Technical considerations for transabdominal loading of the circular stapler in laparoscopic Roux-en-Y gastric bypass

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass is being undertaken with increasing frequency. We describe a technique for introducing the anvil of the circular stapler using a totally transabdominal approach. METHODS: One hundred consecutive patients underwent laparoscopic Roux-en-Y gastric bypass in a university-affiliated teaching hospital. RESULTS: The cardiojejunostomy was constructed in all 100 patients using the circular stapler with no complications. No anastomotic leaks were detected postoperatively. CONCLUSIONS: The totally transabdominal approach for introducing the anvil of the circular stapler into the gastric pouch is safe and feasible.     

腹腔镜Roux-en-Y胃旁路术的研究现状

肥胖及肥胖引起的心血管疾病、高血压、高血脂等并发症已成为当今社会很严重的公共卫生问题。1975~2016年,全球大部分地区的肥胖症患病率呈现上升趋势,其中以亚洲地区的上升趋势尤为显著。到2016年,我国已是全世界肥胖症及2型糖尿病患者最多的国家。外科减重手术是目前治疗肥胖症及相关并发症的主要手段,其中应用最为广泛的减重手术为腹腔镜Roux-en-Y胃旁路术(laparoscopic Roux-en-Y gastric bypass,LRYGB)、腹腔镜袖状胃切除术。笔者对LRYGB的研究现状做一综述。     

Robot-assisted laparoscopic Roux-en-Y gastric bypass

Background Robotic surgery promises to extend the capabilities of the minimally invasive surgeon. The aim of this study was to examine the feasibility of robotic surgery in the setting of laparoscopic gastric bypass.Methods The Zeus robotic surgical system was used in 50 laparoscopic gastric bypass procedures. The learning curve was staged to add complexity to the robotic tasks as experience grew. Robotic setup time, robotic operative time, total operative time, and operative outcomes were tracked prospectively.Results We observed a significant decrease in the robotic setup time. Our robotic learning curve demonstrated decreased operative time, even as more complex tasks were accomplished. Total operative time also decreased significantly over the series. There were no complications in our series that could be attributed to the robotic technique.Conclusions Robot-assisted laparoscopic Roux-en-Y gastric bypass is safe. The steadiness and extra degrees of freedom of surgical robotic systems may improve the accuracy of laparoscopic tasks. The learning curve for robot-assisted laparoscopic Roux-en-Y gastric bypass is significant but manageable.Presented at the annual meeting of the Society of American Gastrointesinal Endoscopic Surgeons (SAGES), Denver, CO, USA, 1 April 2004     

Gastric mesenchymal tumors as incidental findings during Roux-en-Y gastric bypass

Background

Occurrences of mesenchymal tumors have been more recognized in recent years, and the incidental diagnosis of these lesions during bariatric surgery has been previously reported.

Alternative operative techniques in laparoscopic Roux-en-Y gastric bypass for morbid obesity.

The only effective treatment for patients with morbid obesity is surgery. Laparoscopic bariatric surgery has become quite popular in attempts to decrease the morbidity associated with laparotomy. In this article, we describe the technical details of laparoscopic Roux-en-Y gastric bypass with three different techniques for creating the 15-cc gastric pouch. These techniques avoid upper endoscopy for the transoral introduction of the 21-mm circular stapler anvil down to the gastric pouch.     

Gastrojejunal strictures following laparoscopic Roux-en-Y gastric bypass for morbid obesity

Background Gastrojejunal strictures following laparoscopic Roux-en-Y gastric bypass (LRYGBP) present with dysphagia, nausea, and vomiting. Diagnosis is made by endoscopy and/or radiographic studies. Therapeutic options include endoscopic dilation and surgical revision.Methods Of 369 LRYGBP performed, 19 patients developed anastomotic stricture (5.1%). One additional patient was referred from another facility. Pneumatic balloons were used for initial dilation in all patients. Savary-Gilliard bougies were used for some of the subsequent dilations.Results Flexible endoscopy was diagnostic in all 20 patients allowing dilation in 18 (90%). Two patients did not undergo endoscopic dilation because of anastomotic obstruction and ulcer. The median time to stricture development was 32 days (range: 17–85). Most patients (78%) required more than two dilations. The complication rate was 1.6% (one case of microperforation). At a mean follow-up of 21 months, all patients were symptom-free.Conclusions Gastrojejunostomy stricture following LRYGBP is associated with substantial morbidity and patient dissatisfaction. Based on our experience, we propose a clinical grading system and present our strategy for managing gastrojejunal strictures.Presented as a poster of distinction at the 12th Congress of the European Association of Endoscopic Surgery, Barcelona, Spain, June 2004     

Open Roux-en-Y gastric bypass in 925 patients without mortality

BACKGROUND: Open Roux-en-Y gastric bypass has become the gold standard for bariatric surgery. Safety has always been a concern with this elective surgery, especially among the general public. With increasing numbers of bariatric surgeries being performed, the public eye is once again focused on safety and outcomes for these patients. METHODS: Nine hundred twenty-five consecutive open Roux-en-Y gastric bypass patients were reviewed. Charts were retrospectively reviewed for early complications, late complications, and resolution of medical comorbidities. RESULTS: There were no deaths in this study group. The average body mass index (BMI) was 51. Eight leaks at the anastomosis occurred with no reoperations. Hypertension resolved in 70% and diabetes mellitus resolved in 58% of patients. CONCLUSIONS: Open Roux-en-Y gastric bypass is a safe operation, even with increasing numbers of surgeries being performed. Major complications are low and improvement of medical comorbidities is significant. A multidisciplinary team approach helps to improve care and clinical outcomes.     

Nephrolithiasis after bariatric surgery: A comparison of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy

IntroductionLaparoscopic Roux-en-Y gastric bypass (LRYGB) is known to increase risk for calcium oxalate nephrolithiasis due to hyperoxaluria; however, nephrolithiasis rates after laparoscopic sleeve gastrectomy (LSG) are not well described. Our objective was to determine the rate of nephrolithiasis after LRYGB versus LSG.MethodsThe electronic medical records of patients who underwent LRYGB or LSG between 2001 and 2017 were retrospectively reviewed.Results1,802 patients were included. Postoperative nephrolithiasis was observed in 133 (7.4%) patients, overall, and 8.12% of LRYGB (122/1503) vs. 3.68% of LSG (11/299) patients (P < 0.001). Mean time to stone formation was 2.97 ± 2.96 years. Patients with a history of UTI (OR = 2.12, 95%CI 1.41–3.18; P < 0.001) or nephrolithiasis (OR = 8.81, 95%CI 4.93–15.72; P < 0.001) were more likely to have postoperative nephrolithiasis.ConclusionThe overall incidence of symptomatic nephrolithiasis after bariatric surgery was 7.4%. Patients who underwent LRYGB had a higher incidence of nephrolithiasis versus LSG. Patients with a history of stones had the highest risk of postoperative nephrolithiasis.     

Gastrogastric fistula: a possible complication of Roux-en-Y gastric bypass.

BACKGROUND: Gastrogastric fistula is a communication between the proximal gastric pouch and the distal gastric remnant, rarely described in the realm of bariatric procedures. The aim of this study was to review the existing literature about this topic and to demonstrate its laparoscopic treatment. METHODS: An extensive literature review found several articles reporting this complication. However, no citation was found describing the steps of the laparoscopic management of this situation. RESULTS: Gastrogastric fistula occurs in up to 6% of Roux-en-Y gastric bypasses. Two theories exist for fistula formation: (1) it is a technical complication derived from the incomplete division of the stomach during the creation of the pouch, and (2) it occurs after a staple-line failure, developing a leak with an abscess, which then drains into the distal stomach forming the fistula. Early symptoms include fever, tachycardia, and abdominal pain. Failure in weight loss is a late clinical sign observed in these patients. Diagnosis is based on radiologic study, upper endoscopy and computed tomography. When identified in the acute postoperative course, laparoscopic treatment is easy. Chronic fistulas are difficult to manage, and the laparoscopic approach is an alternative to open surgery. CONCLUSIONS: Gastrogastric fistula is a possible complication of Roux-en-Y gastric bypass and its laparoscopic treatment is feasible.     

Mucosal and hormonal adaptations after Roux-en-Y gastric bypass

The aim of this study was to perform a comprehensive literature review regarding the relevant hormonal and histologic changes observed after Roux-en-Y gastric bypass (RYGB). We aimed to describe the relevant hormonal (glucagon-like peptides 1 and 2 [GLP-1 and GLP-2], peptide YY [PYY], oxyntomodulin [OXM], bile acids [BA], cholecystokinin [CCK], ghrelin, glucagon, gastric inhibitory polypeptide [GIP], and amylin) profiles, as well as the histologic (mucosal cellular) adaptations happening after patients undergo RYGB. Our review compiles the current evidence and furthers the understanding of the rationale behind the food intake regulatory adaptations occurring after RYGB surgery. We identify gaps in the literature where the potential for future investigations and therapeutics may lie. We performed a comprehensive database search without language restrictions looking for RYGB bariatric surgery outcomes in patients with pre- and postoperative blood work hormonal profiling and/or gut mucosal biopsies. We gathered the relevant study results and describe them in this review. Where human findings were lacking, we included animal model studies. The amalgamation of physiologic, metabolic, and cellular adaptations following RYGB is yet to be fully characterized. This constitutes a fundamental aspiration for enhancing and individualizing obesity therapy.     

Long-term weight loss outcomes after banded Roux-en-Y gastric bypass: a prospective 10-year follow-up study

Objective

To evaluate the weight loss outcomes of banded Roux-en-Y gastric bypass (RYGB) during a 10-year follow-up.

Postoperative complications are not increased in super-super obese patients who undergo laparoscopic Roux-en-Y gastric bypass

Background It has been suggested that super-super obesity (body mass index [BMI] ≥60 kg/m²) increases the risk of complications after laparoscopic Roux-en-Y gastric bypass (LapRYGB). We hypothesized that a higher BMI does not increase risk the morbidity or mortality rate.Methods Complication rates for patients with a BMI ≥60 kg/m² were compared to those for patients with a BMI <60 kg/m² who underwent LapRYGB during the same time period. Differences between the groups were analyzed by Fisher’s exact test, t-tests, and analysis of variance.Results Forty-five patients with a BMI ≥60 kg/m² and 640 patients with a BMI <60 kg/m² underwent LapRYGB. There were no statistically significant differences between the two groups in the complication or mortality rates. Excess weight loss was less, but actual weight lost was greater in the BMI ≥60 kg/m² group.Conclusions The complication and mortality rates are not increased in super-super obese patients who undergo LapRYGB. Acceptable weight loss can be achieved safely in these patients.     

Plasma homocysteine after laparoscopic Roux-en-Y gastric bypass increases in the early postoperative phase but decreases in the long-term follow-up. A retrospective analysis

BackgroundHomocysteine is an important independent risk factor for predicting cardiovascular disease (CVD). However, changes in the homocysteine levels after bariatric surgery remain controversial.ObjectivesModeling differences in homocysteine after bariatric surgery.SettingUniversity Hospital, Austria.MethodsSeven hundred eight consecutive bariatric surgery patients (78% female, 22% male, mean body mass index 41 kg/m² preoperatively) underwent laparoscopic long-limb Roux-en-Y gastric bypass in a 6-year period and were retrospectively evaluated for changes in their preoperative homocysteine levels, at 3, 6, 9, 12, 18, 24, 36, 48, 60, and 72 months postoperatively. Furthermore, a postal and telephone screening for postoperative CVD with a follow-up of 71% was conducted.ResultsHyperhomocysteinemia was present in 11.8% preoperatively (normal range: <15 μmol/L). The median plasma homocysteine level was 10.4 preoperatively, 12.1 at 3, 11.2 at 6, 10.0 at 9, 9.8 at 12, 8.9 at 18, 8.7 at 24, 8.6 at 36, 9.1 at 48, 9.8 at 60, and 10.0 μmol/L at 72 months postoperatively. After subdividing the study population in morbidly obese (n = 509, body mass index 40–50 kg/m²) and super-obese (n = 199, body mass index >50 kg/m²) patients, the short-term increase into homocysteine levels remained. Overall, newly onset CVD risk was 4.2%. After subdividing the CVD risk into risk for myocardial infarction, stroke, and risk for deep vein thrombosis/pulmonary embolism the distribution was as follows: .2% myocardial infarction, .59% stroke, and 2.97% deep vein thrombosis/pulmonary embolism (median 36 [interquartile range 36–48] mo postoperatively).ConclusionLaparoscopic Roux-en-Y gastric bypass leads to increased homocysteine levels in the early postoperative period. However, there was no relationship between increased homocysteine levels and CVD event onset.     

重度肥胖患者腹腔镜胃旁路术后味觉的改变

目的:探讨腹腔镜Roux-en-Y胃旁路术(laparoscopic Roux-en-Y gastric bypass,LRYGB)对重度肥胖患者味觉的影响。方法:前瞻性地选择13例BMI平均为(38.6±3)kg/m2的重度肥胖患者作为研究对象,利用味觉问卷评估患者LRYGB术前及术后3个月的味觉变化情况。结果:术后12人(92.3%)饮食后口味发生了变化,较术前2人(15.4%)差异有统计学意义(P=0.006),患者术后食用甜食、肉类、脂类较术前明显降低,分别为(6.31±1.25)vs.(7.77±1.09)(P=0.000),(6.77±1.01)vs.(8.54±1.13)(P=0.000),(5.85±1.28)vs.(6.77±1.3)(P=0.004),手术前后在"甜食口感下降、咸食口感下降及总体口感下降"3方面均存在明显差异,分别为:0 vs.61.5%(P=0.008),0 vs.46.2%(P=0.031),15.4%vs.84.6%(P=0.039),肥胖患者术后对"味觉在享受食物的重要性"的认可度,由术前的(6.92±1.38)上升至(8.46±0.78),差异有统计学意义(P=0.000)。结论:术后患者对食物、饮料的口味发生了变化,并且出现部分味觉受损,尤其对甜食、咸食、总体口感的下降影响了肥胖患者LRYGB术后食物的摄入量。     

Two-step conversion surgery after failed laparoscopic adjustable gastric banding. Comparison between laparoscopic Roux-en-Y gastric bypass and laparoscopic gastric sleeve

BackgroundDespite its worldwide popularity, laparoscopic adjustable gastric banding (LAGB) requires revisional surgery for failures or complications, in 20–60% of cases. The purpose of this study was to compare in terms of efficacy and safety, the conversion of failed LAGB to laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy. (LSG).MethodsThe bariatric database of our institution was reviewed to identify patients who had undergone conversion of failed LAGB to LRYGB or to LSG, from November 2007 to June 2012.ResultsA total of 108 patients were included. Of these, 74 (68.5%) underwent conversion to LRYGB and 34 to LSG. All of the procedures were performed in 2-stage and laparoscopically. The mean follow-up for the LRYGB group was 29.1±17.9 months while for the LSG patients was 24.2±14.3 months. The mean body mass index (BMI) prior LRYGB and LSG was 45.6±7.8 and 47.5±5.6 (P = .09), respectively. Postoperative complications occurred in 16.2% of the LRYGB patients and in 2.9% of the LSG group (P = .04). Mean percentage of excess weight loss was 59.9%±16.2% and 70.2%±16.7% in LRYGB, and it was 52.2%±11.4% and 59.9%±14.4% in LSG at 12 months (P = .007) and 24 months (P = .01) after conversion.ConclusionIn this series, LRYGB and LSG are both effective and adequate revisional procedure after failure of LAGB. While LRYGB seems to ensure greater weight loss at 24 months follow-up, LSG is associated with a lower postoperative morbidity.     

Assessment of comorbid conditions in veteran patients after Roux-en-Y gastric bypass

BACKGROUND: The present study assessed the degree to which comorbid conditions improved after bariatric surgery in veteran patients. METHODS: A retrospective review of 55 patients (age 49.1 +/- 1.2, body mass index 49.3 +/- 1.2 kg/m2; 62% male) who underwent open Roux-en-Y gastric bypass surgery at the Dallas Veterans Administration Medical Center was performed. Univariate and multivariate analyses were used to determine factors associated with outcomes. RESULTS: There were 17 minor (8 patients with anastomotic ulcer, 5 patients with hernia, 1 patients with cholecystitis, 1 patients with a wound infection, and 2 patients with seroma) and 4 major (3 patients with pulmonary embolism and 1 patients with gastrojejunostomy leak) complications. Univariate analysis demonstrated that body mass index was associated with increased length of hospital stay but not with morbidity. Age was not associated with length of hospital stay or morbidity. There was improvement in 91% of patients affected with diabetes mellitus, in 89% with hypertension, in 80% with dyslipidemia, and in 62% with obstructive sleep apnea. COMMENTS: Roux-en-Y gastric bypass results in a marked amelioration or elimination of obesity-related comorbid conditions in veteran patients. Morbidity and mortality are within acceptable rage for these patients with substantial comorbidities.     

精准腹腔镜Roux-en-Y胃旁路术治疗肥胖与代谢病140例疗效分析

目的 探讨精准腹腔镜Roux-en-Y胃旁路手术（LRYGB）治疗肥胖与代谢性疾病的疗效和安全性.方法 回顾性分析暨南大学附属第一医院胃肠外科2011年6月至2013年4月期间行精准LRYGB的140例肥胖患者的临床及随访资料.结果 所有患者均顺利完成精准LRYGB手术,无中转开腹或死亡病例,手术时间（138.0±21.3） min;术后住院时间（5.2±1.2）d,未发现严重术后并发症.术后1、6、12和24月的多余体质量减少率分别为（26.4±8.6）％、（53.3±6.7）％、（75.3±7.9）％和（78.5±8.5）％.术后1年,肝肪肝、高脂血症、高血压和2型糖尿病等肥胖相关代谢性疾病的改善率分别为84.6％（33/39）、92.3％（12/13）、77.3％（17/22）和82.4％（14/17）.结论 对传统手术技术进行了改良与优化的精准LRYGB不会增加手术时间,安全可行;患者术后减重效果明显,能有效改善相关合并症.     

Advanced laparoscopic skills decrease the learning curve for laparoscopic Roux-en-Y gastric bypass

Background The reported learning curve for laparoscopic Roux-en-Y gastric bypass (LRYGB) is 20–100 cases. Our aim was to investigate whether advanced laparoscopic skills could decrease the learning curve for LRYGB with regard to major morbidity. Methods The senior author performed all operations in this series. His training included a laparoscopic fellowship without bariatric surgery, six years in surgical practice focusing on upper abdominal laparoscopic surgery, two courses on bariatric surgery at national meetings, one week of observing a bariatric program, and two mentored LRGBY cases. A comprehensive obesity program was put in place before the program began. Data were collected prospectively and reviewed at the series’ end. Results are presented as mean ± standard deviation and standard statistical analysis was applied. Results Between December 2003 and February 2005, 107 LRYGB operations were performed. Mean operative time decreased significantly with experience (p < 0.0001) and was 154 ± 29, 132 ± 40, 127 ± 29, and 114 ± 30 min by quartile. Mean length of stay was 2.9 ± 1.6 days. Mean excess weight loss was 45.3% (n = 41) at six months. There were no conversions to an open procedure, no anastomotic leaks, no pulmonary embolisms, and no bowel obstructions. The five major complications (3 in the first 50 and 2 in the last 57 cases, p = NS) were two cases of biliopancreatic limb obstruction, two cases of significant gastrointestinal bleeding from anastomotic ulcer, and one case of gastric volvulus of the remnant stomach. Conclusions A bariatric fellowship and/or extended mentoring are not required to safely initiate a bariatric program for surgeons with advanced laparoscopic skills. Operative time decreases significantly with experience, but morbidity and mortality remain low even early in the learning curve. A comprehensive obesity program seems necessary for success. Presented at the Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Dallas, TX, 26–29 April 2006