Selective approach to use of upper gastroesophageal imaging study after laparoscopic Roux-en-Y gastric bypass

BACKGROUND: Many institutions routinely perform upper gastroesophageal imaging (UGI) studies on their laparoscopic Roux-en-Y gastric bypass (LRYGB) patients after surgery. We had routinely studied our patients with UGI on postoperative day 1 to rule out an anastomotic leak or obstruction, until recently when we abandoned this practice. As previously reported, we found that routine UGI did not contribute significantly to patient care. The purpose of this study was to determine whether patient outcomes were affected by this change in protocol. METHODS: From March 2004 to September 2005, 508 LRYGB cases were performed at our institution. Linear cutting staplers were used to create both the gastrojejunostomy and the jejunojejunostomy. In each case, the Roux limb was brought up in an antecolic, antegastric configuration. Before changing our protocol, 194 LRYGB cases were performed, and each patient underwent a routine UGI study (group 1). After abandoning this practice, 314 LRYGB cases were performed (group 2), and an UGI study was obtained only if clinical indicators (e.g., tachypnea, tachycardia, nausea, vomiting, low urine output, and/or abdominal pain) were present. The patient demographics, including gender, age, body mass index, length of hospital stay, and complications were recorded in our bariatric database and reviewed retrospectively. RESULTS: A postoperative UGI study was obtained in 204 patients--in 194 patients routinely (group 1) and in 10 patients because of clinical indications (group 2). No obstructions or leaks were found in any of these 204 patients. In group 2, 304 patients were discharged without an UGI series and did well without any leak or obstruction, except for 1 patient who returned 3 months postoperatively with a stricture at his jejunojejunostomy. No statistically significant differences were found between the 2 groups. CONCLUSION: The results of our study have shown that routine UGI studies after LRYGB do not contribute significantly to postoperative patient care at our institution. We now perform them selectively according to clinical indications, without this change adversely affecting our clinical outcomes.     

Compression anastomosis for Roux-en-Y gastric bypass: observations in a large animal model

BackgroundIn the morbidly obese, laparoscopic Roux-en-Y gastric bypass (RYGB) effectively achieves weight loss with the resolution of co-morbidities. The goal is to create a small-volume gastric pouch with a narrow gastrojejunal anastomosis (GJA). The procedure is associated with a GJA stricture rate of approximately 3%. The use of a compression anastomotic device to create a sutureless gastrointestinal anastomosis, replacing sutures or staples, might reduce tissue trauma and improve the GJA patency rate. A temperature-dependent, memory-shape, Nitinol Compression Anastomosis Clip (CAC) has been successfully used in intestinal anastomoses. Compression of the entrapped bowel leads to necrosis, with device expulsion after 7–10 days.MethodsWe designed a pilot animal model study of open RYGB to examine the clip’s safety in the performance of upper gastrointestinal anastomoses. Six 40-kg female pigs underwent RYGB. Group 1 (n = 3) underwent GJA with the CAC and a stapled jejunojejunal anastomosis (JJA). Group 2 (n = 3) underwent GJA and JJA with the CAC. One pig from each group was euthanized at 1, 4, and 8 weeks postoperatively.ResultsTwo pigs, one from each group, developed gastroparesis. At autopsy, all anastomoses were patent; the mean GJA diameter with the CAC was 1.6 cm (range 0.6–3), the mean JJA diameter with the stapler was 3.8 cm (range 35–40), and the mean JJA diameter with the CAC was 3 cm (range 3–3.2). Anastomotic burst pressures were similar between the stapled and CAC anastomoses. The device was passed per rectum by postoperative day 9 (range 8–12). Histologic examination of the CAC anastomoses demonstrated a complete mucosal lining with no evidence of stricture formation at 2 months.ConclusionThe results of this small animal study have demonstrated the safety of sutureless compression anastomoses in an animal model of open RYGB.     

Association between support group attendance and weight loss after Roux-en-Y gastric bypass

BACKGROUND: Attending support group meetings has been linked to increased weight loss after gastric bypass surgery. However, the degree to which support group attendance influences weight loss is still unclear. This study quantitatively described the association between support group attendance and weight loss after Roux-en-Y gastric bypass. METHODS: The weight loss data and support group attendance of 78 consecutive Roux-en-Y gastric bypass patients were studied retrospectively. The patients were analyzed in 2 groups: those who attended >5 monthly support group meetings (group A) compared with those who went to < or =5 support group meetings (group B). The data from the first 12 months after surgery were analyzed. RESULTS: Group A achieved a mean percentage of excess weight loss of 10.5% at 2 weeks after surgery, 21.4% at 6 weeks, 30.9% at 3 months, 45.4% at 6 months, 53.6% at 9 months, and 55.5% at 12 months. Group B achieved a mean percentage of excess weight loss of 11.3% at 2 weeks, 21.8% at 6 weeks, 31.8% at 3 months, 41.3% at 6 months, 45.2% at 9 months, and 47.1% at 12 months. The differences between the 2 groups were significant at P <0.05 at 9 and 12 months. The weight loss was nonlinear and slowed as patients approached 1 year after surgery. CONCLUSION: Support groups are important for maintaining weight loss throughout the first year after surgery, especially after 6 months when the rate of weight loss from surgery begins to naturally decline. The amount of postoperative weight loss was greater than, or comparable to, the published data. Implementing regular support groups within the postoperative follow-up care may provide patients with the best chances of achieving maximal weight loss.     

Incidence of deep vein thrombosis in morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass

BACKGROUND: To define the incidence of deep vein thrombosis in morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass. METHODS: A retrospective study was conducted for all patients undergoing laparoscopic Roux-en-Y gastric bypass from 2004 to 2006. The data collected included patient demographics, body mass index, operative time, conversion rate, thromboprophylaxis measures, hospital stay, and complications. RESULTS: Of the 618 patients included in the study, 451 (73%) were women and 167 (27%) were men, with a mean age of 44 years (range 18-78). The preoperative body mass index was 49 kg/m(2) (range 35-90). All patients received the same thromboprophylaxis regimen. All surgical procedures were performed and completed laparoscopically, with a mean operative time of 93 minutes (range 50-196). All patients underwent lower extremity color Doppler ultrasonography within the first 24 hours after the surgical procedure. The mean hospital stay was 4 days (range 2-21). The most common in-hospital complication was basal atelectasis in 52 patients (8.4%), followed by gastrointestinal bleeding in 10 (1.6%), and anastomotic leak in 6 (1%). The postoperative follow-up visits were done at 2, 8, 12, 24, and 52 weeks after surgery; no mortality occurred. The overall rate of deep vein thrombosis in the group of 500 consecutive patients was .2%, with no clinically significant pulmonary embolism; 9 patients presented with postoperative bleeding. CONCLUSION: The overall rate of deep vein thrombosis in this group of patients was low, most probably because of the use of thromboprophylaxis.     

Intussusception after Roux-en-Y gastric bypass for morbid obesity: case report and literature review of rare complication

Obstruction of the small intestine is a recognized complication after Roux-en-Y gastric bypass surgery for morbid obesity. Reported causes after bariatric surgery include volvulus, adhesion, internal hernia, hemorrhagic bezoar, incarcerated ventral hernia, and intussusception. Intussusception after Roux-en-Y gastric bypass for morbid obesity is rare. The etiology remains largely obscure. A delay in the diagnosis and management may result in catastrophic outcomes. Management should include the early involvement of a bariatric surgeon. We describe the clinical and radiologic presentation of a case of jejunojejunal intussusception 4 years after open Roux-en-Y gastric bypass.     

Incidence of gastroenterostomy stenosis in laparoscopic Roux-en-Y gastric bypass using 21- or 25-mm circular stapler: a randomized prospective blinded study

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass is the most common bariatric procedure performed in the United States today. The most common early complication after laparoscopic Roux-en-Y is stenosis. No randomized studies have compared the effect of the different staplers on the incidence of stenosis or on long-term weight loss. We compared the anastomoses performed with the two sizes of circular stapler in common use. METHODS: A total of 200 patients were randomized to undergo 21-mm (n = 100) or 25-mm (n = 100) circular stapled gastroenterostomy after induction of anesthesia. No other differences were allowed in the operative technique. Stenosis was defined as patient complaints of dysphagia leading to endoscopy within 10 weeks of surgery, in which a 9-mm diameter endoscope would not pass through the gastroenterostomy without dilation. RESULTS: Of the 200 patients, 19 patients in the 21-mm group and 8 in the 25-mm group underwent endoscopy for symptoms (P = 0.027). Of the 19 and 8 patients, 17 and 7, respectively, had measurable stenosis at endoscopy (p = 0.035). Patients with a 21-mm anastomosis developed symptoms an average of 4.8 +/- 1.2 weeks after surgery, and those with a 25-mm anastomosis developed symptoms an average of 8.9 +/- 3.8 weeks postoperatively (P <0.001). CONCLUSIONS: We found a significant difference in the stenosis rate between the 21-mm and 25-mm circular stapled anastomoses in laparoscopic Roux-en-Y gastric bypass. The 21-mm staplers led to significantly more endoscopies than did the 25-mm staplers. Symptoms leading to endoscopy occurred significantly later with use of a 25-mm stapler than after a 21-mm stapler.     

Early results of conversion of laparoscopic adjustable gastric band to Roux-en-Y gastric bypass

BackgroundAs the number of laparoscopic adjustable gastric bands (LAGBs) placed has increased, the number of patients requiring removal of the device has also increased.MethodsThe data from our institution, a U.S. university medical center, were reviewed to determine the feasibility, patient characteristics, and early results of converting patients from LAGB to laparoscopic Roux-en-Y gastric bypass.ResultsA total of 350 patients underwent LAGB placement at our institution from 2001 to 2008. Of these, 26 required conversion to laparoscopic Roux-en-Y gastric bypass for the following reasons: slippage, poor weight loss, LAGB intolerance, esophageal dilation, infection, and gastric ischemia. All conversions were completed laparoscopically. The average operating time and length of stay was 160 minutes and 3 days, respectively. Three complications developed. The average interval to conversion was 29 months. The average follow-up after conversion was 18 months. The average percentage of excess body weight loss at conversion was 23%. At 12 months after conversion, the patients had achieved an average percentage of excess body weight loss of 56% from their pre-LAGB weight.ConclusionThe increasing popularity of the LAGB has led to a considerable number of revisions of the device. Our early experience has shown that converting patients from LAGB to laparoscopic Roux-en-Y gastric bypass is feasible and safe and can offer patients substantial additional weight loss.     

Evaluating preoperative weight loss, binge eating disorder, and sexual abuse history on Roux-en-Y gastric bypass outcome

BACKGROUND: Roux-en-Y gastric bypass patients often undergo preoperative dieting and psychological assessment before surgery. We examined preoperative weight loss, binge eating disorder (BED), and sexual abuse history and the interactions of these predictors to determine whether a cautionary approach to Roux-en-Y gastric bypass is warranted. METHODS: Consecutive subjects undergoing Roux-en-Y gastric bypass at our institution from January 1997 to December 2002 were reviewed. The postoperative excess weight loss (EWL) at 1, 3, 6, 12, 18, and 24 months and the perioperative complications were measured. EWL was compared at 12 and 24 months postoperatively in the categories of the presence/absence of preoperative weight loss, BED, and sexual abuse history. The perioperative complications were examined in the preoperative weight change groups. RESULTS: Of 154 patients, 121 were included. No significant difference in EWL or perioperative complications was observed between those who lost or gained weight preoperatively. Of the 121 patients, 32% and 17% reported a history of BED and sexual abuse, respectively. No statistically significant difference was observed in the EWL between those with and without BED at 12 and 24 months postoperatively. The EWL in those with and without a sexual abuse history at 12 and 24 months was 57.67% and 66.32% (P <.05) and 64.40% and 70.97% (P = NS). No statistically significant interaction between EWL and sexual abuse*BED/sexual abuse*preoperative weight loss was observed. CONCLUSION: Only sexual abuse history at postoperative month 12 had a negative effect on EWL. Otherwise, physicians can expect to see successful EWL in these subjects up to 24 months postoperatively. We recommend that additional investigation be done of those with BED and a sexual abuse history.     

Errant and unrecognized antiperistaltic Roux limb construction during Roux-en-Y gastric bypass for clinically significant obesity

BACKGROUND: Proper isoperistaltic orientation of the Roux limb is important. We report on 5 patients with errant anatomic construction of the Roux limb during Roux-en-Y gastric bypass for clinically significant obesity. METHODS: We performed a retrospective review of the medical records of these 5 patients. Of the 5 patients, 3 had undergone open and 2 laparoscopic Roux-en-Y gastric bypass. RESULTS: These 5 patients developed persistent and predominantly bilious vomiting in the immediate postoperative period, with subsequent protein-calorie malnutrition. At least 18 operations were undertaken in these 5 patients at different times to correct the abnormally dilated Roux limb to no avail. The diagnosis of an antiperistaltic anatomy was unsuspected, and these operations failed to address the errant anatomy of the Roux limb or resolve the symptoms. Definitive treatment involved repositioning of the Roux limb in an isoperistaltic direction, which resulted in immediate resolution of the symptoms and reversal of the protein-calorie malnutrition. CONCLUSION: Antiperistaltic Roux anatomy is deleterious, and repositioning of the Roux limb in an isoperistaltic direction will resolve the symptoms and associated protein-calorie malnutrition.