Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs

Gastrointestinal symptomatic outcome after laparoscopic Roux-en-Y gastric bypass

Laparoscopic Roux-en-Y (RY) gastric bypass is an effective treatment for morbid obesity. However, little information is available regarding the gastrointestinal symptomatic outcome after laparoscopic RY gastric bypass for morbid obesity. The purpose of this study is to identify changes occurring in gastrointestinal symptoms after laparoscopic RY gastric bypass. A previously validated, 19-point gastrointestinal symptom questionnaire was administered prospectively to each patient seen for surgical consultation to treat morbid obesity. Patients rated the degree to which each symptom affected their lives on a 0 to 100 mm Liekert scale with 0 indicating absence of a symptom, 33 indicating the symptom was present occasionally, 67 indicating the symptom occurred frequently, and 100 indicating the symptom was continuous. The same survey was readministered 6 months postoperatively. The mean of each symptom (preoperative vs. postoperative value) was compared using Student's t test with significance at P<0.05. Forty-three preoperative patients (age 37.3+/-8.6 years; body mass index 47.8+/-4.9) and thirty-five, 6 months' postoperative patients (81% follow-up; body mass index 31.6+/-5.3) completed the questionnaire. The result for each symptom is expressed as mean+/-standard deviation of preoperative vs. postoperative scores. Significantly different symptoms include the following: abdominal pain 23.3+/-26.4 vs. 8.6+/-13.5, P=0.003; heartburn 34.0+/-26.6 vs. 8.0+/-14.0, P=0.0001; acid regurgitation 28.1+/-24.0 vs. 10.7+/-21.0, P=0.001; gnawing in epigastrium 19.3+/-22.7 vs. 7.5+/-16.0, P=0.01; abdominal distention 38.2+/-31.5 vs. 11.1+/-19.2, P=0.0001; eructation 27.7+/-24.4 vs. 15.5+/-16.9, P=0.01; increased flatus 40.2+/-25.7 vs. 25.2+/-25.3, P=0.005; decreased stools 5.4+/-16.8 vs. 17.4+/-20.0, P=0.0005; increased stools 23.9+/-26.7 vs. 6.5+/-11.7, P=0.0005; loose stools 29.7+/-26.5 vs. 17.5+/-20.0, P=0.03; urgent defecation 34.3+/-26.5 vs. 14.3+/-19.3, P=0.0009; difficulty falling asleep 44.1+/-38.4 vs. 27.5+/-32.9, P=0.05; insomnia 42.4+/-36.2 vs. 21.6+/-30.5, P=0.008; and rested on awakening 65.1+/-33.8 vs. 30.5+/-28.8, P=0.0001. Symptoms that did not significantly change included the following: nausea/vomiting 17.2+/-22.7 vs. 22.1+/-19.9, P=0.33; borborygmus 28.8+/-25.2 vs. 26.8+/-29.7, P=0.75; hard stools 10.3+/-22.9 vs. 7.1+/-18.6, P=0.56; incomplete evacuation of stool 17.2+/-22.8 vs. 13.4+/-21.7, P=0.45; and dysphagia 10.9+/-15.6 vs. 17.7+/-28.4, P=0.18. Laparoscopic RY gastric bypass significantly improves many gastrointestinal symptoms experienced by morbidly obese patients without adversely affecting any of the measured parameters. This information is useful in preoperative counseling to assure patients of overall symptomatic improvement after this operation in addition to significant weight loss and improvement of comorbid conditions.

Gastric Bypass for Morbid Obesity in Patients 50 Years or Older: Is Laparoscopic Technique Safer?

Some physicians have considered age ≥50 years as a relative contraindication for bariatric surgery. Recent reports demonstrated the safety and efficacy of Roux- en-Y gastric bypass (RYGB) in this patient subgroup, but comparisons between laparoscopic technique (LT) and open technique (OT) have not been reported. A review of 52 patients ≥50 years old who underwent RYGB between January 1999 and April 2002 was conducted. Demographics, operative data, and outcomes were assessed. Preoperative and postoperative renal and hepatic functions, electrolytes, anemia studies, and hematology results were compared. Patients were divided into LT and OT groups and operative outcomes were compared. The percentage of excess body weight loss was 66 ± 4 per cent at mean follow-up of 12 months. Blood samples drawn after a mean of 8 ± 2 months revealed no postoperative metabolic alterations. RYGB resulted in a reduction of the number of patients with hyperglycemia, hypertension, degenerative joint disease, gastroesophageal reflux disease, and continuous positive airway pressure-dependent sleep apnea ( P < 0.05). The LT resulted in fewer intensive care unit admissions and shorter length of stay. RYGB is safe and well tolerated in patients ≥50 years resulting in no renal, hepatic, or electrolytic alterations. Weight loss and control of obesity-related comorbidities are satisfactory. The LT results in fewer intensive care unit admissions and shorter length of stay than the OT.

Comparison of postoperative hepatic function after laparoscopic versus open gastric bypass

BACKGROUND

Pneumoperitoneum has been shown to reduce hepatic portal blood flow and alter postoperative hepatic transaminases. This study evaluated the changes in hepatic function after laparoscopic and open gastric bypass (GBP).

METHODS

Thirty-six morbidly obese patients were randomly assigned to undergo either laparoscopic (n = 18) or open (n = 18) GBP. Liver function tests--total bilirubin (T Bil), gamma GT (GGT), albumin, alkaline phosphatase (ALP), aspartate transferase (AST), alanine transferase (ALT)--and creatine kinase levels were obtained preoperatively and at 1, 24, 48, and 72 hours postoperatively.

RESULTS

The two groups were similar in age, sex, and body mass index. Albumin and ALP levels decreased while T Bil and GGT levels remained unchanged from baseline in both groups without significant difference between the two groups. After laparoscopic GBP, ALT and AST transiently increased by sixfold and returned to near baseline levels at 72 hours. After open GBP, ALT and AST transiently increased by fivefold to eightfold and returned to near baseline levels by 72 hours. Creatine kinase level was significantly lower after laparoscopic GBP than after open GBP at 48 and 72 hours postoperatively. There was no postoperative liver failure or mortality in either group.

CONCLUSIONS

Laparoscopic GBP resulted in transient postoperative elevation of hepatic transaminase (ALT, AST) but did not adversely alter hepatic function to any greater extent than open GBP. Creatine kinase levels were lower after laparoscopic GBP reflecting its lesser degree of abdominal wall trauma.

Effect of standard vs extended Roux limb length on weight loss outcomes after laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Increasing the length of the Roux limb in open Roux-en-Y gastric bypass (RYGB) effectively increases excess weight loss in superobese patients with a body mass index (BMI) >50 kg/m2. Extending the RYGB limb length for obese patients with a BMI < 50 could produce similar results. The purpose of this study was to compare the outcomes of superobese patients undergoing laparoscopic RYGB with standard (< or =100-cm) with those undergoing the procedure with an extended (150-cm) Roux limb length over 1-year period of follow-up.

METHODS

Retrospective data over 2.5 years were reviewed to identify patients with a BMI < 50 who underwent primary laparoscopic RYGB with 1-year follow-up ( n = 58). Forty-five patients (sRYGB group) received limb lengths < or = 100 cm, including 45 cm ( n = 1), 50 cm ( n = 2), 60 cm ( n = 6), 65 cm ( n = 1), 70 cm ( n = 1), 75 cm ( n = 3), and 100 cm ( n = 31). Thirteen patients (eRYGB group) received 150-cm limbs. Postoperative weight loss was compared at 3 weeks, 3 months, 6 months, and 1 year.

RESULTS

Comparing the sRYGB vs the eRYGB group (average +/- SD), respectively: There were no significant differences in age (41.5 +/- 11.0 vs 38.0 +/- 11.9 years), preoperative weight (119.2 +/- 11.9 vs 127.8 +/- 12.5 kg), BMI (43.7 +/- 3.0 vs 45.2 +/- 3.5 kg/m2), operative time (167.1 +/- 72.7 vs 156.5 +/- 62.4 min), estimated blood loss (129.9 +/- 101.1 vs 166.8 +/- 127.3 cc), or length of stay (median, 3 vs 3 days; range, 2-18 vs 3-19). Body weight decreased over time in both groups, except in the sRYGB group between 3 and 6 months and 6 and 12 months after surgery and in the eRYGB group between 6 and 12 months. BMI also decreased over time, except in the eRYGB group between 6 and 12 months. Absolute weight loss leveled out between 6 and 12 months in both groups, with no increase after 6 months. Percent of excess weight loss did not increase in the eRYGB group after 6 months. An extended Roux limb did not significantly affect body weight, BMI, absolute weight loss, or precent of excess weight loss at any time point when the two groups were compared. A trend toward an increased proportion of patients with >50% excess weight loss ( p = 0.07) was observed in the extended Roux limb group.

CONCLUSIONS

In this series, no difference in weight loss outcome variables were observed up to 1 year after laparoscopic RYGB. Thus, extending Roux limb length from < or =100 cm to 150 cm did not significantly improve weight loss outcome in patients with a BMI < 50 kg/m2.

Obesity in general elective surgery

BACKGROUND

Obese patients are generally believed to be at a higher risk for surgery than those who are not obese, although convincing data are lacking.

METHODS

We prospectively investigated a cohort of 6336 patients undergoing general elective surgery at our institution to assess whether obesity affects the outcome of surgery. Exclusion criteria were emergency, vascular, thoracic, and bariatric operations; transplantation procedures; patients under immunosuppression; and operations done under local anaesthesia. Postoperative morbidity was analysed for non-obese and obese patients (body-mass index <30 kg/m(2) vs >or=30 kg/m(2)). Obesity was further stratified into mild obesity (30.0-34.9 kg/m(2)) and severe obesity (>or=35 kg/m(2)). Risk factors were analysed with univariate and multivariate models.

FINDINGS

The cohort consisted of 6336 patients, of whom 808 (13%) were obese, 569 (9%) were mildly obese, and 239 (4%) had severe obesity. The morbidity rates in patients who were obese compared with those who were not were much the same (122 [15.1%] of 808 vs 901 [16.3%] of 5528; p=0.26), with the exception of an increased incidence of wound infections after open surgery in patients who were obese (17 [4%] of 431 vs 92 [3%] of 3555, p=0.03). Incidence of complications did not differ between patients who were mildly obese (91 [16.0%] of 569), severely obese (36 [15.1%] of 239), and non-obese (901 [16.3%] of 5528; p=0.19). In multivariate regression analyses, obesity was not a risk factor for development of postoperative complications. Of note, the additional medical resource use as estimated by a new classification of complications showed no differences between patients who were and were not obese.

INTERPRETATION

Obesity alone is not a risk factor for postoperative complications. The regressive attitude towards general surgery in obese patients is no longer justified.

Application of laparoscopy for bariatric surgery in adolescents

An epidemic increase in adolescent obesity in the United States has resulted in significant obesity-related comorbidities, previously seen only in adults. Although bariatric surgery is an acceptable alternative for weight loss in severely obese adults, no conclusions have been made about the appropriateness of bariatric surgery for individuals younger than 18 years old. Nonetheless, bariatric surgery is increasingly being performed on adolescents with clinically severe obesity and experience suggests that it is effective and safe. Application of the principles of adolescent growth, development, and compliance is essential to avoid adverse physical, cognitive, and psychosocial outcomes following bariatric surgery. Bariatric surgery should be part of a multidisciplinary approach to the management of adolescents with clinically severe obesity and should be performed by specialists dedicated to pediatric care, in institutions capable of meeting the guidelines for surgical treatment outlined by the American Society of Bariatric Surgery.

Laparoscopic radical nephrectomy: financial disincentives by the Health Care Financing Administration

BACKGROUND AND PURPOSE

Laparoscopic radical nephrectomy is a minimally invasive alternative to open radical nephrectomy. We have noticed that since the beginning of 2001, when the Current Procedural Terminology (CPT) code 50545 became available for laparoscopic nephrectomy, the reimbursement for the laparoscopic operation was significantly lowered. This led us to survey 25 laparoscopic urologic surgeons to assess trends in reimbursement from all over the United States.

MATERIALS AND METHODS

During this period, the records of reimbursements for radical nephrectomy were available from a single practice to compare that for the open and laparoscopic techniques. The 19 open and 10 laparoscopic operations were entered in a database for statistical analysis. Endourologists around the country also were polled on the subject.

RESULTS

The average reimbursement for an open radical nephrectomy was $1581 +/- 325 (SD), while the average reimbursement for a laparoscopic radical nephrectomy was $1192 +/- 184. Twenty-five polled endourologists had noted similar reductions in reimbursement for laparoscopic procedures. Many of those polled had participated in the Specialty Society Relative Value Unit (RVU) survey for laparoscopic radical nephrectomy and stated that their recommendations were that the value be considered greater than that of the open counterpart.

CONCLUSION

The highly significant difference in reimbursement reflects a financial disincentive to surgeons performing laparoscopic procedures. It is obvious that in the U.S., the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) is devaluating all surgical procedures, and financial pressures of this type are disturbing.

A comparison of diet and exercise therapy versus laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity: a decision analysis model

BACKGROUND

In the absence of randomized controlled trials that directly compare medical versus surgical treatment of morbid obesity, decision analysis is a useful tool to help determine the optimal treatment strategy. Using decision analysis we simulated a trial comparing diet and exercise therapy to laparoscopic gastric bypass surgery to determine which approach resulted in longer life expectancy.

STUDY DESIGN

A Markov decision analysis model was constructed to evaluate survival after laparoscopic Roux-en-Y gastric bypass surgery compared with a diet and exercise program for a 45-year-old woman with a body mass index (BMI) of 40 kg/m(2). Baseline mortality data were derived from published tables of vital statistics, and the relative risks of death associated with obesity (relative to normal weight) were taken from epidemiologic studies. We assumed that successful surgery resulted in a reduction of BMI to 30 kg/m(2). The baseline assumptions were: an operative mortality of 0.4%; a probability of weight loss after surgery of 80%; a rate of weight loss on a diet and exercise program, 20% at two years; a rate of regain of lost weight, 95% at two years; a relative risk of death for a BMI of 40 kg/m(2), 2.70; and a relative risk of death for a BMI of 30 kg/m(2), 1.51.

RESULTS

The undiscounted life expectancy after surgery was 69.7 years compared with 67.3 years for a diet and exercise program (an absolute increase in life expectancy of 2.4 years, a relative increase in life expectancy of 10.8%). Sensitivity analyses assumed discounting at 5%/y, and showed that surgery was associated with a longer expectation of life when the risk of operative mortality was less than 10%, and when the probability of weight loss after surgery was greater than 4%.

CONCLUSIONS

In a decision analysis model, laparoscopic gastric bypass surgery for morbid obesity was associated with a substantially longer survival than diet and exercise therapy.

Urgent laparoscopic splenectomy in a morbidly obese pregnant woman: case report and literature review

Laparoscopic splenectomy (LS) has undergone significant evolution since its introduction more than a decade ago. It clearly has been shown to be advantageous in comparison with open splenectomy and is considered by some to be the treatment of choice for routine uncomplicated elective splenectomy. When LS was first introduced, contraindications to the procedure included pregnancy, obesity, and splenomegaly. Both technologic advances and experience with the technique have enabled surgeons to perform LS for a growing number of indications with seemingly fewer contraindications. Here, we present a case of successful LS in a morbidly obese pregnant woman with splenomegaly and hemolysis secondary to hereditary spherocytosis.

Establishing a laparoscopic gastric bypass program

OBJECTIVE

To evaluate the outcomes for laparoscopic Roux-en-Y gastric bypass in a newly developed bariatric surgery program.

METHODS

A prospective analysis of the initial 100 patients who underwent laparoscopic Roux-en-Y gastric bypass at a community based teaching hospital between December 2000 and October 2001 was performed. Study endpoints included operative time, early (less than 7 days) and late complication rates, hospital length of stay (LOS), time to initiation of oral diet, and percentage of excess body weight loss.

RESULTS

There were 91 women and 9 men with a mean age of 39 years (range 21 to 57). Mean preoperative weight was 126.4 kg (range 92.3 kg to 214 kg), with a mean preoperative body mass index of 47.4 (range 37.3 to 75.7). Ninety (90%) patients had at least one significant medical comorbidity (median = 6 per patient). Mean operative time was 2.4 hours (range 1.0 to 6.5; 3.0 hours for the first 50 patients and 1.8 hours for the last 50 patients). Three patients required conversion to open gastric bypass, all due to equipment failure (two harmonic scalpel failures and one linear stapler malfunction). Seven patients had early complications, 3 with anastomotic hemorrhage requiring transfusion, 3 with intestinal leaks requiring reoperation, and 1 with transected nasogastric tube. Eleven patients had late complications: 5 patients with small bowel obstruction, all due to herniation through the transverse colon mesentery (these occurred early in the series, prompting a change in technique, with no subsequent occurrences), 3 with gastrojejunostomy strictures requiring endoscopic dilation, 2 superficial wound infections, and 1 port-site incisional hernia. No complications occurred in the last 40 patients. No deaths occurred. Median hospital stay was 2 days (range 1 to 37); 3 days in the first 50 cases and 1 day in the last 50 cases. The median number of days to the start of an oral diet was 1 day. Average excess body weight loss was 34% (median follow-up 4 months).

CONCLUSIONS

Laparoscopic Roux-en-Y gastric bypass is a technically challenging procedure that can be safely integrated into a bariatric treatment program with good results. Improved outcomes, shorter operative times, and fewer complications are associated with increased surgical experience.

Open Roux-en-Y gastric bypass for the morbidly obese in the era of laparoscopy

BACKGROUND

Roux-En-Y gastric bypass (RYGB) has been the preferred operative treatment for morbid obesity. Recently, laparoscopic RYGB has been described. We reviewed our data and believe that open RYGB is still the better option.

METHODS

One hundred three consecutive cases were retrospectively reviewed for preoperative conditions, perioperative outcomes, and postoperative complications with weight/health changes.

RESULTS

The mean follow-up was 5 months. The mean percent excess body weight loss was 33%. Comorbidities improved 50% of the time. The mean operative time was 117 minutes with blood loss averaging 208 cc. The mean intensive care unit stay was 1.3 days, with a total hospital stay of 4.4 days. There was an 8% major complication rate and a 1% mortality rate.

CONCLUSIONS

The health improvement and complication rates are comparable to published series on laparoscopic RYGB. With the technical complexity of the laparoscopic technique, open RYGB should remain the current standard of care, in most centers.

Medical and surgical options in the treatment of severe obesity

Weight loss programs, diets, and drug therapy have not shown long-term effectiveness in treating morbid obesity. A 1992 statement from the National Institutes of Health Consensus Development Conference affirmed the superiority of surgical over nonsurgical approaches to this condition. Bariatric surgical procedures work in 1 of 2 ways: by restricting a patient's ability to eat (restrictive procedures) or by interfering with ingested nutrient absorption (malabsorptive procedures). Many of these procedures can be performed by a laparoscopic approach, which has been shown to reduce operative morbidity. In the United States, the primary operative choice for morbidly obese patients has recently shifted from vertical banded gastroplasty (VBG) to the Roux-en-Y gastric bypass (RYGBP). VBG, a purely restrictive procedure, has fallen into disfavor because of inadequate long-term weight loss. RYGBP combines restriction and malabsorption principles, and has been shown to induce greater weight loss than VBG. Other procedures currently being offered include laparoscopic adjustable gastric banding; biliopancreatic diversion (BPD), including the duodenal switch (BPD-DS) variation; and distal gastric bypass (DGBP). Laparoscopic adjustable gastric banding with the LAP-BAND system (INAMED Health, Santa Barbara, CA), a restrictive procedure involving placement of a silicone band around the upper stomach, was introduced in the early 1990s and approved by the US Food and Drug Administration for use in the United States in June 2001. Outside the United States, LAP-BAND surgery is the most commonly performed operation for severe obesity. The BPD, BPD-DS, and DGBP are all malabsorptive procedures offered primarily by laparotomy. They have been shown to induce good long-term weight loss but have a higher rate of adverse nutritional complications. Many safe and effective surgical options for severe obesity are available. More scientific appraisals comparing different procedures and open and laparoscopic approaches are needed.

Scientific Surgery

The BJS is committed to the practice of surgery based on scientific evidence. Each month we will publish a list of randomized trials and meta-analyses collated from English&&hyphen;language publications. A collection of all these papers will be available in the Scientific Surgery archive which will be held on the BJS website together with links to free Medline sites where the full papers can be accessed (see below for details). If you have recently published a randomized trial that has not been featured in Scientific Surgery, the Editors would be pleased to receive a reprint and consider its inclusion.

National trends in utilization and in-hospital outcomes of bariatric surgery

In view of recent enthusiasm for surgery to treat morbid obesity, we examined national changes in utilization and in-hospital outcomes of bariatric surgery over time. With the use of International Classification of Diseases (ICD-9) codes, we identified all bariatric procedures (n = 12,203) performed on adults from 1990 to 1997 in hospitals participating in the Nationwide Inpatient Sample. We then applied sampling weights and United States Census data to calculate the national population-based rates of bariatric surgery procedures for each year and examined secular trends in utilization. We further evaluated changes in patient characteristics and in-hospital mortality and complications. From 1990 to 1997, the national annual rate of bariatric surgery increased from 2.7 to 6.3 per 100,000 adults (P < 0.001). The percentage of bariatric procedures performed by gastric bypass increased from 52% to 84% (P < 0.001). Patients were slightly older (38.1 years vs. 40.3 years; P < 0.001) with more comorbid conditions (20.9% vs. 31.6%; P < 0.001) in 1997 vs. 1990. In-hospital mortality was 0.37% overall and remained stable. Rates of pulmonary emboli, early reoperation, and pulmonary complications declined significantly over time. Between 1990 and 1997, the annual rate of bariatric surgery in the United States more than doubled, without substantial changes in perioperative morbidity or mortality. This trend was largely associated with an increase in the use of gastric bypass procedures.

Gastric surgery

Most significant research relating to gastric surgery in the past year has centered on surgery for gastroesophageal reflux disease (GERD). Antireflux surgery has become more popular with advanced laparoscopic technology. Two previously accepted surgical principles have been challenged by current studies: the importance of division of the short gastrics and the dictum that partial fundoplication is preferred for patients at risk for dysphagia. Additionally, risk factors for postoperative dysphagia have been identified, allowing for better patient selection and education. Further study on the cause of GERD has shown a positive correlation between pathologic gastroesophageal reflux and those with hiatal hernia or disordered esophageal peristalsis, although cause or effect has not yet been established. Literature relating to bariatric surgery has confirmed the safety and efficacy of the laparoscopic Roux-en-Y gastric bypass, and several papers address the appropriateness of prophylactic cholecystectomy in these patients. The role of laparoscopic surgery for treatment of perforated peptic ulcer disease has now been validated, with subsequent eradication of Helicobacter pylori infection. The relationship of H. pylori infection to acutely bleeding ulcers is less clear. Indications for ulcer surgery are predominantly limited now to perforation and bleeding because of the availability of effective acid-reducing medications and recognition of the role of H. pylori infection.

Evolution of minimally invasive bariatric surgery

BACKGROUND

Minimally invasive Roux-en-Y gastric bypass is a procedure that is being performed with increasing frequency. It is an advanced laparoscopic procedure with a steep learning curve. With experience, it can be performed in a reasonable amount of time with minimal morbidity.

METHODS

We first performed minimally invasive gastric bypass with the hand-assisted laparoscopic surgery (HALS) technique. After significant experience with HALS, we changed our approach to completely laparoscopic (LS). Our technique for all cases involves a circular stapled gastrojejunostomy with a 25-mm anvil passed transgastrically.

RESULTS

From June 1998 to January 2002, 304 patients underwent minimally invasive gastric bypass. Our first 81 cases were with HALS, and the rest were LS. The incidence of early major and minor perioperative complications for the entire series was 5.6% and 7.9%, respectively. Early reoperation (less than 30 days) was required in 4.6% of all patients. There was 1 leak (1.2%) in the HALS group and 4 anastomotic leaks (1.8%) in the LS group. Other measured outcomes were similar in each group with the exception of wound hernia (16% HALS vs 0.9% LS). Weight loss after 1 year was 44% for HALS and 56% for LS. We have not had any deaths in our series.

CONCLUSIONS

HALS may have certain advantages in selected patients and early in a surgeon's experience with minimally invasive gastric bypass. With experience, good results are possible with either approach.

Effect of prolonged pneumoperitoneum on intraoperative urine output during laparoscopic gastric bypass

BACKGROUND

Intraoperative oliguria is common during laparoscopic operations. The objective of this study was to evaluate the effects of prolonged pneumoperitoneum during laparoscopic gastric bypass (GBP) on intraoperative urine output and renal function.

METHODS

104 patients with a body mass index between 40 and 60 kg/m2 were randomly assigned to laparoscopic (n = 54) or open (n = 50) GBP. Intraoperative urine output was recorded at 30-min intervals. Blood urea nitrogen and creatinine levels were measured at baseline and on postoperative days 1, 2, and 3. Levels of antidiuretic hormone, aldosterone, and plasma renin activity were also measured in a subset of laparoscopic (n = 22) and open (n = 24) GBP patients at baseline, 2 hours after surgical incision, and in the recovery room.

RESULTS

The laparoscopic and open groups were similar in age, gender, and body mass index. There was no significant difference in amount of intraoperative fluid administered between groups (5.4 +/- 1.6 L, laparoscopic versus 5.8 +/- 1.7 L, open), but operative time was longer in the laparoscopic group (232 min versus 200 min, p < 0.01). Urinary output during laparoscopic GBP was 64% lower than during open GBP at 1 hour after surgical incision (19 mL versus 55 mL, p < 0.01) and continued to remain lower than that of the open group by 31-50% throughout the operation. Postoperative blood urea nitrogen and creatinine levels remained within the normal range in both groups. Serum levels of antidiuretic hormone, aldosterone, and plasma renin activity peaked at 2 hours after surgical incision with no significant difference between the two groups.

CONCLUSION

Prolonged pneumoperitoneum during laparoscopic gastric bypass significantly reduced intraoperative urine output but did not adversely alter postoperative renal function.

Systemic stress response after laparoscopic and open gastric bypass

BACKGROUND

The magnitude of the systemic stress response is proportional to the degree of operative trauma. We hypothesized that laparoscopic gastric bypass (GBP) is associated with reduced operative trauma compared with open GBP, resulting in a lower systemic stress response.

STUDY DESIGN

Forty-eight patients with a body mass index of 40 to 60 were randomly assigned to laparoscopic (n = 26) or open (n = 22) GBP Blood samples were measured at baseline and at 1, 24, 48, and 72 hours postoperatively. Metabolic (insulin, glucose, epinephrine, norepinephrine, dopamine, ACTH, cortisol), acute phase (C-reactive protein), and cytokine (interleukin [IL]-6, IL-8, tumor necrosis factor [TNF]-alpha) responses were measured. Catabolic response was also measured by calculating the nitrogen balance at 24 and 48 hours postoperatively.

RESULTS

The two groups of patients were similar in terms of age, gender, and preoperative body mass index. The mean operative time was longer for laparoscopic GBP than for open GBP (229 +/- 50 versus 207 43 minutes). After laparoscopic and open GBP, plasma concentrations of insulin, glucose, epinephrine, dopamine, and cortisol increased; IL-8 and TNF-alpha remained unchanged; and negative nitrogen balances occurred at 24 and 48 hours. There was no significant difference in these parameters between groups. Concentrations of norepinephrine, ACTH, C-reactive protein, and IL-6 levels also increased, but these levels were significantly lower after laparoscopic GBP than after open GBP (p < 0.05).

CONCLUSIONS

Systemic stress response after laparoscopic GBP is similar to that after open GBP, except that concentrations of norepinephrine, ACTH, C-reactive protein, and IL-6 are lower after laparoscopic than after open GBP. These findings may suggest a lower degree of operative injury after laparoscopic GBP.

An institutional experience with laparoscopic gastric bypass complications seen in the first year compared with open gastric bypass complications during the same period

BACKGROUND

Complication rates for laparoscopic bariatric surgery remain in evolution.

METHODS

Single institution review of the initial year's experience with laparoscopic gastric bypass compared with open gastric bypass complications for the same period.

RESULTS

There were 20 laparoscopic and 52 open gastric bypass procedures. Five laparoscopic patients had major complications. There were 4 anastomotic leaks. Nine open bypass patients had major complications, with 2 leaks. Leak rate was 20% for the laparoscopic group and 4% for the open group. All leaks in both groups led to substantial morbidity. There were two deaths, one in each group. The laparoscopic death was from postleak sepsis.

CONCLUSIONS

Gastric bypass, whether done open or laparoscopically, has significant surgical risk. Complication profiles differed between the two groups. Anastomotic leaks were significantly more frequent in the laparoscopic group, probably related to the learning curve. There is a continued need for open surgery in many bariatric patients.