LAUSR

Dr. Rafael F. Capella, MD, can best be described as a dedicated surgeon in private practice who performed nearly 6,000 cases of bariatric surgery. His commitment to teaching, publishing and his relationship with other academics came somewhat later in his surgical career. A steady flow of patients and a determination to follow every single case closely allowed him to recognize complications early and to develop what he considered the ideal gastric bypass procedure based on weight loss results and complications. After performing several Gomez transverse gastroplasties, his bariatric surgical career began in earnest with Mason’s Vertical Banded Gastroplasty (VBG). Following completion of over 800 cases of VBG during the 1980s, he realized that the long-term weight loss achieved with this technique was less than desirable. In an effort to maintain some of the qualities of VBG but with the goal of improving weight loss, he began combining the gastric bypass with VBG (VBG-RGB). Dr. Capella soon learned that stapling the pouch in continuity eventually led to an unacceptable rate of staple line disruptions. These staple line disruptions were often followed by severe marginal ulcers. In the next evolution of the operation, the gastric segments were stapled and completely transected and the staple line of the stomach inverted with silk Stitches. Complete transection of the gastric segments led to a drastic reduction in the incidence of staple line disruption and gastro-gastric fistulas to 2.6%. The interposition of a limb of jejunum between the gastric segments, held in place only with a few catgut stiches, essentially eliminated the problem of gastro-gastric fistulas. In reviewing his series, Dr. Capella also found that a stapled gastro-jejunostomy was accompanied by a 6% incidence of chronic or recurrent marginal ulcers. He felt that the ulcers were due to the disruption of the protective mucosa produced by the staple line at the gastrojejunostomy. When using only absorbable sutures the incidence of ulcers was reduced to 0.4%. This latest form of VBG-RGB was the final step in the evolution of his technique for the gastric bypass procedure. The final version of the procedure included a long narrow pouch with a restricting propylene band and an interposed limb of jejunum between the gastric segments. Dr. Capella also observed a high rate of incisional hernias. As his technical expertise grew through the years, he performed the procedure through increasingly small incisions, resulting in less postoperative patient discomfort and a substantial reduction in the incidence of incisional hernias. The reduction in incision size was progressive year to year and from 2006 on, the average size was 7 cm in length. To perform the procedure through smaller incisions, it was necessary to make some changes in the technique to facilitate reaching the first portion of the jejunum. Mobilizing and exteriorizing the greater omentum in these extremely obese individuals was not * Aniceto Baltasar [email protected]