Laparoscopic Roux-en-Y gastric bypass for morbid obesity: technique and preliminary results of our first 400 patients

Bariatric surgery: effects on glucose homeostasis

PURPOSE OF REVIEW

This article provides an overview of the effect of bariatric surgery on type 2 diabetes. It focuses on current hypotheses about the mechanism of diabetes control after Roux-en-Y gastric bypass surgery, and discusses the relationship between gastrointestinal anatomy and glucose homeostasis.

RECENT FINDINGS

Along with sustained body weight loss, all bariatric operations lead to improvement or resolution of comorbid disease states, particularly type 2 diabetes. Roux-en-Y gastric bypass and biliopancreatic diversion are the most effective methods to control diabetes, resulting in persistent normal concentrations of plasma glucose, insulin, and glycosylated haemoglobin in 80-100% of cases. Resolution of diabetes after such treatment typically occurs too fast to be accounted for by weight loss alone. Recent animal investigations using duodenal-jejunal bypass, a stomach-preserving experimental model of Roux-en-Y gastric bypass, have shown that diabetes control is not a mere collateral effect of the treatment of obesity, but directly results from the exclusion of the duodenum and proximal jejunum from the flow of nutrients.

SUMMARY

Results from clinical series and animal studies suggest that type 2 diabetes is a potentially operable disease. This indicates the need for carefully conducted clinical trials to define the ideal candidate patients and the most suitable type of operation for surgical treatment of type 2 diabetes. Understanding the exact mechanism by which Roux-en-Y gastric bypass controls diabetes is a priority because such knowledge may help us to understand the relationship between gastrointestinal physiology and insulin resistance as well as to help us identify new targets for novel antidiabetic medications.

Detection of strictures on upper gastrointestinal tract radiographic examinations after laparoscopic Roux-en-Y gastric bypass surgery: importance of projection

OBJECTIVE

Our objective was to determine the optimal radiographic projections for the detection of strictures at the gastrojejunal anastomosis after gastric bypass surgery.

CONCLUSION

Steep oblique or lateral spot images routinely should be obtained during upper gastrointestinal radiographic studies after gastric bypass surgery to optimize detection of strictures at the gastrojejunal anastomosis.

Update on obesity surgery

The prevalence of obesity in the United States has reached epidemic proportions. With more than 30 million Americans clinically obese, the younger population has also been affected. Surgical therapy should be offered to the severely obese patient who is refractory to nonsurgical therapy, as established by the 1991 NIH Consensus Conference on Gastrointestinal Surgery for Severe Obesity. Surgery is currently the most effective therapy for weight loss. It is far more effective than any other treatment modality, both in terms of the amount of weight loss and in terms of durability in maintaining weight loss.

Surgical treatment of obesity

Obesity has emerged as one of the most complex and debilitating diseases affecting the world's population. It is estimated that more than two thirds of Americans are overweight and more than 20% are obese. This disease is associated with many morbid conditions, including hypertension, coronary artery disease, hypoventilation, sleep apnea syndrome, diabetes mellitus, and an increased incidence of certain malignancies. Medical interventions for achieving and maintaining significant weight loss have generally failed, leaving surgery as the only effective treatment for durable weight loss. A number of surgical options are available today and can be grouped into two categories based on the mechanism of how the weight loss is achieved. Restrictive procedures include vertical banded gastroplasty (VBG), adjustable gastric banding (AGB), and Roux-en-Y gastric bypass (RYGB), although the latter does have some altered absorption as well. Largely malabsorptive procedures include biliopancreatic diversion (BPD) and biliopancreatic diversion with duodenal switch (BPD-DS). Whereas VBG has largely fallen out of favor due to inadequate long-term weight loss, the other procedures have proven successful in achieving and maintaining adequate weight loss. In addition, each has proven successful in reversing or ameliorating many of the comorbidities associated with obesity. RYGB is the most common procedure performed in the United States and is considered the gold standard. It has the best short- and long-term results for safety, efficacy, and durability, and it has been proven to be superior in results to those for AGB. In experienced hands, this technically challenging procedure can now be performed laparoscopically. This method has the same weight loss and health benefits as the open procedure while achieving all the added benefits of a minimally invasive approach. Long-term data seem to support the malabsorptive procedures as most effective in the superobese. All the procedures require compliance and long-term nutritional follow-up.

Perioperative outcomes and risk factors in gastric surgery for morbid obesity: a 9-year experience

OBJECTIVE

Surgical treatment of severe obesity is the most rapidly growing specialty area of surgery. The rapid expansion of bariatric surgery has raised questions and concerns regarding possible increased surgical mortality and morbidity rates in both academic and community settings. The purpose of this study was to evaluate postoperative outcomes and risk factors for bariatric gastric surgery for severe obesity.

METHODS

A community experience of 1009 consecutive patients who underwent open surgical treatment of morbid obesity during a 9-year period was reviewed from a prospective database. The series included 858 primary gastric bypass operations and 151 revision operations. Perioperative outcomes, late complications, and weight loss results were recorded. Morbidity and mortality rates were analyzed according to patient age, body mass index (BMI), and gender.

RESULTS

The mortality rate in the series was 0.6%, and the morbidity rate was 20%. The major complication rate was 6.6%. There were no deaths in the 151 revision patients. The gastrointestinal leak rate was 0.8%, and the thromboembolism rate was 1%. Statistical analysis indicates that BMI is a risk factor for surgical complications.

CONCLUSION

Open gastric surgery for morbid obesity can be carried out in the community setting with low mortality and morbidity rates. BMI is a proven surgical risk factor.

Neurologic complications after surgery for obesity

Bariatric surgical procedures are increasingly common. In this review, we characterize the neurologic complications of such procedures, including their mechanisms, frequency, and prognosis. Literature review yielded 50 case reports of 96 patients with neurologic symptoms after bariatric procedures. The most common presentations were peripheral neuropathy in 60 (62%) and encephalopathy in 30 (31%). Among the 60 patients with peripheral neuropathy, 40 (67%) had a polyneuropathy and 18 (30%) had mononeuropathies, which included 17 (94%) with meralgia paresthetica and 1 with foot drop. Neurologic emergencies including Wernicke's encephalopathy, rhabdomyolysis, and Guillain-Barré syndrome were also reported. In 18 surgical series reported between 1976 and 2004, 133 of 9996 patients (1.3%) were recognized to have neurologic complications (range: 0.08-16%). The only prospective study reported a neurologic complication rate of 4.6%, and a controlled retrospective study identified 16% of patients with peripheral neuropathy. There is evidence to suggest a role for inflammation or an immunologic mechanism in neuropathy after gastric bypass. Micronutrient deficiencies following gastric bypass were evaluated in 957 patients in 8 reports. A total of 236 (25%) had vitamin B(12) deficiency and 11 (1%) had thiamine deficiency. Routine monitoring of micronutrient levels and prompt recognition of neurological complications can reduce morbidity associated with these procedures.

Small-bowel complications of major gastrointestinal tract surgery

OBJECTIVE

Gastrointestinal complications of major abdominal surgery often require radiologic assessment. The purpose of this article is to review the expected imaging findings and complications after commonly performed gastric and pancreatic surgery.

CONCLUSION

It is important to understand the postsurgical anatomy to avoid misinterpreting an expected postoperative finding as a complication. Postoperative complications can be categorized as being related to adhesions, anastomosis, an enteric connection, and abnormal bowel position.

Complications of bariatric surgery

The rise in bariatric operations has been exponential because of the greater acceptance for these procedures. Although complication rates are relatively low, they can result in formidable disability. Adverse outcomes also result in medical malpractice claims that are particularly problematic for bariatric surgery practices. For these reasons, surgeons performing these operations must be knowledgeable and must possess the technical skills required for managing complications when they occur. The purpose of this article is to review the major complications that occur following anti-obesity procedures and to provide recommendations regarding their management.

Obesity: basic science and medical aspects relevant to anaesthetists

Obesity is becoming a major public health problem throughout the world. It is now the second leading cause of death in the United States and is associated with significant, potentially life-threatening co-morbidities. Significant advances in the understanding of the physiology of body weight regulation and the pathogenesis of obesity have been achieved. A better understanding of the physiology of appetite control has enabled advances in the medical and surgical treatment of obesity. Visceral or abdominal obesity is associated with an increased risk of cardiovascular disease and type 2 diabetes. Various drugs are used in the treatment of mild obesity but they are associated with adverse effects. Surgery has become an essential part of the treatment of morbid obesity, notwithstanding the potential adverse events that accompany it. An appreciation of these problems is essential to the anaesthetist and intensivist involved in the management of this group of patients.

Best practice recommendations for surgical care in weight loss surgery

OBJECTIVE

To establish evidence-based guidelines for best practices for surgical care in weight loss surgery (WLS).

RESEARCH METHODS AND PROCEDURES

We carried out a systematic search of English-language literature on WLS in MEDLINE and the Cochrane Library. Key words were used to narrow the field for a selective review of abstracts. Data extraction was performed, and evidence categories were assigned according to a grading system based on established evidence-based models.

RESULTS

We assessed types of WLS, recommended guidelines for appropriateness, developed strategies for medical error reduction, established criteria for credentialing of systems and practitioners, and specified research needed for the future.

DISCUSSION

Surgeon training, credentialing, and type of surgery performed were identified as key factors in patient safety. Other important issues in the delivery of best practice care included appropriate patient selection; use of a multidisciplinary treatment team; facility staffing, equipment, and administrative support; and early recognition and proper management of complications.

Laparoscopic Roux-en-Y versus mini-gastric bypass for the treatment of morbid obesity: a prospective randomized controlled clinical trial

OBJECTIVES

This prospective, randomized trial compared the safety and effectiveness of laparoscopic Roux-en-Y gastric bypass (LRYGBP) and laparoscopic mini-gastric bypass (LMGBP) in the treatment of morbid obesity.

SUMMARY BACKGROUND DATA

LRYGBP has been the gold standard for the treatment of morbid obesity. While LMGBP has been reported to be a simple and effective treatment, data from a randomized trial are lacking.

METHODS

Eighty patients who met the NIH criteria were recruited and randomized to receive either LRYGBP (n = 40) or LMGBP (n = 40). The minimum postoperative follow-up was 2 years (mean, 31.3 months). Perioperative data were assessed. Late complication, excess weight loss, BMI, quality of life, and comorbidities were determined. Changes in quality of life were assessed using the Gastro-Intestinal Quality of Life Index (GIQLI).

RESULTS

There was one conversion (2.5%) in the LRYGBP group. Operation time was shorter in LMGBP group (205 versus 148, P < 0.05). There was no mortality in each group. The operative morbidity rate was higher in the LRYGBP group (20% versus 7.5%, P < 0.05). The late complications rate was the same in the 2 groups (7.5%) with no reoperation. The percentage of excess weight loss was 58.7% and 60.0% at 1 and 2 years, respectively, in the LPYGBP group, and 64.9% and 64.4% in the LMGBP group. The residual excess weight <50% at 2 years postoperatively was achieved in 75% of patients in the LRYGBP group and 95% in the LMGBP group (P < 0.05). A significant improvement of obesity-related clinical parameters and complete resolution of metabolic syndrome in both groups were noted. Both gastrointestinal quality of life increased significantly without any significant difference between the groups.

CONCLUSION

Both LRYGBP and LMGBP are effective for morbid obesity with similar results for resolution of metabolic syndrome and improvement of quality of life. LMGBP is a simpler and safer procedure that has no disadvantage compared with LRYGBP at 2 years of follow-up.

Imaging of small bowel-related complications following major abdominal surgery

To recognize and document the small bowel reactions following major abdominal surgery is an important key for a correct diagnosis. Usually, plain abdominal radiography is the initial imaging examination requested in the immediate postoperative period, whereas gastrointestinal contrast studies are used to look for specific complications. In some countries, especially in Europe, sonography is widely employed to evaluate any acute affection of the abdomen. CT is commonly used to assess postoperative abdominal complications; in our institution also CT enteroclysis is often performed, to provide additional important informations. Radiologist should be able to diagnose less common types of obstruction, such as afferent loop, closed loop, strangulating obstruction as well as internal hernia. This knowledge may assume a critical importance for surgeons to decide on therapy. In this article, we focus our attention on the imaging (particularly CT) in small bowel complications following abdominal surgery.

[Laparoscopic stomach bypass surgery]

Obesity is rapidly becoming a major medical problem in the developed world. Surgery is the only treatment with proven long-term efficiency for morbid obesity. We claim this surgery should be done by laparoscopy, because it is less invasive and morbidity is relatively low in obese patients, who are by definition fragile. Jejunojejunostomy can be performed by different techniques: side-to-side semimechanical, side-to-side entirely mechanical, end-to-side hand-sewn, and side-to-side hand-sewn. Gastrojejunostomy can be performed by different techniques: circular mechanical anastomosis with the anvil inserted through the mouth, gastrostomy, linear mechanical anastomosis, or hand-sewn anastomosis. We report our technique of laparoscopic gastric bypass with different possibilities for the two anastomoses.

Leveling the learning curve for laparoscopic bariatric surgery

BACKGROUND

The learning curve for laparoscopic bariatric surgery is associated with increased morbidity and mortality.

METHODS

The study included the first 100 patients undergoing laparoscopic Roux-en-Y gastric bypass (LGB) by a designated surgical team. Surgeon A operated as primary surgeon, with surgeon B assisting (Stage 1). Surgeon B learned LGB in stages: exposure and jejunojejunostomy (stage 2), gastric pouch (stage 3), gastrojejunostomy (stage 4), and sequence all steps (stage 5).

RESULTS

Surgeon A achieved confidence with LGB after 20 cases and surgeon B after 25 cases (stage 2), 18 cases (stage 3), 21 cases (stage 4), and 16 cases (stage 5). Complications (8%) included small bowel obstruction (three); pulmonary embolus (two), and leak, stomal stenosis, and gastrogastric fistula (one each). There was a decreasing trend for operative duration, length of stay, and complications across the five stages (p < 0.05).

CONCLUSIONS

By transferring skills in stages, a laparoscopic bariatric program can be established with minimal morbidity and mortality.

Laparoscopic gastric bypass for refractory morbid obesity

Morbid obesity has reached epidemic proportions in the United States. Laparoscopic gastric bypass is rapidly becoming the procedure of choice for treatment of morbid obesity. Results demonstrate that the surgery is technically safe. Outcomes are similar to open gastric bypass,but with markedly lower incidences of wound-related and cardiopulmonary complications. Patients also have shorter hospital stay, decreased pain and faster recovery.

Learning curve for laparoscopic Roux-en-Y gastric bypass with totally hand-sewn anastomosis: analysis of first 600 consecutive patients

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a challenging operation for the treatment of morbid obesity with well-demonstrated effectiveness in weight lost. There are several variations to the technique.

METHODS

From September 2000 to July 2004, 600 consecutive patients underwent surgery for morbid obesity at our institution. The surgical technique employed was LRYGB with totally hand-sewn gastrojejunal anastomosis (GJA). All patients were considered candidates for laparoscopic approach regardless of age, gender, body mass index (BMI), or previous bariatric or digestive surgery.

RESULTS

Mean BMI was 44.4 +/- 7.6 kg/m2. Thirty-two patients had undergone previous failed bariatric procedures. Conversion to an open procedure was necessary in three patients. Seventy-two patients (12%) developed early complications, including 23 (3.8%) leaks at the GJA (eight in the first 18 patients). Mortality rate was 1.1% (one death was related to GJA leakage). Early and late reoperation rates were 5.3 and 1.8%, respectively. Rate plateau of morbidity and mortality was reached after the first 18 patients when the surgical technique was fully standardized.

CONCLUSIONS

LRYGB is a technically demanding procedure for the surgical treatment of morbid obesity with significant morbidity during the learning curve. The learning curve can be soon overcome, reaching a rate plateau of complications after adequate training. Morbidly obese patients should be operated on in expert bariatric surgical laparoscopic units to obtain the best results.

Atypical complications of gastric bypass surgery

Although gastric bypass surgery continues to grow in popularity for weight loss and weight maintenance in the morbidly obese, there has been little attention given to the imaging of complications associated with these surgeries. The purpose of our study is to demonstrate the variety of gastric bypass surgery complications that can be identified radiographically, with attention to the more unusual complications. This study was performed with institutional Internal Review Board approval. We performed a 5-year retrospective review of all patients who had undergone gastric bypass surgery, had complications of the surgery, and had studies performed in our department to image these complications. These studies consisted of contrast fluoroscopy and CT. We identified the more common complications of anastomotic stenoses and anastomotic leaks. We also identified six unusual complications as follow: (1) internal herniation through the small bowel mesentery, (2) internal herniation through the transverse mesocolon, (3) external herniation through the abdominal wall incision, (4) enterocutaneous fistulas, (5) antiperistaltic construction of the Roux-en-Y, and (6) incorrect anstomoses of the Roux limbs resulting in a Roux-en-O configuration. Our findings show that a thorough understanding of expected postoperative bowel configuration is essential in the evaluation of these patients. In addition, fluoroscopic evaluation should assess not only anatomy, but also motility.

Evaluation of the learning curve for laparoscopic Roux-en-Y gastric bypass surgery

BACKGROUND

The literature reports that the learning curve for laparoscopic Roux-en-Y gastric bypass (LRYGBP) is approximately 75-100 cases. This aim of the present study was to evaluate the safety and feasibility of shortening the learning curve for performing LRYGBP by an experienced laparoscopic surgeon.

METHODS

This study analyzed retrospectively the first 100 consecutive LRYGBP cases performed by an experienced laparoscopic surgeon between April 2003 and September 2003. The surgeon performed these cases after first assisting in 30 cases, and the first 4 cases were proctored by an experienced laparoscopic bariatric surgeon. Two cases done after previous gastric stapling and Nissen fundoplication were excluded from the study. Outcome variables included operative time, complications, conversion, and mortality.

RESULTS

For the first 100 LRYGBP patients, the mean age was 42.6 years (range, 22-62 years) and mean body mass index (BMI) was 47.6 kg/m2 (range, 36-71.8). The complications included 1 case of intestinal leak, 1 case of small bowel obstruction, 6 cases of gastrojejunal stenosis, 8 cases of wound infection, 1 case of wound seroma, and 2 cases of pulmonary embolism, resulting in 1 mortality. One case was converted to an open technique. Over the second 50 cases, there was a significant reduction in mean operative time, to 73 minutes (range, 39-145 minutes) from 113 minutes (range, 54-238 minutes) (P < .0001). However, despite the reduction in complication frequency (no gastrointestinal leak or obstruction, 2 cases of gastrojejunal stenosis, 2 cases of wound infection, no pulmonary embolism/deep venous thrombosis, and no mortality), there was no significant correlation between the mortality, conversion, and complication rates and the surgeon's experience.

CONCLUSION

A bariatric surgical practice incorporating LRYGBP can be safely done by an experienced laparoscopic surgeon. With appropriate advanced laparoscopic skills, preparatory steps, proctorship, and adequate volume of cases, the learning curve for performing LRYGBP can be reduced to 50 cases. Further experience is associated with a significant reduction in operative time with acceptable mortality, complication, and conversion rates.

Surgical options for obesity

Several bariatric procedures are available that have excellent long-term weight loss results and are backed by several large clinical trials. Purely restrictive procedures like VBG have fallen out of favor because of inadequate long-term weight loss. Gastric bypass and the BPD are well-studied and show significant resolution of obesity-related comorbidities. Long-term nutritional consequences are seen more commonly after malabsorptive procedures like the BPD than after hybrid malabsorptive-restrictive procedures like the gastric bypass. Because compliance and long-term nutritional follow-up are mandatory after any bariatric procedure, purely malabsorptive procedures should be reserved for super obese patients who are at risk for inadequate long-term weight loss. Furthermore, minimally invasive techniques have evolved and essentially have eliminated the high incidence of postoperative wound complications and incisional hernias frequently seen after open gastric bypass. Until the development ofa similarly successful procedure, gastric bypass will continue to be the gold standard bariatric procedure with its concurrent sustained weight loss benefits and resolution of comorbidities.

Laparoscopic Roux-en-Y gastric bypass and the role of the surgical resident

BACKGROUND

Open Roux-en-Y gastric bypass (RYGB) is the gold standard for obesity surgery in this country. The introduction of a totally laparoscopic technique in 1994 has increased the demand for obesity surgery and for this particular approach. Several studies show comparable results and complications between the open and laparoscopic procedure. However, the continued study of surgical technique, analysis of results, and, in particular, the education of the surgical resident in this approach must be accomplished.

METHODS

A retrospective analysis was performed of 204 patients undergoing attempted laparoscopic RYGB, with surgical resident involvement, from March of 2000 to April of 2002. Surgical candidates had a body mass index (BMI) greater than 40 with a history of failed diets. All procedures were performed by a single board-certified general surgeon (P.F.R.) at a tertiary-care, teaching, community hospital with surgical residents assisting. Age, sex, ideal body weight, preoperative BMI and weight, surgical time, length of stay, complications, and resident level and role were recorded. Surgical technique was refined during the study period.

RESULTS

A total of 204 patients underwent attempted laparoscopic RYGB with 4 (2%) being converted to open procedures and 1 mortality. Surgical time averaged 182 minutes. The average length of stay was 1.8 days. Four patients (2%) developed postoperative anastomotic leaks. Three patients (1.5%) developed internal hernias requiring reoperation. Four patients (2%) developed postoperative hemorrhage. One patient (0.5%) had a pulmonary embolism. Surgical residents were involved in all procedures and gradually expanded their role as skill increased.

CONCLUSIONS

Laparoscopic RYGB can be performed safely in a community setting with surgical residents as either assistant or surgeon, further preparing them to perform this and other advanced laparoscopic procedures after completion of their training.

Obesity surgery: evidence-based guidelines of the European Association for Endoscopic Surgery (EAES)

BACKGROUND

The increasing prevalence of morbid obesity together with the development of laparoscopic approaches has led to a steep rise in the number of bariatric operations. These guidelines intend to define the comparative effectiveness and surrounding circumstances of the various types of obesity surgery.

METHODS

A consensus panel representing the fields of general/endoscopic surgery, nutrition and epidemiology convened to agree on specific questions in obesity surgery. Databases were systematically searched for clinical trial results in order to produce evidence-based recommendations. Following two days of discussion by the experts and a plenary discussion, the final statements were issued.

RECOMMENDATIONS

After the patient's multidisciplinary evaluation, obesity surgery should be considered in adults with a documented BMI greater than or equal to 35 and related comorbidity, or a BMI of at least 40. In addition to standard laboratory testing, chest radiography, electrocardiography, spirometry, and abdominal ultrasonography, the preoperative evaluation of obesity surgery patients also includes upper gastrointestinal endoscopy or radiologic evaluation with a barium meal. Psychiatric consultation and polysomnography can safely be restricted to patients with clinical symptoms on preoperative screening. Adjustable gastric banding (GB), vertical banded gastroplasty (VBG), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) are all effective in the treatment of morbid obesity, but differ in degree of weight loss and range of complications. The choice of procedure therefore should be tailored to the individual situation. There is evidence that a laparoscopic approach is advantageous for LAGB, VBG, and GB (and probably also for BPD). Antibiotic and antithromboembolic prophylaxis should be used routinely. Patients should be seen 3 to 8 times during the first postoperative year, 1 to 4 times during the second year and once or twice a year thereafter. Outcome assessment after surgery should include weight loss and maintainance, nutritional status, comorbidities and quality-of-life.

Symptomatic internal hernias after laparoscopic bariatric surgery

BACKGROUND

The aim of this study was to describe the occurrence and clinical characteristics of symptomatic internal hernias (IH) after laparoscopic bariatric procedures.

METHODS

We conducted a retrospective review of cases of IH after 1,064 laparoscopic gastric bypasses (LGB) and biliopancreatic diversions with duodenal switch (LBPD-DS) performed from September 1998 to August 2002.

RESULTS

We documented 35 cases of IH (overall incidence of 3.3%). The IH occurred in 6.0% of patients with retrocolic procedures and 3.3% of patients with antecolic procedures. Most were in the Petersen defect (55.9%) and at the enteroenterostomy site (35.3%). A bimodal presentation was observed, with 22.9% of patients with IH diagnosed in the early postoperative period (2-58 days) and 77.1% in a delayed fashion (187-1,109 days). A laparoscopic approach to the repair of IH was possible in 60.0% of patients. Complications occurred in 18.8% of patients, including one death (2.9%).

CONCLUSION

Complete closure of all mesenteric defects is strongly recommended during laparoscopic bariatric procedures to avoid IH and their associated complications.

Gastrointestinal complications of bariatric Roux-en-Y gastric bypass surgery

Obesity is rapidly becoming the most important public health issue in USA and Europe. Roux-en-Y gastric bypass is now established as the gold standard for treating intractable morbid or super obesity. We reviewed the imaging findings following this surgery in 234 patients. In this pictorial essay we present the CT and upper gastrointestinal contrast study appearances of the expected postoperative anatomy as well as a range of abdominal complications. The complications are classified into leaks, fistula and obstruction. Postoperative gastric outlet and small bowel obstruction can be caused by anastomotic stenosis, mesocolic tunnel stenosis, adhesions, stomal ulcer, obturation, intussusception and internal or external hernia. Small bowel obstruction may be of a simple, closed loop and/or strangulating type. The radiologist should be able to diagnose the type and possible cause of obstruction.

Sealing effect of fibrin glue on the healing of gastrointestinal anastomoses: implications for the endoscopic treatment of leaks

BACKGROUND

The adoption of advanced laparoscopic techniques for complex surgical procedures has raised the concern that the leak rate might be higher than for open surgery, particularly in the surgeon's early experience or in difficult cases. In this study, the sealing effect of fibrin glue on leaking gastrointestinal anastomoses was evaluated in an experimental swine model.

METHODS

A standardized gastrojejunostomy was performed on 20 female pigs (mean weight, 47.7 +/- 5.7 kg). A leak was created on the anterior surface of the anastomosis. The animals were randomized to either fibrin glue or no treatment of the leak. Clinical conditions and vital signs, including body temperature, heart rate and, respiratory rate, were collected three times a day. Preoperative and postoperative complete and differential blood count and lactate dehydrogenase levels were determined. Postmortem analysis was performed when the animals were killed.

RESULTS

Clinical signs of peritonitis developed in the control animals by the second or third postoperative day. Findings that confirmed the presence of an anastomotic leak at the postmortem examination were the presence of food or gastrojejunal juices in the abdominal cavity, a localized abscess, or a positive air leak test. Fibrin glue treatment prevented the development of peritonitis in all the animals. Complete sealing of the leak was observed on postoperative day 7 in all treated animals, except one in which an asymptomatic contained leak developed. The postoperative total white blood count was significantly increased in the untreated group (24.69 +/- 5.5 vs 12.74 +/- 3.7 10(3)/ul p < 0.001, paired t-test), as compared with the treated group (15. 55 +/- 2.4 vs 14.89 +/- 2.7 10(3)/ul; p = 0.24).

CONCLUSION

In this study, fibrin glue showed reproducible sealing effects on leaking gastrojejunal anastomoses. Fibrin glue application may be a valuable approach for the treatment of gastrointestinal anastomotic leaks.

Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients

OBJECTIVE

This study tested the hypothesis that weight-reduction (bariatric) surgery reduces long-term mortality in morbidly obese patients.

BACKGROUND

Obesity is a significant cause of morbidity and mortality. The impact of surgically induced, long-term weight loss on this mortality is unknown.

METHODS

We used an observational 2-cohort study. The treatment cohort (n = 1035) included patients having undergone bariatric surgery at the McGill University Health Centre between 1986 and 2002. The control group (n = 5746) included age- and gender-matched severely obese patients who had not undergone weight-reduction surgery identified from the Quebec provincial health insurance database. Subjects with medical conditions (other then morbid obesity) at cohort-inception into the study were excluded. The cohorts were followed for a maximum of 5 years from inception.

RESULTS

The cohorts were well matched for age, gender, and duration of follow-up. Bariatric surgery resulted in significant reduction in mean percent excess weight loss (67.1%, P < 0.001). Bariatric surgery patients had significant risk reductions for developing cardiovascular, cancer, endocrine, infectious, psychiatric, and mental disorders compared with controls, with the exception of hematologic (no difference) and digestive diseases (increased rates in the bariatric cohort). The mortality rate in the bariatric surgery cohort was 0.68% compared with 6.17% in controls (relative risk 0.11, 95% confidence interval 0.04-0.27), which translates to a reduction in the relative risk of death by 89%.

CONCLUSIONS

This study shows that weight-loss surgery significantly decreases overall mortality as well as the development of new health-related conditions in morbidly obese patients.

Medical and gastroenterologic management of the post-bariatric surgery patient

Morbid obesity is a serious disease resulting in considerable morbidity. Bariatric surgery is an important treatment modality of morbid obesity. It appears to be safe and effective in reduction of excess weight in carefully selected patients. However, it carries a risk of many short- and long-term complications, some of them unique to bariatric surgery. Knowledge of possible postoperative complications and their management will allow the achievement of the best results. Despite many types of bariatric procedures developed, only a few are currently performed. Since the number of bariatric procedures performed annually increases, primary care physicians and gastroenterologists will be increasingly challenged by post-bariatric surgery patients. Hence, better understanding of the anatomy and adaptive changes in bariatric patients allows for a more efficient evaluation and management of post-bariatric surgery problems. This article reviews common complications in post-bariatric surgery patients and provides guidelines for their evaluation and management.

A multidisciplinary approach to the adolescent bariatric surgical patient

PURPOSE

Pediatric obesity is an epidemic in the United States. As of yet, no surgical programs specifically dedicated to the management of clinically severely obese adolescents exist. The purpose of this report was to describe the establishment and early experience of a multidisciplinary Comprehensive Weight Management Center (CWMC) in a free-standing children's hospital.

METHODS

With input from an ethicist, gastroenterologist, pulmonologist, endocrinologist, and adolescent medicine physician, guidelines for patient selection, evaluation, and bariatric surgical management were developed and implemented. Roux-en-Y gastric bypass (RYGBP) surgery has been performed using open and laparoscopic techniques.

RESULTS

The average age and body mas index (BMI) for 79 patients referred to the CWMC has been 16 years and 54 kg/m2, for boys and 17 years and 51 kg/m2 for girls. Twenty-five percent have been considered appropriate for RYGBP, 25% have not met criteria for surgery, and 50% are being evaluated. Ten patients who have undergone RYGBP had comorbidities of their obesity, including type 2 diabetes mellitus (DM), obstructive sleep apnea syndrome (OSAS), pulmonary embolism, hypertension, dyslipidemias, and depression. Clinically significant weight loss with resolution of comorbidities has occurred in all patients. Significant complications have included leak from the gastric remnant, DVT, partial roux limb obstruction, and micronutrient deficiency.

CONCLUSIONS

RYGBP is an effective means to treat obesity-related morbidity in the adolescent. A multidisciplinary team of pediatric specialists is needed for optimal preoperative decision making and postoperative management. Results have been satisfactory and justify a clinical trial to confirm the safety and efficacy of bariatric surgery in the adolescent population.

Evolution of the laparoscopic gastric bypass

Obesity is recognized as a health problem of epidemic proportions. Surgical intervention for the treatment of obesity is a well-studied and effective method. Various procedures have been utilized over the past decades. Roux-en-Y gastric bypass has emerged over the last 20 years and is currently the most commonly offered surgical treatment. Within the last decade, advances in laparoscopic technology and surgical experience have allowed the application of laparoscopic techniques to the surgical treatment of obesity. Many centers and individuals have developed excellent techniques through experience over time as well as improvements in instrumentation. Hand-assisted laparoscopy was reported as a technique, but has mostly fallen out of favor. Currently, laparoscopic application of adjustable gastric band and laparoscopic Roux-en-Y gastric bypass are widely used throughout the United States. Data have been generated to demonstrate the improvement in surgical outcomes associated with minimally invasive surgical techniques for the surgical treatment of obesity. Further advances will allow continued improvement in patient outcomes utilizing a variety of minimally invasive surgical approaches to the treatment of this difficult disease.

The management of the obese diabetic patient

The prevalence of obesity and diabetes is increasing in the United States and worldwide. These diseases are predicted to explode to epidemic proportions, unless appropriate counteractive measures are taken. Several large studies (DCCT, UKPDS, Kumamoto) clearly showed that intensive glycemic control in the diabetic patient reduced microvascular complications and improved mortality. Despite this, the NHANES III showed that only 50% of diabetics have been able to achieve a HgbAic level that is less than 7%; this suggests the need for a re-evaluation of our approach to these patients. The management of the obese diabetic patient involves glycemic control and weight reduction. These goals are particularly difficult to achieve in the obese diabetic patient because progressive beta-cell dysfunction and increasing insulin resistance necessitates the administration of increasingly higher dosages of insulin, which, in turn, promotes weight gain. A vicious cycle may ensue. Lifestyle modifications with diet and exercise are an essential part of the management of the obese diabetic patient. These measures alone are often insufficient and concomitant pharmacologic therapy is usually required to achieve glycemic and weight control. Oral agents that improve glycemia, decrease insulin resistance, and limit weight gain are desirable. Because of the progressive nature of diabetes, glycemic control with monotherapy often deteriorates over time, which necessitates the addition of other pharmacologic agents, including insulin. When insulin therapy is required in the treatment of the obese diabetic patient, combinations with oral agents that have been shown to minimize the amount of exogenous insulin that is required, may minimize weight gain. In addition, the obese diabetic patient who is poorly controlled with maximum oral hypoglycemic therapy may benefit from weight-reducing agents, such as sibutramine or orlistat. The introduction of these agents at other points in the management of the obese diabetic patients have been successful. Finally, for the severely obese diabetic patient, bariatric surgery may be the only effective treatment. Gastric bypass has been unequivocally shown to produce significant weight loss and improve glycemic control on a long-term basis in the obese diabetic patient. It is recommended that physicians avail themselves of all of these strategies in the management of the obese patient who has type 2 diabetes.

Laparoscopic Roux-en-Y Gastric Bypass: Minimally Invasive Bariatric Surgery for the Superobese in the Community Hospital Setting

Roux-en-Y gastric bypass (RYGB) operation has become a popular choice for weight-reduction surgery. We report an outcome analysis of our early results with laparoscopic Roux-en-Y gastric bypass for superobese (BMI >50) patients. Between January 2000 and October 2001, we operated on 71 superobese patients. The mean body mass index (BMI) of patients at time of surgery was 57 kg/m2. The prospectively collected data included patient demographics, comorbidities, operative times, postoperative weight loss, and complications. Conversion to open gastric bypass was required in one patient. The overall complication rate was 10 per cent. Preoperative comorbidities were resolved or improved in 93 per cent of patients at 1-year postoperative. Average operative time and length of hospital stay were 196 minutes and 2.3 days, respectively. Mean percentage excess weight loss at 3, 6, 9, and 12 months was 27 per cent, 39 per cent, 49 per cent, and 55 per cent, respectively. Mean BMI decreased to 36 kg/m2 over a 12-month period. Laparoscopic Roux-en-Y gastric bypass surgery for superobese patients as performed in the community hospital setting can be both safe and effective with respect to overall postoperative course, early weight loss, and reduction of comorbidity.

Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Despite the proliferation of laparoscopic Roux-en-Y gastric bypass (LRYGBP), postoperative bowel obstructions still occur from mesocolonic constrictions, internal hernias, and anastomotic strictures. Obstructed patients do not present with a characteristic history and physical. Therefore, radiographic studies including upper gastrointestinal films and computed tomography are essential for diagnosing these unique obstructive etiologies after LRYGBP.

METHODS

From February 2000 to December 2000, 115 patients underwent standard LRYGBP at the Cleveland Clinic Foundation. Retrocolic anastomoses were performed on all patients. Defects at the mesocolon and mesomesentery were closed with interrupted, nonabsorbable sutures. All patients underwent upper gastrointestinal study on the first postoperative day.

RESULTS

Six patients developed small bowel obstructions postoperatively. Five of these patients required reexploration. The obstructive etiologies were two mesocolonic constrictions, three internal herniations, and one massive clot at the gastrojejunostomy. Repair of the mesocolonic constrictions involved incising the transverse mesocolon vertically to create a larger window for the Roux limb. Internal herniations were reduced, and defects were reclosed with nonabsorbable sutures. The patient with an obstructive clot was treated endoscopically.

CONCLUSIONS

Based on these 6 patients, we have altered our technique to antecolic placement of the Roux limb. This technique requires division of the omentum and additional mobilization of the Roux limb mesentery in order to decrease tension at the gastrojejunostomy. Since initiating these changes and closing all iatrogenic defects, we have not experienced further early small bowel obstructions.

Laparoscopic gastric bypass versus laparoscopic adjustable gastric banding

BACKGROUND

Indications for and results of laparoscopic adjustable gastric banding (LAGB) and laparoscopic gastric bypass (LGB) are still controversial, especially between Europe and the United States. The recent availability of gastric bandings in the United States made it necessary to compare the two techniques.

STUDY DESIGN

We compared a series of 456 LGB to a series of 805 LAGB performed in two different institutions. Body mass index (BMI), complication rate, mortality, and excess weight loss (EWL) after 3, 6, 12, and 18 months were obtained. A Fischer's exact test and a Student t test with covariance analysis were used for statistical analysis.

RESULTS

Results are expressed as a mean +/- standard deviation, comparing LGB with LAGB. Preoperative BMI was 49.4 +/- 8.3 kg/m(2) versus 42.2 +/- 4.9 kg/m(2) (p = 0.0001), respectively. Perioperative major complication rates were 2.0% versus 1.3% (NS), and the early postoperative major complication rates were 4.2% versus 1.7% (p = 0.02), respectively. Mortality rate was 0.4% versus 0% (NS), respectively. The global EWL was 36.3% for LGB versus 14.7% for LAGB at 3 months (p < 0.0001), 51.6% versus 21.9% at 6 months (p < 0.0001), 67.0% versus 33.3% at 12 months (p < 0.0001), and 74.6% versus 40.4% at 18 months (p < 0.0001), respectively. Longterm followup for the LAGB group showed an EWL of 47% at 2 years, 56% at 3 years, and 58% at 4 years. Patients were sorted after their preoperative BMI (30 to 40, 40 to 50, and 50 to 60 kg/m(2)). The EWL at 3, 6, 12, and 18 months was statistically superior in the LGB group, for any BMI ranges.

CONCLUSIONS

These data suggest that LGB provides a higher EWL at 18 months, compared with LAGB, and this was true for any preoperative BMI range. It is associated with a higher early postoperative complication rate.

Laparoscopic adjustable gastric banding for massive superobesity ( > 60 body mass index kg/m2)

Surgery for massive super obesity is a formidable challenge. No existing open or laparoscopic procedure reduces BMI below 30 from a starting point above 55. Laparoscopic adjustable gastric banding has been used to treat 76 massive super obese patients with a BMI > 60 kgs/m2. Median weight was 193 kgs +/-34.7 kgs (154-335 kgs). Five patients had a BMI > 100 kgs/m2. There was neither mortality nor pulmonary emboli. hospital stay was 3 days (1-6 days). Excess weight loss was 46.69 +/-10.5 at 1 year; 59.14 +/- 11.7% at 3 years and 61 +/- 15.1% at 5 years. At 2 years, 84% of the patients had greater than 50% excess weight loss and this was maintained at 3, 4, and 5 years. BMI fell from 69 +/- 6.2 to 49 +/- 7.73 at 1 year to 37 +/- 4.45 at 3 years and this was maintained at 4 and 5 years. BMI in 13 patients with > 5 year follow up was 35.09 +/- 53 kgs/m2 (27-44). Weight loss with laparoscopic adjustable gastric banding in this group of massive super obese patients has been similar to all other surgical techniques with reduction of BMI from 69 to 33 kgs/m2 at 3 years. The relative safety of the Lapband avoids bowel surgery in these very big patients, suggesting that laparoscopic adjustable gastric banding is a valid surgical approach to these difficult patients.

Factors associated with operative outcomes in laparoscopic gastric bypass

BACKGROUND

Laparoscopic gastric bypass (GBP) is becoming a common approach for treatment of morbid obesity. We analyzed preoperative factors that may be associated with operative outcomes in laparoscopic GBP.

STUDY DESIGN

This prospective study evaluates 150 consecutive laparoscopic GBP procedures performed by a single surgeon. Preoperative factors were grouped into three categories: 1) patient-specific (gender, age, abdominal surgical history, smoking), 2) obesity-specific (body mass index, hypertension, diabetes, sleep apnea), and 3) procedure-specific (operative experience of the surgeon [75 cases or less versus more than 75 cases]). Length of operation (240 minutes or less versus more than 240 minutes), postoperative complications (yes versus no), major complications (yes versus no), reoperation (yes versus no), and length of hospital stay (4 days or less versus more than 4 days) were the operative outcomes considered. In this series all patients who had a major complication required a reoperation. Data were analyzed using univariate and multiple logistic regression analyses.

RESULTS

Operative experience of surgeon (75 cases or less) was associated with lengthy operative time (adjusted odds ratio [AOR], 3.8; 95% confidence interval [CI], 1.7 to 8.3), major complications (AOR, 15.0; 95% CI, 1.5 to 143.0), and a lengthy (more than 4 days) hospital stay (AOR, 4.5; 95% CI, 1.1 to 18.0). Higher patient age (50 years or more) was associated with more postoperative complications (AOR, 11.4; 95% CI, 3.0 to 43.1) and major complications (AOR, 7.6; 95% CI, 1.1 to 48.7). Male gender also was associated with more postoperative complications (AOR 5.2; 95% CI, 1.1 to 23.1). Obesity-related comorbidities, body mass index, past abdominal surgical history, and smoking had no statistical association with operative outcomes in this study.

CONCLUSIONS

There is an association of clinical outcomes after laparoscopic GBP with the age and gender of the patient and the operative experience of the surgeon. An operative experience of more than 75 laparoscopic GBP cases was associated with decreases in operative time, length of hospital stay, and number of major complications.

Laparoscopic gastric banding

INTRODUCTION

Laparoscopic gastric banding (LGB) is currently the most popular purely restrictive bariatric operation in Europe and many other countries. It has a low operative morbidity, but is associated with a substantial late complication rate. Many late complications have been attributed to technical errors or to the learning curve. The aim of this paper is to present our results with gastric banding after the learning curve in order to disclose the true incidence of long-term complications.

METHODS

LGB was introduced in our department in December 1995. Thirty patients were operated on until June 1997 using the early banding technique (band within the lesser sac), at which time the surgical technique was slightly modified in order to place the band above the lesser sac. Then another 300 patients underwent LGB using either the Lapband or the SAGB system. This report focuses on the latter patients. All the data were collected prospectively.

RESULTS

The series includes 300 patients (257 women and 43 men) with a mean age of 38.3 years (19-64). The mean initial weight was 119.2 kg (57-179), initial body mass index (BMI) was 43.3 kg/m2 (21-64), and initial excess weight was 96.5% (0-191). The mean duration of surgery was 90 min, decreasing over time to a mean of 75 min for the last 50 cases. Early overall morbidity was 6.6%. Major complications occurred in 7 patients (2.3%). Excess weight loss (EWL) was at least 50% in 66% of the patients after 2 years, averaging 60%, with no substantial change until 4 years, and the BMI stabilized between 30 and 31 kg/m2. Forty-nine patients developed a total of 52 long-term complications, of which 23 (7.6%) were related only to the port or catheter. Band erosion occurred in 17 (5.6%), pouch dilatation with slippage in 8 (2.6%), and infection in 4 (1.3%) patients. Fifty-five reoperations were necessary. Twenty-five of these were related only to the port. The band was removed from 26 (9%) patients, of whom 17 were converted to Roux-en-Y gastric bypass.

CONCLUSIONS

LGB gives satisfactory results in terms of weight loss in about two-thirds of the patients. Even beyond the learning curve, the long-term morbidity is not negligible, but is acceptable compared to other procedures such as vertical banded gastroplasty. Conversion to gastric bypass is possible when complications occur and can be performed when the band is removed in most cases.

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.

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.

Effect of the Learning Curve on the Early Outcomes of Laparoscopic Roux-en-Y Gastric Bypass

Open gastric bypass has been demonstrated to provide durable weight loss in morbidly obese patients. As laparoscopic techniques have evolved surgeons are offering patients such an approach for performance of gastric bypass. The purpose of this study was to evaluate the relationship between increasing experience and outcome for this technically challenging operation. A retrospective analysis was performed on the initial 160 consecutive patients undergoing laparoscopic gastric bypass by a single surgeon over a 24-month period. Patients were divided into quartiles for data analysis. Duration of surgery decreased significantly between quartiles: 324 ± 124, 225 ± 70, 190 ± 47, and 168 ± 40 minutes, respectively ( P < 0.01). However, the conversion rate (3.1%) and mean hospital length of stay (2.1 ± 2.4 days) were unaffected by surgeon experience. The early and late postoperative complication rates were 9.4 and 3.1 per cent, respectively. Early complications included: leak (1.3%), bleeding (3.8%), obstruction (1.9%), acute gastric distention (0.6%), subphrenic abscess (0.6%), and wound infection (0.6%). Late complications include: obstruction (1.3%), anastomotic stricture (1.3%), and marginal ulcer (0.6%). The complication rates did not change statistically between quartiles. The excess weight loss at one year was 77.4 ± 16.7 per cent. These data suggest that throughout the learning curve laparoscopic gastric bypass can be accomplished with acceptable complication rates, conversion rates, and hospital length of stay. Duration of surgery improves with experience. Early weight loss results compare favorably with those of open gastric bypass.

Nutritional assessment and support during pregnancy

This article thoroughly updates the authors' previous review of nutritional assessment and support during pregnancy. After briefly reviewing nutrient metabolism and requirements, the authors discuss the nutritional assessment of the pregnant woman and review the nutritional support principles in hyperemesis gravidarum and other conditions that can compromise the nutritional health of mother or fetus.

Is it necessary to deflate the adjustable gastric band for subsequent operations?

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) is an effective method in the treatment of morbid obesity. However, it is unknown, whether deflating the gastric band before operations under general anesthesia is necessary to avoid complications such as nausea, vomiting, respiratory complications, and weight regain.

METHODS

Between January 1996 and June 2001, we performed LAGB on 408 patients at the University Hospital of Innsbruck. Of these patients, we identified 68 (16.7%) patients who were to undergo subsequent unrelated general, reconstructive, vascular, or orthopedic procedures. These patients were prospectively randomized into two groups: group 1 (n = 32) preoperative deflation of the adjustable band system and group 2 (n = 36) without preoperative deflation of the adjustable band system.

RESULTS

There were no anesthetic or perioperative band-related complications in either group 1 or group 2. There were two reoperations necessary due to surgical complications unrelated to the gastric band.

CONCLUSIONS

Operations after adjustable gastric banding can be safely performed without deflating the adjustable system.