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

Five-Year Experience Training Surgeons with a Laparoscopic Simulation Training Program for Bariatric Surgery: a Quasi-experimental Design

PURPOSE

Nearly 200,000 laparoscopic Roux-en-Y gastric bypass (LRYGB) are performed yearly. Reported learning curves range between 50 and 150, even 500 cases to decrease the operative risk. Simulation programs could accelerate this learning curve safely; however, trainings for LRYGB are scarce. This study aims to describe and share our 5-year experience of a simulated program designed to achieve proficiency in LRYGB technical skills.

MATERIALS AND METHODS

A quasi-experimental design was used. All recruited participants were previously trained with basic and advanced laparoscopic simulation curriculum completing over 50 h of practical training. Ex vivo animal models were used to practice manual and stapled gastrojejunostomy (GJ) and stapled jejunojejunostomy (JJO) in 10, 3, and 4 sessions, respectively. The main outcome was to assess the manual GJ skill acquisition. Pre- and post-training assessments using a Global Rating Scale (GRS; max 25 pts), Specific Rating Scale (SRS; max 20 pts), performance time, permeability, and leakage rates were analyzed. For the stapled GJ and JJO, execution time was registered. Data analysis was performed using parametric tests.

RESULTS

In 5 years, 68 trainees completed the program. For the manual GJ's pre- vs post-training assessment, GRS and SRS scores increased significantly (from 17 to 24 and from 13 to 19 points respectively, p-value < 0.001). Permeability rate increased while leakage rate and procedural time decreased significantly.

CONCLUSION

This simulated training program showed effectiveness in improving laparoscopic skills for manual GJ and JJO in a simulated scenario. This new training program could optimize the clinical learning curve. Further studies are needed to assess the transfer of skills to the operating room.

Robotic Roux-en-Y Gastric Bypass: A Single Surgeon's Experience with 527 Consecutive Patients

Background and Objectives

Robotic bariatric surgery is increasingly adopted by surgeons. We present the surgical results of 527 consecutive patients who underwent robotic Roux-en-Y gastric bypass (RYGB) using the standard technique.

Methods

A retrospective analysis of a prospectively maintained database was performed including 527 consecutive patients who underwent robotic RYGB between January 1, 2018 and December 31, 2021.

Results

The mean age of the patients was 41 years, with a male/female sex distribution of 143/384 (27.1%/72.9%). Type 2 diabetes in the pre-operative period was diagnosed in 31% of patients. The median pre-operative body mass index (BMI) was 44.6 kg/m² (range, 35-64). The mean operation time was 134 min for robotic RYGB, including the docking process. Early (< 30 days) complications included ileus (0.2%), atelectasis (0.2%), thromboembolic (0.2%) events, and surgical-site infection (0.2%). No leakage or bleeding of the gastrojejunal and jejunojejunal anastomoses were recorded. Oral food intake was begun at 1.8 days on average. The average hospital stay was 2 days. Despite a range of BMI values, operation times and gastrojejunal anastomosis times did not show significant differences. There were no significant differences in mean operation time or mean gastrojejunal anastomosis time over the years.

Conclusions

The robotic approach is effective and safe for patients undergoing RYGB. This technique provides satisfactory results with short-term surgical outcomes. However, the real benefits of robotic RYGB should be further evaluated by well-conducted randomized trials. Even in difficult cases with higher BMI values, optimal operation times and similar operative efficiency can be obtained if a standard operation technique is applied.

Current evidence on laparoscopic vs. open resection for gastric stromal tumours

Although the use of laparoscopic surgery is increasing, controversy still surrounds its application for malignant conditions. Gastrointestinal stromal tumours (GISTs) are less demanding in terms of lymphadenectomy, meaning that laparoscopic resection might have a more defined benefit when compared with open resection. To the best of our knowledge, no randomized study exists that compares the laparoscopic and open resection of GISTs. The current study aimed to examine the relevant literature by means of a systematic review. A systematic literature search was performed individually by two authors, in which three independent databases were searched using specific search-terms. Titles, abstracts and full texts were screened, as well as references to relevant articles, in order to comprise a comprehensive list of studies. Data were extracted using a detailed pre-agreed spreadsheet. Studies were evaluated according to the modified MINORS criteria. A total of 10 studies were included in the present review, yielding a total of 14 entries. The majority of studies reported significantly improved perioperative outcomes for the laparoscopic approach, including improved duration of operation, blood loss and length of hospital stay. Only four studies reported long-term outcomes and findings that were controversial, with some studies detecting no statistically significant differences, one reporting improved and one reporting worse disease-free and overall survival for the laparoscopic group. Three studies were deemed to be good quality, two of which had not reported significantly different long-term outcomes, while the third had reported significantly improved outcomes in the open resection group. While there is a clear benefit for performing laparoscopic surgery in patients with GIST with regards to perioperative outcomes, when it comes to long-term oncological outcomes, uncertainty over its application remains. The lack of randomized trials, as well as the poor reporting of retrospective studies, limits the amount of evidence that is currently available. Laparoscopic surgery for GIST is certainly safe, feasible and likely cost-effective; however, further studies are required to inform on whether this technique is superior to open resection.

The importance of the biliopancreatic limb length in gastric bypass: A systematic review

BACKGROUND

Bariatric surgery has proven to be the most durable treatment for obesity, and it also provides improvement of obesity's associated co-morbidities. Although several mechanisms for its metabolic effects have been studied, the implications of the surgically constructed anatomy on its functioning physiology have not been elucidated. This leaves some uncertainty regarding the recommended limb lengths in Roux-en-Y gastric bypass. The alimentary limb length and function has been studied extensively, but few have studied the influences of the biliopancreatic limb length.

OBJECTIVE

To present a systematic review of the literature comparing variations in length of BP limb and results in order to determine BP limb length influence.

SETTING

Academic Hospital, United States.

METHODS

We present a systematic review of all the articles comparing variations of the biliopancreatic limb length and their results.

RESULTS

Thirteen articles were identified and analyzed. Most of the articles are prospective studies. Weight loss was superior in longer limbs.

CONCLUSION

Based on our review of the subject, we can conclude that the release of enterohormones in response to a food load in the distal small bowel seems to play an important role in the remission of co-morbidities. Hence, the length of the biliopancreatic limb might affect this process.

Managing Care of Critically Ill Bariatric Patients

Nearly 160 million Americans are overweight, obese, or morbidly obese. Morbid obesity and its numerous comorbidities are threats to a person's health. Moreover, hospitalized individuals living with adiposity-based chronic conditions are at risk for certain immobility hazards. Many individuals who are morbidly obese look to metabolic surgery as a means for achieving sustainable weight loss. This article addresses critical care needs of people living with excess weight or weight maldistribution, along with specific needs of those undergoing metabolic surgery.

Laparoscopic Suturing as a Barrier to Broader Adoption of Laparoscopic Surgery

BACKGROUND

Laparoscopic surgery is increasingly replacing the open procedure because of its many patient-related benefits that are well aligned with policies and programs that seek to optimize health system performance. However, widespread adoption of laparoscopic surgery has been slow, in part, because of the complexity of laparoscopic suturing. The objective of this study was to review the clinical and economic impacts of laparoscopic suturing in key procedures and to assess its role as a barrier to the broader adoption of laparoscopic surgery.

DATABASE

A medical literature search of MEDLINE, EMBASE, and BIOSIS from January 2010 through June 2016 identified 47 relevant articles.

CONCLUSION

Laparoscopic suturing and intracorporeal knot tying may result in extended surgical time, complications, and surgeon errors, while improving patient quality of life through improved cosmesis, diet toleration, and better bowel movements. Despite advancement in surgical techniques and the availability of newer surgical tools, the complexity of laparoscopic suturing continues to be a barrier to greater adoption of MIS. The results of the study underscore the need for development of proficiency in laparoscopic suturing, which may help improve patient outcomes and reduce healthcare costs.

Esophageal adenocarcinoma five years after laparoscopic sleeve gastrectomy. A case report

INTRODUCTION

Laparoscopic sleeve gastrectomy has become the most popular bariatric procedure worldwide. However, postoperative gastroesophageal reflux disease appearance is a matter of concern. Only two cases of esophageal adenocarcinoma after gastric sleeve have been described, none of them with preoperative endoscopic evaluation.

PRESENTATION OF CASE

We report a case of a 48-year-old male with morbid obesity and normal preoperative endoscopy and esophagram who underwent a laparoscopic sleeve gastrectomy and developed an esophageal adenocarcinoma five years later.

DISCUSSION

Despite promising results in terms of weight loss and resolution of comorbidities, the onset or worsening of gastroesophageal reflux and its related complications, such as Barrett's esophagus or esophageal adenocarcinoma, is a matter of concern and need further study.

CONCLUSION

We present a case of an esophageal adenocarcinoma five years after a laparoscopic sleeve gastrectomy for morbid obesity. There is need to better determine the relationship between sleeve gastrectomy and gastroesophageal reflux disease in order to prevent its related complications, such as esophageal adenocarcinoma.

Quality of life after gastric sleeve and gastric bypass for morbid obesity

Highlights

Quality-of-life measures improve as early as 3 months after bariatric surgery.There is wide variability in reporting that renders direct comparisons difficult.The available comparisons between RYGB and sleeve gastrectomy could not detect any difference.Improvement in PRO measures might be related to weight loss.Larger and better designed studies are required to achieve discrimination in PRO measures.

Background

Obesity is associated with reduced quality-of-life (QoL), which generally improves after bariatric surgery. The differential effect of each type of surgery (gastric sleeve [SG] and gastric bypass [RYGB]) on QoL is not yet fully understood.

Objectives

To understand which of these surgeries offers greatest improvement in QoL and patient satisfaction.

Methods

Systematic literature search on Pubmed in July 2014. Relevant articles were selected in a step-wise approach. The 2482 titles were scanned for relevance and 191 were selected for abstract reviewing; and 88 papers were selected for full text analysis.

Results

Only 5 papers compared the 2 techniques and only 17 more had retrievable data either on SG or RYGB. The reports were very heterogeneous, preventing a direct comparison of patient reported outcomes (PRO) among studies.Improved results have been reported as early has 3 months and SF-36 scores were improved in all domains in medium to long-term. The question remains whether the improvement in QoL is related to the weight loss and which factors are associated with improved patients' perceptions.

Conclusions

There is wide heterogeneity in the reporting of PRO measures after bariatric surgery, but data is consistent with a significant improvement after both surgeries.Larger and better-designed studies are required to understand if there are significant differences in the quality of life after SG or RYGB.

Effects of Intentional Weight Loss on Markers of Oxidative Stress, DNA Repair and Telomere Length - a Systematic Review

BACKGROUND

Altered levels of markers of oxidative stress, DNA repair, and telomere integrity have been detected in obese individuals and may underlie the pathogenesis of obesity-related diseases. However, whether or not such effects are reversed by intentional weight loss has not been systematically reviewed.

METHODS

A literature search in PubMed/Medline identified 2,388 articles of which 21 studies (randomized controlled trial (RCT) (n = 10) and non-randomized intervention studies (n = 11)) were classified as testing the effects of intentional weight loss on i) oxidative stress (n = 15), ii) DNA repair (n = 2), and iii) telomere length (n = 4).

RESULTS

Across a broad range of intervention designs, diet-, exercise-, surgery-, balloon-induced weight loss regimens decreased oxidative stress measures. Studies investigating DNA repair capacity or telomere length as endpoints after weight loss were less common in number and yielded null or inconsistent results, respectively.

CONCLUSION

While this systematic review supports a role for intentional weight loss in reducing obesity-associated oxidative stress, it is not clear whether the effects are primary outcomes or secondary to improvement in obesity-associated insulin resistance and/or chronic inflammation. Although the lack of effect of intentional weight loss on DNA repair capacity might be anticipated given that oxidative stress is reduced, additional studies are needed. The inconsistent effects of weight loss on telomere length or DNA repair suggest the need for a re-assessment of intervention designs and assay methodology to definitively address this topic.

A systematic review of the interrelation between diet- and surgery-induced weight loss and vitamin D status

Obesity is a major global health problem and has been associated with vitamin D deficiency. Intentional weight loss may alter vitamin D status and, conversely, vitamin D supplementation has been hypothesized to aid in weight loss. A systematic literature search in PubMed/Medline identified 3173 articles of which 37 studies (randomized controlled trials (RCT) [n=17], non-RCTs [n=20]) are summarized as effect of: (I) diet-induced weight loss on vitamin D status (n=7), (II) vitamin D supplementation on diet-induced weight loss (n=11), (III) surgery-induced weight loss on vitamin D status (n=15), and (IV) vitamin D supplementation after surgery-induced weight loss on vitamin D status (n=5). While all studies on the effect of diet-induced weight loss on vitamin D status have consistently reported increased vitamin D levels, the targeted percentage of weight loss that is necessary for an increase has varied between 5% and >10%. N=11 RCTs testing the effect of vitamin D supplementation observe that vitamin D supplementation does not result in increased weight loss, but may affect body fat loss. Vitamin D deficiency and subsequent hyperparathyroidism have been detected in post-surgery patients, and there is evidence that vitamin D supplementation improves these post-surgery complications. We review the current evidence addressing the role of vitamin D status and supplementation in diet- and surgery-induced weight loss. Subsequently, we highlight gaps in current research and suggest directions for future research including differences in vitamin D supplementation dosages, indoor vs. outdoor exercise, and the assessment of vitamin D status in different body pools.

Metabolic syndrome resolution by Roux-en-Y gastric bypass in a real world: a case control study

OBJECTIVES

the aim of this study was to evaluate the efficacy of Roux-en-Y Gastric Bypass (RYGB), compared with nonsurgical treatment (NS group), as an instrument for inducing remission of co-morbidities related to Metabolic Syndrome (MetS) in patients with Obesity, grades 2 and 3 (Ob2,3).

METHODS

two hundred and fifty eight Ob2,3 patients were selected in a retrospective analysis and included in a case control study. MetS was defined as described by the International Diabetes Federation. One hundred and twenty-nine of these patients underwent RYGB (S group), and 129 were assessed as an NS group.

RESULTS

at baseline, S and NS groups did not differ in BMI, age, female sex and prevalence of MetS (p>0.05). For the S group the outcomes were a reduction in BMI of 38.1% (p<0.001), waist circumference of 28.6% (p<0.001), fasting plasma glucose of 10.5% (p<0.001), serum LDL-cholesterol of 21.9% (p<0.001) and of 85% in the number of patients with MetS (p<0.001). For the NS group, only a decrease of 4.12%(p=0.047) in triglyceride levels and of 5.9%(p=0.031) in Diastolic Blood Pressure was observed. In the NS group, 98.6% of the patients continued to have MetS. The number needed to treat (NNT) with surgery to resolve one case of MetS was 1.2 (CI 95%: 1.1 - 1.4).

CONCLUSION

in the real world, in the South of Brazil, compared with NS treatment and after 1 year of observation, RYGB is highly effective for decreasing the prevalence of MetS.

Gap Between Evidence and Patient Access: Policy Implications for Bariatric and Metabolic Surgery in the Treatment of Obesity and its Complications

Despite consistently supportive evidence of clinical effectiveness and economic advantages compared with currently available non-surgical obesity treatments, patient access to bariatric and metabolic surgery (BMS) is impeded. To address this gap and better understand the relationship between value and access, the objectives of this study were twofold: (i) identify the multidimensional barriers to adoption of BMS created by clinical guidelines, public policies, and health technology assessments; and, most importantly, (ii) develop recommendations for stakeholders to improve patient access to BMS. Updated public policies focused on treatment and clinical guidelines that reflect the demonstrated advantages of BMS, patient education on safety and effectiveness, updated reimbursement policies, and additional data on long-term BMS effectiveness are needed to improve patient access.

[Surgical options for reducing body weight]

Obesity is a leading preventable cause of death worldwide, with increasing prevalence in adults and children, and authorities view it as one of the most serious public health problems of the 21st century. Sixty-two percent of the Hungarian adult population has overweight and 27% is morbidly obese and, therefore, it is a significant interest to treat this condition. The authors review the diagnosis and the associated diseases of morbid obesity. The initial enthusiasm with the gastric band has settled now, as the long-term outcome showed only very limited reduction in the excess body weight and the complication rate was as high as 50%. The sleeve gastrectomy may induce 60-70% of excess weight loss, however, the long term follow-up data is very limited. The Roux-en-Y gastric bypass is the gold-standard of the bariatric procedures, with proven 60-75% excess weight loss and 80% type 2 diabetes remission. The body image usually changes with weight loss, and frequently a body contouring procedure is required to improve it. Multi-disciplinary team of super-specialised doctors is required to perform these procedures.

Effects of Roux-en-Y gastric bypass or diabetes support and education on insulin sensitivity and insulin secretion in morbidly obese patients with type 2 diabetes

OBJECTIVE

The long-term changes in insulin sensitivity and β-cell function in morbidly obese patients with type 2 diabetes mellitus who undergo Roux-en-Y gastric bypass (RYGB) surgery or standard medical care remain unclear. We prospectively studied longitudinal changes of glucostatic parameters in morbidly obese patients with type 2 diabetes mellitus undergoing RYGB surgery or diabetes support and education (DSE).

RESEARCH METHODS AND DESIGN

Sixty-one morbidly obese subjects (41.7 ± 0.6 kg/m) with type 2 diabetes mellitus were assigned to RYGB surgery (n = 30) or DSE (n = 31). They were matched for sex, age, and body weight. Insulin sensitivity index (Si) and acute insulin response (AIR) were derived from frequently sampled intravenous glucose tolerance test. Body composition was measured using dual-energy x-ray absorptiometry. General linear model with repeated measures was used to examine the longitudinal changes (baseline, 6 months, 12 months) in these parameters.

RESULTS

At 12-month follow-up, significant improvement in obesity measures, body composition, glucose homeostasis, Si, and AIR was observed after RYGB surgery and weight loss. These outcomes were not influenced by preoperative insulin use. Although there were no significant changes in the body composition among DSE subjects, they experienced a decline in the Si and AIR, along with an increase in fasting glucose and HbA1c. The between-group differences in Si and AIR at 12-month follow-up were completely attenuated with adjustment to changes in body weight.

CONCLUSIONS

The long-term effects of RYGB surgery on glucostatic parameters are partly dependent on weight loss. In morbidly obese patients with diabetes who were offered DSE, a progressive decline in the glucose homeostasis and glucostatic parameters is observed despite absence of weight gain. (NCT00787670).

The increasing incidence of adolescent bariatric surgery

BACKGROUND

Morbid obesity continues to be a significant problem within the United States, as overweight/obesity rates are nearing 33%. Bariatric surgery has had success in treating obesity in adults and is becoming a viable treatment option for obese adolescents.

METHODS

We studied 1615 inpatient admissions for children ≤20 years of age undergoing a bariatric procedure for morbid obesity in 2009 using the Kids' Inpatient Database (KID). Patients had a principal diagnosis of obesity and a bariatric procedure listed as one of their first 5 procedures. Procedures (open gastric bypass, laparoscopic gastric bypass, sleeve gastrectomy, laparoscopic gastroplasty, and laparoscopic gastric band) and complications were defined by ICD-9 codes.

RESULTS

There were 90 open gastric bypasses, 906 laparoscopic gastric bypasses, 150 sleeve gastrectomies, 18 laparoscopic gastroplasties, and 445 laparoscopic gastric bandings. The length of stay for each procedure was 2.44, 2.20, 2.33, 1.10, and 1.02 days, respectively (P<0.001). The complication rates were 3.3%, 3.5%, 0.7%, 0.0%, 0.2%, respectively (P=0.004).

CONCLUSIONS

Bariatric surgery is an increasingly utilized option for the treatment of morbid obesity among adolescents. The procedures can be performed safely as evidenced by low complication rates. Additional long-term follow-up is necessary.

Perioperative outcomes after totally robotic gastric bypass: a prospective nonrandomized controlled study

BACKGROUND

Perioperative short-term outcomes could be improved after totally robotic Roux-en-Y gastric bypass (TR-RYGBP) compared with conventional laparoscopic gastric bypass.

METHODS

This is a nonrandomized controlled prospective study (N = 200) to evaluate perioperative short-term outcomes. The primary endpoint was to investigate risk factors for 30-day surgical complications.

RESULTS

Mean total operative time was shorter in patients who underwent TR-RYGBP (130 vs 147 minutes; P < .0001). However, postoperative surgical complications rate (13% vs 1%; P = .001), and mean overall hospital stay (9.3 vs 6.7 days; P < .0001) were higher after TR-RYGBP. By multivariate analysis, robotic surgery (hazard ratio [HR] = 15.1; 95% confidence interval [CI], 2.8 to 280; P = .01), and conversion to laparotomy (HR = 18.8; 95% CI, 1.7 to 250.8; P = .014) were independent risk factors for 30-day surgical complications.

CONCLUSIONS

Although robotic gastric bypass reduces mean operative time, TR-RYGBP is associated with an increased postoperative surgical complications rate and longer hospitalization.

The evolution of minimally invasive bariatric surgery

BACKGROUND

Obesity is a pandemic associated with significant morbidity and mortality. This historical article charts the progress of successful strategies that have been used to tackle weight loss from dietary modifications to the development of surgical interventions that have subsequently evolved. It also provides a précis of the reported outcome data following minimally invasive bariatric procedures.

METHODS

A literature review was performed. All articles relevant to the progression of bariatric surgery and minimally invasive surgery were assessed, as were those articles that described the ultimate evolution, combination, and establishment of the two techniques.

RESULTS

This article charts the progression of early weight loss strategies, from early dietary modifications and pharmacologic interventions to initial techniques in small bowel bypass procedures, banding techniques, and sleeve gastrectomies. It also describes the simultaneous developments of endoscopic interventions and laparoscopic procedures.

CONCLUSIONS

A range of procedures are described, which differ in their success in terms of loss of excess weight and in their complication rates. Weight loss is greatest for biliopancreatic diversion followed by gastric bypass and sleeve gastrectomy and least for adjustable gastric banding. Bariatric surgery is an evolving field, which will continue to expand given current epidemiologic trends. Developments in instrumentation and surgical techniques, including single access and natural orifice approaches, may offer further benefit in terms of patient acceptability.

Technique for salvage ERCP with gastric bypass anatomy and severe intra-abdominal adhesions

BACKGROUND

Choledocholithiasis is a complex problem in patients with Roux-en-Y gastric bypass anatomy. Several techniques of biliary clearance have been described, but these can be limited by intra-abdominal adhesions.

PATIENT AND METHODS

A 36-French surgical gastrostomy was created and was allowed to mature for 10 weeks. It was exchanged for a 15-mm laparoscopic surgery trocar under fluoroscopic guidance. Endoscopic retrograde cholangiopancreatography (ERCP) was carried out using the trocar as a stable access point. Complete biliary clearance was achieved in one sitting using sphincterotomy, large-diameter biliary orifice balloon dilation, and balloon/basket sweeps.

RESULTS

Total endoscopy time was 120 minutes. There were no complications associated with the procedure. The postprocedure length of stay was 2 days. The total bilirubin level at discharge was 1.2 mg/dL (20 μmol/L).

CONCLUSIONS

In patients with gastric bypass anatomy and severe adhesions, successful salvage therapeutic ERCP can be achieved using a gastrostomy tract and a large-bore laparoscopy trocar for access to the defunctioned stomach.