Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy as Revisional Procedure after Adjustable Gastric Band—a Systematic Review

The adjustable gastric band (L)AGB gained popularity as a weight loss procedure. However, long-term results are disappointing; many patients need revision to laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG). The purpose of this study was to assess morbidity, mortality, and results of these two revisional procedures. Fifteen LRYGB studies with a total of 588 patients and eight LSG studies with 286 patients were included. The reason for revision was insufficient weight loss or weight regain in 62.2 and 63.9 % in LRYGB and LSG patients. Short-term complications occurred in 8.5 and 15.7 % and long-term complications in 8.9 and 2.5 %. Reoperation was performed in 6.5 and 3.5 %. Revision to LRYGB or LSG after (L)AGB is feasible and relatively safe. Complication rate is higher than in primary procedures.     

Roux-en-Y Gastric Bypass in Mice—Surgical Technique and Characterisation

Background

A reproducible Roux-en-Y gastric bypass (RYGB) model in mice is needed to study the physiological alterations after surgery.

Methods

Male C57BL6 mice weighing 29.0?±?0.8?g underwent either RYGB (n?=?14) or sham operations (n?=?6). RYGB surgery consisted of a small gastric pouch (~2?% of the initial stomach size), a biliopancreatic and alimentary limb of 10?cm each and a common channel of 15?cm. Animals had free access to standard chow in the postoperative period. Body mass and food intake were recorded for 60?days. Bomb calorimetry was used for faecal analysis. Anatomical rearrangement was assessed using planar X-ray fluoroscopy and computed tomography (CT) after oral Gastrografin? injection.

Results

RYGB surgery led to a sustained reduction in body weight compared to sham-operated mice (postoperative week 1: sham 27.8?±?0.7?g vs. RYGB 26.5?±?1.0?g, p?=?0.008; postoperative week 8: sham 30.7?±?0.8?g vs. RYGB 28.4?±?1.1?g, p?=?0.003). RYGB mice ate less compared to shams (sham 4.6?±?0.2?g/day vs. RYGB 4.3?±?0.4?g/day, p?p?=?0.13) and faecal energy content (p?=?0.44) between RYGB and shams. CT scan demonstrated the expected anatomical rearrangement without leakage or stenosis. Fluoroscopy revealed rapid pouch emptying.

Conclusions

RYGB with a small gastric pouch is technically feasible in mice. With this model in place, genetically manipulated mouse models could be used to study the physiological mechanisms involved with metabolic changes after gastric bypass.     

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.     

Is a Pouch Compulsory in Roux-en-Y Gastric Bypass After Failed Adjustable Gastric Banding?

Background  Pouch formation after failed gastric banding bears a risk of anastomotic leakage, bleeding or ischemic damage due to an impaired vascular supply or demanding preparation in the scarry tissue. We evaluated the clinical outcome in patients following Roux-en-Y gastric bypass (RYBP) with and without gastric pouch reconstruction after removal of adjustable gastric bands. Methods  This study comprised 24 morbidly obese patients undergoing RYBP as their final bariatric procedure. Group 1 consisted of eight patients after band migration or pouch dilatation. An esophago-jejunal anastomosis was performed. Group 2 comprised 16 patients with esophageal motility disorders or pouch dilation after banding. A regular-sized pouch was created. Clinical parameters, such as weight loss, complications and a satiety score were assessed. Serum values of ghrelin and gastrin were measured. Results  All but one procedure (Group 2) could be performed by laparoscopy. Mortality rate was 0%. One patient of Group 1 developed a liver abscess that required percutaneous drainage and one patient of Group 2 developed stenosis at the gastrojejunostomy that necessitated endoscopic balloon-dilation. All patients significantly reduced body weight (p < 0.01 compared to preoperative values) during a median follow-up of 37.5 and 31.5 months, respectively. Two out of 16 (12.5%) patients of Group 2 showed pathologic postoperative DeMeester scores. Esophageal body peristalsis did not reveal statistically significant differences between the two groups. Parameters of satiety assessment did not differ between the two groups as did serum values of gastrin and ghrelin. Conclusion  RYBP in patients experiencing adjustable gastric band failure is technically demanding. Esophago-jejunostomy avoids preparation in scarred tissue whereas routine pouch formation may increase the risk for complications. Adapted procedural strategy is recommended based on intraoperative decision making.     

Weight Loss and Weight Regain—5-Year Follow-Up for Circular- vs. Linear-Stapled Gastrojejunostomy in Laparoscopic Roux-en-Y Gastric Bypass

Background

Weight regain (WR) occurs in some patients after laparoscopic Roux-en-Y gastric bypass (LRYGBP). Loss of restriction due to dilation of the gastrojejunostomy (GJS) or the gastric pouch might be the main cause for WR. With different techniques available for the establishment of the GJS, the surgical technique might influence long-term success.

Methods

We present a 5-year follow-up for weight loss and WR of a matched-pair study comparing circular stapled (CSA) to linear stapled (LSA) GJS in a series of 150 patients who underwent primary antecolic antegastric LRYGBP. Complete 5-year follow-up was obtained for 79 % of the patients.

Results

Excess BMI loss (EBL) at 3 months was better with the CSA (p?=?0.02) and comparable thereafter. The 5-year %EBL was 67.3?±?23.2 vs. 73.3?±?24.3 % (CSA vs. LSA, p?=?0.19) WR of?>?10 kg from nadir was found in 24 patients (16 %) with higher incidence in CSA than in LSA patients (20 % vs. 12 %). The %WR was comparable for both groups, 16?±?13 vs. 15?±?19 % (CSA vs. LSA, p?=?0.345). Eleven patients underwent surgical re-intervention for WR by placement of a non-adjustable band (n?=?2), adjustable band (n?=?7) and conversion to distal gastric bypass (n?=?2).

Conclusions

CSA and LSA lead to comparable weight loss in this 5-year follow-up. More patients in the CSA group had WR. Weight regain of more than 10 kg was found in one out of seven patients within 5 years postoperatively.     

Robotic Roux-en-Y Gastric Bypass,is it Safer than Laparoscopic Bypass?

Background

Along with the development of technology, robotic approach is being performed for laparoscopic Roux-en-Y gastric bypass (LRYGB). Some literatures reported same or better peri-operative outcomes with the robotic procedure. The aim of this study is to compare our experience in robot-assisted LRYGB (RA-LRYGB) with LRYGB in terms of peri-operative outcomes.

Methods

From January 1, 2012 to April 30, 2014, a total of 270 patients underwent LRYGB by one surgeon at a single institution. Of these, 64 cases were done robotically. A retrospective review was performed for these patients, noting the outcomes and complications of the procedure.

Results

The 64 RA-LRYGB patients had a mean age of 45.9?±?10.0 years (range, 23–67) and a mean preoperative body mass index (BMI) of 48.4?±?7.9 kg/m² (range, 33.8–76.4). The 207 LRYGB patients had a mean age of 45.0?±?10.7 years (range, 21–67) and a mean preoperative BMI of 48.4?±?8.1 kg/m² (range, 34.0–80.4). These two groups were clinically comparable. Mean length of hospital stay was 3.0?±?4.1 days (range, 1–19) in RA-LRYGB patients, significantly longer than 1.6?±?1.7 days (range, 1–17) in LRYGB patients (p?<?0.01). Thirty-day readmission rate was 9.3 % (n?=?6) in the RA-LRYGB group and 6.8 % (n?=?14) in the LRYGB group. Higher leak rate was noticed in RA-LRYGB patients at 7.8 % (n?=?5), compared to 0.5 % (n?=?1) in LRYGB patients (p?<?0.01). All the leaks occurred at the pouch level in the RA-LRYGB group, while one leak from the LRYGB group occurred at the gastrojejunal anastomosis site.

Conclusions

Robot-assisted Roux-en-Y gastric bypass may result in higher leak rate at the pouch level, when compared to that of laparoscopic procedures.

     

Conversion from Sleeve Gastrectomy to Roux-en-Y Gastric Bypass—Indications and Outcome

Background  

Due to excellent weight loss success in the short-time follow-up, sleeve gastrectomy (SG) has gained popularity as sole and definitive bariatric procedure. In the long-term follow-up, weight loss failure and intractable severe reflux can necessitate further surgical intervention.     

Is Roux-en-Y Gastric Bypass Adequate in the Super-Obese?

Background:The outcome after Roux-en-Y gastric bypass (RYGBP) in morbidly obese (MO) (body mass index [BMI] 40-50) was compared with super-obese (SO) (BMI >50) and super-super-obese (SSO) (BMI >60) patients. Methods: A prospective study was conducted in 738 consecutive patients who underwent RYGBP. 483 MO were compared with 184 SO and 70 SSO. Study endpoints included: effect on co-morbid conditions, postoperative morbidity and mortality, and long-term results. Statistical analysis utilized SPSS 11.0. Results: Percentage of males was significantly greater in the SO groups (16.5% vs 13%, P=0.01). Obesity-related conditions were significantly more frequent in the SO groups: sleep apnea (38% vs 17%, P<0.0005), gallstones (23% vs 14%, P=0.013); diabetes (29% vs 17%, P=0.002). Hospital stay was longer in the SO groups (5.7±6.1 days vs 4.6±2.6 days, P=0.024). Wound infection was more frequent in the SO groups (4.7% vs 1.4%, P=0.019). Postoperative mortality was greater in the SSO and SO groups (1.6% and 1.4%) than MO (0%) (P=0.019). Incisional hernia was more frequent in the SO groups (14.1% vs 8.6%; P=0.041). There was no significant difference in percent of excess weight loss (%EWL) between the three groups. EWL >50% at 5 years was: MO 81.5%, SO 87.5%, SSO 80%. The surgery was effective in treating the co-morbid conditions. Conclusion: RYGBP achieved significant durable weight loss and effectively treated co-morbid conditions in SO and SSO patients with acceptable postoperative morbidity and slightly greater mortality than in MO patients.     

Metastatic Adenocarcinoma of the Gastric Pouch 5 Years After Roux-en-Y Gastric Bypass

A 65-year-old male presented 5 years after Roux-en-Y gastric bypass (RYGBP) with cancer of the gastric pouch. At the time of detection, the cancer was already metastatic. This case represents the first reported metastatic gastric adenocarcinoma arising from the gastric pouch following RYGBP.     

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.     

Is an Early Resumption of a Regular Diet After Laparoscopic Roux-en-Y Gastric Bypass Safe?

Obesity Surgery - Return to a normal diet is a crucial step after bariatric surgery. Proximal anastomosis is a source of concern for early feeding as the passage of solid food through a recent...     

Laparoscopic Roux-en-Y Gastric Bypass is Safe and Effective in Patients with a BMI ≥60

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been shown to be safe and effective. There is little data on the outcomes in massively super-obese patients, with a body mass index (BMI) &ge60 kg/m²(super-super-obese). The goal of this study was to determine the safety and effectiveness of LRYGBP in these patients, and compare these results to patients with a BMI <60. Methods: 213 consecutive patients undergoing LRYGBP by a single surgeon at a university hospital were included in the study. The patients were divided into 2 groups: BMI <60 kg/m²(n=167) and BMI ≥60 kg/m² (n=46). The 2 groups were compared with regard to perioperative complications, and postoperative weight loss. Results: Both groups had statistically similar complication rates. There were major complications in 8 patients (5%) in the lower BMI group and in 3 patients (7%) in the higher BMI group. There were minor complications in 9 patients (5%) in the lower BMI group and in 4 patients (9%) in the higher BMI group. Mean percent excess weight loss (%EWL) was 64% at 1 year in the BMI <60 group and 53% in the BMI ≥60 group. Conclusion: LRYGBP can be performed safely and effectively in super-super-obese patients (BMI ≥60). Although these patients have less %EWL than lighter patients, they still end up with a good result. Therefore, LRYGBP should be considered a good surgical option even for patients with a BMI ≥60.     

Revisional Bariatric Surgery by Conversion to Gastric Bypass or Sleeve—Good Short-Term Outcomes at Higher Risks

This is a retrospective study of prospectively collected data from 34 patients who had revisional bariatric surgery at a single centre. The aim was to report the indications for revisional surgery, operative time, conversion to open surgery, mortality, hospital stay, early and late complications, reoperations and short-term efficacy. From 2006 to 2011, 31 patients who formerly had been operated for morbid obesity with restrictive operations and 3 patients who had been operated in the upper abdomen for other morbidities (fundoplications 2, Heller's myotomy 1) underwent a revisional Roux-en-Y gastric bypass operation (n = 30) or sleeve gastrectomy (n = 4). Demographic data, perioperative characteristics and follow-up data were entered prospectively in the hospital's database for bariatric patients. Twenty-five operations were done by laparoscopic and nine by open technique. The mean operative time was 113.17 (33.98, 54–184) min. The mean postoperative hospital stay was 3.25 (5.71, 1–32) days. Intra-operative complications occurred in six patients (17.65%), postoperative complications in nine (26.47%), and major complications in three patients (8.82%), including leakage in the gastrojejunal anastomosis in two (5.88%) patients. The conversion rate to open surgery was 2.94% (one emergency patient). There was no mortality. Excess weight loss (%, ±SD) at 3 months follow-up averaged 42.31%, ±21.54. Revisional bariatric surgery can be performed with an increased but acceptable risk, with at least short-term weight loss comparable to primary operations.     

Routine Preoperative Ultrasonography and Selective Cholecystectomy in Laparoscopic Roux-en-Y Gastric Bypass. Why Not?

Background Preoperative evaluation and treatment of biliary lithiasis in morbid obese patients who are candidates to bariatric surgery raise a series of questions which to date has no clear consensus. The aim of this study was to evaluate the results of routine preoperative abdominal ultrasonography and selective cholecystectomy comparing patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP) with and without simultaneous cholecystectomy. Methods The prospective database of all the patients who underwent laparoscopic RYGBP in our institution was reviewed. The demographic characteristics, comorbidities, operative time, hospital stay, and postoperative complications were analyzed. Results From August 2001 to December 2006, 1,311 patients underwent laparoscopic RYGBP, 137 (10.4%) of them were excluded due to previous cholecystectomy. In 128 (10.9%) of the remaining 1,174 patients, a cholecystectomy associated to laparoscopic RYGBP was performed. The mean age was 38.5 ± 10.1 years, and 106 (82.8%) were women. The mean operative time in patients with and without simultaneous cholecystectomy was 129.8 ± 45 and 108.5 ± 43 min, respectively (p < 0.001). The hospital stay was 3.6 ± 0.8 days in patients with simultaneous cholecystectomy and 4 ± 3 days in patients without simultaneous cholecystectomy (p = 0.003). There were no deaths. Postoperative complications were observed in 9 (7%) and 73 (6.9%) patients with and without simultaneous cholecystectomy respectively (p = NS). Postoperative complications were not related to the cholecystectomy. Conclusion Cholecystectomy associated to laparoscopic RYGBP should be considered in all patients with preoperative ultrasound diagnosis of cholelithiasis.     

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,Weight Loss and Improvement of Co-morbidities After Primary and Revisional Laparoscopic Roux Y Gastric Bypass Procedure—Comparative Match Pair Study

Background

The prevalence of morbid obesity and its co-morbidities is dramatically increasing, as is the extent of weight loss surgery. A large number of patients after various bariatric procedures need revisional intervention for various reasons. We investigated the efficacy and the safety of revisional laparoscopic Roux Y gastric bypass (LRYGB) among our patients, who were revised as a consequence of inadequate weight loss or weight regain after previous bariatric interventions.

Methods

A comparative, double-centre, match pair study was performed comparing the data of 44 patients after revisional surgery with 44 patients after primary gastric bypasses, focusing on weight loss, life quality and improvement of co-morbidities. Matching criteria were age, gender, preoperative BMI and follow-up period. Previous procedures consisted of 23 gastric bandings, 13 sleeve resections, 4 LRYGB and 4 vertical banded gastroplasties.

Results

Extra weight loss (EWL) was significantly reduced after revisional gastric bypasses compared to primary intervention (EWL 66 vs. 91 %, p?p?=?0.22; Moorehead-Aldert II score 1.4 vs. 2.0, p?=?0.10). The resolution rate of co-morbidities (T2DM, hypertension, gastro-oesophageal reflux (GER), osteoarthrosis, sleep apnoea) was also higher after primary gastric bypasses.

Conclusions

Revisional LRYGB is an effective and safe method for patients with inadequate weight loss after previous bariatric surgery concerning weight reduction, life quality and improvement of co-morbidities. Our results indicate lower efficacy of revisional compared to primary LRYGB reaching statistical significance in regard to weight loss.     

Prophylactic Cholecystectomy,a Mandatory Step in Morbidly Obese Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass?

Background  

The aim of this study was to determine the incidence of symptomatic gallstone disease requiring cholecystectomy (CCE) after laparoscopic Roux-en-Y gastric bypass (LRYGBP) and to identify the peri-operative risk factors associated with postoperative symptomatic gallstone disease.     

Is Routine Cholecystectomy Necessary at the Time of Roux-en-Y Gastric Bypass?

Background: Morbid obesity is associated with an increased incidence of gallstones. Rapid weight loss, as occurs after Roux-en-Y gastric bypass (RYGBP) may also increase gallstone development. Standard surgical treatments for gallbladder disease and its complications might be more difficult following RYGBP. Controversy still exists whether prophylactic cholecystectomy is indicated at the time of RYGBP. Methods: Retrospective analysis was performed on a database of 535 patients who underwent RYGBP for morbid obesity during a 5.5-year period. Patients were followed and medical records were reviewed. Ursodeoxycholic acid was not prescribed following surgery. Results: 8% of patients had had cholecystectomy before the RYGBP. 75 of 492 patients (15%) were found to have gallstones at RYGBP, and cholecystectomy was performed at the same time. 3 of these patients had bile leaks but only 1 required further intervention (percutaneous transhepatic drainage for 3 weeks). Following RYGBP, 14 patients (3%) have required cholecystectomy for symptomatic cholelithiasis in the postoperative period. All were performed laparoscopically and without complication. Conclusions: Symptomatic gallbladder disease after RYGBP has not been frequent. Prophylactic cholecystectomy for a normal gallbladder is not necessary at the time of RYGBP. Patients without biliary tract symptoms may not require routine preoperative sonogram. If an abnormal gallbladder or gallstones are found at the time of an RYGBP operation, concomitant cholecystectomy should be considered.     

The Repair of Incisional Hernia Following Roux-en-Y Gastric Bypass—With or Without Concomitant Abdominoplasty?

Background  Incisional hernia, found in up to 25% of patients, is a typical complication of open bariatric surgery. Methods  Open Roux-en-Y gastric bypass (RYGB) was performed in 204 patients. They have been followed-up for at least 6 months. Thirty-two patients in whom incisional hernia was diagnosed were divided into two groups—they were scheduled for hernia repair or hernia repair with abdominoplasty. The surgery was performed, on average, 20 months after RYGB operation. Fourteen patients [mean body mass 86.4 kg, mean body mass index (BMI) 30.0 kg/m²] have had hernias repaired. The mean duration of hospital stay was 7.2 days. Hernia repair along with abdominoplasty was performed in 18 patients with mean body mass 89.4 kg and BMI 31.5 kg/m². The mean duration of hospital stay was 8.7 days. Results  Both examined groups were similar in body mass, BMI, age, and duration of hospital stay (p > 0.05), as well as gender distribution. The wound infection was diagnosed in six patients. Conclusion  The simultaneous abdominoplasty does not prolong the time of hospital stay of the patients undergoing incisional hernia repair. Infection is the most frequent complication of incisional hernia repair.     

Operative Complications During Pregnancy After Gastric Bypass—a Register-Based Cohort Study

Background

Late complications to bariatric surgery during pregnancy have become an area of concern. Expansion of the uterus and the following displacement of the small intestine may increase the risk of internal herniation. We wanted to estimate the risk and consequences of surgical complications during pregnancy in a national cohort of women with a history of gastric bypass surgery.

Methods

A national, register-based cohort study of all Danish women with a history of gastric bypass surgery who had given birth from 2004 to 2010 was conducted. Surgical codes registered during pregnancy and until 120 days postpartum were identified in national registers, and the individual charts were reviewed in relevant cases.

Results

Of 286 women giving birth, fourteen women underwent procedures that might be related to the earlier gastric bypass surgery. Three women were operated on suspicion of internal herniation. In all three cases, mesenteric defects were found, and herniation was still present in two women, one of which died postoperatively. Five women were investigated by gastroscopy or sigmoidoscopy either during or after the delivery, and in six women cholecystectomy was performed during the puerperium.

Conclusions

The incidence of internal herniation during pregnancy was 1 % in our study. Internal herniation may be a serious complication in pregnant women, and both the diagnosis and treatment requires handling by experienced obstetrical, radiological, and surgical staff.