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Winter 2001 IBSR Newsletter WINTER
2001 Volume 16,
number 4
Incompatibility of Nissen Fundoplication and Vertical Banded
Gastroplasty By
Edward Eaton Mason MD, Ph.D. and Joseph Cullen MD We were reminded of the problems of combining VBG and fundoplication recently by a patient with severe postprandial pain and vomiting, who was admitted one year following a Nissen fundoplication. She was 55 years of age and had weighed 286 pounds when she had a VBG 15 years earlier. There had been heartburn before the VBG that was relieved and her weight dropped to 190 lb, which was what she weighed on admission to the University of Iowa Hospitals and Clinics (UIHC). An upper gastrointestinal radiograph showed an intact Nissen fundoplication with a large pouch, the walls of which were wrapped around the esophagus and an eccentrically enlarged pouch with delayed emptying. The patient elected to have the VBG reversed rather than revision to a smaller pouch with a new outlet. When there is esophageal reflux with a large VBG pouch, fundoplication may seem attractive as a way of solving both reflux and excessive pouch size. However, it does not address the basic problem of a pouch that was greater than 20 ml to begin with and had stretched, in part, because the tension on the wall is related to the diameter (law of LaPlace). There should not be enough stomach within the pouch to wrap the esophagus after a VBG. The staple line is supposed to be from the angle of His to the window. In the early days of VBG, when pouches were larger than 20 ml, it was not uncommon to see a patient with increasing reflux symptoms, increasing vomiting and weight gain. The combination of weight gain and vomiting seemed impossible. Patients never knew how much food remained in the pouch and they did not know when to stop eating. When the pouches were reduced to a measured, 20 ml, or less, symptoms were relieved and weight decreased. Even with an initial measured pouch of 28 ml, we saw one patient whose pouch dilated to 450 ml over twelve years.1 She developed progressive vomiting and reflux symptoms. She lost weight and had no more vomiting after reduction of the pouch to 12 ml. The appropriate surgical treatment of esophageal reflux when there is an enlarged VBG pouch is to measure the pouch at operation and then reduce the size to a measured 20 ml or less by placing a new staple line from the window to the angle of His. If the pouch is excessively long, a new window and a new staple line can be created within the old pouch. At UIHC we call this a Faberge because it is a pouch within a pouch. It is then advisable to remove the collar from the original pouch. It is important not to leave a closed segment between the new and old staple line. Instead of a second window, a Silastic ring can be used or Long’s three non-absorbable sutures.2 This external type of calibration must be over a 40 bougie to assure an adequate outlet. This patient actually had another problem that was found at operation. She had stenosis of the outlet. Because she had chosen to keep her Nissen fundoplication and relinquish the VBG, this was accomplished by dividing the collar and outlet with a GIA stapler. Another aspect of the care of this patient needs emphasis although the complication did not occur. The chief complaint was vomiting. That should raise the thought of malnutrition and particularly a deficiency of thiamin. We had another call recently from a neurologist wanting to know why obesity surgeons he had talked to were unaware of the potential for neuropathy in the presence of vomiting. Wernecke-Korsakoff syndrome appears most commonly about 90 days after the onset of vomiting.3 We routinely look for lateral nystagmus and loss of deep tendon reflexes during routine follow-up of patients with gastric reduction operations. This not only establishes a base line for these examinations, but reminds us of the need to prevent neurologic damage by adding thiamin and other vitamins to intravenous fluids when treating patients with vomiting that is persistent, recurring and uncontrollable by appropriate changes in eating and drinking.4 Uncontrollable vomiting is not a complication of a normal VBG. Once begun, the W-K syndrome advances rapidly to irreversible changes and death. Administering intravenous glucose without thiamin may bring it on. Early and massive thiamin treatment will minimize the central and peripheral nerve damage. Prevention is better than cure. There is a sequential combination of fundoplication and VBG that is even more likely to result in an early and serious complication. This is the addition of a VBG after a Nissen fundoplication. It may not be evident from the appearance of the stomach that a Nissen has been performed because of the adhesions and the filling in with scar tissue. The result of vertical stapling over a Nissen fundoplication is to create a closed segment of the wrap and to interfere with the blood supply of the stomach wall forming the wrap. We are not aware of any published report of adding a VBG without first taking down the Nissen fundoplication, but there has been such a case, the records of which one of us was asked to review some years ago. The patient died with necrosis of the lower esophagus and pouch. A properly measured and constructed, small vertical pouch with preservation of the angle of His or augmentation of the angle by the staple line is anti-reflux.5 If a patient has a large pouch, make it smaller. Don’t be tempted to wrap it around the esophagus to reduce the pouch size. There is no need to convert a VBG to a gastric bypass if weight loss was initially satisfactory. Make sure of what the problem is by careful history, radiographic study, and examination of old operative records. Design the simplest and safest operation that will correct the problem.
1.
Mason EE, Scott DH, Cullen J, Rodriguez EM, Maher JW,
Soper RT. Vertical
Banded Gastroplasty in the severely obese under age twenty-one.
Obesity Surgery
5:23-33, 1995. 2.
Jamieson AC. Determinants of weight
loss after gastroplasty.
Problems in
General Surgery 9:290-7,
1992. 3.
Cirignotta F, Manconi M, Mondini S, Buzzi G, Ambrosetto
P. Wernicke-Korsakoff encephalopathy and polyneuropathy after gastroplasty
for morbid obesity. Archives
Neurology 57:1356-9,
2000. 4.
Mason EE. Starvation injury after
gastric reduction for obesity.
World Journal of
Surgery 22:1002-7,
1998. 5.
Deitel M, Khanna RK, Hagen J et al.
Vertical Banded
Gastroplasty as an anti-reflux procedure.
American Journal
of Surgery 155:512-6,
1988. NOTICE! On
11-26-2001, ASBS members received an email entitled
"National Bariatric Surgery Registry update".
You should be aware that this did not come from the
NBSR / IBSR. In
1979, the National Bariatric Surgery Registry (NBSR) was
organized at the University of Iowa as a data analysis center
for bariatric surgery with support from the University of Iowa
Department of Surgery and the American Society for Bariatric
Surgery. These
services expanded in 1986 to personal computer software
designed specifically for reporting bariatric surgery outcome.
On August 24, 1987, the US Copyright Office granted
copyright registration for NBSR software, data base
instruction manual and forms (TX 2-142-058).
The NBSR became the International Bariatric Surgery
Registry (IBSR) in 1996, due to international interest.
The NBSR/IBSR currently serves 43 members and has
provided services to 107 past members.
Therefore, we requested the NIH grant application name
be changed, as the NBSR / IBSR are not the same projects. I
strongly support, and will participate in, the effort to have
the NIH fund the development of a registry to accrue rigorous
follow-up and encourage research at 10 surgical centers for
obesity. This
costly study will involve only a minority of institution (10)
performing obesity surgery.
With Dr. Walter Pories' enthusiastic support, and the
prediction of 80,000 bariatric operations next year, IBSR
members will record many more.
Therefore, surgeons and centers not involved with the
NIH study should continue to participate in the NBSR / IBSR. -
Edward E. Mason, MD IBSR 1.0e
Feature: "Other
Reports"
IBSR 1.0e has many useful features for IBSR members to use in their offices for outcome reports "on site". The next few newsletters will highlight some of these features. This issue shows one of the "Other Reports": Changes in hypertension following bariatric surgery. Users may select hypertension, diabetes, vomiting, heartburn, urinary stress incontinence or diarrhea from "Other Reports." The
above report shows that hypertension was managed for 30
percent of the patients prior to surgery.
At follow-up, hypertension management dropped to less
than two percent of the patients, indicating 99% of the
patients no longer had hypertension to manage.
With all outcome reports, care should be taken in
interpreting results when patient numbers are less than 100
and if follow-up is insufficient (<61%, on a yearly basis).
Use the Weight Loss Follow-up Report to determine
completeness of data when examining IBSR 1.0e "Weight
Loss Reports," "Lab Value Reports" and
"Other Reports."
The follow-up for this data set was 97% (0y), 71% (1y),
46% (2y), 24% (3y). -
KR IBSR 1.0e Software Now Available! IBSR Surgeon Members can ORDER NOW. WINTER
2001
IBSR
Newsletter
Volume
16, Number 4
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