WARD O. GRIFFEN, JR. (Frankfort, MI): As an initial comment, I would like to recognize that Dr. Sugerman has discovered something that people have taught for a long time. When you create defects in mesentery you should close all of them before you come out of the abdominal, whether you are developing through a slot or via an incision.
When we first undertook gastric restrictive methods at Kentucky in 1975, we discovered that the loop gastrojejunostomy was an extremely difficult procedure because of the thickness of the mesentery, so we switched to the Roux-en-Y procedure. But we do so with some trepidation because we were worried about marginal ulcer.
However, we discovered that our marginal ulcer rate was no higher than the actual authors have reported today. Plus they have answered my first question already, which was, how did it is treated by them? We found it was treatable very with H2 receptor blockade easily. In the abstract you use the term “chronic heartburn”; in the manuscript, yesterday which you very kindly provided me, you use the term GERD, which is perfect for gastroesophageal reflux disease. In 1981 we offered in the Journal of the Kentucky Medical Association a series of 20 patients who experienced endoscopically proven reflux.
And we were amazed by two things. One, the GERD disappeared practically immediately postoperatively; almost in the recovery room the patient stopped having any type or kind of heartburn. The other thing we found was that only one hands down the 20 patients, or again 5%, continued to have symptoms. Whenever we reendoscoped that patient we found that the patient acquired bile reflux, which we thought was adding to their continued symptoms.
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And we wondered at that time if the Roux-en-Y loop we made was too brief for that one patient. I question if you’ll touch upon whether you feel that perhaps bile reflux is the reason that a few of your patients never have had resolution of their GERD symptoms. I valued the paper and I appreciate you sending me the manuscript.
DR. BRUCE D. SCHIRMER (Charlottesville, VA): I also desire to congratulate the authors on a great presentation and really superb results with using laparoscopic Roux-en-Y gastric bypass. For all those open bariatric surgeons who read this manuscript, the message is clear, as soon as again I am preempted by Dr. Sugerman, in saying that you can teach an old dog new tricks.
My questions for Dr. DeMaria are numerous, and I am going to start by asking Eric what’s the ultimate way to move the Roux limb-sort of the technical question. We don’t have the right answer, and I wonder if you decide to do. Second, we have also experienced a high occurrence of the Roux limb herniating behind the stomach from sutures being drawn loose.
Will the running long-lasting suture be the response to this, or should we consider going to an antegastric placement of the Roux limb perhaps? I also disagree with your choice of using intraoperative ultrasound for assessing gallstones. It would appear an unnecessary and time-consuming step in a long procedure already. And your yield of 5% to 6% is surprisingly lower in this patient population.
Do you have any explanation for this? We choose to do preoperative ultrasounds, intend to remove diseased gallbladders, counsel patients with normal gallbladders preoperatively about the prospect of gallstone formation with rapid weight loss, and then let them decide between the choice of Actigall or prophylactic cholecystectomy. Next, what are your current requirements for weight BMI and limit to attempt the operation laparoscopically? Finally, I agree with your assessment in the manuscript that procedure is to initially be done only by two well-trained laparoscopic surgeons (i.e., read that, attending or fellows). However, now that I have performed over 75 of them personally, I am more comfortable with a skilled senior-level surgery citizen assisting me do them.