The Impact of Preoperative Weight Loss in Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a widely performed bariatric operation. Preoperative factors that predict successful outcomes are currently being studied. The goal of this study was to determine if preoperative weight loss was associated with positive outcomes in patients undergoing LRYGBP. Methods: A retrospective analysis was performed of all patients undergoing LRYGBP at our institution between July 2002 (when a policy of preoperative weight loss was instituted) and August 2003. Outcome measures evaluated at 1 year postoperatively included percent excess weight loss (EWL) and correction of co-morbidities. Statistical analysis was performed by multiple linear regression. P<0.05 was considered significant. Results: The study included 90 subjects. Initial BMI ranged from 35.4 to 63.1 (mean 48.1). Preoperative weight loss ranged from 0 to 23.8% (mean 7.25). At 12 months, postoperative EWL ranged from 40.4% to 110.9 % (mean 74.4%). Preoperative loss of 1% of initial weight correlated with an increase of 1.8% of postoperative EWL at 1 year. In addition, initial BMI correlated negatively with EWL, so that an increase of 1 unit of BMI correlated with a decrease of 1.34% of EWL. Finally, preoperative weight loss of >5% correlated significantly with shorter operative times by 36 minutes. Preoperative weight loss did not correlate with postoperative complications or correction of co-morbidities. Conclusions: Preoperative weight loss resulted in higher postoperative weight loss at 1 year and in shorter operative times with LRYGBP. No differences in correction of co-morbidities or complication rates were found with preoperative weight loss in this study. Preoperative weight loss should be encouraged in patients undergoing bariatric surgery.     

Value of Preoperative Esophagogastroduodenoscopy in Morbidly Obese Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass

Background : Roux-en-Y gastric bypass hinders post-operative endoscopic evaluation of the upper gastrointestinal tract. Our aims were to determine the prevalence of preoperative endoscopic findings in morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) and to determine the proportion of patients in which these findings changed surgical management.

Methods : We retrospectively evaluated electronic medical records of patients undergoing esophagogastroduodenoscopy (EGD) with routine antral biopsy for Helicobacter pylori (HP) detection, prior to LRYGB between January 2003 and January 2010 at our institution. The prevalence of all endoscopic findings was determined.

Results : 652 underwent preoperative endoscopy prior to LRYGB. The mean age was 39.5 ± 11.3 years and mean body mass index was 42.8 ± 5.0 kg/m². Abnormalities were found in 444 patients (68.1%). Findings at EGD were hiatal hernia 24.3% (n = 159), esophagitis 30.8% (n = 201), Barrett’s esophagus 0.8% (n = 5), gastritis 36.2% (n = 236), gastric or duodenal ulcers 7.5% (n = 49) and 2 cases of gastric cancer. The prevalence of HP infection was 17.6% (n = 115). In 51 patients (7.8%), endoscopic findings led to postponement of surgery: in 49 patients, gastric or duodenal ulcer had to be treated prior to surgery, in 2 patients, gastric cancer led to changement in surgical approach.

Conclusions : Routine preoperative EGD detects different abnormalities which need a specific approach prior to bariatric surgery. EGD with routine biopsies for HP detection should be included in the preoperative workup prior to LRYGB. Positive EGD findings led to a change in medical treatment in a quarter (24.3%) of patients. Postponement of surgery due to the EGD findings was less frequent (7.8%).     

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.     

腹腔镜Roux－en－Y胃旁路术

腹腔镜Roux－en－Y胃旁路术(laparoscopic Roux－en－Y gastric bypass, LRYGB)是经典的减重代谢手术术式,属于限制摄入＋减少吸收的混合型减重术式。LRYGB对于2型糖尿病有较高的缓解率,可能与其改变胃肠道激素分泌和旷置十二指肠对胰岛细胞功能的影响有关。LRYGB可以作为合并中重度反流性食管炎或代谢综合征严重的肥胖病人或超级肥胖病人的首选术式。该术式的手术要点包括：①贲门下方建立胃小囊,隔离全部胃底,严格控制胃小囊容积在30 ml以下;②建立食物支和胆胰支,两者长度之和大于200 cm;③严格控制胃肠吻合口直径在1.5 cm以下;④确切关闭系膜缺损预防内疝形成。     

Gastric Bezoar after Laparoscopic Roux-en-Y Gastric Bypass

Gastric bezoar is an uncommon complication following Roux-en-Y gastric bypass (RYGBP). We report two cases of bezoar formation that occurred following laparoscopic RYGBPs. In both cases, the patients presented with abdominal pain, nausea, and "frothy" vomiting. The patients were successfully treated by endoscopic fragmentation and removal of the bezoar.     

Predicting Stricture in Morbidly Obese Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass: A Logistic Regression Analysis

Gastrojejunostomy stricture after Roux-en-Y gastric bypass occurs in 3 to 27% of morbidly obese patients in the USA. We questioned whether preoperative patient characteristics, including demographic attributes and comorbid disease, might be significant factors in the etiology of stricture. In this study from November 2001 to February 2006 (51 months), at a high-volume bariatric center, of the 1,351 patients who underwent laparoscopic gastric bypass, 92 developed stricture (6.8%). All but two were treated successfully by endoscopic dilation. All patients stopped nonsteroidal anti-inflammatory medications 2 weeks prior to surgery and did not restart them. The operative procedure included the use of a 21-mm transoral circular stapler to create the gastrojejunostomy; the Roux limb was brought retrogastric, retrocolic. In an effort to reduce our center’s stricture rate, late in the study, U-clips used at the gastrojejunostomy were replaced by absorbable sutures, and postoperative H₂ antagonists were added to the treatment protocol. The change to absorbable polyglactin suture proved to be significant, resulting in a lower stricture rate. The addition of H₂ antagonists showed no significant effect. Following the retrospective review of the prospective database, univariate and multivariate logistic regression analyses identified factors associated with the development of stricture. Gastroesophageal reflux disease and age were each shown to be statistically significant independent predictors of stricture following laparoscopic gastric bypass. Presented at the 2006 Annual Meeting of the Society for Surgery of the Alimentary Tract, May 20–24, Los Angeles, CA (poster presentation).     

Flexible Endoscopy in the Management of Patients Undergoing Roux-en-Y Gastric Bypass

Background: Flexible upper endoscopy (FUE) is an important diagnostic and therapeutic tool in the management of upper gastrointestinal diseases. We examined the role of FUE in the management of patients undergoing Roux-en-Y gastric bypass (RYGBP). Methods: All patients undergoing RYGBP at a single institution from 1986 to 2001 were studied. Preoperative FUE was performed by the surgeon to assess the anatomy of the esophagus, stomach, and duodenum. Since 1997, gastric biopsies were obtained, testing for the presence of H. pylori. Colonized patients were treated preoperatively. Postoperatively, FUE was performed by the surgeon as indicated clinically,for management of symptoms suggesting anastomotic stenosis, upper gastrointestinal bleeding, inflammation, or ulcers. Endoscopic balloon dilatation was performed as indicated. Results: 560 patients underwent RYGBP during the study period. Of these, 536 underwent preoperative FUE. Endoscopic findings changed or altered the operative procedure in 26 patients (4.9%). Preoperative testing for H. pylori was performed on 206 patients, of whom 62 (30.1%) were positive. Patients tested for H. pylori had a lower incidence of postoperative marginal ulcers (n=5, 2.4%) than did patients who did not undergo such screening (n=354, 6.8%, P <0.05). Postoperatively, 54 patients underwent 80 endoscopic balloon dilatations for stenosis of the gastrojejunostomy. In addition, 18 patients underwent 28 FUEs that proved negative for such stenosis. In addition, 64 patients underwent 88 additional diagnostic or therapeutic FUEs in the postoperative period, including investigation of symptoms of pain, bleeding, persistent vomiting, or weight regain. Conclusion: Upper endoscopy is a tool which may be used by the surgeon in the preoperative and postoperative management of patients undergoing RYGBP to modify therapy, improve outcomes, and diagnose and treat postoperative complications.     

Liver Pathology in Morbidly Obese Patients Undergoing Roux-en-Y Gastric Bypass Surgery

Background: Non-alcoholic fatty liver disease is common. However,little is known about liver disease in the morbidly obese. Methods: 75 subjects (78% female, mean BMI 57 [40-108]) who had intra-operative liver biopsies at the time of Roux-en-Y gastric bypass surgery were studied. Results: 84% of subjects had steatosis while only about 20% had moderate to severe inflammation and fibrosis. 8% had bridging fibrosis or cirrhosis. The presence of fibrosis correlated strongly with the presence of inflammation (p<0.001) and steatosis (p=0.0011), but weakly with ALT (p=0.02) and not with AST (p= 0.12) or with BMI (p=0.34). Steatosis correlated with AST (p=0.04) and ALT (p=0.055), but not with BMI. Conclusion: Liver disease is not rare in the morbidly obese. The exact causes and mechanisms that lead from the very common isolated steatosis to inflammation and fibrosis remain unclear. Intra-operative liver biopsies during bariatric surgery may be helpful to screen for the presence of steatohepatitis and fibrosis.     

Intussusception After Laparoscopic Roux-en-Y Gastric Bypass

Intussusception after open Roux-en-Y gastric bypass procedure (RYGBP) is a rare complication. We present a retrospective review of three cases of antegrade intussusception occurring after laparoscopic RYGBP. To our knowledge, these are the first documented cases of intussusception after laparoscopic RYGBP. We describe the clinical presentation and our management of these three cases. Furthermore, we believe that the initial clinical presentation, radiographic findings, and management of these patients may be different than those patients who have undergone an open RYGBP. With increasing popularity of laparoscopic RYGBP, we are likely to see more of this entity.     

A Novel Surgical Technique: Single-Incision Transumbilical Laparoscopic Roux-en-Y Gastric Bypass

Conventional laparoscopic Roux-en-Y gastric bypass (LRYGB) is a gold standard for bariatric surgery, but the procedure requires five to seven incisions for placement of multiple trocars and thus may produce less-than-ideal cosmetic results. We have developed a new approach, single-incision transumbilical LRYGB (SITU-LRYGB) to treat morbid obesity. We compared the surgical results and patient satisfaction in a study of five-port LRYGB and SITU-LRYGB. Fifty morbidly obese patients (14 males, 36 females) underwent either Roux-en-Y gastric bypass with five-port LRYGB or the SITU-LRYGB approach. During the operation, we used a novel intraoperative liver traction method with a “liver suspension tape” that we specifically designed for SITU-LRYGB. Compared to five-port surgery with SITU-LRYGB, there were no intraoperative complications, wound healing was excellent, and there was no abdominal scarring. SITU surgical time was longer than that with five-port LRYGB (99.8 vs. 67.6 min, P < 0.001). Patients treated with the five-port method were more obese than those in the SITU group (127.9 vs. 112.4 kg, P = 0.016). After the bariatric surgery, no difference in comorbidity was found in both groups. Patient satisfaction was greater with SITU than with the five-port method (4.48 vs. 3.96, P = 0.006). Roux-en-Y gastric bypass can be successfully achieved via a single umbilical incision, a method that provides a short operative time and good recovery and eliminates abdominal scarring.     

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.     

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.     

Hypopharyngeal Perforation during Laparoscopic Roux-en-Y Gastric Bypass

Laparoscopic Roux-en-Y gastric bypass was recently introduced as an alternative surgical treatment for morbid obesity.The technique involves placement of a 21-mm anvil transorally down to the gastric pouch for creation of the gastroenterostomy anastomosis using an EEA stapler placed transabdominally. Esophageal injury is a theoretical concern with transoral manipulation of the anvil. The authors present a case of hypopharyngeal perforation after an attempted transoral insertion of an EEA anvil. The perforation was treated with neck exploration and drainage. We discuss the mechanism of injury and alternative method for placement of the gastric anvil.     

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 Surgery on Morbidly Obese Patients with Hypothyroidism

Background It is well known that obesity is accompanied by changes in thyroid function. Hypothyroidism is associated with increased body weight. The aim of this study was to evaluate the operative outcomes, weight loss, and the effect of weight loss on thyroid function in morbidly obese patients with hypothyroidism who undergo laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. Methods A retrospective review of 20 morbidly obese female patients with hypothyroidism and on thyroid replacement therapy who underwent LRYGB between January 2003 and August 2006. Results Mean preoperative body mass index (BMI) was 47.6 kg/m² (range 38–58.5 kg/m²). Average patient age was 44.5 years (range 21–66 years). There was one early complication (pneumonia). Late complications included one death, three anastomotic strictures, and one small bowel obstruction. The patients were followed for a mean of 13.5 months (range 3–24 months). Their mean excess body weight loss was 13 kg (22%), 24.4 kg (39.4%), 33.2 kg (63.3%), 38.4 kg (65%), 41.7 kg (70%), and 43 kg (73%) at 1, 3, 6, 9, 12, and 24 months, respectively. Change in a mean BMI was the same regardless of the patient preoperative and postoperative thyroxine dose. Hypothyroidism resolved in 5(25%) patients, improved in 2(10%) patients, unchanged in 8(40%) patients, and worsened in 5 (25%) patients. Most of the five whose hypothyroidism worsened had thyroid autoimmune disease. Conclusions Hypothyroidism appears to improve in the vast majority of morbidly obese patients who undergo LRYGB, except for those whose thyroid disease is autoimmune in nature.     

Laparoscopic Conversion of Laparoscopic Gastric Banding to Roux-en-Y Gastric Bypass: a Review of 70 Patients

Background: The feasibility and outcomes of conversion of laparoscopic adjustable gastric banding (LAGB) to laparoscopic Roux-en-Y gastric bypass (LRYGBP) was evaluated. Methods: From November 2000 to March 2004, all patients who underwent laparoscopic conversion of LAGB to LRYGBP were retrospectively analyzed. The procedure included adhesiolysis, resection of the previous band, creation of an isolated gastric pouch, 100-cm Roux-limb, side-to-side jejuno-jejunostomy, and end-to-end gastro-jejunostomy. Results: 70 patients (58 female, mean age 41) with a median BMI of 45±11 (27-81) underwent attempted laparoscopic conversion of LAGB to an RYGBP. Indications for conversion were insufficient weight loss or weight regain after band deflation for gastric pouch dilatation in 34 patients (49%), inadequate weight loss in 17 patients (25%), symptomatic proximal gastric pouch dilatation in 15 patients (20%), intragastric band migration in 3 patients (5%), and psychological band intolerance in 1 patient. 3 of 70 patients (4.3%) had to be converted to a laparotomy because of severe adhesions. Mean operative time was 240±40 SD min (210-280). Mean hospital length of stay was 7.2 days. Early complication rate was 14.3% (10/70). Late major complications occurred in 6 patients (8.6%). There was no mortality. Median excess body weight loss was 70±20%. 60% of patients achieved a BMI of <33 with mean follow-up 18 months. Conclusion: Laparoscopic conversion of LAGB to RYGBP is a technically challenging procedure that can be safely integrated into a bariatric treatment program with good results. Short-term weight loss is very good.     

Value of Preoperative Upper Endoscopy in Patients Undergoing Laparoscopic Gastric Bypass

Background: Preoperative evaluation of patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) has included esophagogastroduodenoscopy (EGD) with little data to substantiate its use. Methods: A retrospective analysis was conducted of patients from Feb 04 to Mar 05 who underwent preoperative EGD and subsequently LRYGBP. Results: 169 patients underwent EGD prior to surgery. Their mean age was 41.1 years (range 14-66), mean BMI 49.7 (range 35-78), and 82% were females. There were no complications from EGD. Significant findings in patients at EGD included gastric ulceration in 3 (2%), duodenal ulcer in 1 (0.7%), Barrett's esophagus in 2 (1.3%), and a GI stromal tumor (GIST) in 1 (0.7%). EGD revealed hiatal hernias in 56 (35.2%), esophagitis in 28 (17%), Schatzki's ring in 5 (3%), gastritis in 43 (27%), gastric polyps in 8 (5%), and duodenitis in 9 (6%). 53 patients (33.3%) had a negative EGD. Ulcer and severe gastritis, esophagitis, and duodenitis diagnosed preoperatively were treated medically before surgery. 9 hiatal hernias were repaired intraoperatively. The patient with the GIST underwent laparoscopic near-total gastrectomy and gastric bypass, while 1 patient with an antral polyp underwent laparoscopic partial gastrectomy in addition to the LRYGBP. Conclusion: EGD is essential for diagnosis of GI diseases including tumors, ulcers, and hiatal hernias that alter the medical and surgical management of patients undergoing gastric bypass.     

Revisional Laparoscopic Roux-en-Y Gastric Bypass Following Failed Laparoscopic Adjustable Gastric Banding

Background

Obesity is a worldwide epidemic and surgery is the only proven long-term treatment. The two most commonly performed bariatric procedures are laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB). There are advocates of both procedures but LAGB is associated with potentially high failure rates and may require conversion to an alternative procedure.

Methods

This study reports our unit results for failed LAGB converted to LRYGB and compares them to primary LRYGB patients. All patients undergoing revisional LRYGB from July 2006 to December 2011 were included in the study. Comparisons were made to patients undergoing primary LRYGB over the same time period for post-operative weight loss, complications and length of stay.

Results

Of the patients, 722 were analysed of which 55 underwent revisional surgery. There was no statistical difference in percentage of excess weight loss at 6 months, 1 year or 2 years following surgery between the primary and revisional surgery cohorts (54.5, 63.7, 65.2 vs 51.6, 59.5, 59.4, p?=?NS). There was no difference in morbidity, mortality or length of stay between the two groups. Revisional LRYGB was carried out as a single surgery in 43 (78 %) patients.

Conclusions

Revisional LRYGB surgery can be carried out safely and efficiently in experienced bariatric units. Good short- and medium-term weight loss can be achieved with no increase in morbidity, mortality or length of hospital stay. This study adds weight to the argument that LRYGB is the revisional procedure of choice following failed LAGB.