Kral J G
St. Luke's-Roosevelt Hospital Center, Department of Surgery, College of Physicians and Surgeons of Columbia University, New York, New York.
Gastroenterol Clin North Am. 1987 Jun;16(2):293-305.
There is no ideal operation for morbid obesity and there probably never will be one. The disease is multifaceted, with unknown polyfactorial etiology. The multitude of surgical methods attests to the frustrations in trying to palliate the morbidly obese. Gastric restriction on its own is proving inadequate for the heaviest patients ("super obese"), for patients with preferences for "sweets," and for patients who have had failure of previous surgery, whether it be jejunoileal bypass or gastroplasty. The current trend toward performing malabsorptive procedures is symptomatic. Experimentation with varying sizes and configurations of gastric remnants in combination with varying lengths of small intestine in continuity is reminiscent of the early experience with jejunoileal bypass. That era has been called by some respected and influential surgeons the "dark ages of surgery." Very few of the tens of thousands of patients would agree with this assessment. Nevertheless, Payne was convinced that the "malignant abuse of all of these operations. . . could result in the abandonment of the only practical method. . . for the treatment of the morbidly obese patient." Jejunoileal bypass operations can be "salvaged" by vigorous medical management. When that fails, there are several surgical options for dealing with the blind loop, short of reanastomosing the bowel. New malabsorptive operations have been developed and are being rigorously scrutinized by relatively few dedicated surgeon-scientists. The most important lesson learned from the many severe late complications of jejunoileal bypass is that operations for morbid obesity need to be studied intensely and for a sufficiently long period of time before they can be considered ready for routine use.
对于病态肥胖症，目前尚无理想的手术方式，而且可能永远都不会有。这种疾病具有多方面特点，病因是未知的多因素综合作用。众多的手术方法证明了在试图缓解病态肥胖问题上的挫败。单纯的胃限制手术对于最重的患者（“超级肥胖者”）、偏爱“甜食”的患者以及先前手术（无论是空肠回肠分流术还是胃成形术）失败的患者来说已被证明是不够的。当前进行吸收不良手术的趋势是有症状表现的。对不同大小和形态的胃残余部分与不同长度的连续小肠进行组合试验，让人想起空肠回肠分流术的早期经历。那个时代被一些备受尊敬且有影响力的外科医生称为“手术的黑暗时代”。成千上万的患者中很少有人会认同这种评价。然而，佩恩确信“对所有这些手术的恶性滥用……可能导致放弃唯一可行的方法……来治疗病态肥胖患者”。空肠回肠分流术可以通过积极的医疗管理“挽救”。当这种方法失败时，除了重新吻合肠道外，还有几种手术选择来处理盲袢。新的吸收不良手术已被开发出来，并正受到相对较少的专注于外科手术的科学家的严格审查。从空肠回肠分流术的许多严重晚期并发症中吸取的最重要教训是，病态肥胖症手术在被认为可以常规使用之前，需要进行深入且足够长时间的研究。
