To the Editor.—Dr Ravitch's reply to my communication1,2 requires clarification.
I certainly do not feel that patients' behavior is to blame for leaks and perforations following bariatric surgery. However, their noncompliance may well be a factor in early, and possibly even late, staple line disruption after gastric partitioning. This is an entirely different situation. Leaks and perforations are life-threatening but staple line disruptions usually are not. A small disruption may only be apparent on upper gastrointestinal tract endoscopy or barium studies, but if the disruption is large, then gastric restriction will be lost. After a small disruption, the whole staple line could "unzip." If restriction is lost, the operation usually fails, particularly if this occurs in the early postoperative stage.
We know little about staple line healing in the morbidly obese human's stomach. If gastric restriction is going to be successful, even in carefully selected cases, knowledge of