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An ideal operation for control of obesity should limit ability to overeat and yet should allow normal nutrition. Subtotal gastric resection would satisfy these objectives but is too radical and.irreversible.Gastric bypass is an operation exactly like Billroth II gastric resection except that nothing is removed. A 15 to 30 per cent fundic segment is anastomosed to the upper jejunum. The distal segment of stomach is closed and sutured to the surface of the fundic pouch. EXCLUSION OPERATIONSAntral exclusion was used early in the history of ulcer operations in order to avoid closing a badly diseased duodenal stump. The operation was abandoned because of stomal ulceration. The procedure was resurrected by McKittrick, Moore, and Warren as the first stage of a two-stage operation. At the second stage the antrum was removed. Waddell and Bartlett performed 50 hemigastric exclusion operations with vagotomy. The inclusion of vagotomy with antral exclusion eliminated the high risk of stomal ulceration. D. W. Kay theorized that if sufftcient acid-secreting mucosa were excluded with the antrum, the acid gastric juice bathing the antrum would inhibit gastrin release. He reported 23 patients with 50 per cent gastric exclusion, three of whom developed stomal ulcers.A. W. Kay reported 20 patients treated with hemigastric exclusion and eight of these developed stomal ulcers between one and 18 months after the operation.The failure of hemigastric exclusion does not seem surprising in view of the failure of hemigastrectomy in the treatment of ulcer. were divided into three experimental groups and subjected to either a sham operation, 85 per cent gastric bypass of 85 per cent gastric resection. Only one of six resected dogs survived for one year and this dog's weight remained unchanged. Gerwig and Zimmerman have shown that there is a hormone in the stomach which is necessary for survival of dogs. This is an added argument for an operation which preserves the stomach even if it is taken out of the food stream. Three sham operated dogs doubled their weight in one year. ANIMAL EXPERIMENTSThree dogs with 85 per cent bypass gained 15, 17 and 46 per cent in body weight in one year and a fourth dog doubled its body weight in ten months. None of these dogs developed stomal or duodenal ulcers. Intravenous glucose tolerance tests one year after gastric bypass revealed normal blood glucose removal rates. The resected dog after one year had a subnormal removal rate. Gastric bypass decreased the rate of weight gain as compared with sham operated dogs but the animals did grow at a normal rate as far as their skeletal development was concerned. Stomal UlcerTwo experiments have been performed to determine whether two-thirds gastric bypass would prevent stomal ulcer. In the first experiment several different procedures were used for ulcer production while twothirds gastric bypass and two-thirds gastric resection were compared. Fifty-two dogs were used. In three groups the experimental variable was an increasing length of the proximal loop with a maxi...

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Gastric bypass is an extensive exclusion operation which was developed in 1966 and has been used in over 600 patients for the treatment of morbid obesity. Stomal ulceration has developed in 2% of patients and has usually occurred because the stomach was transected at too low a level. To determine the effect of varying levels of transection and exclusion of the stomach, graded gastric bypass was studied in 2 peptic ulcer models in dogs. With histamine-in-beeswax, stomal ulcers occurred whenever there was more than 63% of the stomach located above the gastroenterostomy. With common duct ligation, stomal ulcers were not observed in dogs with 44% or less of the stomach excluded, but when more than 44% of the stomach emptied through the duodenum, duodenal ulcers developed. Stomal ulceration occurred as a result of excessive acid production from large fundic segments stimulated by histamine. Duodenal ulcers resulted from a deficiency in buffering of acid when sufficient stomach was excluded and when an adequate volume of acid entered the duodenum where bile was excluded. These experiments add further emphasis to the importance of high transection of the stomach in gastric bypass, but also suggest that the occurrence of common duct obstruction will introduce the risk of duodenal ulcer in patients who have had gastric bypass for the treatment of obesity.

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