouth to the stomach pouch with a wire being placed percutaneously into the peritoneal cavity. This technique was derived from the method used in the percutaneous endoscopic gastrostomy tube placement. The key step was the development of the Endopath Stealth endoscopic/conventional circular stapler, 21 mm, by Ethicon Endo-Surgery.5 Historically, our group had used a hand-sewn gastroenterostomy of 12 mm since the early 1980s and we were comfortable with the results of that operation. As I was in Belgium, studying techniques for the performance of the Nissen Fundoplication, I was reviewing a study on our postoperative gastric bypass patients. It turned out that our highest complication was incisional hernia, at a rate of about 15%. We discussed various ways to try to decrease this hernia rate and decided to try the operation laparoscopically to decrease our number one complication. We had worked in the laboratory for months trying different techniques and then the 21-mm circular stapler was being readied for release and that seemed to fit nicely with the planned procedure. The 21-mm stapler creates a uniform and reproducible 12-mm anastomosis and that was the size of the gastroenterostomy we were used to creating. This technique also allowed us to preserve the small gastric pouch, which is felt to be essential to long-term weight control.6 In the animal model, we had tried several methods of anvil placement as we were developing the concept of the laparoscopic gastric bypass but settled on the transoral placement because we had extensive experience in placing Percutaneous Endoscopic Gastrostomy (PEG) catheters and it was a ...

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