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Lin H, Baker JW, Meister K, Lak KL, Martin Del Campo SE, Smith A, Needleman B, Nadzam G, Ying LD, Varban O, Reyes AM, Breckenbridge J, Tabone L, Gentles C, Echeverri C, Jones SB, Gould J, Vosburg W, Jones DB, Edwards M, Nimeri A, Kindel T, Petrick A. American society for metabolic and bariatric surgery: intra-operative care pathway for minimally invasive Roux-en-Y gastric bypass. Surg Obes Relat Dis 2024:S1550-7289(24)00668-3. [PMID: 39097472 DOI: 10.1016/j.soard.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 06/11/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB). OBJECTIVE This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU). METHODS PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee. RESULTS Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures. CONCLUSIONS This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB.
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Affiliation(s)
- Henry Lin
- Department of Surgery, Signature Healthcare, Brockton, Massachusetts.
| | - John W Baker
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | | | - Kathleen L Lak
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - April Smith
- Department of Pharmacy, Creighton University School of Pharmacy and Health Professions, Omaha, Nebraska
| | | | - Geoffrey Nadzam
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Lee D Ying
- Department of Surgery, Yale New Haven Hospital, New Haven, Connecticut
| | - Oliver Varban
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Angel Manuel Reyes
- Department of General Surgery, St. Michael Medical Center, Silverdale, Washington
| | - Jamie Breckenbridge
- Department of General Surgery, Fort Belvoir Community Hospital, Fort Belvoir, Virginia
| | - Lawrence Tabone
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Charmaine Gentles
- Department of Surgery, Northshore University Hospital, Manhasset, New York
| | | | - Stephanie B Jones
- Department of Anesthesiology, Northwell Health, New Hyde Park, New York
| | - Jon Gould
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Wesley Vosburg
- Department of Surgery, Grand Strand Medical Center, Myrtle Beach, South Carolina
| | - Daniel B Jones
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | | | - Abdelrahman Nimeri
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tammy Kindel
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anthony Petrick
- Department of Surgery, Geisinger Medical Center, Danville, Pennsylvania
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Stenberg E, Ottosson J, Magnuson A, Szabo E, Wallén S, Näslund E, Thorell A, Näslund I. Long-term Safety and Efficacy of Closure of Mesenteric Defects in Laparoscopic Gastric Bypass Surgery: A Randomized Clinical Trial. JAMA Surg 2023; 158:709-717. [PMID: 37163240 PMCID: PMC10173104 DOI: 10.1001/jamasurg.2023.1042] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/30/2022] [Indexed: 05/11/2023]
Abstract
Importance Short-term and midterm data suggest that mesenteric defects closure during laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery reduces the risk of internal herniation with small bowel obstruction (SBO) but may increase risk of kinking of the jejunojejunostomy in the early postoperative period. However, to our knowledge, there are no clinical trials reporting long-term results from this intervention in terms of risk for SBO or opioid use. Objective To evaluate long-term safety and efficacy outcomes of closure of mesenteric defects during LRYGB. Design, Setting, and Participants This randomized clinical trial with a 2-arm, parallel, open-label design included patients with severe obesity scheduled for LRYGB bariatric surgery at 12 centers in Sweden from May 1, 2010, through November 14, 2011, with 10 years of follow-up after the intervention. Interventions During the operation, patients were randomly assigned 1:1 to closure of mesenteric defects beneath the jejunojejunostomy and at the Petersen space using nonabsorbable running sutures during LRYGB or to nonclosure. Main Outcome and Measures The primary outcome was reoperation for SBO. New incident, chronic opioid use was a secondary end point as a measure of harm. Results A total of 2507 patients (mean [SD] age, 41.7 [10.7] years; 1863 female [74.3%]) were randomly assigned to closure of mesenteric defects (n = 1259) or nonclosure (n = 1248). After censoring for death and emigration, 1193 patients in the closure group (94.8%) and 1198 in the nonclosure group (96.0%) were followed up until the study closed. Over a median follow-up of 10 years (IQR, 10.0-10.0 years), a reoperation for SBO from day 31 to 10 years after surgery was performed in 185 patients with nonclosure (10-year cumulative incidence, 14.9%; 95% CI, 13.0%-16.9%) and in 98 patients with closure (10-year cumulative incidence, 7.8%; 95% CI, 6.4%-9.4%) (subhazard ratio [SHR], 0.42; 95% CI, 0.32-0.55). New incident chronic opioid use was seen among 175 of 863 opioid-naive patients with nonclosure (10-year cumulative incidence, 20.4%; 95% CI, 17.7%-23.0%) and 166 of 895 opioid-naive patients with closure (10-year cumulative incidence, 18.7%; 95% CI, 16.2%-21.3%) (SHR, 0.90; 95% CI, 0.73-1.11). Conclusions and Relevance This randomized clinical trial found long-term reduced risk of SBO after mesenteric defects closure in LRYGB. The findings suggest that routine use of this procedure during LRYGB should be considered. Trial Registration ClinicalTrials.gov Identifier: NCT01137201.
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Affiliation(s)
- Erik Stenberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Johan Ottosson
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anders Magnuson
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Eva Szabo
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Stefan Wallén
- Pharmacology and Therapeutic Department, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Erik Näslund
- Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Anders Thorell
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - Ingmar Näslund
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Amanda D, Elin P, Eva N, Stenberg E. The Influence of Mesenteric Defects Closure on the Use of Computed Tomography for Abdominal Pain 5 Years After Laparoscopic Gastric Bypass-a Post Hoc Analysis of a Randomized Clinical Trial. Obes Surg 2021; 32:266-272. [PMID: 34813038 PMCID: PMC8794995 DOI: 10.1007/s11695-021-05778-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/13/2021] [Accepted: 11/03/2021] [Indexed: 11/24/2022]
Abstract
Background Abdominal pain after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common and unwanted complication that typically leads to further exploration through radiology. Concerns have been raised regarding the consequences of this radiation exposure and its correlation with the lifetime risk of cancer. The aim of this study was to evaluate the differences in computed tomography (CT) use between LRYGB patients with open and closed mesenteric defects and to assess the radiological findings and radiation doses. Methods This subgroup analysis included 300 patients randomized to either closure (n = 150) or nonclosure (n = 150) of mesenteric defects during LRYGB. The total number of CT scans performed due to abdominal pain in the first 5 postoperative years was recorded together with the radiological findings and radiation doses. Results A total of 132 patients (44%) underwent 281 abdominal CT scans, including 133 scans for 67 patients with open mesenteric defects (45%) and 148 scans for 65 patients with closed mesenteric defects (43%). Radiological findings consistent with small bowel obstruction or internal hernia were found in 31 (23%) of the scans for patients with open defects and in 18 (12%) of the scans for patients with closed defects (p = 0.014). The other pathological and radiological findings were infrequent and not significantly different between groups. At the 5-year follow-up, the total radiation dose was 82,400 mGy cm in the nonclosure group and 85,800 mGy cm in the closure group. Conclusion Closure of mesenteric defects did not influence the use of CT to assess abdominal pain. Graphical abstract ![]()
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Affiliation(s)
- Demir Amanda
- Department of Surgery, Faculty of Medicine and Health, Örebro University, 701 82, Örebro, Sweden
| | - Påhlson Elin
- Department of Surgery, Faculty of Medicine and Health, Örebro University, 701 82, Örebro, Sweden
| | - Norrman Eva
- Department of Medical Physics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Erik Stenberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University, 701 82, Örebro, Sweden.
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Gastrointestinal quality of life before and short- and long-term after Roux-en-Y gastric bypass for severe obesity. Surg Obes Relat Dis 2021; 17:1583-1590. [PMID: 34099420 DOI: 10.1016/j.soard.2021.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/26/2021] [Accepted: 05/11/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Overall quality of life (QoL) is generally improved after bariatric surgery. Gastrointestinal (GI) symptoms including abdominal pain have been reported in up to >30% of patients after Roux-en-Y gastric bypass (RYGB), and may negatively influence QoL, especially GI-QoL. OBJECTIVES To evaluate the evolution of GI symptoms and GI-QoL short- and long-term after RYGB. SETTING Two public hospitals METHODS: Candidates for bariatric surgery (n = 128, BMI = 44.2 ± 7.4) or patients who had undergone RYGB 2-4 years (n = 161, BMI = 29.3 ± 15.9) and 5-10 years (n = 121, BMI = 31.3 ± 6.5) before were invited to complete a questionnaire combining 3 validated questionnaires (GIQLI, GSRS, and PCS) specifically designed to evaluate GI-QoL. Scores were compared between the preoperative, early, and late postoperative periods. RESULTS The GIQLI score improved from 88.1 before surgery to 118.6 (P < .0001) and 109.7 (P < .0001) in the early and late postoperative periods respectively. GSRS score improved from 15.6 to 10.1 (P = .0001) and 12.8 (P = .012), and PCS-score improved from 19 to 4.5 (P = .0001) and 8.3 (P = .0001), respectively. The GI subscore of the GIQLI improved from 57.4 to 62.1 (P = .007) in the early period but was not significantly different in the late period (59.3 versus 57.4, P = .3). The psychological impact of GI symptoms decreased at both postoperative time points. CONCLUSION GI-QoL is markedly improved after RYGB, and this improvement persists up to 10 years. GI symptoms decrease early after surgery and do not worsen in the longer term. Their psychological impact is markedly reduced.
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Kristensen SD, Gormsen J, Naver L, Helgstrand F, Floyd AK. Randomized clinical trial on closure versus non-closure of mesenteric defects during laparoscopic gastric bypass surgery. Br J Surg 2021; 108:145-151. [PMID: 33711136 DOI: 10.1093/bjs/znaa055] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/24/2020] [Accepted: 09/28/2020] [Indexed: 11/14/2022]
Abstract
BACKGROUND Internal herniation is a well known and potentially life-threatening complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). The aim of this study was to evaluate the benefit and harm of closing the mesenteric defects with clips during LRYGB to prevent internal herniation. METHODS This was a single-centre, single-blinded RCT. Patients eligible for LRYGB were randomized to surgery with or without closure of mesenteric defects with clips. The primary endpoint was the incidence of (intermittent) internal herniation after LRYGB with a minimum follow-up of 24 months. Secondary outcomes were duration of surgery, number of clips used, trocars and sutures used, postoperative pain measured by a visual analogue scale (VAS), and postoperative complications. RESULTS Between 13 August 2012 and 18 May 2017, 401 patients were randomized to closure (201) or non-closure (200) of mesenteric defects. Median follow-up for both groups was 59 months (range 8-67 and 16-67 months in non-closure and closure groups respectively). The cumulated risk of internal herniation after 2 years was 8.0 per cent in the non-closure group compared with 4.5 per cent in the closure group (hazard ratio (HR) 1.81, 95 per cent c.i. 0.80 to 4.12; P = 0.231). At 5 years, rates were 15.5 and 6.5 per cent respectively (HR 2.52, 1.32 to 4.81; P = 0.005). Closure of mesenteric defects increased operating time by a median of 4 min (95 per cent c.i. 52 to 56 min for the non-closure group and 56 to 60 min for the closure group; P = 0.002). There was no difference in postoperative blood transfusion rates and VAS scores between the groups. CONCLUSION Routine closure of the mesenteric defects in LRYGB with clips is associated with a lower rate of internal herniation. Registration number: NCT01595230 (http://www.clinicaltrials.gov).
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Affiliation(s)
- S D Kristensen
- Department of Surgery, Zealand University Hospital, Koege, Denmark
| | - J Gormsen
- Department of Surgery, Zealand University Hospital, Koege, Denmark
| | - L Naver
- Department of Surgery, Zealand University Hospital, Koege, Denmark
| | - F Helgstrand
- Department of Surgery, Zealand University Hospital, Koege, Denmark
| | - A K Floyd
- Department of Surgery, Hospital South West Jutland, University Hospital Southern Denmark, Esbjerg, Denmark
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Brammerloo YGA, Vannijvel M, Devriendt S, Verhaak T, Ultee G, Göttgens KWA, Langenhoff BS. Internal Hernia After Laparoscopic Gastric Bypass Without Preventive Closure of Mesenteric Defects: a Single Institution's Experience. J Gastrointest Surg 2021; 25:623-634. [PMID: 32767016 DOI: 10.1007/s11605-020-04761-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/19/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Internal herniation (IH) is a well-known complication after laparoscopic gastric bypass (LGB). Diagnosing and managing IH can be challenging. This retrospective cohort study aimed to achieve a greater understanding of symptomatology, diagnostic tools, complications, risk of IH recurrence, and symptom relief in IH patients. METHODS We included patients who underwent LGB surgery at our institution between 2011 and 2015. Mesenteric defects were not preventively closed during LGB. We focused on LGB patients who underwent surgical intervention(s) for suspected IH during a 7-year study period. We studied patient characteristics, (predictive) symptoms and signs, abdominal imaging, operative findings, post-operative course, and risk of (recurrent) IH. RESULTS A total of 1588 patients were included. In total, 243 patients underwent IH-related diagnostic laparoscopy. Radiating pain to the back (OR 2.45, p = .03), post-prandial pain (OR 3.23, p = .00), and leukocytosis (OR 15.53, p = .01) were identified as predictors of IH. The estimated risk of IH-related diagnostic laparoscopy was 16% at 3 years post-LGB, and the risk of confirmed IH was 12%. The estimated risk of diagnostic laparoscopy for suspected recurrent IH was 10% at 5 years post-LGB. In patients who underwent secondary mesenteric defects closure, post-operative symptom relief was reported in 84%. CONCLUSION This study demonstrates a considerable risk of developing IH after LGB without preventive closure of the mesenteric defects. We emphasize the value of diagnostic laparoscopy to achieve symptom relief in patients with suspicion of IH. Preoperative diagnosis of IH can be improved by being watchful of specific symptoms and signs which can predict the intra-operative presence of IH.
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Affiliation(s)
- Y G A Brammerloo
- Department of Gastro-intestinal Surgery, Elisabeth-TweeSteden Hospital Tilburg, Dr. Deelenlaan 5, 5042 AD, Tilburg, The Netherlands.
| | - M Vannijvel
- Department of Gastro-intestinal Surgery, Elisabeth-TweeSteden Hospital Tilburg, Dr. Deelenlaan 5, 5042 AD, Tilburg, The Netherlands
| | - S Devriendt
- Department of Gastro-intestinal Surgery, Elisabeth-TweeSteden Hospital Tilburg, Dr. Deelenlaan 5, 5042 AD, Tilburg, The Netherlands
| | - T Verhaak
- Department of Gastro-intestinal Surgery, Elisabeth-TweeSteden Hospital Tilburg, Dr. Deelenlaan 5, 5042 AD, Tilburg, The Netherlands
| | - G Ultee
- Department of Gastro-intestinal Surgery, Elisabeth-TweeSteden Hospital Tilburg, Dr. Deelenlaan 5, 5042 AD, Tilburg, The Netherlands
| | - K W A Göttgens
- Department of Gastro-intestinal Surgery, Elisabeth-TweeSteden Hospital Tilburg, Dr. Deelenlaan 5, 5042 AD, Tilburg, The Netherlands
| | - B S Langenhoff
- Department of Gastro-intestinal Surgery, Elisabeth-TweeSteden Hospital Tilburg, Dr. Deelenlaan 5, 5042 AD, Tilburg, The Netherlands
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Effects of Probiotics Supplementation on Gastrointestinal Symptoms and SIBO after Roux-en-Y Gastric Bypass: a Prospective, Randomized, Double-Blind, Placebo-Controlled Trial. Obes Surg 2020; 31:143-150. [DOI: 10.1007/s11695-020-04900-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/31/2020] [Accepted: 07/31/2020] [Indexed: 02/07/2023]
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