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

Are African-Americans as successful as Caucasians after laparoscopic gastric bypass?

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been demonstrated to provide weight loss comparable to open gastric bypass. It has been suggested that African-Americans (AA) are not as successful as Caucasians (CA) after bariatric surgery. Our hypothesis was that AAs are just as successful as CA after LRYGBP in terms of weight loss and comorbidity improvement.

METHODS

A retrospective chart review was performed on all AA and CA patients who underwent LRYGBP for a 6-month period. Success after LRYGBP [defined as (1) 25% loss of preoperative weight, (2) 50% excess weight loss (EWL), or (3) weight loss to within 50% ideal weight] was compared by ethnicity.

RESULTS

102 patients were included in this study. 97 patients (30 AA patients and 67 CA patients) had at least 1-year follow-up data available. Preoperative data did not differ between both groups. There was a statistically significant difference in %EWL between AA and CA (66% vs 74%; P<0.05). However, there was no ethnic difference in the percentage of patients with successful weight loss (as defined by any of the above 3 criteria). Furthermore, there was no statistical difference between the percentages of AA and CA patients who had improved or resolved diabetes and hypertension.

CONCLUSIONS

LRYGBP offers good weight loss in all patients. While there may be greater %EWL in CA patients, no ethnic difference in successful weight loss exists. More importantly, co-morbidities improve or resolve equally between AA and CA patients. LRYGBP should be considered successful in AA patients.

Complications at gastrojejunostomy after laparoscopic Roux-en-Y gastric bypass: comparison between 21- and 25-mm circular staplers

BACKGROUND

Complications involving the gastrojejunostomy (GJ) after laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity frequently result in hospital readmission and additional procedures. The purpose of this study was to compare the complication rate of GJ performed with the 21- and 25-mm circular staplers.

METHODS

We retrospectively reviewed the incidence of stricture, bleeding, ulcer, and leak at the GJ in 438 consecutive patients who had undergone LRYGB.

RESULTS

The GJ was performed using the 25-mm stapler in 374 patients and the 21-mm stapler in 64 patients. Of the 50 anastomotic complications, 11 (17.2%) occurred with the 21-mm stapler, including 6 strictures (9.4%), 4 ulcers (6.3%), and 1 leak (1.6%), and 39 (10.4%) with the 25-mm stapler, including 11 strictures (2.9%), 6 acute bleeding episodes (1.6%), 19 ulcers (5.4%), and 4 leaks (1.1%). Rehospitalization was required in 9 patients (47%) with a pure stricture and 17 (74%) with ulcers. The incidence of pure stricture was significantly greater in the GJ performed with the 21-mm than with the 25-mm stapler (P = .026, Fisher's exact test). No difference was found in the rate of acute bleeding, leak, or ulcer between the 2 groups. All strictures resolved with balloon dilation. Four patients with stenotic ulcers that failed to respond to dilation and medications required operative revision. No difference was found in postoperative weight loss between the 2 groups.

CONCLUSION

Anastomotic complications were recognized in 50 (11.4%) of 438 patients who had undergone LRYGB in which the GJ was performed using circular staplers, including 11 (17.2%) with the 21-mm and 39 (10.2%) with the 25-mm stapler. The rate of anastomotic stricture was significantly lower using the 25-mm circular stapler.

Results of Teenaged Bariatric Patients Performed in an Adult Program

BACKGROUND

Morbid obesity is a growing epidemic among adolescents. Bariatric surgery has proven to be the only long-term effective method in treating morbidly obese adults for over a decade. The laparoscopic approach has become a popular option. This study tested the hypothesis that laparoscopic Roux-en-Y gastric bypass is a feasible option in teenaged patients with good results through an adult bariatric program.

METHODS

All patients under the age of 20 at the time of surgery were included in this study. Each patient had undergone a laparoscopic Roux-en-Y gastric bypass. Charts were reviewed for preoperative evaluation, operative time, complications, and length of hospital stay. Percentage of excess body weight lost (%EBWL) was calculated at the follow-up.

RESULTS

Of the 202 patients who underwent a laparoscopic gastric bypass procedure at our institution, 5 (2%) were teenagers. The mean age was 18 years (range, 17-19). The mean height was 69 inches (range, 61-75). Average weight was 323 lbs (range, 227-394). The mean preoperative body mass index was 48 kg/m2 (range, 44-56). All patients had medical and psychological clearance prior to surgery. Mean operative time was 150 minutes (range, 130-172). There were no complications in this subset of patients. All 5 patients were discharged on postoperative day 2. Follow-up ranged from 17.8 to 44.8 months. The mean %EBWL was 77% (range, 58%-88%).

CONCLUSIONS

The laparoscopic gastric bypass procedure is technically feasible in teenaged patients, with excellent results even when performed in an adult bariatric program. Long-term data will be needed to determine its role in the treatment of morbidly obese adolescents.

Laparoscopic Gastric Bypass for Morbid Obesity Decreases Bodily Pain, Improves Physical Functioning, and Mental and General Health in Women

INTRODUCTION

Surgery is an effective long-term therapeutic option for morbid obese patients. Although bariatric surgery's amelioration of medical ailments is well established, its nonphysical benefits have not been as well documented.

METHODS

Women who had undergone laparoscopic gastric bypass between August 2003 and May 2005 were provided with an SF-36 1 month before surgery, as well as 1, 3, 6, 9, 12, 15, and 18 months after surgery. Those women who completed three surveys were included in this study. Scores were summed for each of six areas analyzed: physical function, physical role limitations, emotional role limitations, bodily pain, mental health, and general health. The results of the preoperative and the last postoperative surveys were compared using Wilcoxon's signed-rank test.

RESULTS

Of 91 women considered for this study, 40 (44%) completed at least three postoperative surveys. For bodily pain, physical function, physical role limitations, mental health, and general health, median postoperative exceeded median preoperative scores (P < 0.004 for each analysis); for emotional role limitations, the median postoperative score was the same as the median preoperative score.

CONCLUSIONS

In women, gastric bypass for morbid obesity decreases bodily pain and physical role limitations, and improves physical functioning as well as mental and general health. The positive impact of laparoscopic gastric bypass is thus validated by the SF-36 questionnaire.

Successful endoscopic management of gastrojejunal anastomotic strictures after Roux-en-Y gastric bypass

BACKGROUND

Roux-en-Y gastric bypass is the most frequently performed bariatric surgery for morbid obesity. Gastrojejunal anastomotic strictures are a relatively frequent postoperative complication.

OBJECTIVE

To evaluate the clinical outcomes and therapeutic response to through-the-scope balloon dilation performed to treat anastomotic strictures after Roux-en-Y gastric bypass surgery.

DESIGN

Single-center, retrospective study.

SETTING

Academic medical center.

PATIENTS

Between 1997 and 2005, 801 patients with morbid obesity underwent Roux-en-Y gastric bypass surgery at our institution.

MAIN OUTCOME MEASUREMENTS

The development of an anastomotic stricture after Roux-en-Y gastric bypass surgery. The response to through-the-scope balloon dilation after diagnosis.

RESULTS

Forty-three of 801 patients (5.4%) developed an anastomotic stricture (26 of 294 open surgeries [8.8%]; 17 of 507 laparoscopic surgeries [3.4%]; P < .001). Strictures were dilated to 15.5 +/- 0.4 mm. There were no perforations or clinically significant bleeding after dilation; 93% of the strictures were successfully managed with 1 or 2 endoscopic sessions. Dilation to at least 15 mm did not affect weight loss at 1 year when compared with the group without a stricture (percentage excess weight loss: stricture group, 76%; no stricture group, 74%).

LIMITATIONS

Single-center, retrospective study.

CONCLUSIONS

Endoscopic balloon dilation is a safe and effective method for the management of gastrojejunostomy strictures after Roux-en-Y gastric bypass. Dilation to at least 15 mm is safe and decreases the need for further endoscopic dilation.

Weight loss and quality of life after bariatric surgery: a study of 200 patients after vertical gastroplasty or adjustable gastric banding

BACKGROUND AND OBJECTIVES

Long term evaluation of bariatric surgery must include quality of life measurement.

METHODS

Quality of life (QoL) was evaluated using the original Moorehead-Ardelt questionnaire for 200 patients operated for massive obesity in a single centre between 1994 and 2003. QoL and physical data were obtained by retrospective mail questionnaire. Surgical procedures were vertical-banded gastroplasty according to Mason (VBGM) and adjustable gastric banding (AGB) in 61 and 39% of patients, respectively. The aim of the study was to assess the nutritional outcome and QoL according to the procedure.

RESULTS

Overall, the body mass index (BMI) decreased from 50+/-8 kg/m(2) before surgery to 35.2+/-7.5 kg/m(2) at the time of the questionnaire. The percentage of weight loss was 28.8+/-12.2%. In the group treated with VBGM, the mean initial weight (P=0.003) and the percentage of weight loss (P<0.001) were significantly higher, and the QoL was better (P=0.003) than in the group treated with AGB. On the basis of the time spent since surgery, a regular weight loss was observed during the first 5 years, whereas weight subsequently increased over the five following years. Similarly, the total QoL score gradually improved during the first 5 years and worsened thereafter. However, it remained better than before surgery. A linear regression analysis showed a positive correlation between the percentage of weight loss and the QoL score (P<0.001).

CONCLUSIONS

This study suggests that the bariatric surgery, particularly the VBGM technique, improved the QoL of obese patients, at least in the first 5 years following surgery.

Accuracy of upper gastrointestinal swallow study in identifying strictures after laparoscopic gastric bypass surgery

BACKGROUND

Stricture at the gastrojejunal anastomosis after Roux-en-Y gastric bypass is a significant sequela that often requires intervention. The diagnosis of stricture is usually established by a recognized constellation of symptoms, followed by contrast radiography or endoscopy. The purpose of this report was to evaluate the accuracy of contrast swallow studies in excluding the diagnosis of gastrojejunal stricture.

METHODS

A retrospective analysis of the charts of 119 patients who had undergone laparoscopic Roux-en-Y gastric bypass, representing 41 upper gastrointestinal (GI) swallow studies, was conducted. Of those patients who underwent GI swallow studies, 30 then underwent definitive upper endoscopy to confirm or rule out stricture. The overall sensitivity, specificity, and negative predictive value of the swallow studies were calculated.

RESULTS

Of the 30 patients who underwent upper endoscopic examination for symptoms of stricture after laparoscopic gastric bypass, 20 were confirmed to have a stricture. The sensitivity, specificity, and negative predictive value of the upper GI swallow study in this group was 55%, 100%, and 53%, respectively. The demographics of the patients with strictures were similar to those of the study group as a whole.

CONCLUSION

The results of our study have shown that a positive upper GI swallow study is 100% specific for the presence of stricture. However, the sensitivity and negative predictive value of upper GI swallow studies were poor, making this modality unsatisfactory in definitively excluding the diagnosis of gastrojejunal stricture.

Endoscopic balloon dilation of stomal stenosis following gastric bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGBP) is a common operation for severely obese patients, particularly those with co-morbid disease. Postoperative complications include those amenable to endoscopic therapy, specifically those involving the gastric stoma.

METHODS

26 patients with prior history of RYGBP for morbid obesity presented with symptoms of gastric outlet obstruction. Symptoms included accelerated weight loss (n=22), nausea/vomiting (n=26), dehydration (n=5), and dysphagia (n=2). Endoscopic dilatation was performed using through-the-scope dilating balloons (8-15 mm). Following dilatation, a steroid solution was injected to prevent re-stenosis.

RESULTS

Patients underwent 1-7 dilating sessions (mean 2.7/patient) at 2-week intervals. Estimated stoma diameter prior to dilation ranged from 1 mm to 8 mm (mean 3.5). Following dilation, diameter of the stoma increased to 10 to 15 mm (mean 12.4) at final endoscopy. In patients requiring a single dilating session (n=7), predilation stoma size was a mean 5.8 mm (range 3-8 mm), which increased to a mean of 12.7 mm (range 10-15 mm). In patients requiring multiple dilating sessions (n=19), pre-dilation stoma size was a mean of 2.7 mm (range 0-4 mm), which increased to a mean of 12.2 mm (range 10-14 mm). 25 of 26 patients had good long-term response, with follow-up of 6-38 months (mean 26). No treatment-related complications occurred. All had appropriate weight loss as determined at the bariatric clinic following endoscopic therapy.

CONCLUSIONS

Of the complications following bariatric surgery that are amenable to endoscopic therapy, stomal stenosis appears to be relatively common. Endoscopic balloon dilation is an effective nonsurgical method for treatment of stomal stenosis, with no complications observed in this, the largest reported, series.

Antecolic versus retrocolic alimentary limb in laparoscopic Roux-en-Y gastric bypass: a comparative study

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) has become the most common surgical treatment for morbid obesity. Intestinal obstruction and internal hernias are complications more commonly observed after LRYGB than after open RYGB. The aim of this study was to evaluate the incidence of these complications in patients who had undergone LRYGB using an antecolic versus a retrocolic technique.

METHODS

From August 2001 to August 2005, LRYGB was performed in 754 patients. The retrocolic and antecolic technique was used in 300 and 454 consecutive patients, respectively. The mean patient age was 37 +/- 10 years, and 552 of the patients (73%) were women. The mean preoperative body mass index was 41.3 +/- 5 kg/m2. The median follow-up was 16 months.

RESULTS

During follow-up, 36 patients (4.7%) underwent surgical exploration secondary to intestinal obstruction. This complication was observed in 28 (9.3%) and 8 (1.8%) patients in the retrocolic and antecolic technique groups, respectively (P <.001). In the retrocolic technique group, an internal hernia developed in 24 patients compared with 3 patients in the antecolic technique group. On multivariate analysis, the retrocolic technique was identified as a risk factor (P <.001).

CONCLUSION

A greater incidence of intestinal obstruction and internal hernia was observed in the retrocolic technique group than in the antecolic technique group undergoing LRYGB. The results of our study have shown that the use of the retrocolic technique is a risk factor for intestinal obstruction after LRYGB.

Use and outcomes of laparoscopic versus open gastric bypass at academic medical centers

BACKGROUND

A large outcome study of laparoscopic gastric bypass has not been done because of difficulty in differentiating between open and laparoscopic procedures in the absence of a specific ICD-9 procedural code for the laparoscopic operation. The University HealthSystem Consortium (UHC) clinical database recently added a specific procedural code for laparoscopic gastric bypass. The goal of this study was to compare the use and outcomes of laparoscopic versus open gastric bypass at academic centers.

STUDY DESIGN

Using ICD-9 diagnosis and procedure codes, we obtained data from the UHC clinical database for all patients who underwent laparoscopic or open Roux-en-Y gastric bypass for treatment of morbid obesity between 2004 and 2006 (n = 22,422). The main outcomes measures were demographics, comorbidities, length of hospital stay, 30-day readmission, morbidity, observed and expected (risk-adjusted) mortality, and costs.

RESULTS

There were 16,357 patients who underwent laparoscopic gastric bypass and 6,065 patients who underwent open gastric bypass. Laparoscopic gastric bypass patients had a shorter length of hospital stay (2.7 days versus 4.0 days, p < 0.01); lower overall complications (7.4% versus 13.0%, p < 0.01); lower rates of pneumonia, venous thrombosis, leak, wound infection, and pulmonary complications; costs were also lower. The observed-to-expected in-hospital mortality ratio was similar between groups (1.0 versus 1.0).

CONCLUSIONS

This nationwide analysis of academic medical centers between 2004 and 2006 showed that bariatric surgery has shifted to a predominately laparoscopic approach. In addition, laparoscopic gastric bypass is as safe as open gastric bypass and is considerably associated with a lower 30-day morbidity.

Robotic foregut surgery

BACKGROUND

Computer-assisted surgical systems, or surgical robots as they are more commonly called, are complex new devices which may be used to perform minimally invasive surgical procedures. There are certain technical limitations to a traditional laparoscopic approach that these devices can help a surgeon to overcome. Several surgical teams have applied these new devices to surgical procedures of the upper gastrointestinal tract and foregut.

METHODS

A retrospective review of the currently published literature on robotic foregut surgery.

RESULTS

Robotic foregut surgery appears to be feasible and safe. These procedures may be associated with increased operative time and cost when compared to their traditional laparoscopic counterparts. Procedures that require complex manoeuvres, delicate dissection, or a magnified high-definition image may be best suited to a computer-assisted approach.

CONCLUSIONS

Robotic foregut surgery is an exciting new field with tremendous potential for growth and dissemination.

Long-term Follow-up on the Effect of Silastic Ring Vertical Gastroplasty on Weight and Co-Morbidities

BACKGROUND

Silastic ring vertical gastroplasty (SRVG) is a simple, effective and reproducible restrictive operation for the treatment of morbid obesity. Over the last years, it has lost its popularity due to the development of adjustable gastric banding systems performed laparoscopically. In order to evaluate the long-term effect of SRVG on weight loss and co-morbidities, we reviewed the results of SRVG operations in our institution.

METHODS

We reviewed SRVG operations performed in our University-affiliated General Hospital. Data was collected from the patients' in-patient records, their outpatient-clinic files, and from a telephone interview.

RESULTS

Between 1989 and 2001, 162 patients were operated upon. Complete follow-up was obtained of 115 patients (71%). The mean follow-up was 7.1 +/- 3 years (range 4 to 16 years). Mean preoperative BMI was 47 kg/m2 (range 34 to 69 kg/m2). Maximal weight loss was obtained within 1 year to a mean BMI of 29 kg/m2, with a mean excess BMI loss of 67%. Subsequently, there was a small increase in BMI, which stabilized at 34 kg/m2 up to 15 years after the operation. A rapid, significant improvement in obesity-related co-morbidities was observed regarding hypertension (81%), diabetes (100%), sleep disorders (90%), osteoarthritis (83%) and ischemic heart disease (75%). There was no peri-operative mortality. Early complication rate was 10%. Late complications included postoperative ventral hernia (18%), esophagitis (31%), ring stricture (19%), ring erosion (2 patients), failure of staple line (8%) and obstruction of the pouch with food (19%). 35 patients (30%) required another procedure, 8 of them were eventually converted to other bariatric operations, and 2 patients had the ring removed and refused another bariatric procedure. The overall satisfaction rate was 86%.

CONCLUSIONS

SRVG is a simple, safe and effective bariatric operation in selected patients with morbid obesity. It results in a rapid, excellent effect on obesity-related co-morbidities and good long-term effect in weight loss, which compares positively with other, more complicated bariatric operations.

Advanced laparoscopic skills decrease the learning curve for laparoscopic Roux-en-Y gastric bypass

BACKGROUND

The reported learning curve for laparoscopic Roux-en-Y gastric bypass (LRYGB) is 20-100 cases. Our aim was to investigate whether advanced laparoscopic skills could decrease the learning curve for LRYGB with regard to major morbidity.

METHODS

The senior author performed all operations in this series. His training included a laparoscopic fellowship without bariatric surgery, six years in surgical practice focusing on upper abdominal laparoscopic surgery, two courses on bariatric surgery at national meetings, one week of observing a bariatric program, and two mentored LRGBY cases. A comprehensive obesity program was put in place before the program began. Data were collected prospectively and reviewed at the series' end. Results are presented as mean +/- standard deviation and standard statistical analysis was applied.

RESULTS

Between December 2003 and February 2005, 107 LRYGB operations were performed. Mean operative time decreased significantly with experience (p < 0.0001) and was 154 +/- 29, 132 +/- 40, 127 +/- 29, and 114 +/- 30 min by quartile. Mean length of stay was 2.9 +/- 1.6 days. Mean excess weight loss was 45.3% (n = 41) at six months. There were no conversions to an open procedure, no anastomotic leaks, no pulmonary embolisms, and no bowel obstructions. The five major complications (3 in the first 50 and 2 in the last 57 cases, p = NS) were two cases of biliopancreatic limb obstruction, two cases of significant gastrointestinal bleeding from anastomotic ulcer, and one case of gastric volvulus of the remnant stomach.

CONCLUSIONS

A bariatric fellowship and/or extended mentoring are not required to safely initiate a bariatric program for surgeons with advanced laparoscopic skills. Operative time decreases significantly with experience, but morbidity and mortality remain low even early in the learning curve. A comprehensive obesity program seems necessary for success.

Handling of the Bariatric Patient in Critical Care: A Case Study of Lessons Learned

Bariatric admissions across the United States (US) are increasing at an alarming rate. The obesity epidemic costs the US health care system $70 billion per year. Many bariatric surgical and medical patients are admitted to critical care units. The mortality risks for these patients compared with non-bariatric patients is up to 2:1. Managing these patients is a challenge to health care nursing personnel. Patient size, care required, equipment technology, availability, and environmental space can increase risk for injury for nursing personnel and patients. The Health Sciences Center in Winnipeg shares a case study of an admission of a 697-lb patient, reviewing lessons learned, techniques, equipment, and difficulties.

Health-related quality of life after gastric banding

BACKGROUND

Bariatric surgery ameliorates obesity-associated diseases, resulting in psychological and social benefits. Long-term studies of its effects on quality of life (QOL) assessed with well established instruments are lacking. This prospective study investigated the long-term effects of gastric banding on health-related QOL using an obesity-specific validated measure.

METHODS

The Health Related Quality of Life (HRQL) questionnaire was completed by 50 severely obese patients before surgery and at 1, 2.5 and 5 years after gastric banding. Ninety-eight subjects with normal weight, matched for age, sex and education, also completed the HRQL questionnaire as controls.

RESULTS

Surgery was successful in all patients. Mean excess weight loss after 1, 2.5 and 5 years was 42.1, 42.2 and 41.6 per cent respectively. General wellbeing, health distress, depression, perceived attractiveness and self-worth improved significantly over the 5 years and, except for general wellbeing, were still improving after 5 years. There were increases in physical activity and work productivity. Successful weight loss was the main determinant of general wellbeing and health distress, and these were adversely affected by band-related complications. In subjects with a body mass index below 30 kg/m(2), scores improved to values for subjects of normal weight.

CONCLUSION

Bariatric surgery resulted in sustained improvement in health-related QOL even though not all excess weight was lost. Normalization of health-related QOL may necessitate greater weight losses.

Effects of pronounced weight loss on adiponectin oligomer composition and metabolic parameters

OBJECTIVE

Adiponectin is an adipocytokine secreted into circulation in three isoforms. The aim of the study was to investigate changes of adiponectin isoforms during profound weight loss and its relation to anthropomorphometric and metabolic parameters.

RESEARCH METHODS AND PROCEDURES

Thirteen severely obese female subjects were examined before and 1 year after surgical treatment. Total adiponectin was determined by radioimmunosorbent assay, and oligomer composition was detected by nondenaturing Western blot.

RESULTS

BMI decreased substantially (p < 0.001), which was associated with an increase of total adiponectin from 12.9 +/- 5.9 to 14.3 +/- 6.1 microg/mL (p = 0.055). Medium molecular weight (MMW) adiponectin increased from 7.5 +/- 3.6 to 9.1 +/- 4.1 microg/mL (p = 0.009), whereas high (HMW) and low molecular weight adiponectin remained unchanged. Delta values of total adiponectin correlated significantly with Delta values of anthropometric parameters. Similar correlations were found for Delta values of MMW (Delta weight: r(2) = 0.4132, p = 0.0178; Delta BMI: r(2) = 0.3319, p = 0.0393; Delta fat mass: r(2) = 0.5202, p = 0.0054).

DISCUSSION

Thus, profound weight loss was associated with an increase in total adiponectin, which was mainly and consistently caused by increases in MMW adiponectin (p = 0.009). These changes result in a shift from low molecular weight to MMW and HMW adiponectin isoforms, which may be related to improvements in both anthropometric and metabolic parameters.

Bariatric surgery: a review of procedures and outcomes

The prevalence of obesity has increased in recent decades, and obesity is now one of the leading public health concerns on a worldwide scale. There is accumulating agreement that bariatric surgery is currently the most efficacious and enduring treatment for clinically severe obesity, and as a result, the number of bariatric surgery procedures performed has risen dramatically in recent years. This review will summarize historic and contemporary bariatric surgical techniques, including gastric bypass (open and laparoscopic), laparoscopic adjustable gastric banding, and biliopancreatic diversion (with or without duodenal switch). Data are presented on bariatric surgery outcomes, focusing on weight loss and obesity-related comorbidities. We also review possible complications from surgery. Bariatric surgery patients undergo many dramatic lifestyle changes, and comprehensive presurgical screening conducted by a multidisciplinary team is important to prepare patients for the numerous changes necessary for successful outcome. In addition, comprehensive presurgical screening can aid the treatment team in identifying patients who would benefit from additional services prior to or following surgery. Further research focused on presurgical variables that predict outcome-especially the longer term outcome-of bariatric surgery is needed. At present, approximately 1% of eligible individuals with morbid obesity receive bariatric surgery. In addition, there appears to be inequity in access to weight loss surgery. Given the accumulating evidence that bariatric surgery is efficacious in producing significant and durable weight loss, improving obesity-related comorbidities, and extending survival, the U.S. healthcare system should examine ways to improve access to this treatment for obesity.

Psychosocial and behavioral status of patients undergoing bariatric surgery: what to expect before and after surgery

Extreme obesity, characterized by a body mass index (BMI) of 40 kg/m(2) or greater, is associated with significantly increased mortality, principally from cardiovascular disease, type 2 diabetes, and several cancers. It also is associated with an increased risk of psychosocial complications, including depression, eating disorders, and impaired quality of life. This article briefly examines the psychosocial status of extremely obese individuals who seek bariatric surgery and describes changes in functioning that can be expected with surgically induced weight loss. The article combines a review of the literature with clinical impressions gained from the more than 2500 candidates for bariatric surgery whom the authors have evaluated at the Hospital of the University of Pennsylvania.

The tethered bezoar as a delayed complication of laparoscopic Roux-en-Y gastric bypass: a case report

Known complications of Roux-en-Y gastric bypass causing abdominal pain and obstructive symptoms include biliary colic, anastomotic ulcer, anastomotic stenosis, or internal hernia. This case report describes a new complication in a patient 15 months post-bypass: a bezoar at the gastrojejunal anastomosis, the nidus of which was a length of permanent suture material which had eroded through the gastric wall. We include endoscopic images of the bezoar, a review of the related gastric bypass literature, and describe the changes made in our practice as a result of this complication.

Predictors of outcome after obesity surgery in New York state from 1991 to 2003

BACKGROUND

This study aimed to examine hospital volume in New York state as a predictor of complications over 13 years.

METHODS

Data from the New York state Statewide Planning and Research Cooperative Systems database were analyzed by diagnosis-related group, patient demographics, and outcomes. The institution data were analyzed on the basis of volume and logistic regression using chi-square analysis for predicting morbidity and mortality.

RESULTS

From 1991 to 2003, 24,534 patients underwent bariatric surgery at 79 institutions. Case volume increased 36-fold in high-volume centers (HVCs), whereas the overall number of institutions doubled. The average mortality rate was 1.1% in low-volume centers (LVCs), 0.4% in medium-volume centers (MVCs), and 0.2% in HVCs. Whereas 12.4% of the LVC patients had postoperative anastomotic complications (PACs), only 9.7% had PACs in MVCs and only 7.3% had PACs in HVCs (p < 0.05). Furthermore, only 0.7% of the patients required postoperative reintubation (PRI) after surgery at HVCs, as compared with 1.5% at MVCs and 1.8% at LVCs (p < 0.05). Finally, 1.8% of the patients required blood transfusion of packed red blood cells at HVCs, whereas 2.4% required transfusion at MVCs and LVCs.

CONCLUSIONS

Experience correlates with fewer postoperative complications, including death, in bariatric centers in New York state.

Comparing outcomes of hand-assisted versus total laparoscopic gastric bypass

BACKGROUND

Previous studies have compared open versus hand-assisted and open versus total laparoscopic Roux-en-Y gastric bypass. This study compared hand-assisted and total laparoscopic Roux-en-Y gastric bypass surgery performed at 2 institutions by 2 surgeons, each specializing in 1 of the techniques.

METHODS

Gastric bypass operations (n = 272) were evaluated from January 1, 2004 to December 31, 2004. The comparisons between the hand-assisted (n = 149) and laparoscopic (n = 123) approach were done using the median test, t test, chi-square analysis, and Fisher's exact test.

RESULTS

The average patient age was 43.9 years, and 84% (229 of 272) of the patients were women. The average body mass index was 48.8 kg/m2. No significant difference was found between the hand-assist and laparoscopic groups in age, gender, preoperative body mass index, diabetes, hypertension, or operative time. No significant difference was found in the mortality rate between the hand-assist (2 of 149, 1.3%) and laparoscopic (1 of 123, 0.8%) groups. Also, no significant difference was found in the incidence of leaks, pulmonary embolism, deep venous thrombosis, wound infection, bowel obstruction, incisional hernia, fistula, persistent vomiting, or reoperation between the 2 procedures. A significant difference was found in the length of stay, with a median of 3 days for the hand-assist group and 2 days for the laparoscopic group (P <.001), and hemorrhage requiring transfusion, which occurred in 1 (.7%) of 149 hand-assist patients and 7 (5.7%) of 123 laparoscopic patients (P = .025). The percentage of excess weight loss 6 months after surgery was also similar between the two groups, at 50.2% and 52.1% for the hand-assist and laparoscopic groups, respectively (P = .45).

CONCLUSIONS

The results of this study have found that both hand-assist and laparoscopic Roux-en-Y gastric bypass can be accomplished with similar perioperative risks and outcomes, including weight reduction. The choice between the 2 procedures depends on surgeon preference.

Association between support group attendance and weight loss after Roux-en-Y gastric bypass

BACKGROUND

Attending support group meetings has been linked to increased weight loss after gastric bypass surgery. However, the degree to which support group attendance influences weight loss is still unclear. This study quantitatively described the association between support group attendance and weight loss after Roux-en-Y gastric bypass.

METHODS

The weight loss data and support group attendance of 78 consecutive Roux-en-Y gastric bypass patients were studied retrospectively. The patients were analyzed in 2 groups: those who attended >5 monthly support group meetings (group A) compared with those who went to < or =5 support group meetings (group B). The data from the first 12 months after surgery were analyzed.

RESULTS

Group A achieved a mean percentage of excess weight loss of 10.5% at 2 weeks after surgery, 21.4% at 6 weeks, 30.9% at 3 months, 45.4% at 6 months, 53.6% at 9 months, and 55.5% at 12 months. Group B achieved a mean percentage of excess weight loss of 11.3% at 2 weeks, 21.8% at 6 weeks, 31.8% at 3 months, 41.3% at 6 months, 45.2% at 9 months, and 47.1% at 12 months. The differences between the 2 groups were significant at P <0.05 at 9 and 12 months. The weight loss was nonlinear and slowed as patients approached 1 year after surgery.

CONCLUSION

Support groups are important for maintaining weight loss throughout the first year after surgery, especially after 6 months when the rate of weight loss from surgery begins to naturally decline. The amount of postoperative weight loss was greater than, or comparable to, the published data. Implementing regular support groups within the postoperative follow-up care may provide patients with the best chances of achieving maximal weight loss.

Predictors of early quality-of-life improvement after laparoscopic gastric bypass surgery

BACKGROUND

Quality of life is getting more attention in the medical literature. Treatment outcomes are now gauged by their effect on quality of life (QOL), along with their direct effect on diseases they are targeting. Similarly, in obesity, consensus has been reached on the importance of QOL as an independent outcome measure for obesity surgery along with weight loss and comorbidity. Therefore, the aim of this study was to assess the impact of patient demographics and comorbidities on short-term QOL improvement after laparoscopic gastric bypass (LGB) surgery.

METHODS

The change in QOL after LGB was assessed in 171 patients (147 women, 24 men; mean age, 43.1 y) using the Short-Form-36 (SF-36) questionnaire. Multivariate logistic regression analysis was used to identify patients' demographics and comorbidities predictive of major QOL improvement.

RESULTS

Body mass index decreased significantly at 3 months (48.5 +/- 5.8 to 38.4 +/- 5.4 kg/m2; P < .001) with excess weight loss of 37.4% +/- 9.2%. The SF-36 follow-up evaluation showed significant improvement (44.2 +/- 15.7 to 78.6 +/- 15.5; P < .001). A significant inverse correlation was found between QOL (before and after bypass) and the number of comorbidities (r = .29, P = .001; R = .22, P = .005; respectively), but the magnitude of QOL change did not correlate with the number of comorbidities (P = .5). When the entire cohort of patients was dichotomized according to their magnitude of change in SF-36 scores, the univariate analysis showed that the group of patients with no improvement or minor improvement in their SF-36 was characterized by a higher percentage of male sex and a lower prevalence of diabetes. These 2 preoperative factors remained statistically significant in the multivariate analysis. Preoperative diagnosis of type 2 diabetes increased the likelihood of major improvement in QOL after LGB by 6.2 times, whereas being a woman increased this likelihood by 16.1 times.

CONCLUSIONS

Significant weight loss was achieved as early as 3 months after LGB, causing substantial improvement in QOL in more than 95% of patients. Women with type 2 diabetes have the highest odds to achieve a major QOL improvement after LGB and therefore they should represent the ideal target population for surgical weight loss programs.

Obesity and considerations in the bariatric surgery patient

Morbid obesity is a worldwide pandemic. Medical problems associated with being obese include hypertension, diabetes, pulmonary restrictive disease, obstructive sleep apnea, and increased risk of cancer. In addition, there is a tremendous financial burden on society and the health care system to take care of these individuals. Bariatric surgery has proved to be a safe, effective means of sustained weight loss, which can lead to improvement or resolution of obesity-related medical conditions. Individuals who are morbidly obese represent a unique population requiring special consideration when presenting for medical care.

Anastomotic Leak following Antecolic versus Retrocolic Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the most commonly performed operation for the treatment of morbid obesity in the United States. Previous reports suggest that postoperative complications may be influenced by Roux limb orientation (antecolic versus retrocolic), although this remains controversial. The aim of this study was to analyze our experience with anastomotic leaks following LRYGBP with an antecolic- versus retrocolic-routed Roux limb.

METHODS

During the 2-year period of June 2003 to June 2005, 353 patients underwent a LRYGBP. 135 were antecolic and 218 retrocolic. All cases were performed by one of three bariatric surgeons. The decision to perform antecolic versus retrocolic LRYGBP was left to the surgeon's preference. The primary outcome measure was anastomotic leak.

RESULTS

Mean follow-up was 28 weeks. There were no perioperative deaths. Overall complication rate was 16.9%. 17 gastrojejunal leaks (4.8%) were identified, consisting of 12 intraoperative leaks (3.4%) and 5 postoperative leaks (1.4%). Postoperative gastrojejunal leak rate was higher in the antecolic group (P=0.04).

CONCLUSION

Mortality and complication rates were consistent with reported benchmarks on the efficacy and safety of LRYGBP. Our review suggests that anastomotic leak may be more common after antecolic than after retrocolic LRYGBP for morbid obesity. A prospective randomized study is needed to determine whether antecolically-routed Roux limb is an independent predictor for anastomotic leak following LRYGBP.

Efficacy of gastric bypass in the treatment of obesity-related comorbidities

BACKGROUND

Obesity is associated with multiple comorbidities, including hypertension, hypercholesterolemia, hypertriglyceridemia, diabetes mellitus, obstructive sleep apnea, osteoarthritis, back/extremity pain, gastroesophageal reflux disease (GERD), asthma, and depression. Surgical weight loss can markedly improve if not resolve many of these comorbidities.

METHODS

This was a retrospective study of 400 consecutive gastric bypass patients, analyzing postoperative resolution or improvement of obesity-related comorbidities.

RESULTS

Mean follow-up period for these patients was 12.8 months, with a range of 0.3-30.6 months. Comorbidities were present in 21%-65% of the patients. Hypertension, hyperlipidemia, diabetes mellitus, obstructive sleep apnea, GERD, and asthma either resolved or improved in 80%-100% of the patients. Arthritis, back or extremity pain, and depression also improved but to a lesser extent, in 52%-73% of patients. Our patients' quality of life greatly improved even at 6 weeks postoperatively in 35% of the patients, and this increased to >80% after 18 months.

CONCLUSIONS

Gastric bypass surgery for the treatment of morbidly obese patients has a profound positive impact on obesity-related comorbidities. Also, patients' quality of life is dramatically improved in the majority of patients when compared with their preoperative status.

Laparoscopic bariatric surgery can be safe for treatment of morbid obesity in patients older than 60 years

BACKGROUND

Previous reports have questioned the safety of bariatric surgery in older patients. The aim of this study was to quantify the perioperative morbidity and mortality of older patients undergoing laparoscopic bariatric procedures at our institution.

METHODS

A retrospective chart review of all laparoscopic bariatric procedures performed from February 1999 to September 2005 was performed to identify patients at Mount Sinai Medical Center who were older than 60 years at surgery.

RESULTS

We identified 55 patients (36 women and 19 men). The mean age was 61.5 years (range 60-70), and the mean body mass index was 46.2 kg/m2 (range 38.1-61.0). Of the 55 patients, 33 (60%) had undergone laparoscopic Roux-en-Y gastric bypass, 9 (16%) laparoscopic gastric banding, 7 (13%) laparoscopic biliopancreatic diversion with duodenal switch, 3 (5.5%) laparoscopic revisional surgery, and 3 (5.5%) laparoscopic sleeve gastrectomy. The mean operative time was 2.3 hours (range 1.1-5.5). No patients required conversion to open surgery, and no perioperative mortality occurred within 30 days. The morbidity rate was 7.3% (n = 4). One patient developed an anastomotic bleed that was treated conservatively, and another patient developed an empyema that was successfully drained with a chest tube. That patient also developed a urinary tract infection, and another patient had a wound infection. The mean length of stay was 2.8 days (range 1-14).

CONCLUSIONS

In a carefully selected patient population in a medical center with appropriate experience, laparoscopic bariatric surgery can be performed safely with low morbidity and mortality in the elderly population.

Influence of complications and extent of weight loss on quality of life after laparoscopic Roux-en-Y gastric bypass

INTRODUCTION

Obesity decreases health-related quality of life, but bariatric surgery improves it. This study evaluates the effect of laparoscopic Roux-en-Y gastric bypass, postoperative complications, and percentage of excess body weight loss on quality of life.

METHODS

SF-36v.1 questionnaires were administered preoperative (n = 505), 1 year (n = 237) and 2 years (n = 106) following laparoscopic Roux-en-Y gastric bypass. Analysis was performed using Student's t-test and multiple logistic regression analysis. Complications were defined as requiring additional intervention or hospitalization. SF-36 responses were normalized to 1998 US norms.

RESULTS

Bariatric patients scored significantly lower on all scales compared to the normal population. Health-related quality of life notably improves after surgery. At 1 year, scores not only improved from baseline, but were higher than those of the non-obese reference population regardless of complications. Compared to patients at 2 years without complications, patients experiencing complications reported decreased scores, but scores remained higher than preoperative scores in five scales. At 1 and 2 years, < or = 50% excess body weight loss decreased scores; however, scores were significantly improved from baseline.

CONCLUSIONS

Health-related quality of life in bariatric patients is worse than in controls, but it improves 1 and 2 years after laparoscopic Roux-en-Y gastric bypass. Complications or < or = 50% excess body weight loss slightly decreases this improvement.

Complications of antiobesity surgery

Bariatric surgery is an effective long-term treatment for patients who suffer from morbid obesity, the incidence of which is increasing in North America. Laparoscopic gastric bypass and laparoscopic adjustable gastric band placement are the two commonly performed bariatric procedures. This article discusses the indications for bariatric surgery and the early and late complications associated with these two procedures. Laparoscopic biliopancreatic diversion and laparoscopic sleeve gastrectomy are also briefly discussed.

Comparative study between laparoscopic adjustable gastric banding and laparoscopic gastric bypass: single-institution, 5-year experience in bariatric surgery

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are common surgical procedures for morbid obesity. Few single-institution studies have compared LRYGB and LAGB.

METHODS

All patients underwent LRYGB or LAGB at Legacy Health System. The data for the study were obtained from a prospectively maintained database. Preoperatively, most patients were allowed to choose between LRYGB and LAGB. Age, gender, body mass index, complications, mortality, and weight loss were examined.

RESULTS

From October 2000 to October 2005, 492 patients underwent LRYGB and 406 patients underwent LAGB. The mean age was 44 +/- 10 and 47 +/- 11 years, respectively (P <.001). The mean preoperative body mass index was 49 +/- 8 and 51 +/- 9 kg/m(2) (P <.05). Patients undergoing LRYGB had longer operative times (134 +/- 41 min versus 68 +/- 26 min, P <.001) and longer hospital stays (2.5 +/- 3.5 d versus 1.1 +/- 1.1 d, P <.001). Blood loss was minimal in both groups. The percentage of excess weight loss was significantly better for patients who underwent LRYGB at all points of follow-up, except at 5 years. Total complications occurred in 32% of patients who underwent LRYGB and 24% of patients who underwent LAGB (P = .002). The 90-day mortality rate was .2% in both groups. The reoperation rate was the same (17%) in both groups.

CONCLUSIONS

Patients undergoing LAGB had shorter operative times and shorter hospital stays compared with patients undergoing LRYGB. LAGB was associated with a lower complication rate. Early weight loss was significantly greater after LRYGB, but the data comparing long-term weight loss after LRYGB and LAGB have been inconclusive.

Surgery for obesity: a review of the current state of the art and future directions

The number of patients undergoing surgery for the treatment of obesity, and the proportion of the health care budget dedicated to this health problem, is growing exponentially. There are several competing surgical approaches for the management of morbid obesity. We review the literature relating to four of these: gastric bypass, biliopancreatic diversion, gastric banding, and gastric pacing. Our review finds that while enhancing the malabsorptive activity of these procedures may induce an incremental increase in excess body weight loss, the proportion of patients who fail to lose more than 50% of their excess body weight is similar no matter how radical is the surgery performed. There is little guidance from the literature as to appropriate patient selection for the varying procedures, and anonymously reported registries have yet to show that patients who undergo bariatric surgery have enhanced longevity. To date, the bariatric surgical community has not conducted adequately powered randomized prospective trials to elucidate key elements of the surgical procedure such as optimal bypass length, to determine whether mixed operations are superior to those that offer intake restriction only, and to define what constitutes success after bariatric surgery. As a public health measure, bariatric surgery in the United States is being pursued in an irrational manner, being concentrated in areas where there are fewer morbidly obese patients, and used disproportionately among the population of white obese females.

Laparoscopic bariatric patients’ will to help: the foundation of research

BACKGROUND

Bariatric surgery is a fast growing field. Clinical research is essential to its safe delivery. Bariatric patient enthusiasm for research participation has never been objectively measured. Our hypothesis was that most laparoscopic bariatric surgery patients would participate in clinical research.

METHODS

All postoperative patients were surveyed querying their willingness to participate in studies and quantifying the level of time, effort, and commitment they would comply with. Fisher's exact test, the Mann-Whitney U test, and the chi-square test were used to analyzed the responses. A total of 97 patients were the subject of this inquiry.

RESULTS

Of the 97 patients, 92% were willing to participate. Willingness was independent of race or diabetic status. Of those willing to participate, 93% agreed to additional blood tests done during routine blood draws and 75% agreed to additional blood draws. Although 98% agreed to donate fat samples during surgery, only 76% would donate at 1 month postoperatively. Also, 80% would spend 6 hours at 1 month postoperatively in the hospital for preoperative research. This decreased to 56% and 56% for 12 and 24 hours, respectively (P = .004). For postoperative research, 72% committed to 6 hours per month in the hospital. This decreased to 60% and 54% for 12 and 24 hours, respectively (P = .002). No statistical consensus was reached for the financial reimbursement patients desired for their time.

CONCLUSIONS

The results of our study have shown that almost all laparoscopic bariatric surgery patients are willing to participate in obesity-related research, including invasive procedures, when it coincides with their surgery. Enthusiasm decreased with the increasing time commitment in the pre- and postoperative period but remained for most patients.

Skills Acquisition for Laparoscopic Gastric Bypass in the Training Laboratory — an Innovative Approach

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a technically demanding procedure, with a long learning curve. The aim of this study was three-fold: to develop a task-based approach to training in LRYGBP, define a tool for objective technical skills assessments, and objectively determine the efficacy of this approach.

METHODS

Videos of expert and novice surgeons performing LRYGBP on patients and anesthetised porcine models were analyzed to define an appropriate task for skills assessment. Subsequently, a jejuno-jejunostomy model was developed using cadaveric porcine small bowel, placed into a video-box trainer. 27 surgeons of varying experience levels in advanced laparoscopic procedures performed the task. Assessments of technical skill were by hand motion analysis and video-based scoring. A further 16 surgeons inexperienced in LRYGBP attended a task-based hands-on training course and performed the jejuno-jejunostomy task at start and end of the course.

RESULTS

The jejuno-jejunostomy model differentiated between surgeons of varying experience levels for time taken (P<0.001), economy of movement (P=0.001) and video scores (P<0.001). Surgeons attending the training course made significant improvements in time taken (P=0.002) and economy of movement (P=0.006), although not for generic video scores (P=0.243) by the end of course.

CONCLUSIONS

The structured, task-based approach for commencement of training in LRYGBP leads to objective improvements in the technical skills of inexperienced surgeons at the end of a short course. The next stage of the curriculum should be to achieve proficiency in the complete procedure on an anesthetised porcine model, prior to preceptorship on human cases.

Safety and efficacy of bariatric surgery: Longitudinal Assessment of Bariatric Surgery

BACKGROUND

Obesity is a leading health concern in the United States. Because traditional treatment approaches for weight loss are generally unsuccessful in the long term, bariatric surgical procedures are increasingly being performed to treat extreme obesity. To facilitate research in this field, the National Institute of Diabetes and Digestive and Kidney Diseases responded to this knowledge gap by establishing the Longitudinal Assessment of Bariatric Surgery (LABS) consortium.

METHODS

A competitive National Institute of Diabetes and Digestive and Kidney Diseases grant process resulted in the creation of a group of investigators with expertise in bariatric surgery, internal medicine, endocrinology, behavioral science, outcomes research, epidemiology, biostatistics, and other relevant fields. These investigators have worked closely to plan, develop, and conduct the LABS study. The LABS consortium protocol is a prospective, multicenter observational cohort study of consecutive patients undergoing bariatric surgery at 6 clinical centers. LABS includes an extensive database of information systematically collected preoperatively, at surgery, perioperatively during the 30-day postoperative period, and longer term.

RESULTS

The LABS study has been organized into 3 phases. LABS-1 will include all patients > or =18 years of age who have undergone bariatric surgery by LABS-certified surgeons with the goal to evaluate the short-term safety of bariatric surgery. LABS-2, a subset of approximately 2400 LABS-1 patients, will evaluate the relationship of patient and surgical characteristics to the longer term safety and efficacy of bariatric surgery. LABS-3 will involve a subset of LABS-2 subjects who will undergo detailed studies of mechanisms involved in weight change. The rationale, goals, and approach to study bariatric surgery are detailed in this report, along with a description of the outcomes, measures, and hypotheses used in LABS-1 and -2.

CONCLUSION

The goal of the LABS consortium is to accelerate clinical research and understanding of extreme obesity and its complications by evaluating the risks and benefits of bariatric surgery. LABS investigators use standardized definitions, high-fidelity data collection, and validated instruments to enhance the ability of clinicians to provide meaningful evidence-based recommendations for patient evaluation, selection for surgery, and follow-up care.

Incidence of gastroenterostomy stenosis in laparoscopic Roux-en-Y gastric bypass using 21- or 25-mm circular stapler: a randomized prospective blinded study

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass is the most common bariatric procedure performed in the United States today. The most common early complication after laparoscopic Roux-en-Y is stenosis. No randomized studies have compared the effect of the different staplers on the incidence of stenosis or on long-term weight loss. We compared the anastomoses performed with the two sizes of circular stapler in common use.

METHODS

A total of 200 patients were randomized to undergo 21-mm (n = 100) or 25-mm (n = 100) circular stapled gastroenterostomy after induction of anesthesia. No other differences were allowed in the operative technique. Stenosis was defined as patient complaints of dysphagia leading to endoscopy within 10 weeks of surgery, in which a 9-mm diameter endoscope would not pass through the gastroenterostomy without dilation.

RESULTS

Of the 200 patients, 19 patients in the 21-mm group and 8 in the 25-mm group underwent endoscopy for symptoms (P = 0.027). Of the 19 and 8 patients, 17 and 7, respectively, had measurable stenosis at endoscopy (p = 0.035). Patients with a 21-mm anastomosis developed symptoms an average of 4.8 +/- 1.2 weeks after surgery, and those with a 25-mm anastomosis developed symptoms an average of 8.9 +/- 3.8 weeks postoperatively (P <0.001).

CONCLUSIONS

We found a significant difference in the stenosis rate between the 21-mm and 25-mm circular stapled anastomoses in laparoscopic Roux-en-Y gastric bypass. The 21-mm staplers led to significantly more endoscopies than did the 25-mm staplers. Symptoms leading to endoscopy occurred significantly later with use of a 25-mm stapler than after a 21-mm stapler.

Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5-year results of a prospective randomized trial

BACKGROUND

To perform a prospective, randomized comparison of laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB).

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); percentage of excess weight loss 83.8%) or LRYGB (n = 24, 4 men and 20 women, mean age 34.7, mean weight 120 kg, mean BMI 43.8 kg/m(2), percentage of excess weight loss 83.3). Data on the operative time, complications, reoperations with hospital stay, weight, BMI, percentage of excess weight loss, and co-morbidities were collected yearly. Failure was considered a BMI of >35 at 5 years postoperatively. The data were analyzed using Student's t test and Fisher's exact test, with P <.05 considered significant.

RESULTS

The mean operative time was 60 +/- 20 minutes for the LAGB group and 220 +/- 100 minutes for the LRYGB group (P <.001). One patient in the LAGB group was lost to follow-up. No patient died. Conversion to laparotomy was performed in 1 (4.2%) of 24 LRYGB patients because of a posterior leak of the gastrojejunal anastomosis. Reoperations were required in 4 (15.2%) of 26 LAGB patients, 2 because of gastric pouch dilation and 2 because of unsatisfactory weight loss. One of these patients required conversion to biliopancreatic diversion; the remaining 3 patients were on the waiting list for LRYGB. Reoperations were required in 3 (12.5%) of the 24 LRYGB patients, and each was because of a potentially lethal complication. No LAGB patient required reoperation because of an early complication. Of the 27 LAGB patients, 3 had hypertension and 1 had sleep apnea. Of the 24 LRYGB patients, 2 had hyperlipemia, 1 had hypertension, and 1 had type 2 diabetes. Five years after surgery, the diabetes, sleep apnea, and hyperlipemia had resolved. At the 5-year (range 60-66 months) follow-up visit, the LRYGB patients had significantly lower weight and BMI and a greater percentage of excess weight loss than did the LAGB patients. Weight loss failure (BMI >35 kg/m(2) at 5 yr) was observed in 9 (34.6%) of 26 LAGB patients and in 1 (4.2%) of 24 LRYGB patients (P <.001). Of the 26 patients in the LAGB group and 24 in the LRYGB group, 3 (11.5%) and 15 (62.5%) had a BMI of <30 kg/m(2), respectively (P <.001).

CONCLUSION

The results of our study have shown that LRYGB results in better weight loss and a reduced number of failures compared with LAGB, despite the significantly longer operative time and life-threatening complications.

Gastrojejunal anastomotic stricture after Roux-en-Y gastric bypass: ambulatory management with the Savary-Gilliard dilator

BACKGROUND

Roux-en-Y gastric bypass (RYGBP) is currently one of the most frequently performed procedures for the surgical treatment of morbid obesity. The success of this procedure's restrictive component requires a small gastrojejunostomy (GJ), which occasionally results in stenosis. The treatment of choice for this complication is balloon dilation. This study aimed to evaluate the feasibility and safety of ambulatory management for stenosis of the GJ using endoscopically guided Savary-Gilliard dilators.

METHODS

Between January 1998 and October 2003, 769 patients underwent RYGBP. The mean age of these patients was 38 +/- 12 years, and their mean body mass index (BMI) was 43 +/- 6 kg/m2. Of these 769 patients, 520 (68%) underwent open surgery and 249 (32%) underwent laparoscopic RYGBP. Patients suspected of GJ stenosis were referred for upper gastrointestinal endoscopy. Those who presented with stenosis were managed endoscopically with Savary-Gilliard dilators.

RESULTS

Stenosis at the GJ was confirmed in 53 patients (6.9%). A total of 71 dilations were performed for these patients, resulting in a mean of 1.3 dilations per patient. One dilation was needed for 41 patients (75.5%), two dilations for 9 patients (16.9%), three dilations for 3 patients (5.7%), and four dilations 1 patient (1.9%). The patients subjected to open RYGBP required a mean of 1.57 dilations, and those who had laparoscopic RYGBP required mean of 1.08 dilations. The mean time for the first dilation was 51 +/- 28 days after surgery (range, 20-178 days). All the dilations were performed in ambulatory settings. One patient (1.9%) was admitted after GJ dilation for pain. He was discharged without symptoms after 2 days with no need for invasive procedures.

CONCLUSIONS

The management and treatment of GJ stenosis after RYGBP can be effectively accomplished in ambulatory settings using endoscopically guided Savary-Gilliard dilators, with good and safe results.

A comparison of 399 open and 568 laparoscopic gastric bypasses performed during a 4-year period

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass surgery (RYGB) was introduced at the authors' institution 5 years ago. The authors analyzed the short- and long-term results of this procedure compared with those for the same procedure using the laparotomy approach over the same period.

METHODS

Retrospective analysis of a prospectively collected bariatric database used the outcome end points used by the American Society of Bariatric Surgery (ASBS) and the American College of Surgeons (ACS) in their center of excellence programs.

RESULTS

From January 2001 to July 2005, 568 laparoscopic and 399 open gastric bypasses were performed at Vanderbilt University. The patients were from the same bariatric surgery program and therefore received the same pre- and postoperative care. The hospital length of stay in the laparoscopic group was significantly shorter (2.5 +/- 2.4 days) than in the open group (3.7 +/- 3.7 days; p = 0.001). The procedure time was significantly shorter in the laparoscopic group (164 +/- 50 min) than in the open group (195 +/- 50 min; p = 0.0001). The follow-up assessment response at 2 years was 76.6%. At 2 years, the excess weight loss (EWL) was significantly greater in the laparoscopic group (71.3% +/- 18.4%) than in the open group (67.3% +/- 15.3%; p = 0.03). The wound infection rate was significantly higher in open group (9.2%) than in the laparoscopic group (1.7%; p = 0.001). There was no significant difference in 30-day mortality: open (0.50%) versus laparoscopic (0.17%; p = 0.371). There was no significant difference in the 30-day reoperation rate between the open (2.4%) and laparoscopic (2.6%; p = 0.705) groups. The 30-day readmission rate was similar in the open (5.0%) and laparoscopic (5.2%; p = 0.852) groups, as was the rate of leakage from the gastrojejunostomy in the open (0.50%) and laparoscopic (0.35%; p = 0.127) groups. The conversion rate from laparoscopic procedure to laparotomy was 1.7%.

CONCLUSION

In the authors' institution, a laparoscopic bariatric surgery program with a very low rate of morbidity and mortality has been introduced. Operative time, hospital stay, and wound complications are reduced with the laparoscopic approach. The laparoscopic and open procedures are equally safe, with equivalent 30-day mortality, readmission, reoperation, and gastrojejunostomy leakage rates.

Predictive value of upper gastrointestinal studies versus clinical signs for gastrointestinal leaks after laparoscopic gastric bypass

BACKGROUND

The utility of routine upper gastrointestinal (UGI) studies after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a matter of great debate. Because the morbidity and mortality rates associated with an unrecognized postoperative leak are high after LRYGB, diagnosis of a postoperative leak earlier would be of benefit. Clinical signs, however, may predict the diagnosis of a postoperative leak more often. This study explored the hypothesis that UGI studies are more predictive than clinical signs for the early diagnosis of a postoperative leak after LRYGB.

METHODS

All patients who underwent LRYGB at the authors' institution were included in this study. Charts were reviewed to examine immediate clinical signs (heart rate, temperature, and white blood cell count within the first 24 h), UGI studies, and clinical course. Sensitivity, specificity, positive predictive value, negative predictive value, and efficiency of clinical signs and UGI studies were calculated.

RESULTS

This study included 245 patients with a 3% rate of leak. The positive and negative predictive value of UGI studies were 67% and 99%, respectively. Only an elevated white blood count had a better predictive value (100% for negative predictive value). The efficiency of UGI studies (98%) was better than that of heart rate (83%), white blood count (8%), or temperature (95%).

CONCLUSIONS

According to our data, UGI studies are the most predictive of an early leak diagnosis. Clinical signs alone may not be as useful in predicting leaks early after laparoscopic gastric bypasses. Routine early postoperative UGI studies are a reasonable approach to predicting leaks after LRYGB.

What Happens to Patients who Do Not Follow-Up after Bariatric Surgery?

Loss of follow-up is a concern when tracking long-term clinical outcomes after bariatric surgery. The results of patients who are “lost to follow-up” are not known. After bariatric surgery, the lack of follow-up may result in less weight loss for patients. This study investigated the hypothesis that there are differences between patients who do not automatically return for their annual follow-up and those that do return. Patients who were greater than 14 months postoperative after laparoscopic gastric bypass were contacted if they had not returned for their annual appointment. They were seen in clinic and/or a phone interview was performed for follow-up. These patients (Group A) were compared with patients who returned to see us for their annual appointment (Group B) without us having to notify them. There were 105 consecutive patients, with 48 patients who did not automatically return for their annual appointment. Only six of these patients could not ultimately be contacted. There was no difference in preoperative body mass index between the two groups. Percentage excess body weight loss was greater in Group B (76 vs 65%; P < 0.003). More patients had successful weight loss (defined as within 50% of ideal body weight) in Group B (50 [88%] vs 28 [67%]; P < 0.02). We found that a significant number of patients will not comply with regular follow-up care after laparoscopic gastric bypass unless they are prompted to do so by their bariatric clinic. These patients have worse clinical outcome ( i.e., less weight loss). Caution should be taken when examining the results of any bariatric study where there is a significant loss to follow-up.

Technical tips for laparoscopic gastric banding: 6 years’ experience in 2800 procedures by a single surgical team

OBJECTIVE

We present a modified method for laparoscopic gastric banding (LGB) based on the extensive personal experience of a single team, and propose a list of comprehensive technical tips that should shorten the operation time, reduce the hospital stay, and minimize the complication rate.

BACKGROUND

Gastric banding is probably the most commonly performed bariatric procedure in Europe and Australia, as well as in Israel. Because of its minimal invasiveness, efficacy, safety, reversibility, and adjustability, it is considered a breakthrough in bariatric surgery.

METHODS

From December 1997 to December 2003, 2800 morbidly obese patients underwent LGB performed by a single team. All patients strictly met the criteria for surgery as defined by the National Institutes of Health (NIH). We excluded patients with psychiatric disorders, profound incompliance, mental retardation, and portal hypertension. Our modified technique focused especially on positioning of the port sites, retro-gastric transit of the band, band fastening, and placement of the injecting port (IP).

RESULTS

The mean overall operative time was 32 minutes. The mean hospital stay was 23 hours. Follow-up took place between 24 to 96 months, and mean body mass index (BMI) postsurgery was 29 +/- 3.2. The overall morbidity rate was 10%. Gastric perforation occurred in 5 patients. No operative or immediate postoperative deaths occurred. One patient died 8 days postoperatively due to massive pulmonary embolism.

CONCLUSION

Our satisfactory results were achieved by employing the proposed technical tips and adapting "do and don't" rules. We believe that the following compelling data will contribute to the increasing use of LGB worldwide.

Outcomes after open versus laparoscopic gastric bypass

In expert hands, laparoscopic gastric bypass (LGB) is associated with reduced morbidity and mortality compared with open bariatric surgery. The purpose of our study was to determine whether or not the results of LGB have been realized in the general US population. We used data from the nationwide inpatient sample to define differences in outcomes after LGB versus open techniques (OGB). We calculated hospital stay, in-hospital mortality, and major complications for both OGB and LGB. We noted a total of 26,940 gastric bypass procedures: LGB was coded in 16.3% and OGB in 83.7%. The mean hospital stay, mortality, wound, gastrointestinal, pulmonary, and cardiovascular complications were significantly lower after LGB (P<0.001). After we adjusted for covariates, hospital stay, pulmonary morbidity, and mortality remained significantly lower after LGB (P<0.001). In conclusion, LGB is associated with significantly lower mean hospital stay and with reduced morbidity and mortality as compared with OGB.

Can bariatric surgery be done as an outpatient procedure?

It has become increasing clear that some types of bariatric surgery can be performed as outpatient operations. This is currently limited to lap-band, lap-RYGB, and some lap-revision operations, but may soon be applicable to other bariatric procedures. In fact, most lap-band procedures are currently performed in ambulatory surgical centers that often lack the capacity for an overnight stay. Lap-RYGB has been recently reported with 23-hour outpatient admission requiring an overnight stay. Careful patient selection, surgeon experience, and integrating the appropriate perioperative care components are associated with clinical success. Surgeon recognition of these possibilities and patient demand are already pushing this care across the nation. Only time will tell how many other bariatric operations will be performed as outpatient procedures, but if the past is any indication of the future, this trend should continue to increase. The question thus is not whether bariatric surgery can be done as an outpatient procedure, but rather by whom and in what setting can patient outcome be optimized. In the end, rhetoric is rhetoric and data are data, and we should let documented patient outcome, the crown jewel of bariatric surgery, guide the future.

Surgical revision of loop (“mini”) gastric bypass procedure: multicenter review of complications and conversions to Roux-en-Y gastric bypass

BACKGROUND

The claim that the "mini"-gastric bypass (MGB) procedure with its loop gastrojejunostomy is safer and equally effective to the Roux-en-Y gastric bypass (RYGB) procedure has been promoted before validation. Rumors of unreported complications and the accuracy of follow-up are additional concerns. This study was undertaken to identify MGB patients who require or required revisional surgery at 5 hospitals within the region of the United States where the MGB procedure originated to assess the claim that revision to RYGB is rarely needed.

METHODS

The databases of 5 medical centers were retrospectively searched to identify patients undergoing surgical revision after a MGB procedure, all of which had been done elsewhere.

RESULTS

A total of 32 patients were identified who presented with complications after undergoing an MGB procedure and required or require revisional surgery. The complications included gastrojejunostomy leak in 3, bile reflux in 20, intractable marginal ulcer in 5, malabsorption/malnutrition in 8, and weight gain in 2. Of the 32 patients, 21 required conversion to RYGB and an additional 5 have planned revisions in the future. Also, 2 patients were treated with Braun enteroenterostomies and 4 required 1 or more abdominal explorations.

CONCLUSIONS

The results of this preliminary review have confirmed that MGB does require revision in some patients and that conversion to RYGB is a common form of revision. A national registry to record the complications and number of revisions is proposed to gain insight into the need for revision after MGB and other nontraditional bariatric procedures.

Surgery for morbid obesity

The prevalence of morbid obesity in the UK population is rising, bringing with it increased levels of cardiovascular disease, diabetes, arthritis and early mortality. The overall cost to the health service is high, and is set to increase over the coming decades as the overweight population ages. Dietary, lifestyle and pharmacological interventions offer at best reasonable, short-term weight reduction and often fail. Surgical intervention is a safe and effective means of delivering marked long-term weight reduction. This article compares and contrasts the options available for surgical treatment of morbid obesity based on a review of the current literature.

Natural history of morbid obesity without surgical intervention

BACKGROUND

To study the mortality among morbidly obese patients qualifying for bariatric surgery. Mortality from bariatric surgery for morbid obesity has been widely reported; however, little is known about the mortality in morbidly obese patients who defer surgery.

METHODS

Consecutive patients evaluated for bariatric surgery with an initial encounter between 1997 and 2004 were identified. The Social Security Death Index and office records were used to identify mortality through 2006. We conducted telephone interviews to determine whether the 305 patients who did not undergo bariatric surgery at our institution had undergone the surgery elsewhere. Using Cox proportional hazards models, we compared the mortality in patients undergoing surgery with that of those who did not. To evaluate bias resulting from missing data, we conducted analyses assuming that all patients with missing data had (1) undergone surgery and (2) not undergone surgery.

RESULTS

A total of 908 patients underwent bariatric surgery (880 patients at our institution and 28 patients elsewhere). A total of 112 patients did not undergo surgery. Data regarding surgery on 165 patients could not be obtained. The mortality in those patients who did not undergo surgery was 14.3% compared with 2.9% for those who did undergo surgery. Adjusting for age, gender, and body mass index, patients who had undergone surgery had an 82% reduction in mortality (hazard ratio 0.18, 95% confidence interval 0.09-0.35, P <.0001). Sensitivity analysis, assuming that all patients with missing data received surgery resulted in an 85% mortality reduction (P <.001) and assuming that patients did not receive surgery resulted in a 50% mortality reduction (P = .04).

CONCLUSIONS

Mortality among morbidly obese patients without surgery was 14.3% during the study period. Surgical intervention offered a 50%-85% mortality reduction benefit.

Establishing a laparoscopic bariatric program in a safety net hospital

BACKGROUND

Most laparoscopic bariatric programs are situated in a community- or university-based hospital. The authors have recently initiated a program at a safety net hospital. This investigation hypothesizes that a laparoscopic bariatric program can be established at a safety net hospital with good clinical and financial results.

METHODS

A laparoscopic bariatric program was initiated December 2002 at a safety net hospital. The program included a dedicated operative suite, an operative team, a bariatric unit, and a clinical pathway. The data for all the patients who underwent laparoscopic gastric bypasses up to June 2003 were analyzed. The patients were analyzed by type of insurance: government-sponsored insurance (G) or commercial insurance (C).

RESULTS

There were 104 patients during this period. Their mean age was 40 years (range, 18-63 years), and their mean body mass index was 48 (range, 38-62). The median length of hospital stay was 2 days (mean, 3.9 days). Hypertension and diabetes were resolved for more than 80% of the patients. The average percentage of excess body weight loss was 73% after 1 year. There were no significant clinical differences between payor groups. The payor mix was 31% G and 69% C. The mean collection rates for hospital charges were 10% for G versus 53% for C (p < 0.0001).

CONCLUSIONS

A laparoscopic bariatric program can be established in a safety net hospital with good clinical results. Findings showed that 1-year weight loss and comorbidity improvement/resolution compares favorably with those of other programs. Despite the overall poor payor mix of many safety net hospitals, a bariatric program can be established and can attract a high rate of commercially insured patients.