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

Bariatric surgery, safety and type 2 diabetes

Obesity and type 2 diabetes (T2D) represent major health concerns in the USA. Weight loss is the most important aspect in T2D management, as it reduces both morbidity and mortality. Available lifestyle, behavioral, and pharmacological strategies provide just mild to moderate weight loss. The greatest degree of T2D prevention or T2D amelioration in obese subjects has been reported in subjects who underwent bariatric surgery. In the current review, we will describe various types of bariatric surgery, related safety profiles, and their effect on T2D, as well as the potential mechanisms involved in the remission of T2D. Finally, we hereby examine whether bariatric surgery may be considered a treatment for T2D in pregnant women, children, adolescents and subjects at least 65 years old.

Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures

OBJECTIVE

Bariatric surgical procedures have increased exponentially in the United States. Laparoscopic adjustable gastric banding is now promoted as a safer, potentially reversible and effective alternative to Roux-en-Y gastric bypass, the current standard of care. This study evaluated the balance of patient-oriented clinical outcomes for laparoscopic adjustable gastric banding and Roux-en-Y gastric bypass.

METHODS

The MEDLINE database (1966 to January 2007), Cochrane clinical trials database, Cochrane reviews database, and Database of Abstracts of Reviews of Effects were searched using the key terms gastroplasty, gastric bypass, laparoscopy, Swedish band, and gastric banding. Studies with at least 1 year of follow-up that directly compared laparoscopic adjustable gastric banding with Roux-en-Y gastric bypass were included. Resolution of obesity-related comorbidities, percentage of excess body weight loss, quality of life, perioperative complications, and long-term adverse events were the abstracted outcomes.

RESULTS

The search identified 14 comparative studies (1 randomized trial). Few studies reported outcomes beyond 1 year. Excess body weight loss at 1 year was consistently greater for Roux-en-Y gastric bypass than laparoscopic adjustable gastric banding (median difference, 26%; range, 19%-34%; P < .001). Resolution of comorbidities was greater after Roux-en-Y gastric bypass. In the highest-quality study, excess body weight loss was 76% with Roux-en-Y gastric bypass versus 48% with laparoscopic adjustable gastric banding, and diabetes resolved in 78% versus 50% of cases, respectively. Both operating room time and length of hospitalization were shorter for those undergoing laparoscopic adjustable gastric banding. Adverse events were inconsistently reported. Operative mortality was less than 0.5% for both procedures. Perioperative complications were more common with Roux-en-Y gastric bypass (9% vs 5%), whereas long-term reoperation rates were lower after Roux-en-Y gastric bypass (16% vs 24%). Patient satisfaction favored Roux-en-Y gastric bypass (P=.006).

CONCLUSION

Weight loss outcomes strongly favored Roux-en-Y gastric bypass over laparoscopic adjustable gastric banding. Patients treated with laparoscopic adjustable gastric banding had lower short-term morbidity than those treated with Roux-en-Y gastric bypass, but reoperation rates were higher among patients who received laparoscopic adjustable gastric banding. Gastric bypass should remain the primary bariatric procedure used to treat obesity in the United States.

Weight regain and health-related quality of life in postmenopausal women

Weight loss improves health-related quality of life (HRQoL). However, regain after loss is common; little is known about the impact of weight regain on HRQoL in postmenopausal women. Woman on the Move through Activity and Nutrition (WOMAN) is a randomized lifestyle intervention trial of diet, physical activity, and weight loss in 508 postmenopausal women aged 52-62 years. This analysis focused on the women who lost > or =5 lb during the initial phase of the study, baseline to 6 months (n = 248). This cohort was divided into three groups based on subsequent weight change between 6 and 18 months: weight loss (WL; > or =5 lb loss), weight stable (WS; <+/-5 lb change), and weight regain (WR; > or =5 lb gain). HRQoL was measured at baseline, 6, and 18 months using the Short Form-36. Of the 248 women studied, 51 (21%) continued to lose weight after initial weight loss, while 127 (51%) maintained a stable weight, and 70 (28%) regained weight. Between baseline and 6 months, women in WR group had decreased mental health and social-functioning scores, while the WL and WS groups improved in these subscales. Between baseline and 18 months, energy improved most significantly in those with continued weight loss (P = 0.0003). Weight loss was correlated with a small to moderate improvement in perceived general health and energy, which was reversed by weight gain. Further study is needed to investigate the impact of a decline in mental health and social functioning on future weight regain.

Bands and bypasses: 30-day morbidity and mortality of bariatric surgical procedures as assessed by prospective, multi-center, risk-adjusted ACS-NSQIP data

BACKGROUND

Previous multi-institution comparisons of open and laparoscopic Roux-en-Y gastric bypass (ORYGB and LRYGB), and laparoscopic adjustable gastric banding (LAGB) have been limited by the lack of unique current procedural terminology (CPT) codes. Specific codes have been available for LRYGB and LAGB since 2005 and 2006, respectively. We compare the short-term safety of these procedures, using risk-adjusted clinical data from a multi-institutional quality improvement program.

METHODS

The America College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant Use File (PUF) was used to compare patients undergoing LRYGB with those undergoing ORYGB or LAGB.

RESULTS

ORYGB versus LRYGB: The 2-year study period (2005-2006) included 5,777 patients (ORYGB = 1,146, LRYGB = 4,631). Patients undergoing ORYGB experienced a higher 30-day incidence of mortality (0.79% vs. 0.17%; p = 0.002), major complications rate (7.42% vs. 3.37%; p < 0.0001), any complication rate (13.18% vs. 6.69%; p < 0.0001), return visits to the OR (4.97% vs. 3.56%; p = 0.032), and longer postoperative length of stay (LOS) (median 3 vs. 2 days; p < 0.0001). After risk adjustment, ORYGB continued to demonstrate higher odds of major complication (OR = 2.04; [1.54, 2.69]). LAGB versus LRYGB: Analysis of 1 year of data from 2006 included 4,756 patients (LRYGB = 3,580, LAGB = 1,176). Those treated with LAGB experienced an equivalent 30-day mortality (0.09% vs. 0.14%; p = 1.0), and a lower rate of major complications (1.0% vs. 3.3%; p < 0.0001), any complication (2.6% vs. 6.7%; p < 0.0001), return visits to the OR (0.94% vs. 3.6%; p < 0.0001), and shorter postoperative LOS (median 1 vs. 2 days; p < 0.0001). Risk adjustment showed that LAGB was associated with a lower major complication odds (OR = 0.29; [0.16, 0.53]).

CONCLUSIONS

Compared with LRYGB, ORYGB is associated with higher 30-day mortality and higher risk-adjusted major complication rate. While ORYGB may sometimes be indicated, a laparoscopic approach may be safer for RYGB when feasible. LAGB, compared with LRYGB, has a similarly low mortality rate and a small but statistically significant decrease in risk-adjusted 30-day complications. Clinical efficacy and long-term outcomes will need to be evaluated to determine superiority between these procedures.

Preoperative weight loss decreases the operative time of gastric bypass at a Veterans Administration hospital

BACKGROUND

This study assessed whether preoperative weight loss resulted in favorable outcomes after open Roux-en Y gastric bypass (RYGB).

METHODS

A retrospective review of all patients who underwent RYGB at the DVAMC was undertaken. Patients were divided into: patients who did not lose weight within 3 months preoperatively (n=25) and group II, those who did (n=15).

RESULTS

Both groups had similar demographics, body mass index, comorbid conditions, and American Society of Anesthesiology class. Group II lost 28.2+/-6.5 lbs (8.3% of body weight) within 3 months before RYGB. Operative time was longer in group I compared to group II (180.0+/-0.0 vs 161.0+/-0.0 min; p=0.05). Both groups had the same rate of postoperative complications and the same long-term weight loss at a 2-year follow-up (n=6 both groups).

CONCLUSIONS

An 8% reduction of body weight is associated with a decrease in operative time. These preliminary data suggest that preoperative weight loss results in a technically less challenging operation in the super-obese patient.

Factors associated with weight loss after gastric bypass

BACKGROUND

Gastric bypass (GBP) is the most common operation performed in the United States for morbid obesity. However, weight loss is poor in 10% to 15% of patients. We sought to determine the independent factors associated with poor weight loss after GBP.

DESIGN

Prospective cohort study. We examined demographic, operative, and follow-up data by means of multivariate analysis. Variables investigated were age, sex, race, marital and insurance status, initial weight and body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared), comorbidities (diabetes mellitus, hypertension, joint disease, sleep apnea, hyperlipidemia, and psychiatric disease), laparoscopic vs open surgery, gastric pouch area, gastrojejunostomy technique, and alimentary limb length.

SETTING

University tertiary referral center.

PATIENTS

All patients at our institution who underwent GBP from January 1, 2003, through July 30, 2006.

MAIN OUTCOME MEASURES

Weight loss at 12 months defined as poor (< or =40% excess weight loss) or good (>40% excess weight loss).

RESULTS

Follow-up data at 12 months were available for 310 of the 361 patients (85.9%) undergoing GBP during the study period. Mean preoperative BMI was 52 (range, 36-108). Mean BMI and excess weight loss at follow-up were 34 (range, 17-74) and 60% (range, 8%-117%), respectively. Thirty-eight patients (12.3%) had poor weight loss. Of the 4 variables associated with poor weight loss in the univariate analysis (greater initial weight, diabetes, open approach, and larger pouch size), only diabetes (odds ratio, 3.09; 95% confidence interval, 1.35-7.09 [P = .007]) and larger pouch size (odds ratio, 2.77;95% confidence interval, 1.81-4.22 [P <.001]) remained after the multivariate analysis.

CONCLUSIONS

Gastric bypass results in substantial weight loss in most patients. Diabetes and larger pouch size are independently associated with poor weight loss after GBP.

Comparing outcomes of laparoscopic versus open bariatric surgery

OBJECTIVE

The objective of this study was to use nationally representative data to compare outcomes of open gastric bypass (OGB) versus laparoscopic gastric bypass (LGB) surgery.

BACKGROUND

The number of bariatric procedures continues to grow. Increasingly, these surgeries are being performed laparoscopically. However, few population-based studies have examined differences in outcomes between LGB and OGB surgeries. Population-based studies can provide further insight into differences in outcomes between open and laparoscopic bariatric procedures.

METHODS

Using the Nationwide Inpatient Sample, we identified adults undergoing LGB or OGB surgery during 2005 (n = 19,156). Following preliminary descriptive statistics, multiple logistic and linear regressions were used to obtain risk-adjusted outcomes, including postoperative in-hospital complications, reoperation, length of stay, and total charges.

RESULTS

The majority of patients in the study sample (74.5%) underwent laparoscopic bypass surgery in 2005. After adjusting for patient and hospital level factors, patients undergoing OGB surgery were more likely to experience reoperation as well as the following complications: pulmonary (odds ratio [OR] = 1.92 (1.54-2.38), P < 0.001); cardiovascular (OR = 1.54 [1.07-2.23], P = 0.02); procedural (OR = 1.29 [1.06-1.57], P < 0.01); sepsis (OR = 2.18 [1.50-3.16], P < 0.001); and anastomotic leak (OR = 1.32 [1.02-1.71], P = 0.03). After risk adjustment, LGB was associated with a shorter length of stay but higher total charges.

CONCLUSION

Overall, LGB patients are less likely to experience reoperation and postoperative complications in the hospital and have a shorter length of stay but incur higher total charges than OGB patients.

Comparison of three instruments assessing the quality of economic evaluations: A practical exercise on economic evaluations of the surgical treatment of obesity

Objectives:The increasing use of full economic evaluations has led to the development of various instruments to assess their quality. The purpose of this study was to compare the frequently usedBritish Medical Journal(BMJ) check-list and two new instruments: the Consensus Health Economic Criteria (CHEC) list and the Quality of Health Economic Studies (QHES) instrument. The analysis was based on a practical exercise on economic evaluations of the surgical treatment of obesity.

Methods:The quality of nine selected studies was assessed independently by two health economists. To compare instruments, the Spearman rank correlation coefficient was calculated for each assessor. Moreover, the test–retest reliability for each instrument was assessed with the intraclass correlation coefficient (ICC) (3,1). Finally, the inter-rater agreement for each instrument was estimated at two levels: comparison of the total score of each article by the ICC(2,1) and comparison of results per item by kappa values.

Results:The Spearman's rank correlation coefficient between instruments was usually high (rho &gt; 0.70). Furthermore, test–retest reliability was good for every instruments, that is, 0.98 (95 percent CI, 0.86–0.99) for the BMJ check-list, 0.97 (95 percent CI, 0.73–0.98) for the CHEC list, and 0.95 (95 percent CI, 0.75–0.99) for the QHES instrument. However, inter-rater agreement was poor (kappa &lt; 0.40 for most items and ICC(2,1) ≤ 0.5).

Conclusions:The study shows that the results of the quality assessment of economic evaluations are not so much influenced by the instrument used but more by the assessor. Therefore, quality assessments should be performed by at least two independent experts and final scoring based on consensus.

Laparoscopy should be the approach of choice for acute appendicitis in the morbidly obese

BACKGROUND

The current study compared the outcome of morbidly obese patients undergoing laparoscopic versus open appendectomy.

METHODS

We obtained data from the University HealthSystem Consortium (UHC) database on 1,943 morbidly obese patients who underwent appendectomy for acute or perforated appendicitis between 2002 and 2007.

RESULTS

Compared to open appendectomy, laparoscopic appendectomy was associated with a shorter length of stay (3 vs 4 days) and a lower overall complication rate (9% vs 17%). Most notably, a lower rate of wound infection was noted (1% vs 3%). Within a subset analysis of morbidly obese patients who underwent appendectomy for perforated appendicitis, there was a higher overall complication rate (27% vs 18%) and cost ($16,600 vs $12,300) in the open appendectomy group.

CONCLUSION

In the morbidly obese, laparoscopic appendectomy performed for acute and perforated appendicitis is associated with a shorter length of stay and lower morbidity and costs. Laparoscopic appendectomy should be the procedure of choice for the treatment of acute appendicitis in the morbidly obese population.

Laparoscopic Roux-en-Y gastric bypass for morbidly obese Chinese patients: learning curve, advocacy and complications

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) involves a combination of both restrictive and mal-absorptive mechanisms and has become the procedure of choice for patients with morbid obesity in Western countries. However, its efficacy remains uncertain in Asian populations. We report our pilot experience with LRYGB in a Chinese population.

METHODS

Between August 2005 and February 2007, 100 morbidly obese patients received LRYGB. We evaluated the learning curve for the operation, its efficacy in weight reduction, and its postoperative complications.

RESULTS

Surgical time reached a plateau after about 50 cases, decreasing from 216 min for the initial 50 patients to 105 min for the final 50. The conversion rate from laparoscopic to open surgery was 2%. The mean percent body mass index loss was 33.9% after 12 months. Twenty-four complications occurred in 18 patients, but most resolved with conservative treatment without mortality. Patients with advanced age (P = 0.04) or hypertension (P = 0.03) were at increased risk for complications leading to prolonged surgical times and hospital stays. The complication rate declined as technical expertise increased.

CONCLUSION

In Chinese patients with morbid obesity, LRYGB is promising procedure because of its acceptable learning curve, good efficacy, and low complication rate.

Initial laparoscopic access using an optical trocar without pneumoperitoneum is safe and effective in the morbidly obese

Obtaining access to the peritoneal cavity in laparoscopic surgery is more difficult in morbidly obese people. The aim of this study was to examine the safety and efficacy of accessing the peritoneal cavity using an optical, bladeless trocar without previous pneumoperitoneum in morbidly obese patients. The patients' characteristics and outcomes with consecutive and preferential use of an optical, bladeless, first trocar insertion without previous pneumoperitoneum in morbidly obese patients (body mass index > 35 kg/m2) was reviewed. A total of 208 morbidly obese patients were included. The trocar insertion technique was used in 196 patients. No bowel or major abdominal vessel injuries occurred. Ninety-eight patients (50%) had previous abdominal operations. Trocar-related injuries occurred in 3 patients: a superficial mesenteric laceration in 2 and a laceration of a greater omentum vessel in 1. The direct first trocar insertion technique provides safe entry into the peritoneal cavity in morbidly obese patients.

Health-related quality of life in adult patients with morbid obesity coming for bariatric surgery

Background

Obesity has become a major health issue not only in the West but also in Asia. Morbid obesity can lead to much comorbidity and can markedly interfere with quality of life. The aim of this study was to compare the health-related quality of life (HRQL) between patients with morbid obesity coming for bariatric surgery and the healthy population in Taiwan.

Methods

Patients were between age 18 and 65 years. Patients had a BMI between 32 and 40 kg/m² with obesity-related comorbidities or a BMI > 40 kg/m². Patients were enrolled for bariatric surgery by a modified recommendation of the Asia-Pacific consensus. Physical and psychiatric evaluations were accomplished simultaneously. The World Health Organization Quality of Life (WHOQOL-BREF), Taiwan version, was administered 1 month before the operation. The quality of life of the obese patients was compared with age-, sex-, education-, marriage-, and municipality-matched healthy control patients taken from a national survey in Taiwan. Multiple regression analyses were conducted to study risk factors for impairment of HRQL.

Results

A total of 114 consecutive patients with obesity coming for bariatric surgery at our hospital were enrolled in 2007. Obese subjects had poorer WHOQOL-BREF scores than those of the healthy referents in physical, psychological, and social domains but not in environmental domain (P < 0.05). Patients with BMI levels above 32 kg/m² had consistently poorer scores in various facets after adjusting for other risk factors.

Conclusions

The higher the BMI level the poorer the HRQL. Our findings seem to support the recommendations of Asia-Pacific consensus based on HRQL considerations.

Bioabsorbable glycolide copolymer staple-line reinforcement decreases internal hernia rate after laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Internal hernias (IHs) can occur after laparoscopic Roux-en-Y gastric bypass (LRYGBP), perhaps because of a lack of adhesion formation at the cut edges of the mesentery and a cutting through of sutures with a decrease in fat from weight loss. In patients undergoing reoperation after LRYGBP, we observed that bioabsorbable glycolide copolymer staple-line reinforcement (SLR) placed to mitigate staple-line bleeding had evoked adhesiogenesis and tissue fusion at the mesentery edges; therefore, we investigated whether use of this material decreases post-LRYGBP IH rates.

METHODS

The records of the 43 patients (3%) in whom an IH developed during a mean follow-up time of 2 years in a series of 1,704 LRYGBP procedures were reviewed retrospectively.

RESULTS

The IHs were in the Peterson's space (n = 4), the enteroenterostomy (n = 17), or the transverse mesocolon (n = 22). The IH rate was significantly higher in patients who had suture closure of the mesenteric defects at LRYGBP than in those without formal closure of the defects but in whom SLR was applied to the edges of the cut mesentery (P = 0.01). The suture-closure and SLR groups had similar demographic, operative, and follow-up characteristics. When transverse mesocolic IHs were excluded from analysis, patients given SLR remained less likely to have an IH (P = 0.05).

CONCLUSION

Use of bioabsorbable polymer SLR may decrease the occurrence of IHs after LRYGBP. Additional studies of the effect of mesentery closure method on IH incidence after LRYGBP are warranted.

What is the quality of information about bariatric surgery on the internet?

BACKGROUND

The purpose of this study was to evaluate the role of Internet on patients scheduled for bariatric procedures and the quality of information available on different websites.

METHODS

Between July 2003 to July 2005, patients undergoing bariatric surgical procedures completed a survey. Data were collected prospectively. One hundred valid surveys were returned. Independently, two bariatric surgeons evaluated available French and English websites using major search engines.

RESULTS

Forty-two of 100 patients (42%) sought information about bariatric surgery on the Internet. Seventy-four percent of these patients (n = 31/42) used search engines with 81% visiting less than ten websites. According to the patient's evaluation, 58% of the websites visited did not provide technical details of any surgical bariatric procedures, and only 61% provided information regarding postoperative weight loss. Furthermore, 58% of websites did not provide information about the laparoscopic approach, and 54% did not give any information on potential postoperative complications. Bariatric surgeon's evaluation was similar except for two differences: laparoscopic approach and postoperative weight loss information were discussed in 90% (p < 0.001) and 43% (p < 0.1) of visited websites, respectively.

CONCLUSION

When the Internet was used to search for information about bariatric surgery, search engines were preferentially used but search duration was short. Available Internet websites can be considered as moderately reliable; however, 25% of visited websites contain misleading information. Comparison between patients and surgeons views showed that patients were effective in detecting misleading information.

Impact of obesity on health-related quality of life in schizophrenia and bipolar disorder

OBJECTIVE

Studies have reported that up to 60% of individuals with schizophrenia and 68% of those with bipolar disorder are overweight/obese. This paper explores the health-related quality of life (HRQOL) of individuals with schizophrenia or bipolar disorder as a function of obesity status.

METHODS AND PROCEDURES

Two hundred and eleven participants were recruited from four psychiatric programs (outpatient, day treatment, case management, and psychosocial rehabilitation). HRQOL was assessed using both a general measure (Medical Outcomes Study Short-Form-36 (SF-36)) and a weight-related measure (Impact of Weight on Quality of Life-Lite (IWQOL-Lite)). To interpret HRQOL scores obtained by the obese group, we compared scores to those obtained by reference groups from the weight-loss literature.

RESULTS

Sixty-three percent of participants with schizophrenia and 68% of those with bipolar disorder were obese. Obese participants were more likely to be women, on mood stabilizers, taking a greater number of psychiatric medications, and to have poorer weight-related and general HRQOL. Weight-related HRQOL in the obese psychiatric sample was more impaired than in outpatient and day treatment samples seeking weight loss but less impaired than in gastric-bypass patients. Several of the physical domains of general HRQOL were more impaired for the obese psychiatric sample than for the outpatient weight-loss sample. However, physical functioning was less impaired for the obese psychiatric sample than for gastric-bypass patients.

DISCUSSION

The presence of obesity among individuals with schizophrenia or bipolar disorder is associated with decreased HRQOL. These results have implications for prevention and management of weight gain in individuals with schizophrenia or bipolar disorder.

The repair of incisional hernia following Roux-en-Y gastric bypass-with or without concomitant abdominoplasty?

BACKGROUND

Incisional hernia, found in up to 25% of patients, is a typical complication of open bariatric surgery.

METHODS

Open Roux-en-Y gastric bypass (RYGB) was performed in 204 patients. They have been followed-up for at least 6 months. Thirty-two patients in whom incisional hernia was diagnosed were divided into two groups-they were scheduled for hernia repair or hernia repair with abdominoplasty. The surgery was performed, on average, 20 months after RYGB operation. Fourteen patients [mean body mass 86.4 kg, mean body mass index (BMI) 30.0 kg/m(2)] have had hernias repaired. The mean duration of hospital stay was 7.2 days. Hernia repair along with abdominoplasty was performed in 18 patients with mean body mass 89.4 kg and BMI 31.5 kg/m(2). The mean duration of hospital stay was 8.7 days.

RESULTS

Both examined groups were similar in body mass, BMI, age, and duration of hospital stay (p > 0.05), as well as gender distribution. The wound infection was diagnosed in six patients.

CONCLUSION

The simultaneous abdominoplasty does not prolong the time of hospital stay of the patients undergoing incisional hernia repair. Infection is the most frequent complication of incisional hernia repair.

Outcome of endoscopic balloon dilation of strictures after laparoscopic gastric bypass

OBJECTIVE

Stricture formation at the gastrojejunal anastomosis is a relatively common complication after laparoscopic Roux-en-Y gastric bypass (LRYGB). The objective of this study was to report the incidence of stomal strictures after LRYGB in our institution and report our experience with their management by endoscopic balloon dilatation.

METHODS

This is a retrospective study of 1012 patients who underwent LRYGB from January 2001 to May 2004. Patients with nausea and vomiting after the surgery, suspected of having gastrojejunal (GJ) anastomotic stricture, had upper endoscopy. Stomas less than 10 mm in diameter, or those not allowing passage of the scope were considered significant strictures and were treated with balloon dilations. Dilations were performed with a through-the-scope (TTS) balloon, with sizes ranging from 6 to 18 mm. The following data were collected from these patients: age, sex, body mass index (BMI), comorbidities, size of balloon catheter, time from surgery until symptoms onset, number of endoscopies needed to relief symptoms, and complications of the procedure.

RESULTS

Sixty-one patients (46 females and 15 males) were found to have anastomotic strictures, corresponding to an incidence of 6%. In total, 134 upper endoscopies were performed, with 128 dilatations. The average age was 41.7 years (range: 19-68 years); mean preoperative BMI was 45 kg/m(2) (range: 42-61 kg/m(2)). Mean time from surgery to symptoms onset was 2 months (range: 1-6 months). The number of dilations per patient was as follows: a single dilation in 28% of patients, two dilations in 33%, three dilations in 26%, four dilations in 11.5%, and five dilations in 1.5% of patients. All the patients responded to dilation without need for formal surgical revision. However, after balloon dilatation three patients (4.9%), all females, had bowel perforation by radiological criteria (free air on X-ray), which corresponded to 2.2% of all dilatations. The maximum balloon size used in this group was 13.5 mm. All three patients had exploratory laparoscopy without finding of perforation site. They were treated with bowel rest, intravenous antibiotics for 7 days, and drain placement. No factors were identified to predict a risk of perforation.

CONCLUSION

This is the largest study to evaluate the outcome of endoscopic dilatations of GJ strictures after RYGB. Endoscopic balloon dilation is a safe and effective treatment for anastomotic strictures. However, it carries a small risk of perforation. Further case studies are needed to determine risk factors for perforation and if the patients can be managed conservatively in this setting.

Cost analysis of laparoscopic gastric bypass practice using current Medicare reimbursement and practice costs

BACKGROUND

We performed a formal cost analysis of a hypothetical bariatric practice consisting of a surgeon, dietitian, clinical coordinator/office manager, receptionist, and certified medical assistant to determine whether a bariatric practice would have a difficult time surviving financially with the current Medicare reimbursement.

METHODS

The number of possible cases was calculated for the 2005 calendar year. Most of the costs and assumptions were taken from an actual bariatric practice. The malpractice insurance premium (but not physician salary and benefits) was calculated into the practice cost.

RESULTS

With a total of 231 days available for clinical work in 2005, 300 scheduled laparoscopic gastric bypasses could have been performed to allow for appropriate clinic time for new patient visits, postoperative visits, and annual visits. The total reimbursement from Medicare would have been $516,158, with most of the reimbursement coming from procedure fees ($407,063). The total practice cost would have been $444,592. Most of the costs were clinic staff salary and benefits ($207,065) and the malpractice premium ($55,150). The net difference of $71,566 was left to pay the salary and benefits of the bariatric surgeon.

CONCLUSION

The low reimbursement of Medicare for laparoscopic gastric bypass threatens the financial viability of a bariatric surgery practice. With the increasing cost of malpractice and the threatened decrease in Medicare physician reimbursement, Medicare recipients could see a decrease in the number of bariatric surgeons offering them service.

Endoscopic management of early GI hemorrhage after laparoscopic gastric bypass

BACKGROUND

Early upper GI hemorrhage (UGH) is a potential complication after laparoscopic Roux-en-Y gastric bypass (RYGBP), and early reoperative intervention is the most accepted treatment. Experience with endoscopic treatment is limited.

OBJECTIVE

Our purpose was to describe the role of endoscopy and injection therapy in the management of early UGH after laparoscopic RYGBP.

DESIGN

Case series study.

SETTING

Endoscopy Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain.

PATIENTS

We describe the endoscopic treatment of 6 patients with early UGH within 24 hours after a RYGBP.

INSTRUMENTATION

Upper endoscopy was performed in all 6 cases. The origin of the bleeding was identified at the staple line in all cases, and epinephrine alone or combined with polidocanol was successfully injected in 5 of 6 patients.

RESULTS

Endoscopic therapy arrested active bleeding without any complications in all cases without the need for further surgery or endoscopic treatments.

LIMITATION

Our experience is limited to 6 cases.

CONCLUSION

Early postoperative UGH after RYGBP may be adequately controlled with endoscopic treatment and may obviate the need for surgery. Further data are necessary to evaluate the safety and the efficacy of this approach.

Survival and changes in comorbidities after bariatric surgery

OBJECTIVE

To evaluate survival rates and changes in weight-related comorbid conditions after bariatric surgery in a high-risk patient population as compared with a similar cohort of morbidly obese patients who did not undergo surgery.

SUMMARY BACKGROUND DATA

Morbid obesity is increasingly becoming a major public health issue. Existing studies are limited in their ability to assess the risks and benefits of bariatric surgery because few studies compare surgical patients to a similar, morbidly obese, nonsurgical cohort, especially in high-risk populations like the elderly and disabled.

METHODS

A retrospective cohort analysis using Medicare fee-for-service patients from 2001 to 2004. Survival rates and diagnosed presence of 5 conditions commonly comorbid with morbid obesity were examined for morbidly obese patients who did and did not undergo bariatric surgery, with up to 2 years follow-up.

RESULTS

Morbidly obese Medicare patients who underwent bariatric surgery had increased survival rates over the 2 years of this study when compared with a similar morbidly obese nonsurgical group (P < 0.001). For patients under the age of 65, this survival advantage started at 6 months postoperatively and for patients over age 65, at 11 months. The surgical group also experienced significant improvements in the diagnosed prevalence of 5 weight-related comorbid conditions (diabetes, sleep apnea, hypertension, hyperlipidemia, and coronary artery disease) relative to the nonsurgical cohort after 1 year postsurgery (P < 0.001).

CONCLUSIONS

Bariatric surgery appears to increase survival even in the high-risk, Medicare population, both for individuals aged 65 and older and those disabled and under 65. In addition, the diagnosed prevalence of weight-related comorbid conditions declined after bariatric surgery relative to a control cohort of morbidly obese patients who did not undergo surgery.

Internal hernia as a complication of laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Internal hernia (IH) is a well known complication of Roux-en-Y gastric bypass (RYGBP) which is more frequently encountered when the RYGBP is done laparoscopically.

METHODS

Patients with IH were identified from a prospective data-base of morbidly obese patients undergoing bariatric surgery at our center.

RESULTS

10 patients with IH were identified out of 625 patients undergoing LRYGBP from 1998 to 2006 (incidence 1.6 %). The defects were closed in the last 155 cases with non-absorbable running sutures. There were 8 women and 2 men with mean age 38 years (range 28-54). The mean interval of time elapsed between LRYGBP and clinical presentation of IH was 26.5 months (range 7 days - 72 months). Abdominal pain, nausea and vomiting were the most common complaints. White blood cell count was increased to a mean of 64 mg/dl (range 45-155 mg/dl) in 6 patients. CT scan showed signs of intestinal obstruction in all 7 patients with acute presentation. Surgery was done by laparoscopy in 5 cases (2 in the setting of emergency), and by laparotomy in the remaining 5 cases. All IHs were located at the mesenteric defect and were treated with IH reduction in all but one patient who underwent small bowel resection. There was no mortality, and one patient had pneumonia with acute respiratory distress syndrome that resolved favorably.

CONCLUSIONS

IH after LRYGBP occurred mainly at the mesenteric defect and in patients with no closure of the defect. The antecolic approach for the Roux-limb, the division of the greater omentum only when too thick, and the systematic closure of the defects with tight non-absorbable running sutures are recommended.

The health-related quality of life of obese persons seeking or not seeking surgical or non-surgical treatment: a meta-analysis

Background

This meta-analysis examined differences in health-related quality of life (HRQoL) between seekers of surgical and non-surgical treatment, and non-treatment seekers, over and above differences that are explained by weight, age, and gender.

Methods

Our literature search focused on the ‘Impact of Weight on Quality of Life-Lite’ (IWQOL-Lite) and the ‘Short Form-36’ (SF-36) questionnaires. Included were studies published between 1980 and April 2006 providing pre-treatment descriptive statistics of adult overweight, obese or morbidly obese persons. Excluded were elderly and ill patient groups.

Results

54 articles, with a total number of nearly 100,000 participants, met the inclusion criteria. Persons seeking surgical treatment demonstrated the most severely reduced HRQoL. IWQOL-Lite scores showed larger differences between populations than SF-36 scores. After adjustment for weight, the population differences on the IWQOL disappeared. In contrast, the differences on the SF-36 between the surgical treatment seeking population and the other populations were maintained after adjustment for weight.

Conclusion

The IWQOL-Lite questionnaire predominantly reflects weight-related HRQoL, whereas the SF-36 mostly reflects generic HRQoL that is determined by both weight and other factors. Our metaanalysis provides reference values that are useful when explaining or evaluating obesity-specific (IWQOL-Lite) or generic (SF-36) HRQoL, weight, and demographic characteristics of obese persons seeking or not seeking surgical or non-surgical treatment.

Cost-effectiveness analysis of laparoscopic gastric bypass, adjustable gastric banding, and nonoperative weight loss interventions

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the two most commonly performed bariatric procedures. Although both procedures likely reduce healthcare expenditures related to the resolution of co-morbid conditions, they have different rates of perioperative risks and different rates of associated weight loss. We designed a model to evaluate the incremental cost-effectiveness of these procedures compared with nonoperative weight loss interventions and with each other.

METHODS

We used a deterministic, payer-perspective model comparing the lifetime expected costs and outcomes of LAGB, LRYGB, and nonoperative treatment. The major endpoints were survival, health-related quality of life, and weight loss. Life expectancy and lifetime medical costs were calculated across age, gender, and body mass index (BMI) strata using previously published data.

RESULTS

For both men and women, LRYGB and LAGB were cost-effective at <$25,000/quality-adjusted life-year (QALY) even when evaluating the full range of baseline BMI and estimates of adverse outcomes, weight loss, and costs. For base-case scenarios in men (age 35 y, BMI 40 kg/m(2)), the incremental cost-effectiveness was $11,604/QALY for LAGB compared with $18,543/QALY for LRYGB. For base-case scenarios in women (age 35 y, BMI 40 kg/m(2)), the incremental cost-effectiveness was $8878/QALY for LAGB compared with $14,680/QALY for LRYGB.

CONCLUSION

The modeled cost-effectiveness analysis showed that both operative interventions for morbid obesity, LAGB and RYGB, were cost-effective at <$25,000 and that LAGB was more cost-effective than RYGB for all base-case scenarios.

Eliminating respiratory intensive care unit stay after gastric bypass surgery

BACKGROUND

The bariatric patient is among the most complex in general surgery. Morbid obesity and associated comorbidities create a higher likelihood for intensive care unit (ICU) services. Obstructive sleep apnea (OSA) is often unrecognized and may contribute to increased respiratory events and ICU admissions. Identifying and treating occult OSA may decrease the need for ICU utilization. This retrospective review attempts to evaluate this hypothesis.

PATIENTS AND METHODS

From 1998 to 2005, 890 bariatric procedures were performed at our center: 858 primary gastric bypasses and 32 revisions. Before 2004, patients were evaluated selectively for OSA; after 2004, all patients have had a sleep study.

RESULTS

A postoperative ICU stay was required in 43 patients (5%). From 1998 to 2003, when OSA evaluation was not mandatory, a respiratory-related ICU stay was necessary in 11 of 572 patients. When OSA evaluation was mandated in all patients (2004-2005), there was one respiratory related ICU stay (1/318).

CONCLUSION

Multiple variables lead to a decrease in ICU stay. Our study suggests that recognizing and treating occult sleep apnea may further improve this quality metric. In our center, mandatory OSA screening and aggressive preoperative treatment have eliminated the need for respiratory-related ICU stays after bariatric surgery.

Changes in urinary and fecal incontinence symptoms with weight loss surgery in morbidly obese women

OBJECTIVE

To examine changes in the prevalence and severity of urinary incontinence (UI) and fecal incontinence in morbidly obese women undergoing laparoscopic weight loss surgery.

METHODS

In a prospective cohort study, 101 women (aged 20-55 years) with body mass index (BMI) of 40 or more underwent laparoscopic Roux-en-Y gastric bypass and were followed to 6 and 12 months. Presence, severity, and effect of UI were assessed using the Medical, Epidemiological, and Social Aspects of Aging Questionnaire, Urogenital Distress Inventory, and Incontinence Impact Questionnaire. Fecal incontinence was assessed by self-report of anal leakage.

RESULTS

Mean BMI decreased from 48.9+/-7.2 presurgery to 35.3+/-6.5 at 6 months and 30.2+/-5.7 at 12 months postsurgery. Prevalence of UI decreased from 66.7% presurgery to 41.0% at 6 months and 37.0% at 12 months (P<.001; 95% confidence interval [CI] for change 18.6-40.0%). Reduction in prevalence of UI was significantly associated with decreases in BMI (P=.01). Among incontinent women who lost 18 or more BMI points, 71% regained urinary continence at 12 months. Medical, Epidemiological, and Social Aspects of Aging Questionnaire urge and stress scores decreased (both P<.001; 95% CI 0.5-1.85 and 2.71-5.34, respectively), as did scores on the Urogenital Distress Inventory (P<.001; 95% CI 8.31-16.21) and Incontinence Impact Questionnaire (P<.001; 95% CI 4.71-14.60), indicating reduction in severity. Prevalence of fecal incontinence (solid or liquid stool) decreased from 19.4% to 9.1% at 6 months and 8.6% at 12 months (P=.018; 95% CI 2.1-19.4%).

CONCLUSION

Prevalence of UI and fecal incontinence decreased after bariatric surgery. Magnitude of weight loss was associated with reduction in UI prevalence, strengthening the inference that improvements are attributable to weight loss.

LEVEL OF EVIDENCE

II.

Three-year follow-up study of retrocolic versus antecolic laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Since 1994, laparoscopic Roux-en-Y gastric bypass (LRYGBP) has gained popularity for the treatment of morbid obesity. In analogy to open surgery, the operation was initially performed in a retrocolic fashion. Later, an antecolic procedure was introduced. According to short-term studies, the antecolic technique is favorable. In this study, we compared the retrocolic vs the antecolic technique with 3 years of follow-up. We hypothesized that the antecolic technique is superior to the retrocolic in terms of operation time and morbidity.

METHODS

33 consecutive patients with retrocolic technique and 33 patients with antecolic technique of LRYGBP were compared, using a matched-pair analysis. Data were extracted from a prospectively collected database. The matching criteria were: BMI, age, gender and type of bypass (proximal or distal). The end-points of the study were: operation time, length of hospital stay, incidence of early and late complications, reoperation rates and weight loss in the follow-up over 36 months.

RESULTS

In the retrocolic group, operation time was 219 min compared to 188 min in the antecolic group (P = 0.036). In the retrocolic group, 3 patients (9.1%) developed an internal hernia and 4 patients (12.1%) suffered from anastomotic strictures. In the antecolic group, 2 patients (6.1%) developed internal hernias and in 3 patients (9.1%) anastomotic strictures occurred. Median hospital stay in the retrocolic group was 8 days compared to 7 days in the antecolic group. In the antecolic group, the mean BMI dropped from 46 kg/m2 to 32 kg/m2 postoperatively after 36 months. This corresponds to an excess BMI loss of 66%. In the retrocolic group, we found a similar decrease in BMI from preoperative 45 kg/m2 to 34 kg/m2 after 36 months (P = 0.276).

CONCLUSION

The results of our study demonstrate a reduction of operation time and hospital stay in the antecolic group compared to the retrocolic group. No differences between the two groups were found regarding morbidity and weight loss. Taken together, the antecolic seems to be superior to the retrocolic technique.

Single-institutional experience with the surgical infection prevention project in intra-abdominal surgery

BACKGROUND

The incidence of surgical site infection (SSI) is becoming a key component of standard measures of quality of performance. We hypothesized that institutional implementation of a protocol targeting known risk factors would reduce the incidence of SSI associated with intra-abdominal surgery.

METHODS

Beginning in June 2004, a quality control initiative was implemented to prevent SSI in patients undergoing intra-abdominal surgical procedures at an academic medical center. This protocol included administration of the proper prophylactic antibiotic 0-60 minutes before incision, continued antibiotic administration for <or=24 hours, and maintenance of intraoperative normothermia (>or=36 degrees C), along with good glycemic control (goal<200 mg/dL 48 h postoperatively) in diabetic patients. Baseline data collected during the initial four months of protocol development (379 patients) were compared with data collected during the last four months of the 11-month study period (390 patients).

RESULTS

Compliance with antibiotic selection increased from 89 percent to 97 percent (p <or= 0.05). Compliance with timeliness of administration improved from 89 percent to 97 percent (p <or= 0.05), whereas cessation of perioperative antibiotics within 24 hours remained constant at 93 and 92 percent, respectively. The incidence of hypothermia fell from 15 percent to 10 percent (p = 0.27). The 30-day incidence of SSI improved from 9.2 percent to 5.6 percent (p = 0.07).

CONCLUSION

The implementation of a prevention protocol resulted in a substantial trend toward a reduction in the incidence of SSI. These data support the use of protocol implementation as a cost-effective method of reducing perioperative infectious morbidity associated with intra-abdominal surgery.

Developing a New Bariatric Surgery Program

We initiated a new bariatric surgery program in February 2004. Before starting the program, we initiated a systemic planning process to design, develop, and implement a comprehensive, multidisciplinary program. Between May 2004 and June 2006, 178 patients underwent Roux-en-Y gastric bypass to treat morbid obesity at our institution. We have had no pulmonary emboli and no deaths. Twenty-one patients (11.8%) developed wound infection after surgery. Thirteen patients (7.3%) developed stenosis at the gastrojejunostomy. Five patients (2.8%) bled from the gastrojejunostomy. Four patients (2.2%) developed atelectasis. Three patients (1.6%) developed an internal hernia after surgery. One patient (0.5%) developed deep venous thrombosis. Two patients (1.1%) developed small bowel obstruction from adhesions. One patient developed a leak (0.6%). By 6 months after surgery, our patients have lost an average of 85 pounds (53% excess weight loss). By 12 months, they have lost an average of 104 pounds (65% excess weight loss). A focused effort to reduce infection has dropped our wound infection rate to 0 per cent in the past 6 months. Our results indicate that with proper planning, it is possible to initiate a new program and achieve excellent outcomes. Proper planning, systematic implementation, and a focus on patient education are critical to success.

Medicare and Medicaid status predicts prolonged length of stay after bariatric surgery

BACKGROUND

The outcomes of Medicare patients undergoing bariatric surgery have been particularly scrutinized, especially with the Center of Medicare and Medicaid Services' decision to offer bariatric surgery benefits.

METHODS

The length-of-stay (LOS) data were analyzed from the National Hospital Discharge Survey from 2002 to 2004. To test the hypothesis that Medicare and Medicaid beneficiaries were more likely to have a prolonged length of stay (PLOS), we used a multivariate logistic regression model controlling for age, gender, hospital size, and year of procedure.

RESULTS

An estimated 312,000 bariatric procedures were performed nationally from 2002 to 2004. The average patient age was 41.5 years (range 14-75) and 83.6% were women. The in-hospital mortality rate was reported to be .17%. A PLOS occurred in 3.7% of the population. The Medicare and Medicaid beneficiaries represented 5.7% and 6.2% of the population, respectively. The Medicare beneficiaries were 6.0 times (95% confidence interval 2.5-14; P <.001) as likely to have a PLOS, and Medicaid beneficiaries were 3.2 times (95% confidence interval 1.2-8.9; P = .02) as likely to have a PLOS as others after controlling for age, gender, hospital size, and year of procedure. For every 10-year increase in age, the risk of a PLOS increased by 30% (P <.012).

CONCLUSION

Medicare and Medicaid beneficiaries are both at an increased risk of a PLOS. This study was not designed to identify the potential causes of a PLOS. Data from prospectively collected bariatric registries might aid surgeons in assessing the risk/benefit ratio of surgical interventions in groups regarded as high risk.

Initial trocar placement and abdominal insufflation in laparoscopic bariatric surgery

INTRODUCTION

Initial trocar placement and abdominal insufflation in laparoscopic bariatric surgery can be challenging for the novice. One technique is the use of an optical viewing trocar without prior abdominal insufflation. This investigation tests the hypothesis that this technique can be taught to novice surgeons with good results.

METHODS

Patients undergoing laparoscopic bariatric surgery were included. Novice surgeons (residents/fellows) with 0-50 initial trocar placements placed the initial trocar and insufflated the abdomen in the presence of an expert surgeon (>300 initial trocar placements in morbidly obese patients). Trocar placement time was defined as the time to place the trocar into the peritoneal cavity (including infiltration of local anesthesia and incision). Insufflation time was defined as the time to insufflate the abdomen to a pressure of 10 to 15 mm Hg (including time to place tubing on trocar). Novice times were compared with expert times.

RESULTS

There were 81 patients (56 by expert and 25 by novice) in this study. No bowel or vessel injury during initial trocar placement was noted. No correlation was seen between times and BMI or waist/hip circumference (P = NS). Mean expert trocar placement time was shorter than the mean novice time (25 +/- 9 versus 54 +/- 27 s; P < 0.0001); although there was no difference in mean insufflation time (expert versus novice: 16 +/- 5 versus 19 +/- 10; P = NS). The mean total time to place the initial trocar and insufflate the abdomen for the novices was 72 +/- 26 s.

CONCLUSIONS

Initial trocar placement can be taught safely to novices. The technique using an optical viewing trocar without prior abdominal insufflation is effective and efficient in morbidly obese patients.