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1.
Background: Long-term complications leading to reoperation after primary bariatric surgery are not uncommon. Reoperations
are particularly challenging because of tissue scarring and adhesions related to the first operation. Reoperations must address
the complication(s) related to the scarring and, at the same time, prevent weight regain that would inevitably occur after
simple reversal. Conversion to Roux-en-Y gastric bypass (RYGBP) has repeatedly been demonstrated to be the procedure of choice
in most situations. It has traditionally been performed through an open approach. Our aim is to describe our experience with
the laparoscopic approach in reoperations to RYGBP over the past 5 years. Methods: All patients undergoing laparoscopic RYGBP as a reoperation were included in this study. Patients with multiple previous operations or patients with band erosion
after gastric banding were submitted to laparotomy. Data were collected prospectively. Results: Between June 1999 and August
2004, 49 patients (44 women, 5 men) underwent laparoscopic reoperative RYGBP. The first operation was gastric banding in 32
and vertical banded gastroplasty in 15. The mean duration of the reoperation was 195 minutes. No conversion to open was necessary.
Overall morbidity was 20%, with major complications in 2 patients (4%). Weight loss, or weight maintenance, was satisfactory,
with a BMI <35 kg/m2 up to 4 years in close to 75% of the patients. Conclusions: Laparoscopic RYGBP can be safely performed as a reoperation in
selected patients provided that the surgical expertise is available. These procedures are clearly more difficult than primary
operations, as reflected by the long operative time. Overall morbidity and mortality, however, are not different. Long-term
results regarding weight loss or weight maintenance are highly satisfactory, and comparable to those obtained after laparoscopic
RYGBP as a primary operation. 相似文献
2.
Bowel Obstruction after Laparoscopic Roux-en-Y Gastric Bypass 总被引:5,自引:5,他引:0
Background: Bowel obstruction has been frequently reported after laparoscopic Roux-en-Y gastric bypass (LRYGBP). The aim of
this study was to review our experience with bowel obstruction following LRYGBP, specifically examining its etiology and management
and to strategize maneuvers to minimize this complication. Methods: We retrospectively reviewed the charts of 9 patients who
developed postoperative bowel obstruction after LRYGBP. Each chart was reviewed for demographics, timing of bowel obstruction
from the primary operation, etiology of obstruction, and management. Results: 9 of our initial 225 patients (4%) who underwent
LRYGBP developed postoperative bowel obstruction. The mean age was 46 ± 12 years, with mean BMI 47 ± 9 kg/m2. 6 patients developed early bowel obstruction, and 3 patients developed late bowel obstruction. The mean time interval for
development of early bowel obstruction was 16 ±16 days. The causes for early bowel obstruction included narrowing of the jejunojenunostomy
anastomosis (n=3), angulation of the Roux limb (n=2), and obstruction of the Roux limb at the level of the transverse mesocolon
(n=1). The mean time interval for development of late bowel obstruction was 7.4 ± 0.5 months. The causes for late bowel obstruction
included internal herniation (n=2) and adhesions (n=1). 6 of 9 bowel obstructions (66%) were considered technically related
to the learning curve of the laparoscopic approach. Eight of the 9 patients required operative intervention, and 6 of the
8 reoperations were managed laparoscopically. Management included laparoscopic bypass of the jejunojejunostomy obstruction
site (n=5), open reduction of internal hernia (n=2), and laparoscopic lysis of adhesion (n=1). Conclusions: Bowel obstruction
is a frequent complication after LRYGBP, particularly during the learn ing curve of the laparoscopic approach. Specific measures
should be instituted to minimize bowel obstruction after LRYGBP as most of these complications are considered technically
preventable. 相似文献
3.
Background: Laparoscopic Roux-en-Y gastric bypass (RYGBP) is being performed widely as a treatment of choice for morbid obesity.
We present our method and experience with the first 150 consecutive cases of laparoscopic RYGBP with a 2-m long biliopancreatic
limb (BP-limb). Methods: Between November 2001 and November 2003, a prospective analysis of 150 patients was performed identifying
technical success and complications. Before surgery, patients underwent a strict multidisciplinary behavioral program. At
operation the stomach was transected proximally with a linear stapler (60-mm, Endo-GIA) to create a prolongation of the esophagus
(gastric tube) along the lesser curvature, resulting in a 40-50 ml pouch. Two meters of the proximal jejunum were bypassed
(BP-limb), creating an antecolic Roux-en-Y gastro-jejunostomy to the posterior wall of the gastric tube using a 45-mm linear
Endo-GIA stapler. The entero-anastomosis was created 50 cm below the gastro-jejunostomy, also with a 45-mm linear Endo-GIA.
Results: Mean BMI was 50.0, and 78% of patients were females. With 100% follow-up, we found an EWL of 50% 6 months after surgery,
gradually rising to 80% after 18 months. The mean operating time was 116 min for the first 50 cases and decreased to 82 min
for the last 50 cases. Intestinal leakage occurred in 5 patients (3%) and bleeding in 5 (3%). Most of these complications
occurred in the first 50 cases, and all but one were treated successfully with an early laparoscopic re-operation. Marginal
ulcers were found in 16.6% of patients. No internal hernias have occurred. Conclusion: The operation demands advanced laparoscopic
skills, but technically it is relatively simple and has an acceptable complication rate. Short-term results regarding excess
weight loss are at least comparable to the RYGBP with a long alimentary limb. 相似文献
4.
Background: The feasibility of laparoscopic Roux-en-Y gastric bypass (Lap-RYGBP) for morbid obesity is well documented. In
a prospective randomized trial, we compared laparoscopic and open surgery. Methods: 51 patients (48 females, mean (± SD) age
36 ± 9 years and BMI 42 ± 4 kg/m2) were randomly allocated to either laparoscopy (n=30) or open surgery (n=21). All patients were followed for a minimum of
1 year. Results: In the laparoscopy group, 7 patients (23%) were converted to open surgery due to various procedural difficulties.
In an analysis, with the converted patients excluded, the morphine doses used postoperatively were significantly (p< 0.005)
lower in the laparoscopic group compared to the open group. Likewise, postoperative hospital stay was shorter (4 vs 6 days,
p<0.025). Six patients in the laparoscopy group had to be re-operated due to Roux-limb obstruction in the mesocolic tunnel
within 5 weeks. The weight loss expressed in decrease in mean BMI units after year was 14 and 13 after 1 ± 3 ± 3 laparoscopy
and open surgery,respectively (not significant). Conclusions: Both laparoscopic and open RYGBP are effective and well received
surgical procedures in morbid obesity. Reduced postoperative pain, shorter hospital stay and shorter sick-leave are obvious
benefits of laparoscopy but conversions and/or reoperations in 1/4 of the patients indicate that Lap-RYGBP at present must
be considered an investigational procedure. 相似文献
5.
Laparoscopic gastric bypass is a common procedure for morbid obesity. After gastric bypass, the distal stomach is unavailable
for surveillance. When a suspicious distal gastric lesion is present preoperatively, a distal subtotal gastrectomy may be
needed. Herein we describe such a case performed laparoscopically. Laparoscopic gastric bypass with subtotal gastrectomy for
morbid obesity should be considered for patients with suspicious distal gastric lesions. 相似文献
6.
Bariatric surgery is the only solution for morbidly obese individuals who desire to lose weight and maintain it and have failed
to do so by non-surgical means. As the incidence of morbid obesity rises, laparoscopic Roux-en-Y gastric bypass (LRYGBP) is
increasingly performed. With the increase in bariatrics, the chances of discovering aberrant anatomy at the operating-table
also increase. We present two cases of LRYGBP in patients with intestinal malrotation, which is a congenital anomaly caused
by failure of the intestines to rotate and fixate at 270° during embryonic development. It occurs in one out of every 500
births in the United States, accounting for 5% of all intestinal obstructions. To this date, only three reports have been
published describing the incidental finding of congenital malrotation during the initial laparoscopic exploration for gastric
bypass. We found that the operation can still be performed laparoscopically in such patients, with some modifications to the
standard technique. 相似文献
7.
Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is an effective operation for morbidly obese patients who have
failed conservative weight loss treatments. It is currently indicated for patients with BMI >40 kg/m2 or >35 with significant co-morbidities. Controversy exists whether there is an upper limit to BMI beyond which this operation
should not be performed. Methods: Between April 1999 and February 2001, 82 patients (19 male, 63 female) underwent LRYGBP.
Average age was 43.6, and average BMI was 56 kg/m2. These patients were divided into those with BMI <60 and those with BMI ≥60 kg/m2. Results:There were 61 patients with BMI <60 and 21 patients with BMI ≥60. The groups were similar in age, gender, distribution
or incidence of co-morbid conditions (diabetes, coronary artery disease, hypertension, sleep apnea, asthma) between the groups.
The BMI ≥60 group had a significantly longer length of stay (6.6 days vs 5.3 days, P <0.05), and only 1 patient (BMI 85) developed an anastomotic leak and died. 2 patients in this group (BMI 62 and 73) developed
small bowel obstruction requiring lysis of adhesions. 1 patient in the BMI <60 group developed a gastrojejunal stricture requiring
balloon dilatation. Conclusion: While patients with a BMI ≥60 are at higher risk for postoperative complications, they are
also at higher risk from continued extreme obesity. In our series, 85% of these patients had an uneventful postoperative course
and began shedding excess weight. BMI ≥60 should not be a contraindication for LRYGBP. 相似文献
8.
Background: Laparoscopic adjustable gastric banding is a popular bariatric operation. Unfortunately, long-term complications such as
slippage, infection, and intragastric migration (erosion) may occur. With erosion, band removal is mandatory. Options to prevent
weight regain are delayed implantation of a new band, or conversion to another bariatric procedure such as Roux-en-Y gastric
bypass (RYGBP) or biliopancreatic diversion. We present our experience with band erosion and immediate or delayed conversion
to RYGBP. Methods: With a multidisciplinary team approach and prospective data collection, a comparison was made between patients with and
without band erosion. The patients who were converted to RYGBP for band erosion were analyzed. Results: Gastric banding was performed on 347 patients between 1995 and 2002. Median follow-up is 52 months. Band erosion developed
in 24 patients (6.8 %).The latter were heavier before gastric banding (BMI 45.9 vs 43.3, P <0,01). No band had ever been overinflated.
Band erosion was diagnosed after a mean of 22.5 months (3-51). At time of diagnosis, mean BMI of 33.5 kg/m2 (22.5-48) and average excess weight loss (EWL) of 52.9% (25-97) did not differ from that of the remaining patients at the
respective time interval. The band was removed in all cases. Conversion to RYGBP was performed at the same time in 11, and
a few months later in 2 patients. Operative morbidity included 1 leak (reoperation) and 4 wound infections. All but 1 patient
lost further weight after reoperation, or at least maintained their weight. At last follow-up, mean EWL in relation to the
pre-banding weight was 65.1%, and 69.2% of the patients had an EWL >50%, which compares favorably with the results obtained
after primary RYGBP. Conclusions: In our series with a median follow-up >4 years, band erosion was more common than usually reported. Band removal with immediate
or delayed conversion to RYGBP is feasible with an acceptable morbidity, and prevents weight regain in most cases. These results
support further use of this approach for band erosion. 相似文献
9.
Open banded gastric bypass has been the choice of some bariatric surgeons. This procedure includes a band (of various materials)
around the gastric pouch. While there are advantages to this band, erosion and/or displacement of the band may occur. We describe
a case of a symptomatic displaced band which was treated by laparoscopic removal. Laparoscopic removal of the band after open
banded gastric bypass is feasible. Revision of previous bariatric surgery may be performed laparoscopically if the technical
expertise is available. 相似文献
10.
We report the case of a morbidly obese patient with situs inversus totalis presenting for laparoscopic Roux-en-Y gastric bypass
(RYGBP). The operative technique is detailed and we recommend the use of a mirror image approach to all parts of the operation.
Consequently, the operative time is only moderately longer than usual. Laparoscopic RYGBP can be safely performed in patients
with situs inversus. 相似文献