Gastric bypass procedures

Surgical therapy to help the severely overweight has been performed for the past 40 years. As with every therapeutic modality, there have been changes, refinements and improvement as this therapy has evolved. Although the basic concept of gastric bypass remains intact, numerous variations are being performed at this time. Recent data compiled by the International Bariatric Surgery Registry have demonstrated that surgeons are moving from simple gastroplasty procedures, favouring the more complex gastric bypass procedures as the surgical treatment of choice for the morbidly obese patient. This review will discuss the evolution of the gastric bypass procedures, and the reasons for and results of the changes. Gastric bypass may represent the best surgical approach for the treatment of morbid obesity.

Laparoscopic repositioning of an adjustable silicone gastric band for pouch dilatation and stoma obstruction

Pouch dilatation with stoma obstruction is a well-known late complication after adjustable gastric banding operations for morbid obesity. Surgical treatment of this problem usually results in removal of the band, with or without replacement by another, or in repositioning of the band via laparotomy. We present the case of a patient with late pouch dilatation and stoma obstruction after placement of a Laparoscopic Adjustable Gastric Banding system (LAGB-Bioenterics) and in whom the adjustable band was laparoscopically opened, disconnected from the access port, and repositioned more proximally on the stomach. The postoperative course was uneventful. A postoperative radiographic contrast examination showed a correct repositioning of the band. The case demonstrates that the LAGB can be successfully opened and repositioned by a minimal invasive procedure. This is the first time to our knowledge that such a procedure has been reported.

Silastic ring gastric bypass: a comparison of two ring sizes: a preliminary report

BACKGROUND

The silastic ring (vertical) gastric bypass (SRGB) was introduced by Fobi in 1989, in an effort to combine the advantages of the Roux-en-Y gastric bypass with those of the VBG, while avoiding disadvantages of each. We remain unsure of the ideal ring size.

METHODS

Sixty-four patients having SRGB between June 1990 and September 1994 had a 5.5 cm ring placed and 24 patients operated between October 1994 and September 1995 had a 6.0 cm ring placed. Weight loss and quality of eating data is compared 12 months after surgery.

RESULTS

Median preoperative per cent excess weight was 113 (range 76-209) in the 5.5 cm group and 106 (range 79-196) in the 6.0 cm group. Weight loss was equivalent at 12 months, with median percent excess weight of 33 (range 8-109) and 27 (range 6-81) in the two groups respectively. Quality of eating data appears better in those with the larger ring size. Nine patients with a 5.5 cm ring have subsequently had their ring removed to improve their quality of eating and a further six may require this in the future. One patient with a 6.0 cm ring has had the ring removed and two others may require this be done.

CONCLUSION

An SRGB with a 6.0 cm ring achieves equivalent weight loss to one with a 5.5 cm ring, but with better quality of eating, and less prospect of requiring ring removal. However, there remains a small proportion of patients in whom a 6.0 cm ring is poorly tolerated. For this reason a 6.5 cm ring should be tested.

Silastic ring gastric bypass: results in 64 patients

BACKGROUND

The silastic ring gastric bypass (SRGB) was introduced by Fobi in 1989, in an effort to combine the advantages of the Roux-en-Y gastric bypass with those of the vertical banded gastroplasty, while avoiding the disadvantages of each.

METHODS

The results of our first 64 patients who underwent SRGB with a 5.5 cm ring have been reviewed with particular attention to weight loss, short- and medium-term morbidity and patient satisfaction. Most patients have had regular follow-up, and those not seen during the last 6 months were sent a postal questionnaire.

RESULTS

The patients included 52 females and 12 males, ranging in age from 23 to 59 years (median age=39 years) at the time of surgery. Median preoperative weight, body mass index (BMI) and % excess weight were 126 kg (range 89-253 kg), 44 kg/m2 (range 36-78 kg/m2) and 113 (range 76-209) respectively. There were no serious postoperative complications and no deaths. Median hospital stay was 7 days (range 5-14 days). Eight patients (13%) are known to have had a staple-line dihiscence. Eighteen patients (28%) have had major difficulties with eating, and in nine (14%) of these the silastic ring has been removed with resolution of the eating problems, but some gain in weight. In the 54 patients with follow-up data at 2 years, median weight was 78 kg (range 55-137 kg), median BMI was 27 kg/m2 (range 20-43 kg/m2) and mean +/- SD % excess weight loss was 69+/-16. After 2 years of follow-up, eight of 54 patients (15%) were unhappy with the results of the procedure.

CONCLUSION

SRGB is an effective, safe and well-tolerated procedure for achieving weight loss in the morbidly obese. The principal drawbacks relate to staple-line problems and eating difficulties related to the silastic ring. A 5.5 cm ring is probably too small to be ideal.

Laparoscopically assisted gastric surgery using Dexterity Pneumo Sleeve

BACKGROUND

Laparoscopic surgery has been successfully applied to several gastrointestinal procedures. Although the totally laparoscopic gastrectomy is feasible, tactile sensation and manipulation of the organ as well as the lesion are decreased when compared to open surgery. The Dexterity Pneumo Sleeve is a new device which allows the surgeon to insert a hand into the abdominal cavity while preserving the pneumoperitoneum. This device was used for patients who underwent laparoscopic gastric surgery.

METHODS

The first patient presented with a non-Hodgkin's lymphoma of the stomach. A laparoscopically assisted distal gastrectomy was performed with Roux-en-Y reconstruction. The second patient had a 5-cm leiomyoma involving the greater curve of the stomach, and this device was used for manipulation of the tumor. The last patient suffered from morbid obesity with its associated medical complications and a ventral hernia. The Sleeve was applied at the hernia site and a laparoscopically assisted gastric bypass was performed.

RESULTS

The Pneumo Sleeve was useful in these cases for tactile localization of the tumor and for retraction and manipulation of the stomach and surrounding upper abdominal organs.

CONCLUSIONS

The utilization of this device resulted in a more easily performed dissection, resection, and anastomosis and was felt to decrease operation time.

Stapler division of the omentum and small bowel mesentery in morbidly obese patients undergoing gastric bypass surgery

BACKGROUND

Roux-en-Y gastric bypass (RYGB) procedures can be technically demanding because of anatomical factors including fat distribution, organ fixation, and wound depth. We developed a technique using the Multifire Endo GIA 60 2.5 disposable surgical stapler which allows greater mobilization, less blood loss, and decreased operating time.

METHODS

A disposable stapler designed for laparoscopic surgery was used to transect the gastro-colic omentum and small bowel mesentery in 67 morbidly obese patients undergoing RYGB. Generally, five to six stapler cartridges were needed for the transections.

RESULTS

Stapler division of the gastro-colic omentum and small bowel mesentery decreased operating time by an average of 25 minutes.

CONCLUSIONS

Applying principles of laparoscopic surgery to RYGB resulted in more efficient mobilization of the stomach and the small bowel mesentery, as well as decreased blood loss and operating time.