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

Brazilian experience in obesity surgery robot-assisted

BACKGROUND

Minimally invasive techniques were associated with bariatric surgery, leading to a decrease in aggression to the organs and systems. Robotic surgery is a new possibility within the concept of minimal invasion.

AIM

To evaluate the initial experience of robotic surgery for obesity.

METHODS

Twenty seven patients were operated in the same hospital, by the same team with the same surgical system, Da Vinci S.

RESULTS

Were performed six gastric band placement , five sleeve gastrectomies and 16 gastric bypasses. There was one major complication and no death in this series.

CONCLUSIONS

The robotic surgery for obesity surgery was safe during the initial experience.

Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 10-year results of a prospective, randomized trial

BACKGROUND

There are few studies of long-term outcomes for either laparoscopic adjustable gastric banding (LAGB) or laparoscopic Roux-en-Y gastric bypass (LRYGB). The objective of this study was to compare outcomes of patients randomly assigned to undergo LAGB or LRYGB at 10 years.

METHODS

LAGB, using the pars flaccida technique, and standard LRYGB were performed. From January 2000 to November 2000, 51 patients (mean age 34.0 ± 8.9 years; range 20-49) were randomly allocated to undergo either LAGB (n = 27, 5 men and 22 women; mean age 33.3 years; mean weight 120 kg; mean body mass index [BMI] 43.4 kg/m(2)) or LRYGB (n = 24, 4 men and 20 women; mean age 34.7; mean weight 120 kg; mean BMI 43.8 kg/m(2)). Data on complications, reoperations, weight, BMI, percentage of excess weight loss, and co-morbidities were collected yearly. The data were analyzed using Student's t test and Fisher's exact test, with P<.05 considered significant.

RESULTS

Five patients in the LAGB group and 3 patients in the LRYGB group were lost to follow-up. No patient died. Conversion to laparotomy was performed in 1 (4.2%) of 24 LRYGB patients. Reoperations were required in 9 (40.9%) of 22 LAGB patients and in 6 (28.6%) of the 21 LRYGB patients. At 10-year follow-up, the LRYGB patients had a greater percentage of mean excess weight loss than did the LAGB patients (69±29% versus 46±27%; P = .03).

CONCLUSION

LRYGB was superior to LAGB in term of excess weight loss results (76.2% versus 46.2%) at 10 years. However, LRYGB exposes patients to higher early complication rates than LAGB (8.3% versus 0%) and potentially lethal long-term surgical complications (internal hernia and bowel obstruction rate: 4.7%).

What is the actual fate of super-morbid-obese patients who undergo laparoscopic sleeve gastrectomy as the first step of a two-stage weight-reduction operative strategy?

The overall success-rate of the two-stage treatment plan for the treatment of super-morbid obesity has not yet been assessed. We reviewed the long-term results of 41 treated super-morbid-obese patients. Mean initial BMI was 59.5 ± 3.5 kg/m(2). Twelve patients (29.3 %) achieved after only LSG a BMI <35 kg/m(2) (mean 31.9 ± 2). They have lost 78.7 ± 11.8 % of excess body weight (EBW). The remaining 28 patients lost 48.1 ± 11.9 % of EBW and achieved a mean BMI of 44.2 ± 4.3 kg/m(2), thus requiring the second stage. Ten of them (24.4 % of the total or 35.7 % of those in need), were submitted to laparoscopic Roux-en-Y gastric bypass (LRYGBP). They lost 71.9 ± 4.3 % of EBW and have a mean BMI of 33.6 ± 2.7 kg/m(2). The 18 remaining patients have a BMI of 42 ± 3.6 kg/m(2) and they still suffer from morbid obesity. They have lost 48.5 ± 8.7 % of EBW. The mean rate of EBW loss for all the available 39 patients after either LSG or both LSG and LRYGBP has been 63.2 ± 16.5 % after a mean follow-up of 42.8 ± 19.5 months. Out of 41 patients, 1 died, 1 was lost to follow-up, 21 (51.2 %) achieved "healthy" BMIs and 18 (44 %) still require LRYGBP. The rate of cure of morbid obesity was 51.2 %. A remaining 44 % of super-morbid obese patients still need the completion LRYGBP but have not undergone it. Half of these patients have lost >50 % of their EBW. The two-stage strategy is an effective treatment plan for super-morbid obesity. A less patient-dependent strategy may be needed for a subset of patients.

Laparoscopic surgery compared with open surgery decreases surgical site infection in obese patients: a systematic review and meta-analysis

OBJECTIVE

To compare surgical site infections rate in obese patients after laparoscopic surgery with open general abdominal surgery.

BACKGROUND

In mixed surgical populations, surgical site infections are fewer in laparoscopic surgery than in open surgery. It is not clear if this is also the case for obese patients, who have a higher risk of surgical site infections than nonobese patients.

METHODS

MEDLINE, Embase, and The Cochrane library (CENTRAL) were searched systematically for studies on laparoscopic surgery compared with open abdominal surgery. Randomized controlled trials (RCTs) and observational studies reporting surgical site infection in groups of obese patients (body mass index ≥ 30) were included. Separate meta-analyses with a fixed effects model for RCTs and a random effects model for observational studies were performed. Methodological quality of the included studies was assessed according to the Cochrane method and the Newcastle-Ottawa Scale.

RESULTS

Eight RCTs and 36 observational studies on bariatric and nonbariatric surgery were identified. Meta-analyses of RCTs and observational studies showed a significantly lower surgical site infection rate after laparoscopic surgery (OR = 0.19; 95% CI [0.08-0.45]; P = 0.0002 and OR = 0.33; 95% CI [0.26-0.42]; P = 0.00001). Sensitivity analyses to assess the impact of selection and detection bias confirmed the significant estimates with acceptable heterogeneity. No publication bias was present for the observational studies.

CONCLUSIONS

Laparoscopic surgery in obese patients reduces surgical site infection rate by 70%-80% compared with open surgery across general abdominal surgical procedures. Future efforts should be focused on further development of laparoscopic surgery for the growing obese population.

Quality of life after Roux-en-Y gastric bypass and changes in body mass index and obesity-related comorbidities

AIM

Dynamics of improvement in health-related quality of life (QoL) after bariatric surgery have never been fully assessed, and neither has the potential influence of body mass index (BMI) and comorbidity modification. The objective of this study was to investigate early and medium-term changes in QoL following Roux-en-Y gastric bypass (RYGB), and their relationship to BMI and comorbidity variations.

METHODS

A total of 71 obese subjects (80% women, mean age 42.1±11.2 years, mean baseline BMI 47.6±6.2kg/m(2)) undergoing RYGB filled in QoL questionnaires (SF-36) before and 3, 6 and 12 months after surgery. QoL was assessed using repeated-measures Anova, with associations between its changes and changes in BMI and comorbidities (diabetes, hypertension, dyslipidaemia, sleep apnoea, knee pain) assessed by mixed-effects models.

RESULTS

Physical QoL scales (physical component summary, PCS) significantly increased over time (from 38.9±9.3 to 52.6±7.9; P<0.001) as did other physical SF-36 scales (all P<0.001), whereas mental QoL summary scale did not vary significantly (from 45.7±9.5 to 48.6±11.5; P=0.072). Major changes in QoL occurred at 3 months after surgical intervention to reach values comparable to those in the general population. PCS was mostly associated with changes in either BMI or comorbidity status except for diabetes, dyslipidaemia and sleep apnoea.

CONCLUSION

Results show that improvements in physical QoL after RYGB are observed as early as 3 months after intervention, and are independently associated with weight loss and improvements in comorbidities.

Bariatric surgery as potential treatment for nonalcoholic fatty liver disease: a future treatment by choice or by chance?

Morbid obesity is strongly associated with nonalcoholic fatty liver disease (NAFLD) which is one of the most common causes of chronic liver disease worldwide. The current best treatment of NAFLD and NASH is weight reduction through life style modifications, antiobesity medication, and bariatric surgery. Importantly, bariatric surgery is the best alternative option for weight reduction if lifestyle modifications and pharmacological therapy have not yielded long-term success. Bariatric surgery is an effective treatment option for individuals who are grossly obese and associated with marked decrease in obesity-related morbidity and mortality. The most common performed bariatric surgery is Roux-en-Y gastric bypass (RYGB). The current evidence suggests that bariatric surgery in these patients will decrease the grade of steatosis, hepatic inflammation, and fibrosis. NAFLD per se is not an indication for bariatric surgery. Further research is urgently needed to determine (i) the benefit of bariatric surgery in NAFLD patients at high risk of developing liver cirrhosis (ii) the role of bariatric surgery in modulation of complications of NAFLD like diabetes and cardiovascular disease. The outcomes of the future research will determine whether bariatric surgery will be one of the recommended choice for treatment of the most progressive type of NAFLD.

How to train surgical residents to perform laparoscopic Roux-en-Y gastric bypass safely

BACKGROUND

As a result of increasing numbers of patients with morbid obesity there is a worldwide demand for bariatric surgeons. The Roux-en-Y gastric bypass, nowadays performed mostly laparoscopically (LRYGB), has been proven to be a highly effective surgical treatment for morbid obesity. This procedure is technically demanding and requires a long learning curve. Little is known about implementing these demanding techniques in the training of the surgical resident. The aim of this study was to evaluate the safety and feasibility of the introduction of LRYGB into the training of surgical residents.

METHODS

All patients who underwent LRYGB between March 2006 and July 2010 were retrospectively analyzed. The procedure was performed by a surgical resident under strict supervision of a bariatric surgeon (group I) or by a bariatric surgeon (group II). The primary end point was the occurrence of complications. Secondary end points included operative time, days of hospitalization, rate of readmission, and reappearance in the emergency department (ED) within 30 days.

RESULTS

A total of 409 patients were found eligible for inclusion in the study: 83 patients in group I and 326 in group II. There was a significant difference in operating time (129 min in group I vs. 116 min in group II; p < 0.001) and days of hospitalization. Postoperative complication rate, reappearance in the ED, and rate of readmission did not differ between the two groups.

CONCLUSIONS

Our data suggest that under stringent supervision and with sufficient laparoscopic practice, implementation of LRYGB as part of surgical training is safe and results in only a slightly longer operating time. Complication rates, days of hospitalization, and the rates of readmission and reappearance in the ED within 30 days were similar between the both groups. These results should be interpreted by remembering that all procedures in group I were performed in a training environment so occasional intervention by a bariatric surgeon, when necessary, was inevitable.

Obesity and kidney transplant candidates: how big is too big for transplantation?

Obesity impacts many inter-related, and sometimes conflicting, considerations for transplant practice. In this article, we describe an approach for applying available data on the importance of body composition to the kidney transplant population that separates implications for candidate selection, risk stratification among selected candidates, and interventions to optimize health of the individual. Transplant recipients with obesity defined by elevated body mass index (BMI) have been shown in many (but not all) studies to experience an array of adverse outcomes more commonly than normal-weight transplant recipients, including wound infections, delayed graft function, graft failure, cardiac disease, and increased costs. However, current studies have not defined limits of body composition that preclude clinical benefit from transplantation compared with long-term dialysis in patients who have passed a transplant evaluation. Formal cost-effectiveness studies are needed to determine if payers and society should be compensating centers for clinical and financial risks of transplanting obese end-stage renal disease patients. Recent studies also demonstrate the limitations of BMI alone as a measure of adiposity, and further research should be pursued to define practical measures of body composition that refine accuracy for outcomes prediction. Regarding individual management, observational registry studies have not found beneficial associations of pretransplant weight loss with patient or graft survival. However, association studies cannot distinguish purposeful from unintentional weight loss as a result of illness and comorbidity. Prospective evaluations of the impact of targeted risk modification efforts in this population including dietary changes, monitored exercise programs, and bariatric surgery are urgently needed.

Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy is gaining popularity in the US; however, there has been no study examining the use of sleeve gastrectomy at a national level and its impact on the use of other bariatric operations. The aim of this study was to examine contemporary changes in use and outcomes of bariatric surgery performed at academic medical centers.

METHODS

Using ICD-9 diagnosis and procedure codes, clinical data obtained from the University HealthSystem Consortium database for all bariatric procedures performed for the treatment of morbid obesity between October 1, 2008 and September 30, 2012 were reviewed. Quartile trends in use for the 3 most commonly performed bariatric operations were examined, and a comparison of perioperative outcomes between procedures was performed within a subset of patients with minor severity of illness.

RESULTS

A total of 60,738 bariatric procedures were examined. In 2008, the makeup of bariatric surgery consisted primarily of gastric bypass (66.8% laparoscopic, 8.6% open), followed by laparoscopic gastric banding (23.8%). In 2012, there was a precipitous increase in use of laparoscopic sleeve gastrectomy (36.3 %), with a concurrent reduction in the use of laparoscopic (56.4%) and open (3.2%) gastric bypass, and a major reduction in laparoscopic gastric banding (4.1%). The length of hospital stay, in-hospital morbidity and mortality, and costs for laparoscopic sleeve gastrectomy were found to be between those of laparoscopic gastric banding and laparoscopic gastric bypass.

CONCLUSIONS

Within the context of academic medical centers, there has been a recent change in the makeup of bariatric surgery. There has been an increase in the use of laparoscopic sleeve gastrectomy, which has had an impact primarily on reducing the use of laparoscopic adjustable gastric banding.

Perioperative morbi-mortality associated with bariatric surgery: from systematic biliopancreatic diversion to a tailored laparoscopic gastric bypass or sleeve gastrectomy approach

BACKGROUND

The effectiveness and safety of the different bariatric surgical procedures currently available depend, partly, on the characteristics of the populations under study, the technical approach, the expertise of surgical teams, and on institutional factors. To evaluate the effectiveness and safety of these procedures, we compared the surgical results for biliopancreatic diversion surgery versus laparoscopic gastric bypass and sleeve gastrectomies performed in our institution.

METHODS

This was a retrospective observational study of 296 patients undergoing bariatric surgery from January 2005 through October 2010. We analyzed mortality rate, cardiocirculatory and pulmonary perioperative complications, duration of surgery, intensive care unit admissions, and length of stay. We describe the changes in the choice of the surgical procedures throughout the study period.

RESULTS

We observed a rate of pulmonary complications of 2.3 % and a mortality rate 3 months after discharge of 2.36 % with sepsis secondary to anastomotic leak as the main cause of death. Biliopancreatic diversion surgery was associated with higher mortality rates (p value = 0.014) and longer hospital stay (median of 9 versus 6 days for laparoscopic gastric bypass and sleeve gastrectomy, p value <0.001). Body mass index ≥ 50 was also related to higher mortality (p value = 0.023). We confirmed a progressive increase in laparoscopic restrictive and mixed techniques in our institution (from 0 % in 2005 to 87 % of all procedures in 2010).

CONCLUSIONS

Bariatric surgery in our institution has dramatically shifted from systematic biliopancreatic diversion to a tailored laparoscopic gastric bypass or sleeve gastrectomy approach, which has made it possible to reduce hospital stay and mortality rates.

Comparison of thoracic and abdominal cavity volumes during abdominal CO2 insufflation and abdominal wall lift

OBJECTIVE

To compare thoracic and abdominal cavity volumes during abdominal CO2 insufflation and abdominal wall lift (AWL) conditions.

STUDY DESIGN

In vitro cadaveric study.

ANIMALS

Mature medium-to-large breed fresh canine cadavers (n = 6).

METHODS

Each cadaver was imaged with computed tomography (CT) under baseline, abdominal CO2 insufflation, and AWL conditions. Measurements of thoracic and abdominal cavities were performed for each condition using image-analyzing software. Resulting volumes for each cadaver were converted to percent change from baseline to normalize the data. The t-tests were used to compare percent changes of both thoracic and abdominal volumes.

RESULTS

Thoracic volume significantly decreased from baseline during CO2 insufflation (P < .01). No significant difference in thoracic volume occurred with AWL when compared with baseline. Abdominal volume increased by 80% with CO2 insufflation (95% CI: 56.4-107.0%) but only 25% with AWL (95% CI: 12.3-37.8%).

CONCLUSIONS

Abdominal CO2 insufflation results in decreased thoracic volume when compared with baseline. AWL preserved thoracic volume similar to baseline. Abdominal volumes achieved with abdominal CO2 insufflation are significantly greater than those attained with AWL.

Cost-effectiveness analysis of cholecystectomy during Roux-en-Y gastric bypass for morbid obesity

BACKGROUND

Controversy exists regarding the use of concurrent cholecystectomy during Roux-en-Y gastric bypass performed for morbid obesity.

METHODS

A decision model was developed to evaluate the cost-effectiveness of current strategies: routine concurrent cholecystectomy, Roux-en-Y gastric bypass alone with or without postoperative ursodiol therapy, and selective cholecystectomy based on preoperative findings on ultrasonography. Probabilities were obtained from a comprehensive literature review. Costs and hospital days were obtained from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. One-way sensitivity analyses were performed.

RESULTS

The least expensive strategy was to perform RYGB alone without preoperative ultrasonography, with an average cost (over RYGB costs) of $537 per patient. RYGB with concurrent cholecystectomy had a cost of $631. Selective cholecystectomy based on preoperative ultrasonography was dominated by the other 2 strategies. Our model was most sensitive to the probability of developing gallbladder-related symptoms after RYGB alone. When the incidence of gallbladder-related symptoms was <4.6%, the dominant strategy was to perform a RYGB alone without preoperative ultrasonography. For values >6.9%, performing concurrent cholecystectomy at the time of the RYGB was superior to other strategies. When ursodiol was used, the least expensive strategy was to perform a concurrent cholecystectomy during RYGB.

CONCLUSION

The main factor determining the most cost-effective strategy is the incidence of gallbladder-related symptoms after RYGB. The use of ursodiol was associated with an increase in cost that does not justify its use after RYGB. Finally, selective cholecystectomy based on preoperative ultrasonography was dominated by the other strategies in the scenarios evaluated.

Quick fix or long-term cure? Pros and cons of bariatric surgery

The past decade has seen an enormous increase in the number of bariatric, or weight loss, operations performed. This trend is likely to continue, mirroring the epidemic of obesity around the world and its rising prevalence among children. Bariatric surgery is considered by many to be the most effective treatment for obesity in terms of maintenance of long-term weight loss and improvement in obesity-related comorbid conditions. Although overly simplified, the primary mechanisms of the surgical interventions currently utilized to treat obesity are the creation of a restrictive or malabsorptive bowel anatomy. Operations based on these mechanisms include the laparoscopic adjustable gastric band and laparoscopic vertical sleeve gastrectomy (considered primarily restrictive operations), the laparoscopic biliopancreatic diversion with or without a duodenal switch (primarily malabsorptive operation), and the laparoscopic Roux-en-Y gastric bypass (considered a combination restrictive and selective malabsorptive procedure). Each operation has pros and cons. Important considerations, for the patient and surgeon alike, in the decision to proceed with bariatric surgery include the technical aspects of the operation, postoperative complications including long-term nutritional problems, magnitude of initial and sustained weight loss desired, and correction of obesity-related comorbidities. Herein, the pros and cons of the contemporary laparoscopic bariatric operations are reviewed and ongoing controversies relating to bariatric surgery are discussed: appropriate patient selection, appropriate operation selection for an individual patient, surgeon selection, and how to measure success after surgery.

Criteria for Patient Selection and Multidisciplinary Evaluation and Treatment of the Weight Loss Surgery Patient

OBJECTIVE

To provide evidence-based guidelines for patient selection and to recommend the medical and nutritional aspects of multidisciplinary care required to minimize perioperative and postoperative risks in patients with severe obesity who undergo weight loss surgery (WLS).

RESEARCH METHODS AND PROCEDURES

Members of the Multidisciplinary Care Task Group conducted searches of MEDLINE and PubMed for articles related to WLS in general and medical and nutritional care in particular. Pertinent abstracts and literature were reviewed for references. Multiple searches were carried out for various aspects of multidisciplinary care published between 1980 and 2004. A total of 3000 abstracts were identified; 242 were reviewed in detail.

RESULTS

We recommended multidisciplinary screening of WLS patients to ensure appropriate selection; preoperative assessment for cardiovascular, pulmonary, gastrointestinal, endocrine, and other obesity-related diseases associated with increased risk for complications or mortality; preoperative weight loss and cessation of smoking; perioperative prophylaxis for deep vein thrombosis and pulmonary embolism (PE); preoperative and postoperative education and counseling by a registered dietitian; and a well-defined postsurgical diet progression.

DISCUSSION

Obesity-related diseases are often undiagnosed before WLS, putting patients at increased risk for complications and/or early mortality. Multidisciplinary assessment and care to minimize short- and long-term risks include: comprehensive medical screening; appropriate pre-, peri-, and postoperative preparation; collaboration with multiple patient care disciplines (e.g., anesthesiology, pulmonary medicine, cardiology, and psychology); and long-term nutrition education/counseling.

Coding and Reimbursement for Weight Loss Surgery: Best Practice Recommendations

OBJECTIVE

To review the use and usefulness of billing codes for services related to weight loss surgery (WLS) and to examine third party reimbursement policies for these services.

RESEARCH METHODS AND PROCEDURES

The Task Group carried out a systematic search of MEDLINE, the Internet, and the trade press for publications on WLS, coding, reimbursement, and coding and reimbursement policy. Twenty-eight articles were each reviewed and graded using a system based on established evidence-based models. The Massachusetts Dietetics Association provided reimbursement data for nutrition services. Three suppliers of laparoscopic WLS equipment provided summaries of coding and reimbursement information. WLS program directors were surveyed for information on use of procedure codes related to WLS.

RESULTS

Recommendations focused on correcting or improving on the current lack of congruity among coding practices, reimbursement policies, and accepted clinical practice; lack of uniform coding and reimbursement data across institutions; inconsistent and/or inaccurate diagnostic and billing codes; inconsistent insurance reimbursement criteria; and inability to leverage reimbursement and coding data to track outcomes, identify best practices, and perform accurate risk-benefit analyses.

DISCUSSION

Rapid changes in the prevalence of obesity, our understanding of its clinical impact, and the technologies for surgical treatment have yet to be adequately reflected in coding, coverage, and reimbursement policies. Issues identified as key to effective change include improved characterization of the risks, benefits, and costs of WLS; anticipation and monitoring of technological advances; encouragement of consistent patterns of insurance coverage; and promotion of billing codes for WLS procedures that facilitate accurate tracking of clinical use and outcomes.

Laparoscopic sleeve gastrectomy versus laparoscopic adjustable gastric banding for the treatment severe obesity in high risk patients

Laparoscopic sleeve gastrectomy was found to improve short-term total weight loss; however, it was associated with prolonged operative time, blood loss, and hospital stay compared with laparoscopic adjustable gastric banding.

Background:

Laparoscopic sleeve gastrectomy (LSG) has emerged as an alternative restrictive bariatric procedure to the most popular laparoscopic adjustable gastric banding (LAGB). We analyze and compare the clinical and weight loss outcomes of LSG versus LAGB for the treatment of severe obesity in high-risk patients.

Methods:

Forty severely obese veterans (20/group) received either LSG or LAGB and were followed prospectively for 2 years. Outcome measures included operating room (OR) time, estimated blood loss (EBL), length of hospital stay (LOS), morbidity, mortality, reoperations, readmission rates, and weight loss over time.

Results:

The cohort primarily comprised high-risk and older male veterans. Patient's baseline demographics were similar between groups. LSG was associated with prolonged OR time (116±31 vs. 94±28min), higher EBL (34±28 vs. 17±19mL), and LOS (2±.9 vs. 1±.4days) when compared with LAGB. Minor morbidity and readmissions were similar between groups, while no major morbidity, reoperations, or mortality occurred. Total weight and BMI decreased significantly after surgery in both groups (LSG: 302±52 to 237lbs and 45±5 to 36±5kg/m² vs. LAGB: 280±36 to 231±29lbs and 43±5 to 36±5kg/m², respectively). Total weight loss was superior in the LSG vs. LAGB group at 2 years (TWL=65±24 vs. 49±28 lbs (P=.03); %EWL=51±20 vs. 46±23%; %EBMI loss=48±22 vs. 45±23%, and %BWL = 21±8 vs. 17±9%, respectively).

Conclusion:

In severely obese and high-risk patients, laparoscopic sleeve gastrectomy provides superior total weight loss at 2 years.

Use of laparoscopy in general surgical operations at academic centers

BACKGROUND

Laparoscopy is commonly being used in many different types of general surgical procedures. The aim of the present study was to examine the use of laparoscopy and perioperative outcomes in 7 general surgical operations commonly performed at U.S. academic medical centers.

METHODS

The clinical data of patients who underwent 1 of the 7 general surgical operations from 2008 to 2012 were obtained from the University HealthSystem Consortium database. The University HealthSystem Consortium database contains data from all major teaching hospitals in the United States. The 7 analyzed operations included only elective, inpatient procedures (except for appendectomy): open and laparoscopic antireflux surgery for gastroesophageal reflux, colectomy for colon cancer or diverticulitis, bariatric surgery for morbid obesity, ventral hernia repair for incisional hernia, appendectomy for acute appendicitis, rectal resection for rectal cancer, and cholecystectomy for cholelithiasis. The outcome measures included the number of procedures, rate of laparoscopy, rate of conversion to laparotomy, and in-hospital mortality.

RESULTS

During the 3.5-year period, 53,958 patients underwent bariatric surgery, 13,918 patients underwent antireflux surgery, 8654 patients underwent appendectomy, 8512 patients underwent cholecystectomy, 29,934 patients underwent colectomy, 17,746 patients underwent ventral hernia repair, and 4729 patients underwent rectal resection. The present rate of laparoscopic use was 94.0% for bariatric surgery, 83.7% for antireflux surgery, 79.2% for appendectomy, 77.1% for cholecystectomy, 52.4% for colectomy, 28.1% for ventral hernia repair, and 18.3% for rectal resection. In-hospital mortality was greatest for colorectal resection (.38%-.58%). In-hospital mortality for bariatric surgery (.06%) was comparable to that for appendectomy (.01%), cholecystectomy (.27%), antireflux surgery (.15%), and ventral hernia repair (.20%). The rate of laparoscopic conversion to open surgery was lowest for bariatric surgery (.89%) and greatest for rectal resection (16.4%).

CONCLUSION

Within the context of academic centers and elective, inpatient procedures, bariatric surgery had the greatest use of laparoscopy and the lowest rate of laparoscopic conversion to open surgery. The mortality for laparoscopic bariatric surgery is now comparable to that of laparoscopic cholecystectomy, ventral hernia repair, appendectomy, and antireflux surgery.

[Advances in bariatric surgery: from the open approach to the biliopancreatic bypass with laparoscopic gastric preservation. Twelve years of experience]

INTRODUCTION

An analysis is presented of the results in the treatment of morbid obesity after 12 years experience.

MATERIAL AND METHODS

A retrospective study of patients subjected to surgery for morbid obesity from July 1998 to April 2010. Open techniques were initially used, and from January 2005 using biliopancreatic bypass with gastric diversion by a laparoscopic approach.

RESULTS

A total of 165 patients have been subjected to surgery, 65 with open surgery (gastric bypass and Scopinaro), and 100 laparoscopic. The mean age was 40 years, with 74% females. The mean BMI was 48.6±6 kg/m(2), with 35% super-obese. The mean hospital stay was 7 days, with a morbidity of 26% (43 patients). Seven patients required further surgery, and 2 patients died. There was 99.4% follow-up during a median period of 46 months (1 to 141). There were complications of the gastro-jejunostomy in 17 patients. Seven patients required further surgery due to transmesenteric hernias. The rate of overweight lost was 67% (95% CI: 65-72%), 68% (95% CI: 65-72%) and 68% (95% CI: 63-73%) at 12, 36 and 60 months, respectively. The rate of excess BMI lost was 73% (95% CI: 70-76%), 74% (95% CI: 70-79%) and 74% (95% CI: 68-69%) at 12, 36 and 60 months, respectively. Comparing both approaches, there were more post-operative complications, longer hospital stays, and more incisional hernias in the open approach, with no significant differences found in the rest of the parameters analysed.

CONCLUSION

Our long-term results are within those classified as excellent, with acceptable morbidity and mortality. A great advance has been observed in the laparoscopic approach due to the less aggressive surgery, and maintaining an excellent weight loss.

Surgical Management of Malignant Bowel Obstruction: At What Price Palliation?

Several options exist to palliate malignant obstruction (MBO), none of which have established consensus among surgeons. The purpose of this study was to establish outcomes of diverting stoma (DS), internal bypass (IB), and palliative resection (PR) for a tertiary academic referral surgical oncology service. All patients presenting to a surgical oncology service with malignant bowel obstruction over a 3-year period were identified. Records were reviewed to determine success of diversion, bypass, or resection and associated cost, length of stay (LOS), morbidity, and mortality. Forty-three patients undergoing palliative surgery were identified. The success of each approach was 80, 78, and 63 per cent for diversion, bypass, and resection, respectively. Major morbidity (63%), mortality (16%), and LOS (26 days) were greatest in those undergoing PR, but so was survival (8.4 months). DS and IB had comparable morbidity (40 and 33%), mortality (10 and 0%), and LOS (25 and 21 days), but survival was shorter for DS (5.3 vs 6.5 months). Cost of PR was significantly greater ($79,000) than both DS ($36,000) and IB ($51,000). Escalation in complexity of palliative measures for MBO results in improved survival but at significant cost both economically and physiologically. Quality of life should be discussed with patients when deciding how best to palliate their symptoms.

Clinical outcomes after bariatric surgery: a five-year matched cohort analysis in seven US states

BACKGROUND

Bariatric surgery is the most effective weight loss treatment, yet few studies have reported on short- and long-term outcomes postsurgery.

METHODS

Using claims data from seven Blue Cross/Blue Shield health plans serving seven states, we conducted a non-concurrent, matched cohort study. We followed 22,693 persons who underwent bariatric surgery during 2003-2007 and were enrolled at least 6 months before and after surgery. Using logistic regression, we compared serious and less serious adverse clinical outcomes, hospitalizations, planned procedures, and obesity-related co-morbidities between groups for up to 5 years.

RESULTS

Relative to controls, surgery patients were more likely to experience a serious [odds ratio (OR) 1.9; 95% confidence interval (CI) 1.8-2.0] or less serious (OR 2.5, CI 2.4-2.7) adverse clinical outcome or hospitalization (OR 1.3, CI 1.3-1.4) at 1 year postsurgery. The risk remained elevated until 4 years postsurgery for serious events and 5 years for less serious outcomes and hospitalizations. Some complication rates were lower for patients undergoing laparoscopic surgery. Planned procedures, such as skin reduction, peaked in postsurgery year 2 but remained elevated through year 5. Surgery patients had a 55% decreased risk of obesity-related co-morbidities, such as type 2 diabetes, in the first year postsurgery, which remained low throughout the study (year 5: OR 0.4, CI 0.4-0.5).

CONCLUSIONS

While bariatric surgery is associated with a higher risk of adverse clinical outcomes compared to controls, it also substantially decreased obesity-related co-morbidities during the 5-year follow-up.

Simulation-based training and learning curves in laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Ex vivo simulation-based technical skills training has been shown to improve operating room performance and shorten learning curves for basic laparoscopic procedures. The application of such training for laparoscopic Roux-en-Y gastric bypass (LRYGBP) has not been reviewed.

METHODS

Relevant studies were identified by one author from a search of MEDLINE and Embase databases from 1 January 1994 to 30 November 2010. Studies examining the learning curves and ex vivo training methods for LRYGBP were included; all other types of bariatric operations were excluded. A manual search of the references was also performed to identify additional potentially relevant papers.

RESULTS

Twelve studies (5 prospective and 7 retrospective case series) were selected for review. The learning curve for LRYGBP was reported to be 50-100 procedures. Bench-top laparoscopic jejunojejunostomy, anaesthetized animals and Thiel human cadavers made up the bulk of the reported models for ex vivo training. Most studies were of relatively poor quality. An evidence-based ex vivo training curriculum for LRYGBP is currently lacking.

CONCLUSION

Better quality studies are needed to define the learning curve for LRYGBP. Future studies should focus on the design and validation of training models, and a comprehensive curriculum for training and assessment of cognitive, technical and non-technical components of competency for laparoscopic bariatric surgery.

Surgical resident participation in laparoscopic Roux-en-Y bypass: Is it safe?

BACKGROUND

The majority of bariatric surgeons use dedicated surgical assistants when performing laparoscopic Roux-en-Y gastric bypass (LGBP) because of the technical difficulty and steep learning curve involved in the operation. At our institution, either a senior surgical resident (SSR) or a physician assistant (PA) participates in LGBP cases. The PA's role is confined to assisting, whereas the SSR progressively acts as the operating surgeon. We were interested in evaluating patient outcomes to determine whether any differences existed between the LGBP operations in which either the PA or the SSR participated.

METHODS

All patients undergoing LGBP between January 2007 and December 2009 in our prospectively collected bariatric database were reviewed. Demographics, baseline measures, intraoperative parameters, and outcomes were compared.

RESULTS

A total of 711 patients were identified. The group involving PAs included 343 patients, and the group involving SSRs included 368 patients. Preoperative comorbidities, including diabetes, hypertension, coronary artery disease, asthma, sleep apnea, hyperlipidemia, musculoskeletal disability, and depression, were similar in both groups. Personal histories of venous thromboembolism were higher in the PA group (5.1% vs 2.5%; P = .075). The mean body-mass indexes (BMI) (53 ± 9 vs 51 ± 8 kg/m(2); P = .006) and weights (323 ± 67 vs 306 ± 59 lbs; P < .001) in the PA group were significantly higher than in the SSR group. The proportion of males was higher in the PA group (24% vs 16%; P = .008). The operative time was significantly shorter in the PA group (121 ± 36 vs 164 ± 30 minutes; P < .001). There was no significant difference between the groups in intraoperative complications, length of hospital stay, 30-day complications, or reoperations within 1 year. There were no mortalities in either group. The 1-year percent excess weight loss (64% vs 66%) was similar in the PA and SSR groups, respectively.

CONCLUSION

SSR participation in LGBP prolongs operative time but does not increase complications, mortality rates, or length of stay. Therefore, SSR participation in LGBP is safe and produces outcomes comparable to those performed with PAs.

Utility of routine versus selective upper gastrointestinal series to detect anastomotic leaks after laparoscopic gastric bypass

BACKGROUND

In up to 4% of laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures, anastomotic leaks occur. Early detection of gastrointestinal leakage is important for successful treatment. Consequently, many centers advocate routine postoperative upper gastrointestinal (UGI) series. The aim of this study was to determine the utility of this practice after LRYGB.

METHODS

Eight hundred four consecutive patients undergoing LRYGB from June 2000 to April 2010 were analyzed prospectively. The first 382 patients received routine UGI series between the third and fifth postoperative days (group A). Thereafter, the test was only performed when clinical findings (tachycardia, fever, and drainage content) were suspicious for a leak of the gastrointestinal anastomosis (group B; n = 422).

RESULTS

Overall, nine of 804 (1.1%) patients suffered from leaks at the gastroenterostomy. In group A, four of 382 (1%) patients had a leak, but only two were detected by the routine UGI series. This corresponds to a sensitivity of 50%. In group B, the sensitivity was higher with 80%. Specificities were comparable with 97% and 91%, respectively. Routine UGI series cost only 1.6% of the overall costs of a non-complicated gastric bypass procedure. With this leak rate and sensitivity, US $86,800 would have to be spent on 200 routine UGI series to find one leak which is not justified.

CONCLUSIONS

This study shows that routine UGI series have a low sensitivity for the detection of anastomotic leaks after LRYGB. In most cases, the diagnosis is initiated by clinical findings. Therefore, routine upper gastrointestinal series are of limited value for the diagnosis of a leak.

Is bariatric surgery safe in patients who refuse blood transfusion?

BACKGROUND

A small, but significant, number of patients undergoing bariatric surgery refuse blood transfusion for religious or other personal reasons. Jehovah's Witnesses number more than 1 million members in the United States alone. The reported rates of hemorrhage vary from .5% to 4% after bariatric surgery, with transfusion required in one half of these cases. Pharmacologic prophylaxis against venous thromboembolism could further increase the perioperative bleeding risk. Our objective was to report the perioperative outcomes of bariatric surgery who refuse blood transfusion at a bariatric center of excellence, private practice in the United States.

METHODS

A retrospective review of all patients who refused blood transfusion when undergoing bariatric surgery during a 10-year period was conducted. Patients were identified from a prospectively maintained database by the bloodless surgery program at Legacy Good Samaritan Hospital. Data were collected on demographics, co-morbidities, laboratory values, medication use, blood loss, and 30-day complications.

RESULTS

Thirty-five bloodless surgery patients underwent bariatric surgery from 2000 to 2009. Of these 35 patients, 21 underwent laparoscopic adjustable gastric banding and 14 Roux-en-Y gastric bypass. Before 2006, only pneumatic compression devices were applied for venous thromboembolism prophylaxis (n = 6). Subsequently, combination venous thromboembolism prophylaxis was performed with fondaparinux sodium 2.5 mg for RYGB or enoxaparin 40 mg for LAGB (n = 29). One RYGB patient developed postoperative hemorrhage requiring reoperation. No venous thromboembolisms or deaths occurred.

CONCLUSION

Bariatric surgery can be performed in patients who refuse blood transfusion with acceptable postoperative morbidity. Larger studies are necessary to confirm the safety of this approach and to examine the effect of pharmacologic thromboprophylaxis in this patient group.

Six-year changes in health-related quality of life in gastric bypass patients versus obese comparison groups

BACKGROUND

Few studies have evaluated the long-term outcomes of bariatric surgery patients in relation to obese individuals not participating in weight loss interventions. Our objective was to evaluate the 6-year changes in health-related quality of life (HRQOL) in gastric bypass (GB) patients versus 2 obese groups not undergoing surgical weight loss. The study setting was a bariatric surgery practice.

METHODS

A total of 323 GB patients were compared with 257 individuals who sought but did not undergo gastric bypass and 272 population-based obese individuals using weight-specific (impact of weight on quality of life-lite) and general (medical outcomes study short-form 36 health survey) HRQOL questionnaires at baseline and 2 and 6 years later.

RESULTS

At 6 years, compared with the controls, the GB group exhibited significant improvements in all domains of weight-specific and most domains of general HRQOL (i.e., all physical and some mental/psychosocial). The 6-year percentage of excess weight loss correlated significantly with improvements in both weight-specific and physical HRQOL. The HRQOL scores were fairly stable from 2 to 6 years for the GB group, with small decreases in HRQOL corresponding to some weight regain.

CONCLUSIONS

GB patients demonstrated significant improvements in most aspects of HRQOL at 6 years compared with 2 nonsurgical obese groups. Despite some weight regain and small decreases in HRQOL from 2 to 6 years postoperatively, the HRQOL was relatively stable. These results support the effectiveness of weight loss achieved with gastric bypass surgery for improving and maintaining long-term HRQOL.

Influence of reoperations on long-term quality of life after restrictive procedures: a prospective study

Quality of life improves after bariatric surgery. However, long-term results and the influence of reoperations are not well known. A prospective quality of life assessment before, 1 and 7 years after laparoscopic adjustable gastric banding (LAGB) and vertical banded gastroplasty (VBG) was performed in order to determine the influence of reoperations during follow-up. One hundred patients were included in the study. Fifty patients underwent VBG and 50 LAGB. Patients completed the quality of life questionnaires prior to surgery and two times during follow-up. Health-related quality of life (HRQoL) questionnaires included the Nottingham Health Profile I and II and the Sickness Impact Profile 68. Follow-up was 84% with a mean duration of 84 months (7 years). During follow-up, 65% of VBG patients underwent conversion to Roux-en-Y gastric bypass while 44% of LAGB patients underwent a reoperation or conversion. One year after the procedure, nearly all quality-of-life parameters significantly improved. After 7 years, the Nottingham Health Profile (NHP)-I domain “physical ability”, the NHP-II and the SIP-68 domains “mobility control”, “social behavior”, and “mobility range” were still significantly improved in both groups. The domains “emotional reaction”, “social isolation” (NHP-I), and “emotional stability” (SIP-68) remained significantly improved in the VBG group while this was true for the domain “energy level” (NHP-I) in the LAGB group. Both the type of procedure and reoperations during follow-up were not of significant influence on the HRQoL results. Weight loss and decrease in comorbidities were the only significant factors influencing quality of life. Restrictive bariatric surgery improves quality of life. Although results are most impressive 1 year after surgery, the improvement remains significant after long-term follow-up. Postoperative quality of life is mainly dependent on weight loss and decrease in comorbidities and not on the type of procedure or surgical complications.

Surgical treatment for morbid obesity: the laparoscopic Roux-en-Y gastric bypass

Over the past 20 years bariatric surgery proved to be a valid treatment for reduction and elimination of obesity-related diseases and long-term sustainable weight loss. Minimally invasive or laparoscopic techniques such as laparoscopic Roux-en-Y (LRNY) have replaced open procedures. Many factors play important roles in the small intricacies and variations of the procedure, chief of which is the creation and size of the gastrojejunostomy. Regardless of the variations in technique, the LRNY remains the gold standard for the surgical treatment of clinically severe or morbid obesity, with relatively low morbidity and mortality.

Complications of laparoscopic Roux-en-Y gastric bypass

Despite the well-documented safety of laparoscopic RYGB, several short-term and long-term complications, with varying degrees of morbidity and mortality risk, are known to occur. Bariatric surgeons, all too familiar with these complications, should be knowledgeable in risk-reduction strategies to minimize the incidence of complication occurrence and recurrence. Bariatric and nonbariatric surgeons who evaluate and treat abdominal pain should be familiar with these complications to facilitate early recognition and intervention, thereby minimizing the associated morbidity and mortality.

Comparison of outcomes and costs between laparoscopic distal pancreatectomy and open resection at a single center

BACKGROUND

The cost implications of laparoscopic distal pancreatectomy (LDP) and a detailed breakdown of hospital expenditures has not been presented in the literature to date. This study aimed to compare hospital costs and short-term clinical outcomes between LDP and open distal pancreatectomy (ODP).

METHODS

The authors evaluated all the distal pancreatic resections performed at their center between January 2004 and March 2010. Parametric and nonparametric statistical analysis was used to compare hospital departmental and total hospital costs as well as oncologic and surgical outcomes.

RESULTS

A total of 118 cases (42 laparoscopic resections, including 5 conversions, and 76 open resections) were analyzed. The demographic characteristics were similar between the groups except for a predominance of females in the laparoscopic group (P = 0.036). The indications for surgery differed by a paucity of malignant tumors being approached laparoscopically (P < 0.001). Intraoperatively, there were no differences in estimated blood loss, operating room time, or transfusion requirement. The pathologic outcomes did not differ significantly. The median hospital length of stay (LOS) was 5 days (range 3-31 days) for the LDP cohort and 7 days (range 4-19 days) for the ODP cohort (P < 0.001). Postoperative pancreatic fistula occurred for 22 patients, with a higher proportion observed in the LDP group (28.57%; n = 12) than in the open group (13.16%; n = 10; P = 0.05). However, the rates for grade B and higher grade fistula were higher in the ODP group (0 LDP and 4 ODP). The median preadmission and operative costs did not differ significantly. The ODP cohort had significantly higher costs in all other hospital departments, including the total cost.

CONCLUSION

LDP is both a cost-effective and safe approach for distal pancreatic lesions. This series showed a shorter LOS and lower total hospital costs for LDP than for ODP, accompanied by equivalent postoperative outcomes.

Laparoscopic Roux-en-Y gastric bypass: comparison between hand-sewn and mechanical gastrojejunostomy

The laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the ideal operations in the treatment of morbid obesity. There are several variations in the operation, especially during the construction of the gastrojejunostomy (GJA). From June 2006 to September 2008, 104 consecutive obese patients underwent LRYGB. The procedure was standardized, with the exception of the construction of the GJA, which was linear-stapled in 51 patients and hand-sewn in 53 other patients. A retrospective analysis was performed to compare the procedures. The series comprised 81 women and 23 men with a median age of 44 years, and a median BMI of 46.7 kg/m(2). There was no significant difference between the two groups of patients with respect to age, gender, BMI, ASA, and previously failed bariatric surgery. There was no significant difference between the two groups with respect to mortality, conversion, early reoperation, surgical complications, GJA leakage or stricture, and bariatric results. The only significant differences between the two groups were in regards to operating time (190 min for stapled GJA vs. 160 min for hand-sewn GJA, p value 0.029) and operating supply cost (100 Euros less for hand-sewn GJA). In our experience, hand-sewn GJA during LRYGB appears to be as safe as linear-stapled GJA and provides the same bariatric results while remaining slightly less expensive.

Complicações e óbitos nas operações para tratar a obesidade mórbida

RACIONAL: A cirurgia bariátrica, apesar de complexa, apresenta baixa morbimortalidade; contudo, quando presente apresenta graves conseqüências. OBJETIVO: Avaliar a presença de complicações e óbitos nos pacientes portadores de obesidade mórbida submetidos a tratamento cirúrgico. MÉTODOS: Análise retrospectiva de 656 pacientes submetidos a procedimento cirúrgico bariátrico. Foram analisados: sexo, idade, peso pré-operatório, índice de massa corporal pré-operatório, procedimento realizado, tempo de internação, complicações pós-operatórias e mortalidade. RESULTADOS: A idade variou entre 16 a 68 anos (média de 36,6 anos). Do total, 80,7% eram do sexo feminino. O índice de massa corporal médio foi de 42,8 kg/m2 (35 e 68 kg/m2) O tempo médio de internação foi de 4,5 dias (1 a 125 dias). O bypass gástrico foi realizado em 370 pacientes (56,40%) e a operação de Capella em 236 casos (35,97%). A principal complicação encontrada foi fístula, em 17 pacientes (2,59%). Houve necessidade de reoperação em 17 pacientes (2,59%). Oito pacientes morreram (1,21%), três foram submetidos à operação de Capella, três à bypass, um à opração de Scopinaro e um à gastrectomia vertical. CONCLUSÃO: A principal complicação foi a fístula digestiva, que ocorreu em 2,59% e a mortalidade foi de 1,21%.

Perioperative complications in a consecutive series of 1000 duodenal switches

BACKGROUND

In the past 10 years, most bariatric surgeries have seen an important reduction in the early complication rate, partly associated with the development of the laparoscopic approach. Our objective was to assess the current early complication rate associated with biliopancreatic diversion with duodenal switch (BPD-DS) since the introduction of a laparoscopic approach in our institution, a university-affiliated tertiary care center.

METHODS

A consecutive series of 1000 patients who had undergone BPD-DS from November 2006 to January 2010 was surveyed. The primary endpoint was the mortality rate. The secondary endpoints were the major 30-day complication rate and hospital stay >10 days. The data are reported as a mean ± SD, comparing the laparoscopic (n = 228) and open (n = 772) groups.

RESULTS

The mean age of the patients was 43 ± 10 years (40 ± 10 years in the laparoscopy group versus 44 ± 10 years in the open group, P < .01). The preoperative body mass index was 51 ± 8 kg/m(2) (47 ± 7 laparoscopy versus 52 ± 8 kg/m(2) open, P < .01). The conversion rate in the laparoscopy group was 2.6%. There was 1 postoperative death (.1%) from a pulmonary embolism in the laparoscopy group. The mean hospital stay was shorter after laparoscopic surgery (6 ± 6 d versus 7 ± 9 d, P = .01), and a hospital stay >10 days was more frequent in the open group (4.4% versus 7%, P = .04). Major complications occurred in 7% of the patients, with no significant differences between the 2 groups (7% versus 7.4%, P = .1). No differences were found in the overall leak or intra-abdominal abscess rate (3.5% versus 4%, P = .1); however, gastric leaks were more frequent after open surgery (0% versus 2%, P = .02). During a mean 2-year follow-up, 1 additional death occurred from myocardial infarction, 2 years after open BPD-DS.

CONCLUSION

The early and late mortality rate of BPD-DS is low and comparable to that of other bariatric surgeries.

The evolution of minimally invasive bariatric surgery

The number of bariatric operations performed annually in the U.S. for the treatment of severe obesity [body mass index (BMI)≥40 kg/m2] has increased tenfold since the mid 1990s, with approximately 220,000 operations performed in 2009. This article reviews the evolution of laparoscopic bariatric surgery over the last 20 years. The results of the most common procedures are analyzed and current and future trends described.

[Treating morbid obesity with laparoscopic biliopancreatic diversion with duodenal switch]

BACKGROUND

Biliopancreatic diversion with duodenal switch is used in the treatment of morbid obesity. Few centres perform the procedure laparoscopically. We aimed to evaluate the perioperative outcomes and weight loss after laparoscopic duodenal switch.

MATERIAL AND METHODS

All patients operated with biliopancreatic diversion with duodenal switch at the Centre for Morbid Obesity at Oslo University Hospital (2004-2009) were included. The perioperative period was defined as within 30 days of surgery.

RESULTS

A total of 48 patients were operated, all laparoscopically. Median preoperative BMI was 54 kg/m2 (range 41-88), and 33 patients (69 %) were women. Ten patients (21 %) were operated in two steps: first gastric sleeve and later duodenal switch. Median operation time was 200 minutes (100-658). Twelve patients (25 %) had complications, four (8 %) were reoperated, and one died. Median postoperative hospital stay was three (1-56) days. After two years, median BMI was 32 kg/m2 (24-45), median weight loss 39 % (22-60) and median excess BMI (> 25 kg/m2) loss 73 % (43-106).

INTERPRETATION

Duodenal switch was applied in a minority of patients operated for morbid obesity. The procedure can be performed laparoscopically with a short hospital stay and leads to a substantial weight loss. Perioperative morbidity was high and was comparable to the results from other series.

Costs of bariatric surgery in a teaching hospital and the financing provided by the Public Unified Health System

PURPOSE

Analyze the effect of some measures on the costs of bariatric surgery, adopting as reference the remuneration of the procedure provided by the Unified Health System (SUS).

METHODS

A retrospective evaluation conducted in the Costs Section of the University Hospital of Ribeirão Preto, of the costs involved in the perioperative period for patients submitted to bariatric surgery from 2004 to 2007. Changes in the routines and protocols of the service aiming at the reduction of these costs during the study period were also analyzed.

RESULTS

Nine patients in 2004 and seven in 2007 submitted to conventional vertical banded 'Roux-en-Y' gastric bypass were studied. All patients presented good postoperative evolution. The average cost with these patients was R$ 6,845.17 in 2004. Even though an effort was made to contain expenditures, the cost in 2007 was of R$ 7,525.64 because of the increase in the price of materials and medicines. The Government remuneration of the procedure in the two years was R$ 3,259.72.

CONCLUSION

Despite the adoption of diverse measures to reduce the expenditures of bariatric surgery, in fact there was an increase in the costs, a fact supporting the necessity of permanent evaluation of the financing of public health.