Evolution of the laparoscopic gastric bypass

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.

Transoral technique for gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass (LRYGBP) can accelerate learning curve and reduce cost

BACKGROUND

The stapled gastrojejunostomy of the laparoscopic Roux-en-Y gastric bypass (LRYGBP) can be created by linear and circular stapling techniques. In the circular-stapled technique, the anvil of the stapler can be introduced into the gastric pouch transabdominally or pulled down the esophagus (transorally) by attachment to a modified gastric tube. The purpose of this study is to determine if the transoral technique to introduce the anvil will reduce operative time and cost compared with the transabdominal technique, which requires creating a new gastrotomy to insert the anvil and followed by its closure.

METHODS

We compared 60 consecutive morbidly obese patients who underwent laparoscopic RYGBP. First 30 cases were performed by transabdominal anvil insertion, followed by 30 cases using transoral anvil insertion. All of the transabdominal cases were assisted by experienced fellows. The first ten transoral cases were assisted by experienced fellows and the remaining 20 by new fellows in order to evaluate if the transoral technique shortens the learning curve. Surgery duration and operative costs were compared. Complications (bleeding, leaks, anastomotic strictures, ulcers, wound infections) and length of stay were also evaluated. Data are expressed as mean +/- SD.

RESULTS

Mean operative time was shorter in the transoral group compared with the transabdominal group (162.2 +/- 35.8 vs. 186 +/- 33.6 min respectively, p = 0.01), even though most of the transoral cases (n = 20) were assisted by new fellows and all of the transabdominal cases by experienced fellows. Operative times were not different between new and experienced fellows in the transoral technique. Supply costs per patient were higher in the transabdominal technique compared with the transoral technique (2,983.5 +/- 540.9 vs. 2,658.8 +/- 474.4 USD, respectively, p = 0.03). Perioperative complications and length of stay were not statistically different.

CONCLUSION

The transoral introduction of the anvil of the circular stapler into the gastric pouch is a simple, safe, and efficient technique for creating the gastrojejunostomy in laparoscopic RYGBP. In addition, the transoral technique is less expensive and appears to accelerate the learning curve compared with the transabdominal technique.

Optimizing outcomes in bariatric surgery: outpatient laparoscopic gastric bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is an effective treatment of severe obesity and one of the fastest growing surgical procedures in the United States.

METHODS

A single institution prospective database of patients undergoing outpatient laparoscopic (lap) RYGB over a 3-year period was reviewed. Study end points included hospital discharge within 23 hours, 30-day hospital readmission rate, early (<30 day) and late complication rates, and 30-day perioperative mortality. Variables assessed included surgeon experience, patient demographics, comorbidities, operative time, Roux limb pathway, intraoperative steroid bolus, and use of dexmedetomidine.

RESULTS

Two thousand consecutive patients undergoing outpatient lap RYGB were identified, and 84% (n = 1669) were discharged within 23 hours. Of these, 1.7% (n = 34) were readmitted within 30 days. The overall early and late complication rates were 1.9% (n = 38) and 4.3% (n = 86), respectively. The 30-day mortality rate was 0.1% (n = 2), and neither patient was discharged before death. Univariate analysis demonstrated surgeon experience (<50 cases), age (<56 years), body mass index (<60 kg/m), weight (400 lbs), comorbidities (<5), and intraoperative steroid bolus as predictive of successful outpatient discharge. Multivariate analysis revealed surgeon experience, comorbidities, body mass index, and steroid bolus as predictive variables.

CONCLUSIONS

These data suggest that outpatient lap RYGB can be performed with acceptable perioperative complication rates, hospital readmission, and mortality rates. Surgeon experience, careful patient selection, and the use of intraoperative steroid bolus predicted optimal patient outcomes.

Initiation and progression of physical activity after laparoscopic and open gastric bypass surgery

This study compared postoperative physical activity participation among patients who underwent laparoscopic (LGBS) or open gastric bypass surgery (OGBS). Postoperative physical activity participation is considered important for achieving optimal weight loss and maintenance after gastric bypass surgery. However, no study has examined the relationship between surgery type and postoperative physical activity. Minimal invasiveness and reduced recovery time associated with LGBS compared with OGBS may permit earlier initiation and faster progression of postsurgical physical activity and potentially contribute to greater long-term adherence rates. Self-reported physical activity participation and aerobic physical activity hours per week at 2-weeks, 3-months, and 6-months postsurgery were assessed among LGBS and OGBS patients (presurgical body mass index of 35 to 70 kg/m(2)) at a university hospital from 1988-2002. Of the 2,235 patients, 531 (24%) and 1704 (76%) underwent LGBS and OGBS, respectively. A greater proportion of LGBS patients reported physical activity participation at each time point compared with OGBS patients (2 week, 76% vs 62%; 3 months, 84% vs 74%; 6 months, 85% vs 76%). Furthermore, LGBS patients reported a significantly greater physical activity duration at 2-weeks postsurgery compared with OGBS patients. A nonsignificant trend toward greater physical activity duration was observed in the LGBS patients at 3 months, whereas 6-month physical activity duration was similar between groups. LGBS, compared with OGBS, may promote earlier onset, progression, and maintenance of physical activity until 6 months postsurgery. Future studies need to prospectively determine whether LGBS, via facilitation of greater engagement in postsurgical physical activity, contributes to more successful weight loss and weight maintenance compared with OGBS.