Are Laparoscopic Gastric Bypass After Gastroplasty and Primary Laparoscopic Gastric Bypass Similar in Terms of Results?

Background  

This retrospective study compares the results of primary gastric bypass (PGB) versus secondary gastric bypass (SGB) performed after gastroplasty.     

Does Laparoscopic Gastric Banding Demand Sophisticated Measurement Devices?

Background: One of the most frequently discussed issues in gastric banding is the problem of intraoperative upper gastric pouch volume assessment and the calibration of the connecting stoma diameter. Having experience with more than 200 adjustable and non-adjustable laparoscopic gastric bandings in last 3 years, we started to study whether it is possible to assess the pouch volume and stoma diameter by relying on anatomical landmarks and simple bougie calibration, rather than on sophisticated measuring devices. Methods: We compared results of postoperative pouch volume control measurements in a group of patients in whom a balloon method of pouch volume measurement was performed during the gastric banding with a group of patients where no intraoperative measurements of the upper gastric pouch were done. In the latter group the pouch volume was assessed according to the anatomical landmarks during the dissection: the cardia at the lesser curvature and the avascular area of gastrophrenic ligament at the greater curvature. In both groups endoscopic study 2 weeks following surgery was performed. Concerning stoma diameter we started with a prospective randomized study of two groups. In the first group, we intraoperatively measured by monometry the insidestoma pressure. In the second group, a simple bougie calibration was used, and a space was left for the tip ofthe Endo-Babcock instrument between the stomach wall and the band. Postoperatively, the stoma diameters were compared, using the ‘balloon catheter pulled through the stoma’ method. Results: Pouch volume: in the group operated according to surgeon's assessment of the anatomical landmarks, 96% of the patients' pouch volume did not exceed 60 ml at 2 weeks postoperative check-up. The results were no different from the group of patients where intraoperative volume measurements were performed. The stoma diameter: a group of patients where intraoperative stoma pressure measurements were performed and a second group where a simple calibration bougie was used and a free space for the tip of the Endo-Babcock instrument was left between stomach wall and band were compared prospectively. There was no statistical difference between the two groups in stoma diameter measured 2 weeks after operation by the ‘balloon pull through’ method. Conclusions: It is possible to rely on anatomical landmarks in constructing the upper gastric pouch. Postoperative volume measurements did not show any statistical difference between the group in whom intraoperative pouch volume measurements were performed and the group where anatomical landmarks were used. There was no statistical difference in postoperative stoma diameter measurements between the group where intraoperative stoma pressure measurements were performed before closing the band and the group where just a calibration bougie was used and a free space for the tip of an endoscopic instrument was left between stomach wall and band. These measurements were made with the non-adjustable band. With the adjustable band, the stoma diameter measurements would be even less important.     

Is Routine Cholecystectomy Required During Laparoscopic Gastric Bypass?

Background: Routine cholecystectomy is often performed at the time of gastric bypass for morbid obesity.The aim of this study was to determine the incidence of gallstone formation requiring cholecystectomy following a laparoscopic Roux-en-Y gastric bypass (LRYGBP). Methods: 289 LRYGBP were performed between November 1999 and May 2002. 60 patients (21%) who had prior cholecystectomy were excluded. If gallstones were identified by intra-operative ultrasound (IOUS), simultaneous cholecystectomy was performed. Patients without gallstones were prescribed ursodiol for 6 months and scheduled for follow-up with transabdominal ultrasound. Results: During LRYGBP, gallstones were detected in 40 patients using IOUS (14%) and simultaneous cholecystectomy was performed. Of 189 patients with no stones identified by IOUS, 151 patients (80%) had a postoperative ultrasound after 6 months. 33 patients developed gallstones (22%) and 12 developed sludge (8%) as demonstrated by ultrasound at the time of follow-up. 11 patients had gallstone-related symptoms and subsequently underwent cholecystectomy (7%). 106 patients (70%) were gallstone-free at the time of ultrasound follow-up. Ursodiol compliance was found to be significantly lower for patients who developed stones than for gallstone-free patients (38.9% vs 58.3%, z =-2.00, P = 0.045). Conclusions: There is a low incidence of symptomatic gallstones requiring cholecystectomy after LRYGBP. Prophylactic ursodiol is protective. Routine IOUS and selective cholecystectomy with close patient follow-up is a rational approach in the era of laparoscopy.     

Is Routine Cholecystectomy Required During Laparoscopic Gastric Bypass?

Background: Routine cholecystectomy is often performed at the time of gastric bypass for morbid obesity. The aim of our study was to determine the incidence of gallstone formation requiring cholecystectomy following a laparoscopic Roux-en-Y gastric bypass (LRYGBP). Methods: 289 LRYGBP were performed between November 1999 and May 2002. 60 patients (21%) who had prior cholecystectomy were excluded. If gallstones were identified by intra-operative ultrasound (IOUS), simultaneous cholecystectomy was performed. Patients without gallstones were prescribed ursodiol for 6 months and scheduled for follow-up with transabdominal ultrasound. Results: During LRYGBP, gallstones were detected in 40 patients using IOUS (14%) and simultaneous cholecystectomy was performed. Of 189 patients with no stones identified by IOUS, 151 patients (80%) had a postoperative ultrasound after 6 months. 39 patients developed gallstones (22%) and 12 developed sludge (8%), as demonstrated by ultrasound at the time of follow-up. 11 patients had gallstone-related symptoms and subsequently underwent cholecystectomy (7%). 106 patients (70%) were gallstone-free at the time of ultrasound follow-up. Ursodiol compliance was found to be significantly lower for patients developing stones than for gallstone-free patients (38.9% vs 58.3%, z =-2.00, P = 0.045). Conclusions: There is a low incidence of symptomatic gallstones requiring cholecystectomy after LRYGBP. Prophylactic ursodiol is protective. Routine IOUS and selective cholecystectomy with close patient follow-up is a rational approach in the era of laparoscopy.     

Single Incision Transumbilical Laparoscopic Roux-en-Y Gastric Bypass—Our Technique

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the gold standard procedure in bariatric surgery but requires 4–7 ports. We have reported the first single incision transumbilical Roux-en-Y gastric bypass (SITU-RYGB) in 2009 (Huang et al. Obes Surg 19:1711–1715, 2009). Over the years, we have standardized our procedure and this video highlights the same by showing both inside and outside views. This video was shot from outside as well to give better understanding of the procedure. A 4.5-cm incision was made according to the contour of umbilicus and space was created over the sheath to give more range of movement to the instruments. The procedure was carried out using conventional laparoscopic instruments and replicating all the steps of the procedure under adequate visualization. Picture-in-picture effect has been used at important steps. Findings were recorded. The procedure took 96 min without any intraoperative complication. Blood loss was 20 cc. The incision was hardly noticeable at the end of the procedure. We have previously compared our results of SITU-RYGB with that of our multiport RYGB where operative time was longer for SITU-RYGB versus multiport technique (101.1 vs. 81.1 min, P?=?0.001) (Huang et al. Surg Obes Relat Dis 8:201–207, 2012). No difference in complications was observed. The SITU-LRYGB patients reported greater satisfaction related to scarring than those who had undergone five-port surgery (P?=?0.005). Difference in analgesia requirement was not statistically significant. There was no mortality. Compared with conventional LRYGB, SITU-RYGB resulted in acceptable complications, the same recovery, comparative weight loss, and better patient satisfaction related to scarring.     

Why Would Laparoscopic Gastric Bypass Patients Choose Open Instead?

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been demonstrated to be comparable to open Roux-en-Y gastric bypass (ORYGBP) surgery in randomized studies. Although a steep learning curve exists, laparoscopic bariatric surgery offers advantages if performed by an experienced bariatric surgeon. Despite these facts, some patients still choose to undergo ORYGBP. This investigation explored the reasons why patients who have had LRYGBP would decide to undergo the laparoscopic operation. Methods: A survey was given to patients who had undergone LRYGBP. The survey was designed to ascertain what factors would influence them to have LRYGBP versus ORYGBP. Incomplete responses were not included in the data analysis. Results: There were 41 patients who filled out the survey. Over 90% of the patients felt LRYGBP is better than open gastric bypass. There were 4 patients who had seen another surgeon who recommended ORYGBP. Approximately 61% (23/38) of the patients would have stayed with their surgeon even if their surgeon did not offer LRYGBP. In addition, 79% of patients (31/39) would have ORYGBP if their insurance did not cover LRYGBP. Most patients (67%) would have ORYGBP if their surgeon thought LRYGBP was experimental. If they were told that LRYGBP was too risky for them, 77% of patients (30/39) would have undergone ORYGBP. Only 15% of patients (6/40) would not have had surgery if LRYGBP did not exist. Conclusions: Patients are willing to undergo ORYGBP even if they believe that LRYGBP is better. Non-medical factors and/or surgeon recommendations instead of scientific data influence patient decision-making when choosing ORYGBP over LRYGBP.     

Is Esophageal Dysmotility after Laparoscopic Adjustable Gastric Banding Reversible?

Laparoscopic adjustable gastric banding (LAGB) has become an increasingly popular option to treat morbid obesity. Esophageal dysmotility secondary to LAGB has been described, but is usually reversible after removal of the band. Long-term esophageal dysmotility persisting after removal of the band is an unusual and not yet described complication. We report the case of a 58-year-old obese patient who developed severe dysphagia and vomiting associated with atypical esophageal dysmotility 22 months after gastric band placement. Radiological exploration revealed no acute band slippage but only a pseudoachalasia. Device deflation and then band removal were required in an attempt to treat her symptoms. Esophageal dysmotility persisted for several months after band removal and was still present after a Rouxen-Y gastric bypass performed as revisional operation. Possible mechanisms generating this complication and clinical implications are discussed.     

Patients’ Experience of Surplus Skin After Laparoscopic Gastric Bypass

Background  

Previous studies have described that many obese patients who undergo bariatric surgery develop surplus skin. However, there is a lack of knowledge about where on the body the problems are located and to what extent surplus skin affects the person. The aim of this study was to examine whether and where patients develop surplus skin after laparoscopic gastric bypass and if there is any relation between surplus skin and the patient’s sex, age, weight loss, or activity level.     

Is Laparoscopic Adjustable Gastric Banding a Day Surgery Procedure?

Background: Laparoscopic adjustable gastric banding is the least invasive bariatric operation. However, just isolated attempts to perform this procedure as a Day Case have been published. This study highlights some aspects that might contribute to safe patient discharge within 23 hours after LAGB. Methods: Prospective evaluation of 20 consecutive patients was carried out. Patients were indicated for laparoscopic Swedish adjustable gastric banding (SAGB, Obtech, Ethicon Endo-Surgery) in a private Bariatric center in the first 6 months of 2003. The effect of extensive pre- and immediate postoperative education and psychological support, and information on postoperative health consequences delivered through a multi-disciplinary bariatric team effort, was evaluated, regarding the influence of these facilitators in shortening the length of hospital stay. Results: Mean preoperative BMI of the 20 patients entering the study was 42.3. Mean operating-time was 91 minutes (58-112 min). Time spent on information and education of each patient was 60 minutes in total during the preoperative period. Average postoperative hospitalization was 21 hours. There were no intraoperative or early postoperative complications. Excess weight loss was 44% at 12 months after surgery. Conclusion: SAGB performed on a Day Case basis in selected patients who are subjected to intensive pre- and immediate postoperative dedicated education appears to be a feasible alternative.     

Laparoscopic Repositioning of Heliogast® Gastric Band after Anterior Slippage

Background: Gastric slippage is a well-described complication of gastric banding. The Heliogast? band is equipped with a locking mechanism that enables its straightforward reopening and repositioning. Our experience with Heliogast? band salvage after anterior slippage is reported. Methods: The study sample comprised 418 consecutive patients who underwent 2-step laparoscopic gastric banding with the Lap-Band? first (n=235) followed with the Heliogast? band (n=183). Gastric slippage was diagnosed by symptoms of dysphagia and vomiting and was confirmed with Gastrografin? swallow. Patients who did not respond to conservative treatment were laparoscopically reoperated. In the Heliogast? group, the band was dissected free, unlocked, and repositioned. In the Lap-Band? group, when reopening proved impossible, the band was removed with or without replacement. Results: 10 patients (2.4%) underwent reoperation for anterior slippage, 5 with a Lap-Band? (2.1%) and 5 with a Heliogast? band (2.7%). Band repositioning was feasible in all 5 patients in the Heliogast? group, but in only one of the patients in the Lap-Band? group; in the others, the band was removed. Band repositioning was confirmed radiologically. No postoperative complications were recorded, and all patients were discharged on the first day after surgery. At a median 10 months' follow-up after Heliogast? repositioning, all patients had satisfactory weight loss. Conclusion: Laparoscopic Heliogast? band salvage after anterior slippage is comparatively simple and safe, with excellent postoperative results and no interference with continued weight loss. This constitutes an important means of management for the bariatric surgeon.     

Outcome after Laparoscopic Adjustable Gastric Banding – 8 Years Experience

Background: Laparoscopic adjustable gastric banding (LAGB) has been our choice operation for morbid obesity since 1994. Despite a long list of publications about the LAGB during recent years, the evidence with regard to long-term weight loss after LAGB has been rather sparse. The outcome of the first 100 patients and the total number of 984 LAGB procedures were evaluated. Methods: 984 consecutive patients (82.5% female) underwent LAGB. Initial body weight was 132.2 ± 23.9 SD kg and body mass index (BMI) was 46.8 ± 7.2 kg/m². Mean age was 37.9 (18-65). Retrogastric placement was performed in 577 patients up to June 1998. Thereafter, the pars flaccida to perigastric (two-step technique) was used in the following 407 patients. Results: Mortality and conversion rates were 0. Follow-up of the first 100 patients has been 97% and ranges in the following years between 95% and 100% (mean 97.2%). Median follow-up of the first 100 patients who were available for follow-up was 98.9 months (8.24 years). Median follow-up of all patients was 55.5 months (range 99-1). Early complications were 1 gastric perforation after previous hiatal surgery and 1 gastric slippage (band was removed). All complications were seen during the first 100 procedures. Late complications of the first 100 cases included 17 slippages requiring reinterventions during the following years; total rate of slippage decreased later to 3.7%. Mean excess weight loss was 59.3% after 8 years, if patients with band loss are excluded. BMI dropped from 46.8 to 32.3 kg/m². 5 patients of the first 100 LAGB had the band removed, followed by weight gain; 3 of the 5 patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP) with successful weight loss after the redo-surgery. 14 patients were switched to a "banded" LRYGBP and 2 patients to a LRYGBP during 2001-2002. The quality of life indices were still improved in 82% of the first 100 patients. The percentages of good and excellent results were at the highest level at 2 years after LAGB (92%). Conclusions: LAGB is safe, with a lower complication rate than other bariatric operations. Reoperations can be performed laparoscopically with low morbidity and short hospitalizations. The LAGB seems to be the basic bariatric procedure, which can be switched laparoscopically to combined bariatric procedures if treatment fails. After the learning curve of the surgeon, results are markedly improved. On the basis of 8 years long-term follow-up, it is an effective procedure.     

Redo Laparoscopic Gastric Bypass: One-Step or Two-Step Procedure?

Background

The adjustable gastric band (AGB) is a bariatric procedure that used to be widely performed. However, AGB failure—signifying band-related complications or unsatisfactory weight loss, resulting in revision surgery (redo operations)—frequently occurs. Often this entails a conversion to a laparoscopic Roux-en-Y gastric bypass (LRYGB). This can be performed as a one-step or two-step (separate band removal) procedure.

Methods

Data were collected from patients operated from 2012 to 2014 in a single bariatric centre. We compared 107 redo LRYGB after AGB failure with 1020 primary LRYGB. An analysis was performed of the one-step vs. two-step redo procedures. All redo procedures were performed by experienced bariatric surgeons.

Results

No difference in major complication rate was seen (2.8 vs. 2.3 %, p?=?0.73) between redo and primary LRYGB, and overall complication severity for redos was low (mainly Clavien–Dindo 1 or 2). Weight loss results were comparable for primary and redo procedures. The one-step and two-step redos were comparable regarding complication rates and readmissions. The operating time for the one-step redo LRYGB was 136 vs. 107.5 min for the two-step (median, p?<?0.001), excluding the operating time of separate AGB removal (mean 61 min, range 36–110).

Conclusions

Removal of a failed AGB and LRYGB in a one-step procedure is safe when performed by experienced bariatric surgeons. However, when erosion or perforation of the AGB occurs, we advise caution and would perform the redo LRYGB as a two-step procedure. Equal weights can be achieved at 1 year post redo LRYGB as after primary LRYGB procedures.

     

Laparoscopic Roux-en-Y Gastric Bypass:Transoral Or Transgastric Anvil Placement?

Background: Laparoscopic techniques have been used to perform the Roux-en-Y gastric bypass (RYGBP). The gastrojejunostomy may be constructed using an end-to-end anastomosis (EEA) stapler. Most reports describe passing the EEA anvil transorally using an esophagogastroscope and a pullwire technique. Method: We describe problems experienced using this technique and present an alternative method. Results: Esophageal injury may occur during laparoscopic RYGBP (LRYGBP) using the transoral anvil placement technique. When the anvil is retrieved into the gastric pouch, the anvil may become lodged at the cricopharngeus muscle. Dislodgment can be problematic and time-consuming. We present a case of mild esophageal injury which occurred during transoral anvil placement. The patient had transient postoperative dysphagia and recovered without sequelae. We present an alternative method in which the anvil is passed through a gastrotomy. Conclusion: Transgastric anvil placement alleviates the need for endoscopy, thereby saving time and resources.This technique eliminates the potential for esophageal injury. The transgastric anvil placement technique has proven reliable. The transgastric method may make the LRYGBP operation safer and easier to perform.     

Quality of Life Parameters,Weight Change and Improvement of Co-morbidities After Laparoscopic Roux Y Gastric Bypass and Laparoscopic Gastric Sleeve Resection—Comparative Study

The laparoscopic Roux Y gastric bypass (LRYGB) and the laparoscopic gastric sleeve resection are frequently used methods for the treatment of morbid obesity. Quality of life, weight loss and improvement of the co-morbidities were examined. Match pair analysis of the prospectively collected database of the 47 gastric bypass and 47 gastric sleeve resection patients operated on in our hospital was performed. The quality of life parameters were measured with two standard questionnaires (SF 36 and Moorehead–Ardelt II). The mean preoperative and postoperative BMI was in gastric bypass group 46.1 and 28.1 kg/m² (mean follow-up: 15.7 months) and in gastric sleeve group 50.3 and 33.5 kg/m² (mean follow-up: 38.3 months). The SF 36 questionnaire yielded a mean total score of 671 for the bypass and 611 for the sleeve resection patients (p = 0.06). The Moorehead–Ardelt II test signed a total score of 2.09 for gastric bypass versus 1.70 for gastric sleeve patients (p = 0.13). Ninety percent of the diabetes was resolved in the bypass and 55% in the sleeve resection group. Seventy-three percent of the hypertension patients needed no more antihypertensive treatment after gastric bypass and 30% after sleeve resection. Ninety-two percent of the gastro-oesophageal reflux were resolved in the bypass group and 25% in the sleeve (with 33% progression) group. Ninety-four percent of the patients were satisfied with the result after gastric bypass and 90% after sleeve resection. The patients have scored a high level of satisfaction in both study groups. The gastric bypass is associated with a trend toward a better quality of life without reaching statistical significance, pronounced loss of weight and more remarkable positive effects on the co-morbidities comparing with the gastric sleeve resection.     

Age ≥50 Does Not Influence Outcome in Laparoscopic Gastric Banding

Background  Laparoscopic adjustable gastric banding is an accepted treatment for obesity. Age greater than 50 carries a theoretically increased risk from weight loss surgery and perhaps less clinical benefit in the long term. We compare results of gastric banding at age 50 and above with age below 50 in our unit. Methods  Between April 2003 and November 2007, 1,335 patients, mean weight 121.7 kg (range 73–268 kg), mean body mass index (BMI) 44.1 kg/m² (range 35–99), underwent gastric banding. Three hundred and twenty four patients had age ≥50. Band adjustments were usually carried out using fluoroscopy. Results  There was no statistically significant difference in the preoperative weights and BMIs for the two patient groups (age < 50: weight 120.7 ± 24.9, BMI 43.6 ± 7.3 kg/m²; age ≥ 50: weight 118 ± 23.7 kg, BMI 43.8 ± 7 kg/m²). Similarly, there was no statistically significant difference with regards to excess percent BMI loss in the two groups over 36 months (age < 50 = 49 ± 27.9; age ≥ 50 = 47.3 ± 35.1). There was no difference in the incidence of complications with patient age. Conclusion  These results demonstrate that, at age ≥50, this procedure is successful in producing weight loss and, at the same time, has a complication rate comparable to younger patients.     

Results of Laparoscopic Gastric Bypass in Patients ≥55 Years Old

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a commonly performed surgical intervention for morbid obesity. Some authors considered age ≥55 years as a relative contraindication to bariatric surgery. We examined the operative outcomes, weight loss, hospital stay and resolution of co-morbidities in patients ≥55 years old compared with those <55 years old undergoing LRYGBP. Methods: From Jan 2000 to Feb 2005, 350 LRYGBPs were performed. 48 patients ≥55 years old (13.7%) were compared to the remaining patients. Results: Analysis of the 48 patients ≥55 years old compared with 302 patients <55 revealed no difference in complication rate, although the older patients had a significantly greater percentage of serious complications. Younger patients lost more weight than older patients. Both groups demonstrated resolution of comorbidities, although the difference was not significant. Conclusions: LRYGBP is safe and well tolerated in morbidly obese patients ≥55 years. The older patients had more serious complications and lost less weight; however, their weight loss and resolution of co-morbidities improved their quality of life. Age should not be a contraindication to bariatric surgery.     

Routine Upper Gastrointestinal Gastrografin® Swallow after Laparoscopic Roux-En-Y Gastric Bypass

Background: Upper gastrointestinal (UGI) swallow radiographs following laparoscopic Roux-en-Y gastric bypass (LRYGBP) may detect an obstruction or an anastomotic leak. The aim of our study was to determine the efficacy of routine imaging following LRYGBP. Methods: Radiograph reports were reviewed for 201 consecutive LRYGBP operations between April 1999 and June 2001. UGI swallow used Gastrografin?, static films, fluoroscopic video, and a delayed image at 10 minutes. Mean values with one standard deviation were tested for significance (P<0.05) using the Mann-Whitney U test statistic. Results: Of 198 available reports, UGI detected jejunal efferent (Roux) limb narrowing (n=17), partial obstruction (n=12), anastomotic leak (n=3), complete bowel obstruction (n=3), diverticulum (n=1), hiatal hernia (n=1), and proximal Roux limb narrowing (n=1). A normal study was reported in 160 cases (81%). Partial obstruction resolved without intervention. Complete obstruction required re-operation. Compared to 6 patients who developed delayed leaks, early identification of a leak by routine UGI swallow resulted in a shorter hospital stay (mean 7.7±1.5 days vs 40.2±12.3 days, P<0.03). Conclusions: Early intervention after UGI swallow may lessen morbidity. Routine UGI swallow following LRYGBP does not obviate the importance of close clinical follow-up.