Laparoscopic vs Open Gastric Bypass in the Management of Morbid Obesity: A 7-year Retrospective Study of 1,364 Patients from a Single Center

Robotic-assisted bariatric surgery: case series analysis and comparison with the laparoscopic approach

OBJECTIVE

to report a series of cases of robotic bariatric surgery in the treatment of obesity in Brazil.

METHODS

we evaluated patients undergoing robotic bariatric surgery at the Garrido Institute and compared them with a group submitted to conventional laparoscopic surgery.

RESULTS

we analyzed 45 patients, with a mean age of 39.44 years, of which 34 were female, with an initial mean BMI of 41.26kg/m2. Among the procedures performed, 91.11% were Roux-en-Y gastric bypass, while 8.89% were sleeve gastrectomy. The mean total surgery time was 158 (±56.54) minutes, with mean docking time of 7.93 (±3.9) minutes, and console time 113.0 (±41.4) minutes. The average pain presented in the post anesthetic recovery was 2.61 (±3.30) points on a scale of 0 to 10; four patients presented with mild signs of nausea, responding well to drug treatment. Only one patient needed ICU admission for a period of two days after surgery due to previous cardiopathy. In two cases, there was an incisional hernia at the trocar site, which were surgically treated without further complications. In the comparison between robotic versus laparoscopic surgery groups, 45 patients were selected for each group. Operative time was significantly longer in the robotic surgery group, with most other variables being equivalent, including postoperative control of comorbidities.

CONCLUSION

robotic bariatric surgery is a safe procedure, with results comparable to laparoscopic surgery.

Access to excluded structures after Roux-en-Y gastric bypass: Experience in a high-level bariatric center without a technical platform for endoscopic retrograde cholangiopancreatography

BACKGROUND

Rapid weight loss after bariatric surgery is associated with a high prevalence of gallstone formation. In laparoscopic Roux-en-Y gastric bypass (RYGBP), the bypassed segment is not readily available for endoscopic or radiographic examination. We propose a laparoscopic Janeway gastrostomy for secondary access to excluded structures in bariatric centers with no mandatory technical equipment in endoscopic retrograde cholangiopancreatography (ERCP), double-balloon ERCP or spiral enteroscopy.

METHOD

This was a single-institution retrospective review of a prospectively collected database of patients with a history of laparoscopic RYGBP who underwent laparoscopic Janeway gastrostomy for duodenal and biliary access. The operative indications, technical aspects, endoscopic findings, outcomes, and complications were investigated.

RESULTS

Five patients with a history of RYGBP underwent laparoscopic Janeway gastrostomy for exploration of the bypassed segment. All of them had biliary pathology, and all underwent successful ERCP and papillotomy. The gastrostomies were closed secondarily. The mean duration of hospitalization was 12 days. No complications developed. All procedures were performed laparoscopically.

CONCLUSION

If access to excluded structures and simultaneous ERCP was not possible, temporary laparoscopic Janeway gastrostomy could be the last option alternative for a staged ERCP to gain access to the bypassed structures. It is a feasible and safe solution for the exploration and treatment of patients with a history of RYGBP in bariatric centers that have no endoscopists with expertise in ERCP.

Monitoring of Liver Function Tests after Roux-en-Y Gastric Bypass: An Examination of Evidence Base

There is no consensus on the monitoring of liver function tests after Roux-en-Y gastric bypass (RYGB). Since the main objective of such monitoring would be to diagnose early those who will eventually develop liver failure after RYGB, we performed a systematic review on this topic. An extensive search of literature revealed only 10 such cases in 6 published articles. It would hence appear that liver failure is a rare problem after RYGB. Routine lifelong monitoring of liver function tests is therefore unnecessary for otherwise asymptomatic individuals. Such monitoring should hence be reserved for high-risk groups, such as patients with liver cirrhosis, those undergoing extended limb/distal RYGB, patients with new illnesses, those abusing alcohol, those on hepatotoxic drugs and those presenting with a surgical complication.

Rate of Death and Complications in Laparoscopic and Open Roux-en-Y Gastric Bypass. A Meta-analysis and Meta-regression Analysis on 69,494 Patients

Morbid obesity is a life threatening condition. Currently, surgery represents the only effective and durable therapeutic option to treat it. The first aim of the study was to estimate and compare the major surgical complications and the 30-day rate of mortality between laparoscopic and open Roux-en-Y gastric bypass (LRYGB and RYGB). The second aim was to evaluate the change in outcomes, complications, and deaths, with increased experience over the time period of the review. A random effect of the meta-analysis and meta-regression was used to evaluate surgical complications (i.e., reoperation, stenosis, bleeding, surgical site infection, fistula, internal hernia, and incisional ventral hernia) and the rate of mortality after LRYGB and RYGB over time. A search of literature from 2000 to 2014 led to the selection of 17 papers. When looking at surgical techniques separately, we observed a higher rate of mortality for open surgery (death rate 0.82 %, 95 % CI = 0.49-1.23) compared to laparoscopic surgery (death rate 0.22 %, 95 % CI = 0.09-0.40). This difference resulted highly significant when the two techniques were formally compared (p < 0.001). The improving of surgery technique resulted in a mean rate of mortality reduction of 0.069 %. Laparoscopy represents the approach of choice for bariatric surgery. Contemporary reports of LRYGB show low mortality rates and progressive decline in postoperative complications. Laparoscopic bariatric surgery requires advanced laparoscopic skills, and probably an extended learning curve is not accounted for by current mortality statistics.

Postoperative pain after conventional laparoscopic versus single-port sleeve gastrectomy: a prospective, randomized, controlled pilot study

BACKGROUND

Laparoscopic approach is the gold standard for surgical treatment of morbid obesity. The single-port (SP) approach has been demonstrated to be a safe and effective technique for the treatment of morbid obesity in several case control studies.

OBJECTIVES

Compare conventional multiport laparoscopy (LAP) with an SP approach for the treatment of morbid obesity using sleeve gastrectomy in terms of postoperative pain using a visual analog scale (VAS) 0-100, surgical outcome, weight loss, and aesthetical satisfaction at 6 months after surgery.

SETTING

University Hospital, Spain.

METHODS

Randomized, controlled pilot study. The trial enrolled patients suitable for bariatric surgery, with a body mass index lower than 50 kg/m² and xiphoumbilical distance lower than 25 cm. Patients were randomly assigned to receive LAP or SP sleeve gastrectomy.

RESULTS

A total of 30 patients were enrolled; 15 were assigned to LAP group and 15 to SP group. No patients were lost during follow-up. Baseline characteristics were similar in both groups. A significantly higher level of pain during movement was noted for the patients in the LAP group on the first (mean VAS 49.3±12.2 versus 34.1±8.9, P = .046) and second days (mean VAS 35.9±10.2 versus 22.1±7.9, P = .044) but not the third day (mean VAS 20.1±5.2 versus 34.12.9 ±4.3, P = .620). No differences regarding pain at rest, operative time, complications, or weight loss at 6 months were observed. Higher aesthetical satisfaction was noticed in SP group.

CONCLUSIONS

In selected patients, SP surgery presented less postoperative pain in sleeve gastrectomy compared with the conventional laparoscopic approach with similar surgical results.

Robotic vs. Laparoscopic Roux-En-Y Gastric Bypass: a Systematic Review and Meta-Analysis

We aim to summarize the available literature on patients treated with robotic RYGB and compare the clinical outcomes of patients treated with robotic RYGB with those treated with the standard laparoscopic RYGB. A systematic literature search of PubMed and Scopus databases was conducted in accordance with the PRISMA guidelines. Fourteen comparative and 11 non-comparative studies were included in this study, reporting data on 5145 patients. This study points to comparable clinical outcomes between robotic and laparoscopic RYGB. Robotic-assisted RYGB was associated with significantly less frequent anastomotic stricture events, reoperations, and a decreased length of hospital stay compared with the standard laparoscopic procedures; however, these findings should be interpreted with caution given the low number and poor quality of the studies currently available in the literature.

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.

Early outcomes of the first Brazilian experience in totally robotic bariatric surgery

BACKGROUND

Currently, bariatric surgery is the most effective therapy for morbid obesity, and the laparoscopic approach is considered gold-standard for Roux-en-Y gastric bypass. Totally robotic Roux-en-Y gastric bypass has been proposed as a major evolution in minimally invasive bariatric surgery and its use is becoming more widespread.

AIM

To provide an early report of the first Brazilian case-series of totally robotic gastric bypass and perioperative short-term outcomes.

METHODS

All consecutive patients who underwent totally robotic gastric bypass at two recognized centers of bariatric surgery were included. Patient demographic data, body mass index, operative times, hospital stay, complications and mortality in the 30 postoperative days were recorded. The surgeons received the same training program before the clinical procedures and all the surgeries were performed under the supervision of an experienced robotic surgeon.

RESULTS

The surgeries were performed by five surgeons and included 68 patients (52 women - 76.5%), with a mean age of 40.5 years (range 18 to 59) and mean BMI of 41.3 (35.2 - 59.2). Total mean operative time was 158 minutes (range 90 to 230) and mean overall hospital stay was 48 h. Postoperative surgical complication rate (30 day) was 5.9%, with three minor and one major complication. There was no mortality, leak or stricture.

CONCLUSION

Even with surgeons in early learning curves, the robotic approach within a well-structured training model was safe and reproducible for the surgical treatment of the morbid obesity.

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.

High-volume bariatric surgery in a single center: safety, quality, cost-efficacy and teaching aspects in 2,000 consecutive cases

BACKGROUND

Obesity surgery is the most effective treatment for morbid obesity and the fastest growing area in surgery. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the gold standard procedure in many countries. Optimization of the treatment process is important in order to keep the morbidity rate down and cost of treatment as low as possible.

METHODS

In September 2005, we established a bariatric surgery program. Until December 2010, 2,000 patients underwent LRYGB. Clinical pathways were established, with focus on safety, fast-track methodology and training of surgeons. Time recordings from all parts of the treatment, as well as clinical outcome, were prospectively registered.

RESULTS

Time consumption for the total procedure in the operating theater was reduced from 102 to 54 min (P < 0.001). With only 11 min turnover between patients, the total time for one patient has been reduced to 65 min, enabling us to perform six operations in a single operating theater during ordinary daytime. Early complication rate was 2.8%, and mean hospital stay was 2.3 days. We were able to double the patients treated in 2010 compared to 2007 with only 10% increase in staff. Three surgeons were trained during the period into fully qualified senior bariatric surgeons.

CONCLUSIONS

Multimodal evidence-based care within the fast-track methodology and routine time recordings was successful in order to increase the production volumes and reduce costs, without compromising the safety or quality for the patients. This kind of approach may be transferred to other types of standardized surgery.

Risk of complications after bariatric surgery among individuals with and without type 2 diabetes mellitus

BACKGROUND

Type 2 diabetes mellitus is highly prevalent in obese individuals. Bariatric surgery, promoted for reducing the medical problems of morbid obesity, has been increasingly recognized for its particular efficacy in treating diabetes. However, before bariatric surgery can be recommended for the treatment of diabetes, its safety in the diabetic population must be known. We assessed the odds of complications after bariatric surgery in patients with and without diabetes.

METHODS

This was a retrospective cohort study. Using an administrative database from 7 Blue Cross/Blue Shield plans, we identified 22,288 subjects who had undergone bariatric surgery from 2002 to 2008. From this cohort, we selected 6754 pairs of surgical patients (1 with and 1 without diabetes) matched by age, gender, health plan, and year of surgery. With conditional logistic regression analysis, we determined the relative odds of postoperative complications for ≤ 12 months after surgery in the 2 groups.

RESULTS

The mean age of the surgical patients was 46 years, and 79% were women. Postoperative complications were rare and comparable in those with and without diabetes. The most common complications were nausea, vomiting, and abdominal pain (8.8%), the need for a gastric revision procedure (5.0%), and upper endoscopy (2.3%). Select cardiac, infectious, and renal complications occurred more frequently in the diabetic group. The incidence of cardiac complications was greater in the 2-3-month and 4-6-month postoperative periods (odds ratio [OR] 1.7, P < .001), the incidence of infectious complications was greater in the 0-1-month (OR 1.3, P < .02) and 4-6-month (OR 1.8, P < .001) periods, and the incidence of renal complications was greater in the 2-3-month postoperative period (OR 4.6, P = .01).

CONCLUSIONS

Our findings support the safety of bariatric surgery in obese individuals with diabetes, although management strategies to avert postoperative cardiac, infectious, and renal complications in this population might be warranted.

Revision laparoscopic gastric bypass: an effective approach following failure of primary bariatric procedures

BACKGROUND

The laparoscopic approach plays an important role in the primary surgical management of morbid obesity. This study evaluated the potential role of the laparoscopic approach to revision Roux-en-Y gastric bypass (LRYGB) in the management of selected patients who fail to lose adequate weight or regain weight after primary bariatric surgery.

METHODS

Revision LRYGB was carried out to remedy early or delayed failure of primary bariatric procedures. Patients who underwent laparoscopic revision surgery to re-establish a functioning gastric band were not included in this report. The results are presented as mean (SD).

RESULTS

Between April 2002 and March 2009, 21 patients underwent 21 laparoscopic revision procedures. The initial bariatric operations were laparoscopic gastric band (n = 10), open vertical banded gastroplasty (n = 6), open Magenstrasse and Mill (n = 2), open gastric bypass with pouch dilatation (n = 2), and open gastric band (n = 1). All revision procedures were completed laparoscopically and included conversion to LRYGB (n = 19), and others (n = 2). The postoperative hospital stay was 2.0 (1.3) days. The anastomotic leak, morbidity, and mortality rates were 0%, 4.8%, and 0% respectively. At a follow-up of 12.9 (7.9) months, the prerevision body mass index has decreased significantly from 43.9 (7.4) to 32.7 (6.6) kg/m(2) (p < 0.001) with a percentage excess weight loss of 61.1 (21.2).

CONCLUSIONS

The laparoscopic approach to revision Roux-en-Y gastric bypass is safe and effective even in patients with previous open bariatric surgery and is associated with rapid recovery and short hospital stay.

Single port access transumbilical laparoscopic Roux-en-Y gastric bypass using the SILS Port: first reported case

The emergence of natural orifice translumenal endoscopic surgery (NOTES) has brought significantly more attention to the single-incision transumbilical laparoscopic approach (SILS) for minimally invasive surgery. SILS combines the cosmetic advantage of NOTES with the technical familiarity of the conventional multiport laparoscopic approach. Additionally, SILS does not involve penetration of an organ, nor does it involve the steep learning curve and costly instruments associated with NOTES. Given these advantages, the authors believe that the single-incision transumbilical approach highlights the future direction of minimally invasive surgery. However, because of the associated technical challenges, the single-incision approach has not quite yet achieved the crossover to advanced surgical procedures that conventional multiport laparoscopy achieved in its early years. In this report, the authors present what is, to the best of their knowledge, the first reported case of a single-port access laparoscopic Roux-en-Y gastric bypass using the SILS Port placed through a single intraumbilical skin incision.

Standardization of the fully stapled laparoscopic Roux-en-Y gastric bypass for obesity reduces early immediate postoperative morbidity and mortality: a single center study on 2606 patients

Background

Various techniques of laparoscopic Roux-en-Y gastric bypass have been described. We completely standardized this procedure to minimize its sometimes substantial morbidity and mortality. This study describes our experience with the standardized fully stapled laparoscopic Roux-en-Y gastric bypass (FS-LRYGB) and its influence on the 30-day morbidity and mortality.

Methods

We retrospectively analyzed 2,645 patients who underwent FS-LRYGB from May 2004 to August 2008. Operative time, hospital stay and readmission, re-operation, and 30-day morbidity/mortality rates were then calculated. The 30-day follow-up data were complete for 2,606 patients (98.5%).

Results

There were 539 male and 2,067 female patients. Mean age was 39.2 years (range 14–73), mean BMI 41.44 kg/m² (range, 23–75.5). The mean hospital stay was 3.35 days (range 2–71). Mean total operative time was 63 min (range 35–150).

One patient died of pneumonia within 30 days of surgery (0.04%). One hundred and fifty one (5.8%) patients had postoperative complications as follows: gastrointestinal hemorrhage (n = 89, 3.42%), intestinal obstruction (n = 9, 0.35%), anastomotic leak (n = 5, 0.19%) and others (n = 47, 1.80%). In 66 patients, the bleeding resolved without any surgical re-intervention. One hemorrhage resulted in hypovolemic shock with subsequent renal and hepatic failure.

Conclusion

The systematic approach and the full standardization of the FS-LRYGB procedure contribute highly to the very low mortality and the low morbidity rates in our institution. Gastrointestinal bleeding appears to be the commonest complication, but is self-limiting in the majority of cases. Our approach also significantly reduces operative time and turns the technically demanding laparoscopic Roux-en-Y gastric bypass procedure into an easy reproducible operation, effective for training.

Results of completion gastrectomies in 44 patients with postsurgical gastric atony

INTRODUCTION

Postsurgical gastric atony occurs infrequently after gastric surgery. However, the symptoms are disabling and refractory to medical management. The only effective treatment is completion gastrectomy. A few studies have examined in detail the long-term results of this radical procedure.

METHODS

From 1988 through 2007, 44 patients (84% female, 16% male) underwent near-total or total completion gastrectomies for refractory postsurgical gastric atony. The average age was 52 (range 32-72). Gastric atony was documented using radionuclide solid food emptying studies. Charts were reviewed retrospectively to identify preoperative symptoms and long-term postoperative function, and the patients were contacted by phone to evaluate their current level of function.

RESULTS

Of the original 44 patients, 66% (n = 29) were evaluated postoperatively at a mean of 5.6 + 4.5 years (range 0.5-15.0 years). Fourteen patients (32%) had died, and seven (16%) were lost to follow-up. Most common presenting symptoms were abdominal pain (98%), vomiting (98%), nausea (77%), diet limitation (75%), heartburn (64%), and weight loss (59%, average = 19% of BW). Postoperative complications occurred in 36% (n = 16), most commonly bowel obstruction (11%), anastomotic stricture (9%), and anastomotic leak (7%), and there was one perioperative death. At last follow-up, there were significant improvements in abdominal pain (97% to 59%, p < 0.001), vomiting (97% to 31%, p < 0.001), nausea (86% to 45%, p < 0.001), and diet limited to liquids or nothing at all (57% to 7%, p < 0.001). Some symptoms were more common postoperatively, including early satiety (24% to 89%, p < 0.001), and postprandial fullness (10% to 72%, p < 0.001). Average BMI at the time of surgery and at last follow-up were 23 and 21, respectively. Osteoporosis was diagnosed pre- and postoperatively in 17% and 67% of patients, respectively (p < 0.001). Seventy-eight percent of patients stated that they were in better health after surgery, while 17% were neutral, and 6% stated that they were worse off. Mean satisfaction with surgery was 4.7 (1-5 Likert scale).

CONCLUSION

Completion gastrectomies in this patient population resulted in significant improvements in abdominal pain, vomiting, nausea, and severe diet limitations. Most patients, however, have significant ongoing gastrointestinal complaints, and the incidence of osteoporosis is high. Patient satisfaction is high; about 78% of patients believed their health status is improved. We believe these data support the selective use of completion gastrectomies in patients with severe postsurgical gastroparesis.