Randomized clinical trial of hand-assisted laparoscopic versus open Roux-en-Y gastric bypass for the treatment of morbid obesity

Short- and long-term mortality after bariatric surgery: A systematic review and meta-analysis

AIMS

The objective of this study was to investigate short- (≤ 30 days) and long-term (≥ 2 years) all-cause mortality after bariatric surgery among adult patients with obesity.

MATERIALS AND METHODS

For short-term mortality, eligible studies comprised randomized controlled trials (RCTs) reporting perioperative mortality. For long-term mortality, eligible studies comprised RCTs and observational studies comparing mortality between obese patients after bariatric surgery and non-operated controls. Random-effects models using a Bayesian or frequentist approach were used to pool effect estimates of short- and long-term mortality, respectively.

RESULTS

Short-term all-cause mortality based on 38 RCTs involving 4030 patients was 0.18% (95% CI, 0.04%-0.38%) and was higher for open surgeries (0.31%; 95% CI, 0.03%-0.97%) and similar in mixed surgeries (0.17%; 95% CI, 0.03%-0.43%) and restrictive surgeries (0.17%; 95% CI, 0.03%-0.45%). For long-term mortality, 12 observational studies involving 27 258 operated patients and 97 154 non-operated obese controls were included. Of these, 8 studies were eligible for the meta-analysis, which showed a reduction of 41% in all-cause mortality (hazard ratio, 0.59; 95% CI, 0.52-0.67; P < .001). Additionally, operated patients were 0.42 times as likely (95% CI, 0.25-0.72, P < .001) and 0.47 times as likely (95% CI, 0.36-0.63, P < .001) as non-operated obese controls to die from cardiovascular diseases and cancer, respectively.

CONCLUSIONS

Bariatric surgery is associated with low short-term mortality and may be associated with long-term reductions in all-cause, cardiovascular and cancer-related mortality.

Laparoscopic versus open obesity surgery: a meta-analysis of pulmonary complications

The clinical effects of laparoscopy in the pulmonary function of obese patients have been poorly investigated in the past. A systematic review was undertaken, with the objective to identify published evidence on pulmonary complications in laparoscopic surgery in the obese. Outcome measures included pulmonary morbidity, pulmonary infection and mortality. The random effects model was used to calculate combined overall effect sizes of pooled data. Data are presented as the odds ratio (OR) with 95% confidence interval (CI). A total of 6 randomized and 14 observational studies were included, which reported data on 185,328 patients. Pulmonary complications occurred in 1.6% of laparoscopic and in 3.6% of open procedures (OR 0.45, 95% CI 0.34-0.60). Pneumonia was reported in 0.5% and in 1.1%, respectively (OR 0.45, 95% CI 0.40-0.51). Available evidence suggests lower pulmonary morbidity for laparoscopic surgery in obese patients; further quality studies are however necessary to consolidate these findings.

Laparoscopic revolution in bariatric surgery

The history of bariatric surgery is investigational. Dedicated surgeons have continuously sought for an ideal procedure to relieve morbidly obese patients from their burden of comorbid conditions, reduced life expectancy and low quality of life. The ideal procedure must have low complication risk, both in short- and long term, as well as minimal impact on daily life. The revolution of laparoscopic techniques in bariatric surgery is described in this summary. Advances in minimal invasive techniques have contributed to reduced operative time, length of stay, and complications. The development in bariatric surgery has been exceptional, resulting in a dramatic increase of the number of procedures performed world wide during the last decades. Although, a complex bariatric procedure can be performed with operative mortality no greater than cholecystectomy, specific procedure-related complications and other drawbacks must be taken into account. The evolution of laparoscopy will be the legacy of the 21^st century and at present, day-care surgery and further reduction of the operative trauma is in focus. The impressive effects on comorbid conditions have prompted the adoption of minimal invasive bariatric procedures into the field of metabolic surgery.

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Surgical approaches to the treatment of obesity: bariatric surgery

As the obesity epidemic continues to grow in the Unites States, so does the search for the ideal nonsurgical or surgical solution. Bariatric surgery continues to be the most sustainable form of weight loss available to morbidly obese patients. In addition, bariatric surgery has established an acceptable safety profile with respect to morbidity and mortality. With the number of elective bariatric cases growing in recent years, it is unsurprising that results have improved and better data are emerging regarding improvement of obesity-related comorbid conditions. Additionally, ample evidence suggests that bariatric surgery may increase longevity, particularly through reducing cardiovascular deaths. Although the specific mechanisms involved in the remission of these medical conditions remain to be fully elucidated, it has become clear that bariatric surgery has established a significant and firm role in the treatment of medical comorbidities that result directly from obesity. However, until commercial insurance carriers provide improved coverage for bariatric surgery, patient access to these treatments will remain limited.

The effects of laparoscopic vs. open gastric bypass for morbid obesity: a systematic review and meta-analysis of randomized controlled trials

The aim of this meta-analysis was to assess the effects of laparoscopic vs. open gastric bypass for morbid obesity. A systematic review of the literature was undertaken to assess randomized controlled trials on laparoscopic and open gastric bypass for morbid obesity. Six randomized controlled trials involving a total of 422 patients were included. There were 214 patients in the laparoscopic group and 208 patients in the open group separately. Compared with open surgery, laparoscopic surgery for morbid obesity could significantly shorten hospital stays (WMD=-1.11 d, 95% confidence interval [CI][-1.65, -0.56]). However, laparoscopic surgery for morbid obesity showed higher re-operation (RR=4.82, 95% CI [1.29, 17.98]) and longer surgical time (WMD=28.00 min, 95% CI [7.84, 48.16]). There were no statistical differences in complication (RR=0.84, 95% CI [0.64, 1.10]) and weight loss (WMD=1.00 kg m(-2), 95% CI [-0.79, 2.79]). The effects of laparoscopic and open gastric bypass for morbid obesity were basically the same except that laparoscopic had a shorter hospital stay and open surgery had a rate of fewer re-operations and shorter surgical time. Further high-quality, long follow-up period randomized controlled trials should be carried out to provide more reliable evidence.

Gastric bypass promotes more lipid mobilization than a similar weight loss induced by low-calorie diet

Background. Recently, we found large reductions in visceral and subcutaneous fat one month after gastric bypass (GBP), without any change in liver fat content. Purpose. Firstly to characterize weight loss-induced lipid mobilization after one month with preoperative low-calorie diet (LCD) and a subsequent month following GBP, and secondly, to discuss the observations with reference to our previous published findings after GBP intervention alone. Methods. 15 morbidly obese women were studied prior to LCD, at GBP, and one month after GBP. Effects on metabolism were measured by magnetic resonance techniques and blood tests. Results. Body weight was similarly reduced after both months (mean: -8.0 kg, n = 13). Relative body fat changes were smaller after LCD than after GBP (-7.1 ± 3.6% versus -10 ± 3.2%, P = .029, n = 13). Liver fat fell during the LCD month (-41%, P = .001, n = 13) but was unaltered one month after GBP (+12%). Conclusion. Gastric bypass seems to cause a greater lipid mobilization than a comparable LCD-induced weight loss. One may speculate that GBP-altered gastrointestinal signalling sensitizes adipose tissue to lipolysis, promoting the changes observed.

Vasoreactivity is rapidly improved in obese subjects after gastric bypass surgery

BACKGROUND

Obesity is associated with increased risk of cardiovascular disease. We investigated vasoreactivity in conduit and resistance arteries in morbidly obese subjects, and the effect of weight loss after gastric bypass surgery.

METHODS

A total of 19 obese subjects (body mass index (BMI): 43.8+/-3.1 kg m(-2), 75% female, mean age 41 years) were investigated before surgery and after 1 and 12 months of surgery. Nineteen non-obese controls matched for age and gender were examined. Vasoreactivity was evaluated by ultrasound to measure flow-mediated dilation (FMD, evaluating a conduit vessel) and pulse-wave analysis with terbutaline provocation (change in reflectance index (RI), evaluating resistance vessels).

RESULTS

Before surgery, the obese showed a low change in RI (18+/-12 vs 37+/-15% in controls, P=0.0001), but not significantly regarding FMD (7.9+/-6.4 vs 8.9+/-5.4% in controls). Surgery resulted in a weight loss of 9% at 1 month and 30% at 1 year. Change in RI markedly improved to 36+/-12% at 1 month (P=0.0001 vs baseline) and further to 44+/-11% at 1 year (P=0.014 vs 1 month). FMD did not change significantly. Heart rate and brachial artery diameter were reduced, with no significant change in blood pressure. The improvement in resistance vessel vasodilation, estimated as change in RI, was not correlated to changes in weight or measures of glucose and lipid metabolism.

CONCLUSIONS

Obese patients showed impaired vasoreactivity in resistance arteries that was normalized already 1 month after gastric bypass surgery. The basis for this remarkable outcome, not significantly related to changes in body weight and metabolic variables, remains to be clarified.

Surgery for obesity

BACKGROUND

Bariatric (weight loss) surgery for obesity is considered when other treatments have failed. The effects of the available bariatric procedures compared with medical management and with each other are uncertain. This is an update of a Cochrane review first published in 2003 and previously updated in 2005.

OBJECTIVES

To assess the effects of bariatric surgery for obesity.

SEARCH STRATEGY

Studies were obtained from computerized searches of multiple electronic bibliographic databases, supplemented with searches of reference lists and consultation with experts in obesity research.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing different surgical procedures, and RCTs, controlled clinical trials and prospective cohort studies comparing surgery with non-surgical management for obesity.

DATA COLLECTION AND ANALYSIS

Data were extracted by one reviewer and checked independently by two reviewers. Two reviewers independently assessed trial quality.

MAIN RESULTS

Twenty six studies were included. Three RCTs and three prospective cohort studies compared surgery with non-surgical management, and 20 RCTs compared different bariatric procedures. The risk of bias of many trials was uncertain; just five had adequate allocation concealment. A meta-analysis was not appropriate.Surgery results in greater weight loss than conventional treatment in moderate (body mass index greater than 30) as well as severe obesity. Reductions in comorbidities, such as diabetes and hypertension, also occur. Improvements in health-related quality of life occurred after two years, but effects at ten years are less clear.Surgery is associated with complications, such as pulmonary embolism, and some postoperative deaths occurred.Five different bariatric procedures were assessed, but some comparisons were assessed by just one trial. The limited evidence suggests that weight loss following gastric bypass is greater than vertical banded gastroplasty or adjustable gastric banding, but similar to isolated sleeve gastrectomy and banded gastric bypass. Isolated sleeve gastrectomy appears to result in greater weight loss than adjustable gastric banding. Evidence comparing vertical banded gastroplasty with adjustable gastric banding is inconclusive. Data on the comparative safety of the bariatric procedures was limited.Weight loss and quality of life were similar between open and laparoscopic surgery. Conversion from laparoscopic to open surgery may occur.

AUTHORS' CONCLUSIONS

Surgery is more effective than conventional management. Certain procedures produce greater weight loss, but data are limited. The evidence on safety is even less clear. Due to limited evidence and poor quality of the trials, caution is required when interpreting comparative safety and effectiveness.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist health-care professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Surgical approaches to the treatment of obesity: bariatric surgery

As bariatric surgery for the treatment of morbid obesity enters its sixth decade, much has been and continues to be learned from the results of several key bariatric operations, particularly the Roux-en-Y gastric bypass. Because of the obesity epidemic and development of the laparoscopic approach, bariatric procedures have increased exponentially in the past decade and are now among the more commonly performed gastrointestinal operations. Emerging data support the role of bariatric surgery as an effective treatment for improvement or remission of type 2 diabetes, hypertension, dyslipidemia, and multiple other comorbid conditions that accompany obesity. The mechanisms involved in the remission of these conditions, however, remain poorly understood and constitute an exciting area of research. This article delineates the current types of bariatric surgery, their respective outcomes, and their impact on obesity-related medical comorbidities.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Lipid mobilization following Roux-en-Y gastric bypass examined by magnetic resonance imaging and spectroscopy

BACKGROUND

Recent developments of magnetic resonance imaging (MRI) and spectroscopy have made it possible to quantify lipid deposited in different tissues. To what extent an improvement of glucose tolerance shortly after Roux-en-Y gastric bypass surgery (RYGBP) is reflected in lipid levels in liver and skeletal muscle, markers of insulin resistance, has not been clarified.

METHODS

Whole-body MRI and MR spectroscopy (MRS) of liver and muscle and measurements of biochemical markers of glucose and lipid metabolism were performed at baseline and 1, 6, and 12 months following surgery in seven morbidly obese women. Volumes of adipose tissue depots and liver and muscle lipids were assessed from the MRI/MRS data.

RESULTS

At 1 month postoperatively, body mass index and visceral and subcutaneous adipose tissues were reduced by 9%, 26%, and 10%, respectively, whereas no reductions in intrahepatocellular or skeletal intramyocellular lipid concentrations were found. Free fatty acid and beta-hydroxybutyrate levels were elevated two- and sixfold, respectively; glucose and insulin levels were lowered, indicating increased insulin sensitivity. Further weight loss up to 1 year was associated with reductions in all investigated lipid depots investigated, with the exception of the intramyocellular compartment.

CONCLUSION

RYGBP causes rapid lipid mobilization from visceral and subcutaneous adipose depots and enhanced free fatty acid flux to the liver. An exceptional disconnection between liver fat and insulin sensitivity occurs in the early dynamic phase after surgery. However, in the late phase, the energy restriction imposed by the surgical procedure also reduces the liver lipids, but not the intramyocellular lipids.

Outcome of hand-assisted laparoscopic gastric bypass in super obese patients

BACKGROUND

The optimal surgical treatment for super obese patients (body mass index [BMI] >or=50 kg/m2) has been a challenge and debate for most bariatric surgeons. To compare the outcomes of hand-assisted laparoscopic Roux-en-Y gastric bypass (HALGB) in super obese patients (BMI >or=50 kg/m2) to morbidly obese patients (BMI <50 kg/m2).

METHODS

A total of 295 patients who underwent HALGB from October 2003 to December 2005 were studied. These patients included 177 with a BMI of <or=49 kg/m2 (morbidly obese) and 118 with a BMI of >or=50 kg/m2 (super-obese). The patient demographics, complications, and outcomes were examined. Additionally, the 12-month postoperative outcomes included the percentage of excess weight loss and improvement of co-morbidities.

RESULTS

The patient age and gender were similar between the 2 groups. The super-obese patients had significantly more co-morbidities and required a greater number of medications. A significant difference was found in 3 early postoperative complications, with super-obese patients experiencing more wound infections (P = .039), nausea/vomiting (P = .003), and pulmonary failure (P = .010). Logistic regression analysis found, after controlling for significant risk factors, that the difference in the incidence of nausea/vomiting was still significant (odds ratio 14.33, 95% confidence interval 1.73-118.60, P = .01). Morbidly obese patients had a significantly greater percentage of excess weight loss at 12 months postoperatively compared with the super-obese patients (80% versus 55%, respectively, P <.001).

CONCLUSION

HALGB is a safe and effective procedure in the super obese but with less favorable outcomes compared with those for morbidly obese patients regarding the percentage of excess weight loss.

Mortality after bariatric surgery: analysis of 13,871 morbidly obese patients from a national registry

OBJECTIVE

To define mortality rates and risk factors of different bariatric procedures and to identify strategies to reduce the surgical risk in patients undergoing bariatric surgery.

SUMMARY BACKGROUND DATA

Postoperative mortality is a rare event after bariatric surgery. Therefore, comprehensive data on mortality are lacking in the literature.

METHODS

A retrospective analysis of a large prospective database was carried out. The Italian Society of Obesity Surgery runs a National Registry on bariatric surgery where all procedures performed by members of the Society should be included prospectively. This Registry represents at present the largest database on bariatric surgery worldwide.

RESULTS

Between January 1996 and January 2006, 13,871 bariatric surgical procedures were included: 6122 adjustable silicone gastric bandings (ASGB), 4215 vertical banded gastroplasties (VBG), 1106 gastric bypasses, 1988 biliopancreatic diversions (BPD), 303 biliointestinal bypasses, and 137 various procedures. Sixty day mortality was 0.25%. The type of surgical procedure significantly influenced (P < 0.001) mortality risk: 0.1% ASGB, 0.15% VBG, 0.54% gastric bypasses, 0.8% BPD. Pulmonary embolism represented the most common cause of death (38.2%) and was significantly higher in the BPD group (0.4% vs. 0.07% VBG and 0.03% ASGB). Other causes of mortality were the following: cardiac failure 17.6%, intestinal leak 17.6%, respiratory failure 11.8%, and 1 case each of acute pancreatitis, cerebral ischemia, bleeding gastric ulcer, intestinal ischemia, and internal hernia. Therefore, 29.4% of patients died as a result of a direct technical complication of the procedure. Additional significant risk factors included open surgery (P < 0.001), prolonged operative time (P < 0.05), preoperative hypertension (P < 0.01) or diabetes (P < 0.05), and case load per Center (P < 0.01).

CONCLUSIONS

Mortality after bariatric surgery is a rare event. It is influenced by different risk factors including type of surgery, open surgery, prolonged operative time, comorbidities, and volume of activity. In defining the best bariatric procedure for each patient the different mortality risks should be taken into account. Choice of the procedure, prevention, early diagnosis, and therapy for cardiovascular complications may reduce postoperative mortality.

Alteration in human defensin-5 expression following gastric bypass surgery

BACKGROUND

Roux-en-Y gastric bypass surgery provides a novel human model to investigate small bowel mucosal innate immunity, in which there is loss of gastric acid-mediated protection against orally-acquired microorganisms.

AIM

To study changes in jejunal mucosal immunoreactivity of human defensin (HD)-5, an antimicrobial peptide normally produced by Paneth cells.

METHODS

Mucosal samples were obtained from 18 female patients (24-54 years), from the same segment of jejunum during and after gastric bypass surgery. Samples were used for bacterial culture and immunohistochemistry using anti-HD-5 antibody. The number of immunoreactive cells per crypt and villus were determined and expressed as mean (SD).

RESULTS

No bacteria were cultured from any of the perioperative jejunal samples but colonies of bacteria normally present in the pharynx were identified during culture of all postoperative jejunal biopsy specimens (1->100 colonies). Paneth cell numbers per crypt were unchanged after gastric bypass (4.16 (0.71) vs 4.24 (0.78)). However, following surgery, there was an increase in HD-5-positive intermediate cells per crypt (0.25 (0.41) vs 1.12 (0.66), p<0.01), HD-5 staining enterocytes per crypt (0.03 (0.09) vs 1.38 (1.10), p<0.01), HD-5 staining material in the crypt lumen (crypt lumens: 5.0% (10.9%) vs 68.1% (27.9%), p<0.01) and HD-5 immunoreactivity coating the luminal surface of villus enterocytes (villi sampled: 15.0% (31.0%) vs 67.5% (42.0%), p<0.01).

CONCLUSIONS

Bacteria normally resident in the pharynx were present in the proximal jejunal mucosa following Roux-en-Y gastric bypass surgery. After gastric bypass, there was increased secretion of HD-5 and an increase in HD-5 expressing intermediate cells and enterocytes in the crypt. The increase in HD-5 expression in the jejunal mucosa following gastric bypass surgery is likely to be secondary to exposure to orally-acquired microorganisms.

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.

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.

A comparison of open and laparoscopic Roux-en-Y gastric bypass surgery for morbid and super obesity: a decision-analysis model

BACKGROUND

The aim of this study was to compare laparoscopic Roux-en-Y gastric bypass (LGBP) with open Roux-en-Y gastric bypass (OGBP) to determine which approach resulted in better clinical outcomes and cost effectiveness in patients with morbid obesity.

METHODS

A decision-analysis model was constructed to evaluate outcomes of LGBP versus OGBP in patients with body mass index (BMI) ranges of 35 to 49, 50 to 60, and greater than 60. Baseline assumptions for the model were derived from published reports. Sensitivity and cost-effectiveness analyses were performed to determine the optimal strategy. Success was defined as no major procedure-related complications and no long-term complications over a 1-year period after surgery. Failure of therapy was defined as either recurrent symptoms or death attributed to a surgical complication.

RESULTS

In patients with a BMI of 35 to 49, LGBP failed in 14% and OGBP failed in 18% of patients, favoring LGBP alone as the dominant strategy. Mortality in the OGBP group was 1.3 times that of the LGBP group. For a BMI of 50 to 60, LGBP was dominant with an overall success rate of 82% as compared with OGBP (77%). Mortality in the OGBP group was 1.3 times that of the LGBP group. For a BMI of greater than 60, LGBP was the dominant strategy with an overall success rate of 67% compared with OGBP (63%). Sensitivity and cost-effective analysis showed that LGBP was the dominant strategy in terms of greater success and less overall morbidity and mortality for all 3 groups.

CONCLUSIONS

This analysis suggests that for all BMI ranges evaluated, LGBP is preferable to OGBP. These conclusions are limited by potential selection and publication bias in the trials assessed for this analysis. These limitations can be resolved only by randomized control trials.

Meal suppression of circulating ghrelin is normalized in obese individuals following gastric bypass surgery

OBJECTIVE

It has been proposed that the success of maintained weight loss in morbidly obese subjects following Roux-en-Y gastric bypass (RYGBP) surgery depends on inappropriately low circulating concentrations of the appetite-stimulating peptide ghrelin, being unresponsive to food intake. In this study, this hypothesis was examined.

DESIGN

Cross-sectional study with repeated blood samples in 40 subjects after 14 h of prolonged overnight fasting followed by a standardized mixed meal (770 kcal).

SUBJECTS

Twenty men and 20 women were included: 10 middle-aged morbidly obese (body mass index (BMI) 43.9+/-3.3 kg/m(2)), 10 middle-aged subjects who had undergone RYGBP at the Uppsala University Hospital (BMI 34.7+/-5.8 kg/m(2)), 10 middle-aged non-obese (BMI 23.5+/-2.2 kg/m(2)) and 10 young non-obese (BMI 22.7+/-1.8 kg/m(2)).

MEASUREMENTS

Ghrelin, glucose and insulin levels were analysed pre- and postprandially.

RESULTS

In the morbidly obese, ghrelin concentrations were lower in the morning than in the RYGBP group and did not change following the meal. In the RYGBP group, fasting ghrelin levels fell after meal intake and showed similar suppression as both age-matched and young non-obese controls. The RYGBP surgery resulted in an increased meal-induced insulin secretion, which was related to the degree of postprandial ghrelin suppression.

CONCLUSION

The present study demonstrates low circulating concentrations of ghrelin and blunted responses to fast and feeding in morbidly obese subjects. Marked weight reduction after RYGBP at our hospital is followed by a normalization of ghrelin secretion, illustrated by increased fasting levels compared to the preoperative obese state and regain of meal-induced ghrelin suppression.

The endoscopic transilluminator: an endoscopic device for identification of the proximal jejunum for transgastric endoscopic gastrojejunostomy

BACKGROUND

Localization of the proximal jejunum is important for creation of gastrojejunal anastomosis to palliate gastric outlet obstruction or for treatment of obesity with gastric bypass.

OBJECTIVE

To facilitate identification of the proximal jejunum during transgastric endoscopic gastrojejunostomy with the use of an endoscopic transilluminator (ET).

DESIGN AND SETTING

Acute experiments in a live porcine model.

INTERVENTIONS

The ET is a 3500-mm long, 6F radio-opaque tube with a fiberoptic core that lights up at its distal end. When situated in the intestinal lumen, it transilluminates the bowel wall. With the animal under general anesthesia with endotracheal intubation, a colonoscope was advanced to the proximal jejunum. A plastic tube (3500-mm long, 3.5 mm in diameter) was passed through the biopsy channel and placed into the small bowel. The colonoscope was withdrawn, leaving the tube in place. The ET was introduced into the jejunum through the tube. A gastric wall incision was made and the endoscope was advanced to the peritoneal cavity. The transilluminated loop of the proximal jejunum was identified and gastrojejunal anastomosis was made by use of a previously reported endoscopic technique.

MAIN OUTCOME MEASUREMENTS

Identification of the proximal jejunum.

RESULTS

Eleven pigs (average weight 55 kg) had ET placement. In all of the pigs, placement of the ET was performed easily to the proximal small bowel, and the proximal jejunum was successfully localized by either direct visualization of the transilluminated loop only or with the aid of fluoroscopy. The tip of the ET was usually located about 50 to 70 cm distal to the ligament of Treitz. There were no complications related to the use of ET.

LIMITATIONS

The device has not yet been evaluated in humans.

CONCLUSIONS

The ET is a safe instrument and can be used to identify the proximal jejunum to facilitate endoscopic gastrojejunostomy.

La cirugía laparoscópica en Europa: ¿hacia dónde vamos?

The most important factors that have facilitated the development of laparoscopic surgery (LS) are technological innovations and the vision of a small number of surgeons who took advantage of these advances. There are few surgical innovations that have stimulated such controversies and concerns and have raised so many medico-legal issues as LS. Although much progress has been made in LS, some important controversies remain unresolved, which are reviewed in the present article: 1. Evolution of the laparoscopic approach: total laparoscopic approach through positive-pressure capnoperitoneum, gasless laparoscopy, hand-assisted laparoscopy, and laparoscopy-assisted surgery. 2. Classification of current instrumental technology in laparoscopic surgery: a) facilitating instruments (high-power ultrasonic dissection systems); b) enabling instruments (endostapling and linear dissection devices), and c) complementary instruments: the Da Vinci robotic system. 3. Current laparoscopic surgical practice: a) interventions that definitively improve the patient's outcome (diagnostic and staging laparoscopy, cholecystectomy, adrenalectomy, splenectomy, antireflux surgery, cardiomyotomy, bariatric surgery, laparoscopic colon surgery, living donor nephrectomy); b) interventions that seem to be useful to the patient (distal pancreatic surgery, laparoscopic left hepatic resection, gastric and esophageal resections, hernioplasty), and c) interventions with uncertain benefit (right hepatectomy, pancreatoduodenectomy). 4. Future lines of development: video monitors in laparoscopic surgery, endoluminal surgery, robotic surgery, and finally, 5. Problems faced by laparoscopic surgery: quality guarantees in laparoscopic surgery, training the future laparoscopic generation, and allocation of sufficient material and human resources to laparoscopic surgery and its subspecialties.

Nonsurgical and surgical treatment of obesity

An increasing number of morbidly obese patients are presenting for surgery, with the potential for increased perioperative morbidity and mortality. This article reviews surgical and nonsurgical options in the management of morbidly obese patients. Overweight and obese individuals should be treated with diet, exercise, and behavioral therapy. The failure of this approach is an indication for pharmacologic therapy. Bariatric surgery reduces obesity-related complications and reduces long-term morbidity, mortality, and health care resources use.

Surgery for morbid obesity

BACKGROUND

Obesity is associated with increased morbidity and mortality. Surgery for morbid obesity is considered when other treatments have failed. A number of procedures are available, but the effects of these surgical procedures compared with medical management and with each other are uncertain.

OBJECTIVES

To assess the effects of surgery for morbid obesity.

SEARCH STRATEGY

Studies were obtained from computerized searches of multiple electronic bibliographic databases, supplemented with hand searches of selected journals and consultation with experts in obesity research. Date of the most recent searches: December 2004.

SELECTION CRITERIA

Randomised controlled trials comparing different surgical procedures, and randomised controlled trials and prospective cohort studies comparing surgery with non-surgical management for morbid obesity.

DATA COLLECTION AND ANALYSIS

Data were extracted by one reviewer and checked independently by two reviewers. Two reviewers independently assessed trial quality.

MAIN RESULTS

Twenty-six trials were included. Two randomised controlled trials and three prospective cohort studies compared surgery with non-surgical management, and 21 randomised controlled trials compared different surgical procedures. The quality of most of the trials was poor; just three trials had adequate allocation concealment. A meta-analysis was not possible due to differences in the surgical procedures performed, measures of weight change and length of follow-up. Compared with conventional management, surgery resulted in greater weight loss (21 kg weight loss at eight years versus weight gain), with improvements in quality of life and comorbidities. Some complications of surgery occurred, such as wound infection. Gastric bypass was associated with greater weight loss, better quality of life and fewer revisions, reoperations and/or conversions than gastroplasty, but had more side-effects. Greater weight loss and fewer side-effects and reoperations occurred with adjustable gastric banding than vertical banded gastroplasty, but laparoscopic vertical banded gastroplasty produced more patients with an excellent or good result and fewer late complications than laparoscopic adjustable silicone gastric banding. Vertical banded gastroplasty was associated with greater weight loss but more vomiting than horizontal gastroplasty. Some postoperative deaths occurred in the studies. Weight loss was similar between open and laparoscopic procedures. Fewer serious complications occurred with laparoscopic surgery, although conversion to open surgery was sometimes required. Most studies found that laparoscopic surgery had a longer operative time. But, it resulted in reduced blood loss and quicker recovery.

AUTHORS' CONCLUSIONS

The limited evidence suggests that surgery is more effective than conventional management for weight loss in morbid obesity. The comparative safety and effectiveness of different surgical procedures is unclear.

Laparoscopic surgery: current status, issues and future developments

Laparoscopic surgery has come a long way since its introduction two decades ago. In essence it represents a new era of technology-dependent surgical interventions, and to some extent its future progress depends on the growth of interventional technologies and devices (facilitative, enabling and additive). Laparoscopic surgery has had a significant impact on all surgical disciplines and is now firmly embedded in routine surgical practice. There remain, however, several outstanding issues that need to be addressed. These concern mainly quality assurance, training, resource allocation, assessment of competence and tiers of laparoscopic surgical practice in line with the changing situation facing the next generation of surgeons.

Endoscopic gastrojejunostomy with survival in a porcine model

BACKGROUND

We have previously reported the feasibility and the safety of an endoscopic transgastric approach to the peritoneal cavity in a porcine model. We now report successful performance of endoscopic gastrojejunostomy with survival.

METHODS

All procedures were performed on 50-kg pigs, with the pigs under general anesthesia, in aseptic conditions with sterilized endoscopes and accessories. The stomach was irrigated with antibiotic solution, and a gastric incision was performed with a needle-knife and a sphincterotome. A standard upper endoscope was advanced through a sterile overtube into the peritoneal cavity. A loop of jejunum was identified, was retracted into the stomach, and was secured with sutures while using a prototype endoscopic suturing device. An incision was made into the jejunal loop with a needle-knife, and the filet-opened ends of the jejunal wall were secured to the gastric wall with a second line of sutures, completing the gastrojejunostomy.

OBSERVATIONS

Two pigs survived for 2 weeks. Endoscopy and a radiographic contrast study performed after gastrojejunostomy revealed a patent anastomosis with normal-appearing gastric and jejunal mucosa. Postmortem examination demonstrated a well-healed anastomosis without infection or adhesions.

CONCLUSIONS

The endoscopic transgastric approach to create a gastrojejunostomy is technically feasible and can be performed, with survival, in a porcine model.

CRP reduction following gastric bypass surgery is most pronounced in insulin-sensitive subjects

OBJECTIVE

Obesity is frequently associated with insulin resistance, dyslipidemia, hypertension and an increased risk of cardiovascular disease, reflected in elevated markers of inflammation, in particular C-reactive protein (CRP). To what extent the insulin resistance or the obesity per se contributes to increased CRP levels is unclear. In morbidly obese patients, gastric bypass surgery causes marked changes in body weight and improves metabolism, thereby providing informative material for studies on the regulation of inflammatory markers.

DESIGN

Prospective, surgical intervention study of inflammatory markers in morbidly obese subjects.

SUBJECTS

In total, 66 obese subjects with mean age 39 y and mean body mass index (BMI) 45 kg/m2 were studied prior to and 6 and 12 months following Roux-en-Y gastric bypass (RYGBP) surgery.

MEASUREMENTS

Serum concentrations of high sensitivity CRP, serum amyloid A (SAA) and interleukin-6 (IL-6), as well as markers of glucose and lipid metabolism.

RESULTS

Prior to surgery, CRP levels were elevated compared to the reference range of healthy, normal-weight subjects. CRP correlated with insulin sensitivity, as reflected by the homeostatic model assessment (HOMA) index, but not BMI, when corrected for age and gender. Surgery reduced BMI from 45 to 31 kg/m2 and lowered CRP, SAA and IL-6 levels by 82, 57 and 50%, respectively, at 12 months. The reduction in CRP was inversely related to HOMA at baseline independently of the change in body weight (r=-0.36, P=0.005). At 12 months, 140 and 40% reductions in CRP were seen in subjects with HOMA < 4 (insulin sensitive) and HOMA>9 (insulin resistant) despite similar reductions in BMI. Reductions in SAA and IL-6 tended to parallel the changes in CRP, but were less informative.

CONCLUSION

In morbidly obese subjects, gastric bypass surgery lowers energy intake, reduces inflammatory markers and improves insulin sensitivity. Despite a marked reduction in body weight, only a small effect on CRP levels was seen in insulin-resistant patients, indicating that flexibility of circulating CRP levels is primarily dependent upon insulin sensitivity rather than energy supply.

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

BACKGROUND

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

METHODS

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

RECOMMENDATIONS

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