Reoperative Laparoscopic Roux-en-Y Gastric Bypass: An Experience with 49 Cases

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.     

Bowel Obstruction after Laparoscopic Roux-en-Y Gastric Bypass

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.     

Laparoscopic Roux-en-Y Gastric Bypass with 2-metre Long Biliopancreatic Limb for Morbid Obesity: Technique and Experience with the First 150 Patients

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.     

Laparoscopic vs Open Roux-en-Y Gastric Bypass: A Prospective Randomized Trial

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.     

Laparoscopic Roux-en-Y Gastric Bypass with Subtotal Gastrectomy

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.     

Laparoscopic Roux-en-Y Gastric Bypass in Patients with Congenital Malrotation

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.     

Extremely High Body Mass Index is not a Contraindication to Laparoscopic Gastric Bypass

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.     

Band Erosion after Laparoscopic Gastric Banding: Occurrence and Results after Conversion to Roux-en-Y Gastric Bypass

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.     

Laparoscopic Roux-en-Y Gastric Bypass in a Patient with Situs Inversus

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.     

Management of Acute Bleeding after Laparoscopic Roux-en-Y Gastric Bypass

Background: The authors reviewed the incidence of hemorrhage after laparoscopic Roux-en-Y gastric bypass (LRYGBP). The purpose of this study was to determine the incidence of this complication and to evaluate various treatment options. Material and Methods: The records for 450 consecutive patients who had undergone LRYGBP over a 30-month period, were retrospectively reviewed. In all patients, the abdominal cavity had been drained with 2 19-Fr closed suction drains. The charts of patients who had developed an intraluminal or an intraabdominal bleed were chosen for further review. Results: 20 patients (4.4%) developed an acute postoperative hemorrhage. The bleeding was intraluminal in 12 cases (60%), manifested by a drop in hematocrit, tachycardia and melena. The other 8 patients (40%) developed intra-abdominal hemorrhage, confirmed by large bloody output from the drains. 3 patients (15%) with intraluminal bleeding were unstable and required a reoperation. All others were successfully treated with observation, and 15 patients (75%) required blood transfusions. Conclusions: The diagnosis and treatment of acute intraluminal bleeding after LRYGBP represents a surgical dilemma, mainly due to the inaccessibility of the bypassed stomach and the jejuno-jejunostomy, as well as the risks associated with early postoperative endoscopy. The presence of large intra-abdominal drains allows for bleeding site localization (intraluminal vs intraabdominal) and for more accurate monitoring of the bleeding rate. Most cases respond to conservative therapy. Failure of conservative management of intraluminal bleeding, however, is more problematic and may require operative intervention. A treatment algorithm is proposed.