Laparoscopic Roux-en-Y gastric bypass versus laparoscopic vertical banded gastroplasty: results of a 2-year follow-up study

BACKGROUND: The world's epidemic of obesity is responsible for the development of bariatric surgery in recent decades. The number of gastrointestinal surgeries performed annually for severe obesity (BMI > 40 kg/m2) in the United States has increased from about 16,000 in the early 1990s to about 103,000 in 2003. The surgical techniques can be classified as restrictive, malabsorptive, or mixed procedures. This article presents the results for 2 years of bariatric surgery in the authors' minimally invasive center and analyzes the results of the most used surgical techniques with regard to eating habits. METHODS: Between January 2002 and January 2004, the authors attempted operations for morbid obesity in 110 consecutive patients adequately selected by a multidisciplinary obesity unit. This represented 43% of all consultations for morbidly obese patients. The patients were classified as sweet eaters or non-sweet eaters. All sweet eaters underwent gastric bypass. The procedures included 70 Roux-en-Y gastric bypasses, 39 Mason's vertical banded gastroplasties, and 1 combination of vertical gastroplasty with an antireflux procedure. Revision procedures were excluded. RESULTS: The mean age of the patients was 41.36 years (range, 23-67 years), and 72.3% were female. The mean preoperative body mass index was 44.78 kg/m2 (range, 34.75-70.16 kg/m2). The mean operating time was longer for gastric bypass than for the Mason procedure. Three patients required conversion to an open procedure (2.7%). The two operative techniques had the same efficacy in weight reduction. Early complications developed in 11 patients (10%), and late complications occurred in 9 patients (8.1%). The postoperative length of hospital stay averaged 4.4 days (range, 1-47 days; median, 4 days), and was longer in the gastric bypass group. The mortality rate was zero. Data were available 2 years after surgery for 101 of the 110 patients (91%). Most comorbid conditions resolved by 1 year after surgery regardless of the type of operation used. CONCLUSION: With zero mortality and low morbidity, bariatric surgery performed for adequately selected patients is the most effective therapeutic intervention for weight loss and subsequent amelioration or resolution of comorbidities. The patient's eating habits before surgery play an important role in the choice of the operative technique used.     

Banded Roux-en-Y gastric bypass for the treatment of morbid obesity

BackgroundLaparoscopic Roux-en-Y gastric bypass (LRYGB) is the most effective treatment for morbid obesity. The additional benefit of placing a nonadjustable band around the pouch remains to be determined. The objective of this study was to compare outcomes between banded and nonbanded LRYGB patients in a single bariatric center.MethodsA matched cohort analysis was performed between patients who had undergone banded and nonbanded (standard) LRYGB. In the banded bypass cohort, an 8 F, 6.5 cm silastic ring was placed around the proximal gastric pouch. Both cohorts were matched for age, body mass index (BMI), and anastomotic technique. Endpoints included percentage excess weight loss (%EWL), postoperative morbidity, and band-related complications.ResultsBetween January 2007 and July 2010, 134 banded LRYGB were performed (55% female, mean age 45 years). They were compared with a matched cohort of 134 concurrent nonbanded LRYGB patients (67% female, mean age 45.4 years). Mean preoperative BMI was 54.6 and 52.8 kg/m², respectively (P = .084). At 24 months postoperatively, the average %EWL was 58.6% in banded bypass patients and 51.4% in the nonbanded group (P = .015). The difference in EWL was more pronounced in super-obese patients than in those with BMI<50 (among super-obese, 57.5% versus 47.6%, P = .003; among those with BMI<50, 62.9% versus 57.9%, P = .406]. There was no difference in early (19.4% versus 19.4%) or late complications (10.4% versus 13.4%, P = .451) between banded and nonbanded LRYGB patients.ConclusionBanding the pouch during LRYGB can be performed safely and may provide better weight loss, particularly in super-obese patients. Further prospective and long-term comparative studies of this technique are warranted.     

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     

病态肥胖患者胃减容术的麻醉管理

病态肥胖症（morbid obesity,MO）,特别是合并阻塞性睡眠呼吸暂停综合征（obstructive sleep apnea syndrome,OSAS）患者的麻醉给麻醉医师提出了诸多挑战。充分的术前评估和围术期准备是患者平稳渡过围手术期的关键。MO影响多个重要器官,麻醉前评估除了病史及体格检查外,应着重了解循环和呼吸系统的问题,MO患者气管插管可能更困难,应详细评估气道,制定插管备选策略。此外,不同的药代动力学和药效学,围手术期及术后的管理也同样棘手。现通过1例MO患者的病例,讨论分析此类患者适合的麻醉方法和管理技术。     

Laparoscopic gastric plication versus mini-gastric bypass surgery in the treatment of morbid obesity: A randomized clinical trial

BackgroundLaparoscopic gastric plication (LGP) is emerging as a safe and effective bariatric procedure. However, there are no reports on the comparison between the efficacy and complications of LGP and laparoscopic mini-gastric bypass (LMGB), which is still an investigational bariatric procedure. The objective of this study was to compare safety and efficacy of LGP and LMGB in the treatment of morbid obesity in a one-year follow-up study.MethodsForty patients met the National Institutes of Health criteria and were randomly assigned to receive either LGP (n = 20) or LMGB (n = 20) by a block randomization method. Early and late complications, body mass index (BMI), excess weight loss, and obesity-related co-morbidities were determined at the 1-year follow-up.ResultsOperative time and mean length of hospitalization were shorter in the LGP group (71.0 minutes versus 125.0 minutes, P<.001, and 1.6 days versus 5.2 days; P<.001, respectively). The mean percentage of excess weight loss (%EWL) at 12 months follow-up was 66.9% in the LMGB group and 60.8% in the LGP group (P = .34). Improvement was observed in all co-morbidities in both groups, with the exception of hyperlipidemia, which remained unresolved in 4 patients. Lower incidence of iron deficiency occurred in the LGP group (P = .035). Rehospitalization and reoperation were not required in any cases. Considering the cost of instruments used in the LMGB procedure and operative time, LGP saved approximately $2,500 per case compared with LMGB.ConclusionBoth LGP and LMGB are effective weight loss procedures. LGP proved to be a simpler and less costly procedure compared with LMGB with a lower risk of iron deficiency during a 1-year follow-up study.     

Safety and feasibility of revisional laparoscopic surgery for morbid obesity: conversion of open silastic vertical banded gastroplasty to laparoscopic adjustable gastric banding

Background: Since the 1980s, bypass operations have been largely replaced by gastric restrictive operations. One of the most commonly performed operations for gastric restriction is vertical banded gastroplasty (VBG). However, the results are often disappointing. Adjustable gastric banding (AGB) is a viable alternative to VBG, and the ability to perform this surgery laparoscopically makes it an attractive option for patients in need of revisional surgery. It allows for refashioning of the gastric pouch in patients with a dilation of the pouch or disruption of the staple line. Methods: A total of 48 patients were referred to our center due to post-VBG weight gain. All patients underwent preoperative evaluation to determine the cause for failure of the operation. All patients found suitable for revisional surgery underwent laparoscopic placement of an adjustable band. Results: All but one of the operations were completed laparoscopically; one patient required conversion to open surgery prior to band placement via laparoscopy. This patient needed a blood transfusion. Postoperative band erosion occurred in one patient; laparoscopy surgery was used successfully for removal of the band and suturing of the stomach. Conclusions: Our short-term results indicate that revisional operation for morbid obesity using laparoscopic AGB is a safe procedure when performed cautiously. It enables early patient mobilization and discharge with good functional results and fewer perioperative complications.     

Emergency room visits after laparoscopic Roux-en-Y gastric bypass for morbid obesity

BACKGROUND: Patients can be symptomatic after laparoscopic Roux-en-Y gastric bypass because of either surgical complications or physiologic changes and adjustment to the new anatomy. The aim of this study was to evaluate the factors that could influence the rate of postoperative emergency room admissions (ERAs) and the clinical implication of these visits for patients who have undergone laparoscopic Roux-en-Y gastric bypass. METHODS: The medical records of patients who underwent laparoscopic Roux-en-Y gastric bypass for morbid obesity from 2001 to 2004 were retrospectively reviewed. The data of patients with a history of an ERA after surgery was compared with the data of patients without a history of ERAs. The data collected included demographics, weight, body mass index, operative time, and more. The ERAs were subdivided into early ERAs and late ERAs, and the data were analyzed further. RESULTS: Of 733 patients, 228 (31.1%) had a history of ERAs. Patients with early postoperative complication (<7 days after the procedure) had a greater rate of ERAs (60.9% versus 30.1%, P <.05). The operative time was significantly longer in the ERA group (91.4 versus 86.5 min). The most frequent complaint in the emergency room was abdominal pain (61.4%) followed by vomiting (35.5%). Gastric outlet obstruction was the most frequent cause of an ERA within 2 weeks after surgery. Most patients were treated conservatively. CONCLUSION: Our results suggest that the rate of potential ERAs should not be disregarded. A prolonged operative time and early postoperative complications were significant predictors for late ERAs. Abdominal pain with or without vomiting was the most common presenting symptom. Most patients can be treated conservatively.     

30-Day readmission rates at a high volume bariatric surgery center: Laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and vertical banded gastroplasty-Roux-en-Y gastric bypass

Background Recent studies suggest that weight loss operations may actually increase the costs to society due to increased hospital readmission rates. The purpose of this study was to determine the 30-day readmission rates following bariatric operations at a high volume bariatric surgery program. Methods Records for all patients undergoing bariatric operations during a 3-year period were harvested from the hospital electronic medical database. All hospital readmissions within 30 days of surgery were reviewed to determine the cause, demographics, and patient characteristics. Logistic regression analysis assessed the impact of various factors on the risk of readmission. Results 2,823 consecutive patients were identified using the corrected operative log. Of these patients, 165 (5.8%) patients required 184 (6.5%) readmissions within 30 days of their index bariatric operation. Laparoscopic adjustable gastric banding (LAGB) had the lowest patient readmission rate of 3.1%; vertical banded gastroplasty-Roux-en-Y gastric bypass (VBGRYGBP) 6.8% and Laparoscopic Roux-en-Y gastric bypass (LRYGBP) 7.3%. Technical considerations were the most common cause for readmission (41% of readmissions). White race and undergoing LAGB decreased the odds for readmission, while total operating-room time >120 minutes, initial hospital stay of >3 days and deep venous thrombosis increased the odds for readmission. Conclusion This study found an overall 30-day readmission rate of 6.5% following bariatric operations at a high volume bariatric surgery program.This study supports the concept of bariatric surgery Centers of Excellence and accreditation of Bariatric Surgery Programs based on hospital volume of bariatric operations.     

Ten and more years after vertical banded gastroplasty as primary operation for morbid obesity

Long-term follow-up (>l0 years) after vertical banded gastroplasty (VBG) is almost nonexistent. The aim of this study was to determine long-term outcome after VBG in a group of 71 patients studied prospectively. Seventy-one consecutive patients with morbid obesity (54 women and 17 men; mean age 40 years [range 22 to 71 years]) underwent VBG from 1985 to 1989 and were followed prospectively. Follow-up was obtained in 70 (99%) of the 71 patients. Weight (mean ± standard error of the mean) preoperatively was 138 ±3 kg and decreased to 108 ±2 kg 10 or more years postoperatively. Body mass index decreased from 49 ±1 to 39 ±1. Only 14 (20%) of 70 patients lost and maintained the loss of at least half of their excess body weight with the VBG anatomy. Vomiting one or more times per week continues to occur in 21% and heartburn in 16%. Fourteen patients have undergone conversion from VBG to Roux-en-Y gastric bypass (11 patients) or other procedures (3 patients) because of a combination of inadequate weight loss in 13 patients, gastroesophageal reflux in five, and frequent vomiting in four. Only 26% of patients after VBG have maintained a weight loss of at least 50% of their excess body weight; 17% underwent bariatric reoperation with good results. Thus VBG is not an effective, durable bariatric operation. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 21–24, 2000, and published as an absaact in Gastroenterology 118(Suppl l):A1060, 2000.     

Gastroesophageal reflux after intact vertical banded gastroplasty: Correction by conversion to Roux-en-Y gastric bypass

Symptomatic gastroesophageal reflux disease is common in our experience after vertical banded gastroplasty. Our aim was to determine the safety and efficacy of Roux-en-Y gastric bypass in the treatment of symptomatic gastroesophageal reflux disease complicating vertical banded gastroplasty. We evaluated prospectively collected data on 25 patients who underwent revisional bariatric surgery because of severe gastroesophageal reflux disease after vertical banded gastroplasty. Only 4 of 25 patients had gastroesophageal reflux disease symptoms prior to vertical banded gastroplasty. Endoscopic findings in 24 patients included esophagitis (SS%), Barrett’s esophagus (28%), pouchitis (29%), and gastritis (2 1%); 7 (28%) of 25 patients had evidence of stenosis at the pouch outlet. Mean follow-up (complete in all 2 5) after Roux-en-Y gastric bypass was 3 7 ±7 months (range 3 to 102 months). There were no deaths. Post-operative complications occurred in six patients: pneumonia in two, wound infection in two, prolonged drainage of the defunctionalized stomach via gastrostomy in one, and fever in one. Median hospitalization was 7 days (range 5 to 43 days). At follow-up (3 7 ±7 months), 24 (96%) of 25 are completely or almost completely symptom free. Body mass index was 33 ±2 kg/m2 before and 28 ±2 kg/m² after Roux-en-Y gastric bypass (P = 0.001). Symptoms of gastroesophageal reflux disease are common after vertical banded gastroplasty. Conversion to Roux-en-Y gastric bypass is safe, relieves gastroesophageal reflux disease, and promotes further weight loss. Moreover, maladaptive eating (vomiting, and so forth) induced by vertical banded gastroplasty is relieved. Supported by the Mayo Foundation, Astra Pharmaceuticals AG, Basel, Switzerland, and the Department of Visceral and Transplantation Surgery, University of Bern, Switzerland. Presented in part at the Fortieth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Fla., May 16–19, 1999, and published as an abstract in Gastroenrerology 116:A1348, 1999.     

Laparoscopic conversion of vertical banded gastroplasty to a Roux-en-Y gastric bypass

The vertical banded gastroplasty was the mainstay of bariatric surgery for over a decade. Though this procedure is now rarely performed many of these patients will present with failure or maladaptive eating and its sequelae. Some of these patients who demonstrate the motivation for lifestyle modification as well as many of these with complications will be candidates for revisional surgery. This article reviews the technical challenges in performing these revisions using minimally invasive techniques. In addition it reviews outcomes of laparoscopic conversion and tips for patient selection and success.     

Use of robotics during laparoscopic gastric bypass for morbid obesity.

To evaluate the theoretical increased precision offered by utilization of the robotic instrument, we attempted to determine whether incorporation of its use into traditional laparoscopic gastric bypass would duplicate or improve the success of the operation without increasing complications. The Roux-en-Y gastric bypass is the most commonly performed procedure for morbid obesity in the United States. We performed 120 gastric bypass procedures with traditional laparoscopy during a 30-month period. We began introducing the da Vinci Robotic Surgical System into our laparoscopic gastric bypass procedure and evaluated its effectiveness.     

Health-related quality of life following vertical banded gastroplasty

Background  Morbid obesity is associated with increased risks of morbidity and mortality as well as poor quality of life (QoL). Therefore, the goal of bariatric surgery should not only be reducing weight and treatment of comorbid conditions, but also improving QoL. Moreover, enhanced QoL may motivate patients to adhere to adequate health behavior in order to maintain the surgically established weight loss. Methods  We evaluated early postoperative health-related quality of life (HRQoL) over time. Preoperatively as well as 6, 12, and 24 months after vertical banded gastroplasty (VBG), 107 patients were psychologically assessed using a semistructured interview and the RAND 36-item Health Survey (RAND-36). Results  Over time, we found significant changes in weight: 2 years after surgery, excess weight loss (EWL) was 58.4%. HRQoL showed significant improvements over time, especially in the physical domains. Two years after surgery, 74% of patients were satisfied with the results of the operation and 94.1% would opt for surgery again. Conclusions  VBG not only leads to considerable weight loss, but also to significant improvements in HRQoL. However, some of the initially reported improvements lessened over time and not all patients appeared to profit in the same way.     

Prospective randomized trial of banded versus nonbanded gastric bypass for the super obese: early results

BACKGROUND: Banded gastric bypass has been reported to result in superior weight loss compared with standard nonbanded gastric bypass. However, an adequate comparison of these procedures has not yet been reported. METHODS: A total of 90 patients were enrolled in this prospective randomized double-blind trial comparing banded and nonbanded open gastric bypass for the treatment of super obesity. The banding technique involved placement of a 1.5 x 5.5-cm polypropylene band around the proximal gastric pouch of a standard gastric bypass procedure using the technique of Capella. Chi-square testing and analysis of variance were performed to find any differences in patient characteristics (gender, age, and initial body mass index), percentage of excess weight lost at 6, 12, 24, and 36 months postoperatively, improvement or resolution of co-morbidities, and complications in the banded versus nonbanded gastric bypass groups. RESULTS: As expected, no differences were present in the patient characteristics or incidence of co-morbidities between the banded (n = 46) and nonbanded (n = 44) groups. The body mass index, percentage of women, and mean age was 59.5 and 56.5 kg/m2, 64% and 73.8% (P = .09), and 40.6 +/- 7.4 and 42.6 +/- 7.2 years for the banded and nonbanded groups, respectively; all differences were nonsignificant. No significant differences were found in the resolution of co-morbidities. No significant difference was present in the percentage of excess weight loss at 6, 12, and 24 months (43.1% versus 24.7%, 64.0% versus 57.4%, and 64.2% versus 57.2%, respectively) postoperatively; however, the banded patients had achieved a significantly greater percentage of excess weight loss at 36 months (73.4% versus 57.7%; P <.05). The incidence of intolerance to meat and bread was greater in the banded patients. The overall number of complications was 12 (26%) in the banded and 13 (29.5%) in the nonbanded group, a nonsignficant difference. No band erosions had occurred at the last follow-up visit, and no patients in either group died. CONCLUSION: These results suggest that although the initial weight loss was not significantly different between the 2 groups, the banded patients continued to lose weight for < or = 3 years. The polypropylene band appeared to be well tolerated. We plan longer follow-up to confirm the possibility of additional weight loss and the prevention of weight regain in the banded group, as well as to document any long-term band complications.     

Results of gastric bypass plus resection of the distal excluded gastric segment in patients with morbid obesity

Surgical treatment is the procedure of choice for morbidly obese patients. Gastric bypass with a long limb Roux-en-Y anastomosis is the "gold standard" technique for these patients. We sought to determine the early and late results of open gastric bypass with resection of the distal excluded stomach in patients with morbid obesity. We included in this prospective study 400 patients who were seen from September 1999 through August 2003 (311 women and 89 men; mean age, 38.5 years). The mean body mass index of the patients was 46 kg/m2. All underwent 95% distal gastrectomy, with resection of the bypassed stomach, leaving a small gastric pouch of 15 to 20 ml. An end-to-side gastrojejunostomy was performed with circular stapler No. 25. The length of the Roux-en-Y loop was 125 to 150 cm. In all patients, a biopsy was taken from the liver and routine cholecystectomy was performed. Follow-up was as long as 36 months. A barium study was performed in all patients at 5 days after surgery. Mortality and postoperative morbidity rates were 0.5% and 4.75%, respectively, mainly due to anastomotic leak in 10 patients (2.5%). Hospital length of stay was 7 days for 95% of the patients. Follow-up data for longer than 12 months were available in 184 patients. There was excess body weight loss of 70% at 24 and 36 months, and there was an inverse correlation among preoperative body mass index and the loss of weight. Anemia was present in 10%, and incisional hernia was present in 10.2%. At 1 year after surgery, the BAROS index demonstrated very good or excellent index in 96.6% of the patients. Gastric bypass with resection of the distal excluded segment has results very similar to those of gastric bypass alone but eliminates the potential risks of gastric bypass such as anastomotic ulcer, gastrogastric fistula, postoperative bleeding due to peptic ulcer and gastritis, and the eventual future development of gastric cancer. It is also possible to perform via laparoscopy, as we started to do recently.     

Twelve-year results for revisional gastric bypass after failed restrictive surgery in 131 patients

BackgroundGastric banding (GB) and vertical banded gastroplasty (VBG) may result in unsatisfactory weight loss or intolerable side effects. Such outcomes are potential indications for additional bariatric surgery, and Roux-en-Y gastric bypass is frequently used at such revisions (rRYGB). The present study examined long-term results of rRYGB.MethodsIn total, 175 patients who had undergone rRYGB between 1993 and 2003 at 2 university hospitals received a questionnaire regarding their current status. The questionnaire was returned by 131 patients (75% follow-up rate, 66 VBG and 65 GB patients). Blood samples were obtained and medical charts studied. The reason for conversion was mainly unsatisfactory weight loss among the VBG patients and intolerable side effects among GB patients.ResultsThe 131 patients (112 women), mean age 41.8 years at rRYGB, were evaluated at mean 11.9 years (range 7–17) after rRYGB. Mean body mass index of those with prior unsatisfactory weight loss was reduced from 40.1 kg/m² (range 28.7–52.2) to 32.6 kg/m² (range 19.1–50.2) (P<.01). Only 2 patients (2%) underwent additional bariatric surgery after rRYGB. The overall result was satisfactory for 74% of the patients. Only 21% of the patients adhered to the recommendation of lifelong multivitamin supplements while 76% took vitamin B₁₂. Anemia was present in 18%.ConclusionsrRYGB results in sustained weight loss and satisfied patients when VBG or GB have failed. Subsequent bariatric surgery was rare but micronutrient deficiencies were frequent.     

A comparison of open and laparoscopic Roux-en-Y gastric bypass surgery for morbid and super obesity: a decision-analysis model

BACKGROUND: The aim of this study was to compare laparoscopic Roux-en-Y gastric bypass (LGBP) with open Roux-en-Y gastric bypass (OGBP) to determine which approach resulted in better clinical outcomes and cost effectiveness in patients with morbid obesity. METHODS: A decision-analysis model was constructed to evaluate outcomes of LGBP versus OGBP in patients with body mass index (BMI) ranges of 35 to 49, 50 to 60, and greater than 60. Baseline assumptions for the model were derived from published reports. Sensitivity and cost-effectiveness analyses were performed to determine the optimal strategy. Success was defined as no major procedure-related complications and no long-term complications over a 1-year period after surgery. Failure of therapy was defined as either recurrent symptoms or death attributed to a surgical complication. RESULTS: In patients with a BMI of 35 to 49, LGBP failed in 14% and OGBP failed in 18% of patients, favoring LGBP alone as the dominant strategy. Mortality in the OGBP group was 1.3 times that of the LGBP group. For a BMI of 50 to 60, LGBP was dominant with an overall success rate of 82% as compared with OGBP (77%). Mortality in the OGBP group was 1.3 times that of the LGBP group. For a BMI of greater than 60, LGBP was the dominant strategy with an overall success rate of 67% compared with OGBP (63%). Sensitivity and cost-effective analysis showed that LGBP was the dominant strategy in terms of greater success and less overall morbidity and mortality for all 3 groups. CONCLUSIONS: This analysis suggests that for all BMI ranges evaluated, LGBP is preferable to OGBP. These conclusions are limited by potential selection and publication bias in the trials assessed for this analysis. These limitations can be resolved only by randomized control trials.     

Laparoscopic adjustable gastric banding versus laparoscopic gastric bypass for morbid obesity: A single-institution comparison study of early results

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are common surgical procedures for morbid obesity, but few studies have compared LRYGB and LAGB. All patients who underwent LRYGB and LAGB by a single surgeon at Legacy Health System were identified from a prospectively maintained database. Preoperatively, most patients were allowed to choose between LRYGB and LAGB. Age, sex, body mass index (BMI), complications, mortality, and weight loss were examined. From October 2000 to November 2003, 219 patients underwent LRYGB and 154 patients underwent LAGB. Mean preoperative BMI was 49.5 ± 6.6 and 50.9 ± 9.4 kg/m2, respectively (P = 0.10). Mean age was 42 ± 9 and 47 < 11 years (P < 0.001). The LAGB group had a higher proportion of male patients (21% versus 7%, P < 0.001). Patients undergoing LRYGB had longer operative times (134 versus 76 minutes, P < 0.001), more blood loss (43 versus 28 ml, P < 0.01), and longer hospital stays (2.6 versus 1.3 days, P < 0.001). Excess weight loss was 35% for LRYGB versus 19% for LAGB at 3-month follow-up (P < 0.001), 49% versus 25% at 6 months (P < 0.001), 64% versus 36% at 12 months (P < 0.001), 70% versus 45% at 24 months (P < 0.001), and 60% versus 57% at 36 months (P = 0.85). Major complications occurred in 7% and 6% (P < 0.58) and minor complications occurred in 18% and 20% (P = 0.65) of patients, respectively. Reoperation occurred in 21 patients (10%) after LRYGB and 31 (20%) patients after LAGB (P < 0.01). Of patients undergoing reoperation, eight (38%) LRYGB patients and one (3%) LAGB patient required open laparotomy. One death occurred in each group. Patients undergoing laparoscopic adjustable gastric banding have shorter operative times, less blood loss, and shorter hospital stays compared with laparoscopic gastric bypass patients. The incidence of major and minor complications is similar; however, morbidity after LRYGB is potentially greater and the reoperation rate is higher in the LAGB group. Early weight loss is greater with gastric bypass, but the difference appears to diminish over time. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 (oral presentation). Supported in part by an educational grant from U.S. Surgical (Norwalk, CT).     

Anesthetic management of laparoscopic adjustable gastric banding in Japanese patients with morbid obesity

Laparoscopic adjustable gastric banding (LAGB) is a common type of bariatric surgery worldwide, though not so in Japan. Here we report the anesthetic management of LAGB in ten Japanese patients with morbid obesity. General anesthesia was induced with propofol, fentanyl, and vecuronium bromide and maintained with sevoflurane in oxygen and air (or nitrous oxide in some cases). In a limited number of patients, perioperative epidural analgesia was performed, with fentanyl injected intravenously for analgesia in the remaining patients. Although some special considerations were needed, in perioperative management, including thromboprophylaxis, there were no severe complications in any of the patients.