Open vs Laparoscopic Roux-en-Y Gastric Bypass: Comparison of Operative Morbidity and Mortality

Background: Open Roux-en-Y gastric bypass (RYGBP) has proven to be an effective method for weight control for the morbidly obese patient. With technologic and surgical skill advancement in the application of laparoscopic surgery, laparoscopic RYGBP has also been found to be of value in surgical control of obesity. Risk/benefit ratios in comparison of the 2 methods are undergoing definition by experience. Methods: 779 patients who underwent RYGBP between March 1, 2000 and June 30, 2002 were evaluated retrospectively. 328 patients underwent laparoscopic RYGBP (Group A) and 451 underwent open RYGBP (Group B). All charts and hospital records of these patients were reviewed. Questionnaires were mailed to all patients who had undergone RYGBP. Follow-up was 5-29 months. Results: 89 patients in Group A and 162 patients in Group B experienced significant morbidity. There were no surgical deaths in Group A and one surgical death in Group B.Weight loss profiles were the same. Significant differences in morbidity were noted with respect to gastrojejunal stenosis (Group A = 11.6%, Group B = 4.7%, P=.0012), occurrence of ventral incisonal hernia (A=0%, B=10%, P<.00013), and wound problems (abdominal wall hematoma A=1.5%%, B=0%, P=.013; wound infection A=1.2%, B=6.2%, P=.00037). Gastrojejunal perforation was not significantly different (A=1.5%, B=0.89%, P=.50), as was true of small bowel obstruction (A=2.7%, B=3.3%, P=.68). Conclusions: Each operative approach has associated problems.Wound care problems and ventral hernias are more common in Group B (open) and anas tomotic stenoses are more common in Group A (laparoscopic). Anastomotic leaks and small bowel obstruction are troublesome but not statistically different in occurrence.     

Laparoscopic Roux-en-Y Gastric Bypass for Super/Super Obesity

Laparoscopic gastric bypass has been recently introduced as an alternative method to conventional open gastric bypass. This procedure has been generally limited to patients with a BMI <60 kg/m² due to the possible technical limitations of the laparoscopic instruments. In this article, we present a patient with super/super obesity (61 kg/m²) who underwent Rouxen-Y gastric bypass using the laparoscopic approach.     

Roux-en-Y Gastric Bypass: A 7-year Retrospective Review of 3855 Patients

Background: 3855 patients undergoing Roux-en-Y gastric bypass for morbid obesity between 1988 and 1994 are presented. Methods: All patients were sent a standard questionnaire reflecting current weight, intervening complications and general health status and 1039 patients responded. Information gleaned from review of these questionnaires and a review of individual charts provided the data for this study. Results: Average weight loss at 1 year was 46 kg and at 5 years was 34.5 kg. Operative mortality was 0.18%. Surgical morbidity rate was 3.4%. Average length of stay for patients hospitalized in 1994 was 3.6 days. The average operating time during that same year was 78 min, and the average hospital charges were $7250. Conclusions: Roux-en-Y gastric bypass can be performed with relative safety and acceptable morbidity. There is a demonstrable weight loss benefit which is maintained in the majority of patients over a period greater than 5 years. The expense and consumption of provider services are modest, and this procedure remains an excellent alternative for weight control among morbidly obese individuals.     

Preoperative Endoscopic Screening for Laparoscopic Roux-en-Y Gastric Bypass has a Low Yield for Anatomic Findings

BACKGROUND: Patients undergoing laparoscopic Roux-en-Y bariatric surgery undergo screening esophagoduodenoscopy (EGD) during preoperative evaluation. The hypothesis is to examine the utility of this examination. The purpose of this study was to evaluate the prevalence of clinically significant upper gastrointestinal (UGI) tract findings at screening EGD in patients undergoing laparoscopic Roux-en-Y bariatric surgery. A secondary aim was to determine whether preprocedure symptoms could predict findings at EGD. METHODS: We evaluated records of patients undergoing EGD prior to bariatric surgery between 2000 and 2005 at the Stanford University Medical Center. Clinical, endoscopic, and pathological data were analyzed. The prevalence of endoscopic findings of clinical significance was determined. RESULTS: Two hundred seventy two complete patient records were identified and included in the study. Of these, 237 (87%) were female and 197 (72%) were Caucasian. The mean age was 43 +/- 9.68 years and mean body mass index was 48 +/- 7.95 kg/m(2). Of the 272 patients, 33 (12%) had EGD findings of clinical significance including erosive esophagitis (3.7%), Barrett's esophagus (3.7%), gastric ulcers (2.9%), erosive gastritis (1.8%), duodenal ulcers (0.7%), and gastric carcinoid (0.3%). No patients had malignancy. Of these 33 patients, 22 (67%) had UGI symptoms. CONCLUSIONS: Significant findings at screening EGD were found in 12% of patients. While EGD may be low-yield, the findings could be useful in guiding clinical decision making.     

Laparoscopic Transgastric Access to the Biliary Tree after Roux-en-Y Gastric Bypass

Gallstone disease, common after Roux-en-Y gastricbypass (RYGBP), may be complicated by biliary ductobstruction and gallstone pancreatitis. Althoughendoscopic retrograde cholangiopancreatographyplays an important role in management of biliary ductobstruction, the altered anatomy of patients who havehad a RYGBP makes this procedure technically difficult.With the increased number of patients undergoingRYGBP for morbid obesity, bariatric surgeonsmay benefit from an alternative laparoscopic techniquefor accessing the biliary tree. We describe alaparoscopic technique of accessing the biliary treethrough the bypassed stomach.     

Laparoscopic Gastric Bypass,Roux-en-Y: Preliminary Report of Five Cases

The technique of laparoscopic gastric bypass, Roux-en-Y, has been developed, and performed in five patients. The detailed technique and instrumentation is described. Early case results show comparable weight loss, and reduced morbidity and disability. Laparoscopic gastric bypass is a feasible alternative to the open operative procedure.     

Gastric Bypass Distal Roux-en-Y with Jejunal Interposition

Gastric bypass with jejunal interposition is a version of the distal Roux-en-Y. Ninety cm of the jejunum is interposed between the gastric stoma and the ileum. This new procedure initially was used in super-obese patients mainly to facilitate the gastric anastomosis.     

Post-operative Complications in a Series of Gastric Bypass Patients

In order to evaluate the short- and long-term complications of obesity surgery, a review was done on 452 cases of morbidly obese patients who met the basic guidelines for obesity surgery and were operated upon; gastric bypass was performed in all of them. There were seven major complications: one myocardial infarction, two pulmonary embolisms, two gastric fistulas, one sepsis from bowel infection and one acute thrombocytopenia purpura. Five of the patients died. It is important to note, in those patients with abdominal complications, the absence of classical signs and symptoms of peritonitis, and the need to act immediately in order to solve the post-operative problem. As in other series, minor complications were also present: subcutaneous infection in 18 cases, hernia in four, peptic syndrome in three, mild anemia in 28 and hypovitaminosis A and B in 58; all received medical treatment without problem. It is concluded that obesity surgery, like all major surgery in high-risk patients, may have complications, and therefore it is necessary to recognize them in order to prevent them, and if they emerge, diagnose and treat properly.     

Anastomotic Leak following Antecolic versus Retrocolic Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Background Laparoscopic Roux-en-Y gastric bypass(LRYGBP) is the most commonly performed operation for the treatment of morbid obesity in the United States. Previous reports suggest that postoperative complications may be influenced by Roux limb orientation (antecolic versus retrocolic), although thisremains controversial. The aim of this study was toanalyze our experience with anastomotic leaks following LRYGBP with an antecolic- versus retrocolicrouted Roux limb. Methods During the 2-year period of June 2003 to June 2005, 353 patients underwent a LRYGBP. 135 were antecolic and 218 retrocolic. All cases were performedby one of three bariatric surgeons. The decisionto perform antecolic versus retrocolic LRYGBP was left to the surgeon’s preference. The primary outcome measure was anastomotic leak. Results Mean follow-up was 28 weeks. There wereno perioperative deaths. Overall complication rate was 16.9%. 17 gastrojejunal leaks (4.8%) were identified, consisting of 12 intraoperative leaks (3.4%) and 5 postoperative leaks (1.4%). Postoperative gastrojejunal leak rate was higher in the antecolic group (P = 0.04). Conclusion Mortality and complication rates were consistent with reported benchmarks on the efficacy and safety of LRYGBP. Our review suggests that anastomotic leak may be more common after antecolic than after retrocolic LRYGBP for morbid obesity. A prospective randomized study is needed to determine whether antecolically-routed Roux limb is an independent predictor for anastomotic leak following LRYGBP.     

Intra-operative Pneumothorax Complicating Laparoscopic Roux-en-Y Gastric Bypass

Background: Intra-operative pneumothorax (PTX) is an infrequent complication of laparoscopic surgery. Most cases are attributed to CO₂ diffusion across congenital diaphragmatic defects and resolve spontaneously. We report a case of PTX during a laparoscopic Roux-en-Y gastric bypass (LRYGBP). When applied to this specific patient population, the current literature recommendations for the management of intra-operative PTX are questioned. Material and Methods: A retrospective chart review of 400 consecutive LRYGBP procedures performed over a 30-month period revealed 1 case of PTX (0.025%). Results: A bulging left diaphragm, hypotension, bradycardia, decreased pO₂, and elevated EtCO₂ and airway pressures, were noted early in the case. She initially responded to conservative management but required multiple subsequent hospital admissions for pulmonary complications. Conclusions: Pneumoperitoneum-induced PTX during laparoscopic bariatric surgery is a rare complication. Its treatment must be based on the potential underlying cause, with consideration of these patients' often delicate pulmonary status. In stable patients, where the PTX is attributed to diaphragmatic or hiatal dissection, expectant treatment is appropriate. In all other situations, however, we believe that tube thoracostomy is indicated. An algorithm for treatment of PTX in laparoscopic bariatric surgery is proposed. It follows the dictum of maintaining extreme vigilance and a low threshold for aggressive intervention in this group of patients.     

Intussusception Complicating Pregnancy following Laparoscopic Roux-en-Y Gastric Bypass

Laparoscopic Roux-en-Y gastric bypass is the most common bariatric surgical procedure in the USA in women of reproductive age. A pregnant patient presented with nonspecific upper abdominal pain and nausea, suggesting an internal hernia. At surgery, an intussusception was identified and reduced without complications. Obstetricians should be familiar with late serious complications of bariatric surgery.     

The Effect of Roux-en-Y Gastric Bypass on Zinc Nutritional Status

Background Researchers have found that zinc nutritional status in obese and diabetic subjects is altered: low zinc concentrations in plasma and erythrocytes, with high urinary zinc excretion, were observed. This study evaluated the effect of Roux-en-Y gastric bypass (RYGBP) on plasma, erythrocyte and urinary zinc concentration. Methods 22 morbidly obese patients were studied before and 6 months after RYGBP. Fasting blood sample and 24-hour urine were collected in the pre- and postoperative phases. A software analyzed the diet information from 3-day food records after RYGBP. Zinc nutritional status was evaluated by determination of the concentration of this mineral in plasma and erythrocytes, and the urinary excretion of zinc / 24 hours by atomic absorption spectrophotometry. Results The diets consumed by the patients had adequate average concentrations of zinc. Zinc concentration in plasma, erythrocytes and urine were within the values of normality before RYGBP, with mean values of 93.25 ± 19.34 μg/dL, 43.85 ± 7.76 μg Zn/gHb and 583.05 ± 359.30 μg Zn/24 hours, respectively. At 6 months after RYGBP, there was a change in these parameters to 69.82 ± 10.95 μg/dL, 51.80 ± 6.92 μg Zn/gHb, 535.29 ± 216.40 μg Zn/24 hours in the concentration of plasma, erythrocyte and urinary zinc. Conclusion These results suggest that RYGBP promoted, besides change in body composition, an alteration in the zinc plasma and erythrocytes concentrations which in the medium and long term, could cause problems for these patients.     

Non-closure of Defects during Laparoscopic Roux-en-Y Gastric Bypass

Background The concern about internal hernias has prompted recommendations for routine closure of defects during laparoscopic Roux-en-Y gastric bypass (LRYGBP). Our belief is that not all techniques require closure of defects. We hypothesize that nonclosure of defects with our particular technique would not cause a significant clinically evident internal hernia rate. Methods All patients who were operated on between December 2002 and June 2005 were included in this study. The technique that was utilized included an antecolic antegastric gastrojejunostomy (GJ), division of the greater omentum, a long jejunojejunostomy (JJ) performed with three staple-lines, a short (<4 cm) division of the small bowel mesentery, and placement of the JJ above the colon in the left upper quadrant. Clinical records were reviewed for reoperations. Results here was a total of 300 patients, and no incidence of internal hernia. In the first 100 patients, there was 97% follow-up for 1 year or more. Four patients underwent reoperations for unexplained abdominal pain. Intraoperative findings included an adhesive band from the JJ to the colon (1), an adhesive band from the JJ to the anterior abdominal wall (1), an adhesive band 3 cm from the GJ to the anterior abdominal wall (1), and adhesions of the jejunum to the anterior abdominal wall (1). No patient had an internal hernia. Conclusions Internal hernias are not common after this particular method of LRYGBP. Before adopting routine closure of potential spaces, surgeons should consider their technique, follow-up, and incidence of internal hernias. Routine closure of these defects is not always necessary.     

Technical Alternatives Laparoscopic Distal Gastric Bypass for Morbid Obesity in a Porcine Model

Background: Laparoscopic gastric bypass and vertical banded gastroplasty are two procedures used in the treatment of morbid obesity. The authors describe alternative techniques of laparoscopic distal gastric bypass as a modification of the Scopinaro procedure, which were used experimentally in a porcine model. Methods: Five pigs were used. The laparoscopic procedure was performed with the pigs under general anesthesia after pneumoperitoneum had been achieved. Five or six trocars were used. One port was converted from 12 to 33 mm, and all the other ports were 10-11 mm. The initial surgical technique was similar to that used by others for laparoscopic gastrectomy, except that atraumatic ultracision was used for all the dissection. The stomach was stapled with a linear cutter stapler (Endopath, 31 mm) to create a 50-ml pouch. The ileum was divided with a linear cutter-stapler (Endopath, 31 mm) or ultracision cautery. A long length of ileum was positioned between the stomach pouch and the jejunoileostomy. Only 50-70 cm of terminal ileum was preserved as a common channel. In three animals, the circular stapler (ILS, 21 mm) was used to produce an end-to-side anastomosis. In one animal, two purse-string sutures were handsewn in the ileum and jejunum stumps, and in another two animals, two endoloops were used for the anvil. In two animals, the linear stapler was used to form a side-to-side pouch stomach-ileum and jejunoileostomy anastomosis. In other animals, the two types of anastomosis have been combined. All animals were killed after surgery so that the anastomoses could be evaluated for size and integrity. Results: In all animals, with the circular and linear stapler, both 21 and 13-15 mm anastomoses were intact. Conclusion: Distal gastric bypass is feasible laparoscopically, with intact anastomoses.     

Influence of a Forced Air Warming System on Morbidly Obese Patients Undergoing Roux-en-Y Gastric Bypass

Background: Hypothermia during and after major abdominal surgery decreases host defenses, increases the incidence of coagulopathy and may alter blood pressure, cardiac contractility and myocardial stability. Methods: We designed a prospective randomized study to compare the benefits of a forced air warming system with warm blanket treatments in minimizing the effects of hypothermia on 64 morbidly obese patients undergoing Roux-en-Y gastric bypass. Results: Patients in the forced air warming group (n = 32) had significantly higher perioperative body core temperature, lower central venous pressure and blood pressure readings, lower incidence of shivering, less blood loss intraoperatively and achieved a higher post anesthesia Aldrete Score than those patients in the warmed blanket group (n = 32). Conclusion: The forced air warming system is safe, cost effective and beneficial in minimizing the undesirable consequences of hypothermia in morbidly obese patients undergoing Roux-en-Y gastric bypass.     

Changes in Diabetic Management After Roux-en-Y Gastric Bypass

Background: Control of hyperglycemia in diabetes mellitus through diet, exercise, oral hypoglycemics and insulin has underlined the medical treatment for that disease. Morbidly obese diabetics can be more successfully rendered euglycemic if their excess body weight is reduced and their diets are carefully controlled. Methods: Roux-en-Y Gastric Bypass has been used as a weight control measure for 205 morbidly obese diabetics over an 8-year period, 1988-1995. Early follow-up has been possible in all patients up to 3 months, and late follow-up has been achieved by phone contact and office visits in 133 patients. Results: Operative mortality occurred in 1/205 patients (0.49%). Major operative morbidity occurred in 14/205 (6.8%). While 46/133 (35%) patients were on insulin preoperatively, only 11/133 (8%) have remained on insulin and 9/11 at lower doses. 64/133 (48%) were on oral hypoglycemics, but only 8/133 (6%) continue their use. 23/133 (17%) were on diet alone or no treatment before surgery, and 91/133 (68%) claimed diet alone or no treatment after surgery. The long-term mean % Excess Body Weight Loss is 55%. Conclusions: Morbidly obese diabetics undergoing Roux-en-Y Gastric Bypass can experience markedly diminished need for insulin and oral hypoglycemics to control hyperglycemia.     

Double Closed Loop Obstruction and Perforation in a Previous Roux-en-Y Gastric Bypass

A healthy 45-year-old woman with a previous Rouxen-Y gastric bypass presented with the signs, symptoms and blood analysis results consistent with acute pancreatitis. She was initially treated nonoperatively and subsequently went into circulatory shock. Computerized tomographic scan and exploratory laparotomy revealed a volvulus of the afferent jejunal limb with secondary obstruction, necrosis, and perforation of the bypassed stomach.