Laparoscopic Totally Stapled Entero-Enterostomy: A Safe and Reproducible New Technique

Background Laparoscopic gastric bypass for morbid obesity is a technically demanding procedure partially because of the necessity to construct two anastomoses. In this study, a new technique to perform the entero-enterostomy is presented. Methods We evaluated the procedure in a consecutive series of 100 patients who underwent laparoscopic gastric bypass. Intra- and postoperative complications were analyzed. Results No complications in relation to the construction of the entero-enterostomy occurred. No leakage, kinking, or stenosis was observed during a mean follow-up of 13.5 months (range 6–20 months). Conclusion This new technique for a totally stapled entero-enterostomy can be recommended. Presented at the 5th International Obesity Surgery Expert Meeting, Saalfelden, Austria, March 11, 2007.     

Pilot study evaluating technical feasibility and early outcomes of second-generation endosurgical platform for treatment of weight regain after gastric bypass surgery

BackgroundFor some gastric bypass patients, dilation of the gastrojejunal anastomosis (GJA) and/or gastric pouch is believed to contribute to weight regain. The present study had 2 objectives: (1) to assess the technical feasibility and safety of a novel endoscopic procedure called “revision obesity surgery endoscopic” (ROSE) using a second-generation, prototype endoscopic operating system that creates tissue plications to reduce the diameter of the GJA and the size of the gastric pouch; and (2) to assess the early outcomes regarding weight loss at a university hospital in the United States.MethodsThis was a prospective study of 5 patients who had regained a mean of 14.7 kg after gastric bypass with a dilated pouch and GJA on screening endoscopy. The gastric pouch and the GJA were measured before and after the procedure. The patients were followed up for a minimum of 3 months after the procedure. Weight changes were recorded.ResultsTechnical success was achieved in all 5 patients (100%). The mean weight loss in the successful cases was 7.8 kg at 3 months. No major complications developed.ConclusionThe results of our study have shown that the ROSE procedure using this second-generation prototype endoscopic operating system is technically feasible and appears safe. Our preliminary results suggest that the ROSE procedure is effective in reducing the size of both the GJA and the gastric pouch and could therefore be an alternative therapy for weight regain in postgastric bypass patients.     

Prospective randomized trial of banded versus nonbanded gastric bypass for the super obese: early results

BACKGROUND: Banded gastric bypass has been reported to result in superior weight loss compared with standard nonbanded gastric bypass. However, an adequate comparison of these procedures has not yet been reported. METHODS: A total of 90 patients were enrolled in this prospective randomized double-blind trial comparing banded and nonbanded open gastric bypass for the treatment of super obesity. The banding technique involved placement of a 1.5 x 5.5-cm polypropylene band around the proximal gastric pouch of a standard gastric bypass procedure using the technique of Capella. Chi-square testing and analysis of variance were performed to find any differences in patient characteristics (gender, age, and initial body mass index), percentage of excess weight lost at 6, 12, 24, and 36 months postoperatively, improvement or resolution of co-morbidities, and complications in the banded versus nonbanded gastric bypass groups. RESULTS: As expected, no differences were present in the patient characteristics or incidence of co-morbidities between the banded (n = 46) and nonbanded (n = 44) groups. The body mass index, percentage of women, and mean age was 59.5 and 56.5 kg/m2, 64% and 73.8% (P = .09), and 40.6 +/- 7.4 and 42.6 +/- 7.2 years for the banded and nonbanded groups, respectively; all differences were nonsignificant. No significant differences were found in the resolution of co-morbidities. No significant difference was present in the percentage of excess weight loss at 6, 12, and 24 months (43.1% versus 24.7%, 64.0% versus 57.4%, and 64.2% versus 57.2%, respectively) postoperatively; however, the banded patients had achieved a significantly greater percentage of excess weight loss at 36 months (73.4% versus 57.7%; P <.05). The incidence of intolerance to meat and bread was greater in the banded patients. The overall number of complications was 12 (26%) in the banded and 13 (29.5%) in the nonbanded group, a nonsignficant difference. No band erosions had occurred at the last follow-up visit, and no patients in either group died. CONCLUSION: These results suggest that although the initial weight loss was not significantly different between the 2 groups, the banded patients continued to lose weight for < or = 3 years. The polypropylene band appeared to be well tolerated. We plan longer follow-up to confirm the possibility of additional weight loss and the prevention of weight regain in the banded group, as well as to document any long-term band complications.     

Zero frequency of internal hernias after laparoscopic double loop gastric bypass without closure of mesenteric defects

Purpose

Laparoscopic Roux-en-Y gastric bypass is among the most effective surgical procedures for morbid obesity; however, one of its most common long-term complications is internal hernia. The purpose of this study was to evaluate the incidence of internal hernia in patients undergoing a new gastric bypass surgical technique known as “double loop” without closure of the mesenteric defects.

Methods

We reviewed 44 patients with morbid obesity, who underwent laparoscopic double loop gastric bypass. There were 34 women and 10 men, followed up for a mean period of 18 ± 3 months, mainly by periodic medical examinations and blood tests.

Results

The initial body mass index (BMI) was 44.23 ± 4.7 and the mean % excess weight (%EW) was 105.83 ± 24.41. After 18 postoperative months, the mean BMI was 29.68 ± 3.7 kg/m², representing a mean loss of 14.5 BMI units, with the mean % excess weight loss (%EWL) of 64.33 ± 13.47. No cases of internal hernia were recorded.

Conclusions

Laparoscopic double loop gastric bypass without closure of the mesenteric defects is a safe and feasible procedure. A longer observational follow-up and a large number of patients are required to confirm significant results.     

Laparoscopic Sleeve Gastrectomy as an Alternative to Gastric Bypass in Patients with Multiple Intraabdominal Adhesions

Background Laparoscopic sleeve gastrectomy and its indications are currently being evaluated. The objective of this study was to show the preliminary results obtained with this technique indicated as an alternative to gastric bypass in patients with multiple intraabdominal adhesions, therefore preserving the benefits of the laparoscopic approach. Methods An analysis of all patients who underwent a laparoscopic sleeve gastrectomy for the above indication was done. Data included demographics, number of previous surgeries, operative time, morbidity, mortality, and %EWL at 3 and 6 months. Results Fifteen patients underwent laparoscopic sleeve gastrectomy as an alternative to gastric bypass because of multiple intraabdominal adhesions. No patient required conversion to an open procedure; morbidity was 6% with no mortality. %EWL at 3 months was 41% and at 6 months was 44%. Mean follow-up was 6 months. Conclusion In our initial experience, laparoscopic sleeve gastrectomy proved to be a safe and effective alternative to gastric bypass for patients with multiple intraabdominal adhesions.     

腹腔镜胃后、结肠后路胃空肠Roux—en—Y吻合术治疗单纯性肥胖症22例

目的探讨腹腔镜胃旁路手术方式中,胃后路胃空肠吻合手术方式的可行性和临床价值。方法2010年12月～2012年3月,对体重指数（BMI）≥35．0的单纯性肥胖症病例行结肠后腹腔镜胃空肠Roux—en—Y吻合术,随意分组,胃后路径22例,胃前路径38例。对比2组手术时间、出血量、术后住院时间、术后近期并发症发生率,术后6个月体重、BMI、多余体重减除率（EWL％）的差异。结果胃后路组手术时间较胃前路组长[（157．2±9．2）minVS．（144．9±12．1）min,t=-4．127,P=0．000];2组术中出血量,术后住院时间,术后6个月体重、BMI、EWL％差异均无显著性。胃前路组8例（21％）术后出现呕吐等上消化道不全梗阻症状,均在1周内缓解;胃后路组未出现类似并发症（P=0．022）。结论胃后路腹腔镜胃旁路手术是一种可行的术式,相比胃前路术式更符合生理,术后胃肠道近期并发症较少,胃肠道功能恢复较快。     

Current status of laparoscopic gastric bypass

Laparoscopic gastric bypass is emerging as a commonly performed procedure for the treatment of morbid obesity. This article discusses the indications for surgery, patient selection, surgical technique, management of complications, and outcomes of laparoscopic gastric bypass.     

Laparoscopic Roux-en-Y gastric bypass: a case report at one-year follow-up

Surgery is the only treatment for morbid obesity that has been proven to achieve a significant long-term weight loss. The Roux-en-Y gastric bypass procedure has been performed for the treatment of morbid obesity over the past two decades with excellent results. Wound complications and perioperative morbidity remain unresolved problems of the procedure. A laparoscopic approach to this procedure has great potential to minimize the complications of this highly effective technique. We describe a laparoscopically performed Roux-en-Y gastric bypass in a 28-year-old woman with morbid obesity. The technique described here preserves the anatomic construct of the operation but introduces the benefit of the laparoscopic approach.     

Transumbilical Laparoscopic Roux-en-Y Gastric Bypass with Hand-Sewn Gastrojejunal Anastomosis

Single-port laparoscopic surgery has undergone significant development over the past 5 years. Single port is used in various procedures, including bariatric surgery. The aim of this paper is to describe a surgical technique for gastric bypass with a transumbilical approach (transumbilical gastric bypass—TUGB) with hand-sewn gastrojejunostomy, in selected patients who may be benefited by a better cosmetic result. The procedure begins with a transumbilical vertical incision. We use the GelPOINT single-port device and a 5-mm assistant trocar in the left flank (in the first two cases, a 2-mm subxiphoid liver retractor was used). A gastric pouch is made and calibrated with a 36-Fr bougie. The gastrojejunal anastomosis is performed by hand-sewing in two layers. A Roux-en-Y with a biliary limb of 50 cm and an alimentary limb of 120 cm is performed with a stapler. Three women were subjected to TUGB. The women were aged 28, 31, and 42 years; they had body mass indexes of 40.3, 33, and 38.2; and the operating times were 150, 200, and 150 min, respectively. The first two women underwent a Roux-en-Y gastric bypass (RYGB), and the last woman underwent a RYGB with a resection of the stomach remnant. There were no conversions to open or multitrocar techniques. No complications or deaths occurred. The three patients were satisfied with the cosmetic result. The technique described for TUGB is a feasible procedure for surgeons who have previous experience with the transumbilical approach.     

Endoscopic findings in the excluded stomach after Roux-en-Y gastric bypass surgery

HYPOTHESIS: After gastric bypass surgery performed because of morbid obesity, the excluded stomach can rarely be endoscopically examined. With the advent of a new apparatus and technique, possible mucosal changes can be routinely accessed and monitored, thus preventing potential benign and malignant complications. DESIGN: Prospective observational study in a homogeneous population with nonspecific symptoms. SETTING: Outpatient clinic of a large public academic hospital. PATIENTS: Forty consecutive patients (mean +/- SD age, 44.5 +/- 10.0 y ears; 85.0% women) were seen at a mean +/- SD of 77.3 +/- 19.4 months after Roux-en-Y gastric bypass surgery. INTERVENTION: Elective double-balloon enteroscopy of the excluded stomach was performed. MAIN OUTCOME MEASURES: Rate of successful intubation, endoscopic findings, and complications. RESULTS: The excluded stomach was reached in 35 of 40 patients (87.5%). Mean +/- SD time to enter the organ was 24.9 +/- 14.3 minutes (range, 5-75 minutes). Endoscopic findings were normal in 9 patients (25.7%), whereas in 26 (74.3%), various types of gastritis (erythematous, erosive, hemorrhagic erosive, and atrophic) were identified, primarily in the gastric body and antrum. No cancer was documented in the present series. Tolerance was good, and no complications were recorded during or after the intervention. CONCLUSIONS: The double-balloon method is useful and practical for access to the excluded stomach. Although cancer was not noted, most of the studied population had gastritis, including moderate and severe forms. Surveillance of the excluded stomach is recommended after Roux-en-Y gastric bypass surgery performed because of morbid obesity.     

Superior gastric reduction procedure for morbid obesity: a prospective, randomized trial.

A prospective randomized clinical trial was undertaken to compare the effects of gastric bypass with Roux-en-Y gastrojejunostomy and a gastric partitioning procedure. Operative groups were comparable, with regard to preoperative weight, age, sex, historic findings and operative complications. Post-operative weight loss was followed for one year. Patients receiving the gastric partitioning procedure showed significantly poorer weight loss as early as three months postoperatively than did those receiving gastric bypass. This poorer performance persisted throughout the study period.     

Utility of Divided Omentum for Preventing Complications Associated with Laparoscopic Gastric Bypass

Background Laparoscopic Roux-en-Y gastric bypass has emerged as a standard surgical treatment for morbid obesity. However, prevention of postoperative complications associated with bariatric surgery is an important consideration. Methods To reduce postoperative complications and achieve adequate body weight loss, we introduce a simple procedure using a divided omentum during laparoscopic Roux-en-Y gastric bypass. The actual aim of this procedure is to prevent leakage from the gastric pouch or anastomosis and the gastro-gastric fistula because of reentry of the alimentary tract. Between February 2002 and April 2007, we performed laparoscopic Roux-en-Y gastric bypass for morbid obesity in 94 patients. In the most recent 83 cases, our simple procedure using a divided omentum was employed. Results These patients comprised 20 males and 63 females, with a mean age of 38 years, and a mean body mass index of 44.1 kg/m². At surgery, the omentum is routinely divided using laparoscopic coagulating shears before performing gastrojejunostomy to reduce the tension on the anastomosis caused by the route of reconstruction. After performing hand-sewn gastrojejunostomy, the left side of the divided omentum is moved cranially and interposed between the gastric pouch and the excluded stomach. The omentum is then sutured from the posterior aspect of the gastric pouch to the anterior side of the anastomosis. Conclusion Our procedure using a divided omentum during bariatric surgery is feasible and safe for obtaining better outcomes without artificial materials. Although the long-term outcome of this technique is still unclear, we believe that it will contribute to decreasing the particular complications related to laparoscopic Roux-en-Y gastric bypass for morbid obesity.     

Adjustable gastric banding as revisional bariatric procedure after failed gastric bypass—intermediate results

BackgroundAlthough gastric bypass is the most common bariatric procedure in the United States, it is has been associated with a failure rate of 15% (range 5–40%). The addition of an adjustable gastric band to Roux-en-Y gastric bypass has been reported to be a useful revision strategy in a small series of patients with inadequate weight loss after proximal gastric bypass.MethodsWe report on 22 patients who presented with inadequate weight loss or significant weight regain after proximal gastric bypass. All patients underwent revision with the placement of an adjustable silicone gastric band around the proximal gastric pouch. The bands were adjusted at 6 weeks postoperatively and beyond, as needed. Complications and weight loss at the most recent follow-up visit were evaluated.ResultsThe mean age and body mass index at revision was 41.27 years (range 25–58) and 44.8 ± 6.34 kg/m², respectively. Patients had experienced a loss of 19%, 27%, 47.3%, 42.3%, 43%, and 47% of their excess weight at 6, 12, 24, 36, 48, and 60 months after the revisional procedure, respectively. Three major complications occurred requiring reoperation. No band erosions have been documented.ConclusionThe results from this larger series of patients have also indicated that the addition of the adjustable silicone gastric band causes significant weight loss in patients with poor weight loss outcomes after gastric bypass. That no anastomosis or change in absorption is required makes this an attractive revisional strategy. As with all revisional procedures, the complication rates appear to be increased compared with a similar primary operation.     

Laparoscopic re-exploration in mechanical bowel obstruction after laparoscopic gastric bypass for morbid obesità

AIM: This study reports a series of 7 patients who experienced small-bowel obstruction (SBO) after laparoscopic gastric bypass (LGBP). METHODS: Between July 2001 and June 2004, 211 patients underwent surgery for morbid obesity in 2 different institutions and 7 of them required reoperative laparoscopic surgery or laparotomy for mechanical SBO. RESULTS: Seven patients in the series (3%) developed a postoperative bowel obstruction requiring operative management. Their mean body mass index was 49 (range: 38-65) and the average age was 48 years (range 29-60). Six (86%) had undergone an initial LGBP. One (14%) had been converted to open surgery because of the presence of thick adhesions. One percent of the patients (14%) had undergone abdominal surgery prior to gastric bypass. The most common cause of SBO was internal hernia through a mesenteric defect (57%), followed by adhesions (14%), obstruction at the entero-enterostomy (14%) and Petersen hernia (14%). The obstruction was managed laparoscopically. Small-bowel resection was required in 14% with no death encountered after the second revision of the entero-enterostomy. Recovery time was less than 72 h after laparoscopic approach and more than 92 h following the open procedure. CONCLUSIONS: Laparoscopic surgical correction of SBO following LGBP in morbidly obese patients is feasible. Reoperation of morbidly obese patients after LGBP can be achieved successfully through laparoscopic techniques.     

Endoscopic balloon dilation of outlet stenosis after gastric bypass

Eighteen of 22 patients with stenotic gastrojejunostomies following gastric bypass surgery were successfully corrected by endoscopically placing a guidewire through the narrowed outlet and then passing a dilating balloon catheter over the wire. No complications occurred. All procedures were done without general anesthesia, and 64 per cent were done without hospitalization. This procedure can spare patients prolonged hospitalization for nasogastric decompression or reoperation, the two standard approaches to this problem. Successful use of this technique to dilate obstructed gastric partitions and distal esophageal strictures suggests that it may be considered for any gastrointestinal stenosis within reach of the endoscope.     

Ulcer disease after gastric bypass surgery

BACKGROUND: The mechanism of marginal ulceration after laparoscopic gastric bypass surgery is poorly understood. We reviewed the incidence, presentation, and outcome of ulcer disease in consecutive patients undergoing laparoscopic gastric bypass surgery. METHODS: The outcomes of 201 consecutive laparoscopic gastric bypass surgery procedures were prospectively analyzed for complications. All procedures were performed using a linear stapled anastomosis and absorbable suture. RESULTS: The incidence of marginal ulcer disease was 3.5% (7 patients). One patient, the only smoker, presented with an acute perforation 4 months postoperatively. Three other patients presented with bleeding-all required transfusion. The remaining 3 patients presented with severe pain. At endoscopy, all patients had ulcerations associated with the Roux limb mucosa and were all successfully treated using proton pump inhibitors and sucralfate therapy. Symptoms of marginal ulceration occurred an average of 7.4 months (range 3-14) after surgery. The average follow-up was 19.8 months. No preoperative factors were predictors of ulcer disease, including body mass index, age, gender, or co-morbidities. CONCLUSION: Marginal ulcers using the linear-stapled technique occurred in 3.5% of patients. Three distinct clinical presentations occurred: bleeding, pain, or perforation. No preoperative risk factors were identified that predicted for this complication. Medical management is an effective treatment.     

Late Perforation and Abscess Formation at the Site of the Jejunojejunal Anastomosis Following Laparoscopic Roux-en-Y Gastric Bypass Surgery

Late complications involving the site of the jejunojejunal (J-J) anastomosis are uncommon after laparoscopic Roux-en-Y gastric bypass. We present a case of a perforation at the J-J anastomosis complicated by the formation of an abscess 6 months after surgery. Following clinical and radiological evaluation, the patient underwent an exploratory laparoscopy which had to be converted to an open technique because of technical difficulties. The abscess was drained, the anastomosis was resected, and a new anastomosis was undertaken. When the surgical specimen was inspected, a perforation was found at the site of the previous J-J anastomosis. The patient had an uneventful recovery. To our knowledge, this is the first report of the formation of an abscess due to a perforation at the site of the J-J anastomosis after laparoscopic Roux-en-Y gastric bypass surgery. This complication, although rare, should be taken into account in patients with abdominal pain and systemic inflammatory response syndrome after bariatric surgery. No commercial interests to disclose.     

Totally robotic Roux-en-Y gastric bypass

HYPOTHESIS: We hypothesized that we could develop a safe and effective technique for performing a totally robotic laparoscopic Roux-en-Y gastric bypass procedure using the da Vinci surgical system. We anticipated that the learning curve for this totally robotic procedure could be shorter than the learning curve for standard laparoscopic bariatric surgery. DESIGN: Retrospective case comparison study. SETTING: Academic tertiary care center. PATIENTS: Consecutive samples of patients who met National Institutes of Health (NIH) criteria for morbid obesity and who completed the Stanford Bariatric Surgery Program evaluation process. INTERVENTION: A port placement and robot positioning scheme was developed so that the entire case could be performed robotically. The first 10 patients who underwent a totally robotic laparoscopic Roux-en-Y gastric bypass were compared with a retrospective sample of 10 patients who had undergone laparoscopic Roux-en-Y gastric bypass surgery. MAIN OUTCOME MEASURES: Patient age, gender, body mass index (BMI), numbers of NIH-defined comorbidities, operative time, length of stay, and complications. RESULTS: No significant differences existed between the 2 patient series with regard to age, gender, or BMI. The median surgical times were significantly lower for the robotic procedures (169 vs 208 minutes; P = .03), as was the ratio of procedure time to BMI (3.8 vs 5.0 minutes per BMI for the laparoscopic cases; P = .04). CONCLUSIONS: This study details the first report, to our knowledge, of a totally robotic laparoscopic Roux-en-Y gastric bypass and demonstrates the feasibility, safety, and potential superiority of such a procedure. In addition, the learning curve may be significantly shorter with the robotic procedure. Further experience is needed to understand the long-term advantages and disadvantages of the totally robotic approach.     

Jejunoileal bypass. A legacy of late complications

Since 1977, we have managed 56 patients (36 Payne and 20 Scott bypasses) with late (one to 18 years) complications resulting from a jejunoileal bypass. All patients underwent a one-stage conversion of the jejunoileal bypass to a gastric bypass. Patients were classified according to postbypass weight, the need for nutritional support, the type and severity of complication, and the time interval between jejunoileal bypass and the onset of the complication and correction of the complication. There were no operative deaths; one patient died 18 months after surgery of cirrhosis. The complication rate was 34%; however, most complications were minor. Our experience with this procedure has shown it to be highly effective in correcting complications other than polyarthritis. When coupled with nutritional support, it is safe even in malnourished patients.     

Establishing a laparoscopic gastric bypass program

OBJECTIVE: To evaluate the outcomes for laparoscopic Roux-en-Y gastric bypass in a newly developed bariatric surgery program. METHODS: A prospective analysis of the initial 100 patients who underwent laparoscopic Roux-en-Y gastric bypass at a community based teaching hospital between December 2000 and October 2001 was performed. Study endpoints included operative time, early (less than 7 days) and late complication rates, hospital length of stay (LOS), time to initiation of oral diet, and percentage of excess body weight loss. RESULTS: There were 91 women and 9 men with a mean age of 39 years (range 21 to 57). Mean preoperative weight was 126.4 kg (range 92.3 kg to 214 kg), with a mean preoperative body mass index of 47.4 (range 37.3 to 75.7). Ninety (90%) patients had at least one significant medical comorbidity (median = 6 per patient). Mean operative time was 2.4 hours (range 1.0 to 6.5; 3.0 hours for the first 50 patients and 1.8 hours for the last 50 patients). Three patients required conversion to open gastric bypass, all due to equipment failure (two harmonic scalpel failures and one linear stapler malfunction). Seven patients had early complications, 3 with anastomotic hemorrhage requiring transfusion, 3 with intestinal leaks requiring reoperation, and 1 with transected nasogastric tube. Eleven patients had late complications: 5 patients with small bowel obstruction, all due to herniation through the transverse colon mesentery (these occurred early in the series, prompting a change in technique, with no subsequent occurrences), 3 with gastrojejunostomy strictures requiring endoscopic dilation, 2 superficial wound infections, and 1 port-site incisional hernia. No complications occurred in the last 40 patients. No deaths occurred. Median hospital stay was 2 days (range 1 to 37); 3 days in the first 50 cases and 1 day in the last 50 cases. The median number of days to the start of an oral diet was 1 day. Average excess body weight loss was 34% (median follow-up 4 months). CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass is a technically challenging procedure that can be safely integrated into a bariatric treatment program with good results. Improved outcomes, shorter operative times, and fewer complications are associated with increased surgical experience.