Utility and techniques of intraoperative endoscopy and interventions

Intraoperative endoscopy is an indispensable tool for gastrointestinal surgery. Advent of CO₂ endoscopy has allowed for incremental expansion of its applications. With experienced endoscopist surgeon and operating room staffs, intraoperative endoscopy can be done without added morbidity in time-efficient manner, while providing value in diagnosis and treatment. Intraoperative endoscopy has long been used to localize small tumor when palpation and preoperative endoscopic tattoo do not clarify the precise location of the tumor. It can be used to ascertain distal transection point in rectum, to assess integrity and perfusion of pelvic anastomosis, to aid in laparoscopic sleeve cecectomy or combined endo-laparoscopic surgery (CELS), and to localize small intestine bleeding. Intraoperative endoscopy is invaluable in the case of anastomotic leak and bleeding. Utility of intraoperative endoscopy is expected to grow as new device and platform become available.     

Early Experience with Intraluminal Reinforcement of Stapled Gastrojejunostomy During Laparoscopic Roux-En-Y Gastric Bypass

Background The use of extraluminal staple-line buttressing material during laparoscopic Roux-en-y gastric bypass has shown the potential to reduce staple-line leak and bleeding. We herein present our early experience with intraluminal reinforcement of linear-cutting stapled gastrojejunal anastomosis with the use of bioabsorbable glycolide copolymer staple-line reinforcement. Methods Laparoscopic Roux-en-Y gastric bypass was performed in 80 consecutive non-randomized morbidly obese patients. Gastrojejunal anastomosis was performed using a linear-cutting stapler without staple-line reinforcement in 40 patients (group A), while in the other 40 patients (group B), gastrojejunostomy was performed using a linear cutting stapler with intraluminal reinforcement material (bioabsorbable glycolide copolymer). Demographic data were collected. The rate of gastrojejunal anastomotic leak, bleeding, and stricture was determined. Results There was a statistically significant reduction in bleeding complications between the two groups (15% bleeding in group A vs. no bleeding in group B, P value = 0.0255). Stricture rate was higher in-group A (10% group A vs. 2.5% in group B); however, the difference was not statistically significant (P value = 0.2007). None of our patients developed a gastrojejunal leak. Conclusion Intraluminal reinforcement of gastrojejunal anastomosis during laparoscopic gastric bypass is safe and feasible. The use of intraluminal bioabsorbable glycolide copolymer staple-line reinforcement significantly reduces the incidence of gastrojejunal bleeding.     

Role of Intraoperative Esophagogastroenteroscopy in Minimizing Gastrojejunostomy-Related Morbidity: Experience with 2,311 Laparoscopic Gastric Bypasses with Linear Stapler Anastomosis

Background

Anastomotic leaks and strictures of the gastrojejunostomy are a cause of major morbidity following laparoscopic Roux-en-Y gastric bypass (LRYGB). Reported rates of leaks vary between 0 and 5.2 %. This has led bariatric surgeons to use a variety of intraoperative methods to detect incompetent suture lines. The aim of the study was to evaluate the role of intraoperative endoscopy in reducing the rate of postoperative anastomotic complications. The setting of this study is in a community teaching hospital.

Methods

Medical records of 2,311 patients who underwent a LRYGB from 2002 to 2011 were retrospectively reviewed utilizing the hospitals’ bariatric surgery database. Demographics, weight, body mass index, intraoperative endoscopy results, and postoperative outcomes within 90 days after surgery were analyzed.

Results

Endoscopy was attempted in 2,311 patients and completed in 2,308 (99.9 %). Intraoperative leak was detected in 80 (3.5 %) patients; suture line was reinforced in 46 patients (2 %), while in the other 34 patients the leak was transient at only high insufflation pressure. Postoperative clinical leaks were detected in four cases (0.2 %) two of which had initial leaks intraoperatively. In two cases, the anastomosis was too tight and required reconstruction. Twenty-five patients (1.1 %) developed early postoperative strictures requiring endoscopic dilatation within 90 days. Three patients (0.1 %) had iatrogenic injury at the time of intraoperative endoscopy, all three healed without delayed morbidity.

Conclusions

The routine use of intraoperative endoscopy in LRYGB with the linear stapler anastomosis technique is associated with a complication/failure rate of 0.3 % and low gastrojejunostomy-related morbidity after LRYGB within 90 days (leak rate of 0.2 % and stricture rate of 1.1 %).     

Clinical results using bioabsorbable staple line reinforcement for circular staplers

Although linear surgical staple line reinforcement has been shown to increase anastomotic tensile strength in animal models and reduce the incidence of staple line bleeding and anastomotic leaks in colorectal surgery, the benefits of staple line reinforcement on circular stapled anastomoses in bariatric surgery remain unreported in the literature. The purpose if this study was to compare the incidence of anastomotic bleeding, leak, and stricture in patients undergoing laparoscopic gastric bypass with circular staple line reinforcements with those with no circular staple line reinforcements. Since May 2006, 138 consecutive patients (Group B) have undergone laparoscopic Roux-en-Y divided gastric bypass with a 25-mm circular stapled gastrojejunal anastomosis using GORE SEAMGUARD bioabsorbable circular staple line reinforcement (CBSG) with a mean follow up of 9 months. The incidence of anastomotic bleeding, leak, and stricture was compared with 255 similar patients (Group A) who underwent surgery before May 2006 without gastrojejunal reinforcement with a mean follow up of 22 months. The rates of anastomotic bleeding, leak, and stricture for Group B versus Group A were 0.7 per cent versus 1.1 per cent (P = 0.64); 0.7 per cent versus 1.9 per cent (P = 0.34); and 0.7 per cent versus 9.3 per cent (P = 0.0005), respectively. The use of CBSG reduced the incidence of anastomotic stricture by 93 per cent and the incidence of a composite end point of all anastomotic complications by 85 per cent. Our results indicate that the use of circular staple line reinforcement at the gastrojejunal anastomosis in patients undergoing laparoscopic gastric bypass significantly decreases the incidence of anastomotic stricture and a composite end point of all anastomotic complications. On this basis, strong consideration should be given to the routine use of CBSG staple line reinforcement in patients undergoing laparoscopic divided gastric bypass with a circular stapled gastrojejunal anastomosis.     

Feasibility of Sleeve Gastrectomy as a Revision Operation for Failed Silastic Ring Vertical Gastroplasty

Background  Restrictive bariatric operations are efficient with low morbidity but entail high rate of failure on follow up of several years. We present our experience in laparoscopic revision of patients who previously underwent silastic ring vertical gastroplasty (SRVG) into laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (LRYGB). Methods  Data on 12 patients who underwent revisional operations after SRVG was prospectively collected. Six patients underwent LRYGB and six patients underwent LSG. The pathogeneses for failures of SRVG were disruption of staple line, enlargement of gastric pouch, and opening of the ring. Results  The average age and body mass index (BMI) were 39 and 43, respectively, in the LSG group versus average age and BMI of 39 and 45, respectively, in the LRYGP group (p = 0.45 and p = 0.35, respectively). The average operative time were 206 and 368 min in the LSG and LRYGB groups, respectively (p < 0.01). There were five postoperative complications among LSG group versus two complications in LRYGB group (p < 0.01). Patients who underwent LSG suffered from the following complications: staple line leak in two patients, intra-abdominal hematoma in one patient, intra-abdominal collection in one patient, and gastric outlet obstruction in one patient. Anastomotic leak and wound infection were the complications seen among patients underwent LRYGB. All complications were treated conservatively without necessitating immediate reoperations. Follow-up has shown adequate reduction of body weight and improved quality of life in both groups of patients. Conclusions  Revisional bariatric operation is a challenging laparoscopic procedure with higher morbidity compared to primary bariatric operations. Morbidity of LSG compared to LRYGB as a revisional procedure for SRVG is significantly higher.     

Linear stapler technique may be safer than circular in gastrojejunal anastomosis for laparoscopic Roux-en-Y gastric bypass: a meta-analysis of comparative studies

The technique of choice for gastrojejunostomy (GJ) during laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity is controversial. We performed a meta-analysis comparing linear versus circular stapler technique to evaluate this issue. A systematic literature search was performed. Primary outcomes were gastrojejunal leak and stricture. Secondary outcomes were operative time, length of hospital stay, post-operative bleeding, wound infection, marginal ulcers and estimated weight loss. Eight studies involving 1,321 patients were retrieved and included in the present study. A significantly decreased risk of GJ stricture was observed after using linear versus circular stapler (RR, 0.34; 95% CI, 0.12–0.93; p = 0.04). Wound infection risk (RR, 0.38; 95% CI, 0.22–0.67; p = 0.0008) and operative time (MD, −24.18; 95% CI, −35.31, −13.05; p < 0.0001) were significantly reduced by using linear stapling. No significant differences were observed in the other outcome end-points. The use of the linear stapler compared with circular stapler for GJ during LRYGB for morbid obesity may be associated with a reduced risk of anastomosis stricture and wound infection, as well as with a shorter operative time.     

胃小弯空肠侧侧吻合在腹腔镜Roux-en-Y胃旁路手术中的应用

目的探讨胃小弯空肠侧侧吻合在腹腔镜Roux-en-Y胃旁路手术中的应用。方法回顾性分析2012年5-11月间在首都医科大学附属北京天坛医院普通外科接受腹腔镜Roux-en-Y胃旁路手术治疗的29例2型糖尿病患者的临床资料,术中均采用直线切割闭合器进行胃小弯空肠侧侧吻合。结果29例患者中男9例,女20例,年龄30-65（平均50．1）岁。所有病例均顺利完成手术．无中转开腹。术后无一例出现胃空肠吻合13出血、吻合13瘘或吻合13梗阻等并发症。术后随访1-7个月未见胃空肠吻合13相关的并发症。结论腹腔镜Roux-en-Y胃旁路手术中采用胃小弯空肠侧侧吻合能准确地控制吻合口大小,避免了镜下缝合操作,操作简单、易于掌握。     

胃肠肿瘤腹腔镜手术中内镜检查的应用价值

目的评价胃肠肿瘤腹腔镜手术中内镜检查的应用价值。方法回顾分析2004年1月～2008年11月我院505例胃肠肿瘤腹腔镜手术中39例(7.7%)术中内镜检查的临床资料。结果 32例以定位病变为指征,其中30例找到病变,检出率达93.8%(30/32);5例以评价吻合口为指征,术后均未出现吻合口狭窄,其中3例同时内镜定位病变切除了合并存在的结肠腺瘤;1例术中出血,行术中内镜明确了出血部位;1例拟在腹腔镜辅助下行内镜下胃脂肪瘤切除,因内镜下注射后抬举征阴性,提示病变深度超过黏膜下层,故改为腹腔镜下切除。结论术中内镜检查对腹腔镜胃肠肿瘤手术病变定位及吻合口评估有重要价值。     

Long-term Results of a Primary End-to-end Anastomosis in Peroperative Detected Bile Duct Injury

The management of a bile duct injury detected during laparoscopic cholecystectomy is still under discussion. An end-to-end anastomosis (with or without T-tube drainage) in peroperative detected bile duct injury has been reported to be associated with stricture formation of the anastomosis area and recurrent jaundice. Between 1991 and 2005, 56 of a total of 500 bile duct injury patients were referred for treating complications after a primary end-to-end anastomosis. After referral, 43 (77%) patients were initially treated endoscopically or by percutaneous transhepatic stent placement (n = 3; 5%). After a mean follow-up of 7 ± 3.3 years, 37 patients (66%) were successfully treated with dilatation and endoscopically placed stents. One patient died due to a treatment-related complication. A total of 18 patients (32%) underwent a hepaticojejunostomy. Postoperative complications occurred in three patients (5%) without hospital mortality. These data confirm that end-to-end anastomosis might be considered as a primary treatment for peroperative detected transection of the bile duct without extensive tissue loss. Complications (stricture or leakage) can be adequately managed by endoscopic or percutaneous drainage the majority of patients (66%) and reconstructive surgery after complicated end-to-end anastomosis is a procedure with relative low morbidity and no mortality. This paper has been presented at the 47th SSAT Annual Meeting, May 20–24, 2006, in Los Angeles, California.     

Surgical Management of Gastro–Gastric Fistula After Divided Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Background Gastro–gastric fistula (GGF) formation is uncommon after divided laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity. Optimal surgical management remains controversial. Methods A retrospective review was performed of a prospectively maintained database of patients undergoing LRYGB from January 2001 to October 2006. Results Of 1,763 primary procedures, 27 patients (1.5%) developed a GGF and 10 (37%) resolved with medical management, whereas 17 (63%) required surgical intervention. An additional seven patients requiring surgical intervention for GGF after RYGB were referred from another institution. Indications for surgery included weight regain, recurrent, or non-healing gastrojejunal anastomotic (GJA) ulceration with persistent abdominal pain and/or hemorrhage, and/or recurrent GJA stricture. Remnant gastrectomy with GGF excision or exclusion was performed in 23 patients (96%) with an average in-hospital stay of 7.5 days (range, 3–27). Morbidity in six patients (25%) was caused by pneumonia, n = 2; wound infection, n = 2; staple-line bleed, n = 1; and subcapsular splenic hematoma, n = 1. There were no mortalities. Complete resolution of symptoms and associated ulceration was seen in the majority of patients. Conclusion Although uncommon, GGF formation can complicate divided LRYGB. Laparoscopic remnant gastrectomy with fistula excision or exclusion can be used to effectively manage symptomatic patients who fail to respond to conservative measures. This paper was presented at the SSAT Poster Presentation session on May 21st 2007 at the SSAT Annual Meeting at Digestive Disease Week, Washington (poster ID M1590).     

Outcome of endoscopic balloon dilation of strictures after laparoscopic gastric bypass

Objective  Stricture formation at the gastrojejunal anastomosis is a relatively common complication after laparoscopic Roux-en-Y gastric bypass (LRYGB). The objective of this study was to report the incidence of stomal strictures after LRYGB in our institution and report our experience with their management by endoscopic balloon dilatation. Methods  This is a retrospective study of 1012 patients who underwent LRYGB from January 2001 to May 2004. Patients with nausea and vomiting after the surgery, suspected of having gastrojejunal (GJ) anastomotic stricture, had upper endoscopy. Stomas less than 10 mm in diameter, or those not allowing passage of the scope were considered significant strictures and were treated with balloon dilations. Dilations were performed with a through-the-scope (TTS) balloon, with sizes ranging from 6 to 18 mm. The following data were collected from these patients: age, sex, body mass index (BMI), comorbidities, size of balloon catheter, time from surgery until symptoms onset, number of endoscopies needed to relief symptoms, and complications of the procedure. Results  Sixty-one patients (46 females and 15 males) were found to have anastomotic strictures, corresponding to an incidence of 6%. In total, 134 upper endoscopies were performed, with 128 dilatations. The average age was 41.7 years (range: 19–68 years); mean preoperative BMI was 45 kg/m² (range: 42–61 kg/m²). Mean time from surgery to symptoms onset was 2 months (range: 1–6 months). The number of dilations per patient was as follows: a single dilation in 28% of patients, two dilations in 33%, three dilations in 26%, four dilations in 11.5%, and five dilations in 1.5% of patients. All the patients responded to dilation without need for formal surgical revision. However, after balloon dilatation three patients (4.9%), all females, had bowel perforation by radiological criteria (free air on X-ray), which corresponded to 2.2% of all dilatations. The maximum balloon size used in this group was 13.5 mm. All three patients had exploratory laparoscopy without finding of perforation site. They were treated with bowel rest, intravenous antibiotics for 7 days, and drain placement. No factors were identified to predict a risk of perforation. Conclusion  This is the largest study to evaluate the outcome of endoscopic dilatations of GJ strictures after RYGB. Endoscopic balloon dilation is a safe and effective treatment for anastomotic strictures. However, it carries a small risk of perforation. Further case studies are needed to determine risk factors for perforation and if the patients can be managed conservatively in this setting.     

Effect of Location and Speed of Diagnosis on Anastomotic Leak Outcomes in 3828 Gastric Bypass Cases

Introduction Leaks after Roux-en-Y gastric bypass are a major cause of mortality. This study attempts to define the relationship between the leak site, time from surgery to detection, and outcome. Methods Retrospective review of 3,828 gastric bypass procedures. Results Of the leaks (3.9% overall), 60/2,337 (2.6%) occurred after open gastric bypass, 57/1,080 (5.2%) after laparoscopic gastric bypass, and 33/411 (8.0%) after revisions. Overall leak-related mortality after Roux-en-Y gastric bypass was 0.6% (22/3,828). Mortality rate from gastrojejunostomy leaks (38 in the open gastric bypass, and 43 in the laparoscopic) was higher in the open group than the laparoscopic group (18.4 vs 2.3%, p = 0.015). Median time of detection for a gastrojejunostomy leak in the open group was longer than in the laparoscopic group (3 vs 1 days, Wilcoxon score p < 0.001). Jejunojejunostomy (JJ) leak was associated with a 40% mortality rate. Initial upper gastrointestinal series did not detect 9/10 jejunojejunostomy leaks. Median detection time was longer in the jejunojejunostomy leak group than the gastrojejunostomy leak group (4 vs 2 days, p = 0.037). Discussion Leak mortality and time of detection was higher after open gastric bypass than laparoscopic gastric bypass. GBP patients with normal upper gastrointestinal (UGI) studies may harbor leaks, especially at the JJ or excluded stomach. Normal UGI findings should not delay therapy if clinical signs suggest a leak. This paper was presented at The Society for Surgery of the Alimentary Tract, 47th Annual Meeting at Digestive Disease Week 2006, May 20–24, 2006, Los Angeles, California.     

Incidence of Anastomotic Strictures after Gastric Bypass: A Prospective Consecutive Routine Endoscopic Study 1 Month and 17 Months After Surgery in 441 Patients with Morbid Obesity

Background  Anastomotic stricture after gastric bypass for morbid obesity has been reported as the most frequent complication after surgery. The objective of this study is to determine in a prospective and consecutive endoscopic evaluation the true incidence of this complication early and late after gastric bypass. Methods  A total of 441 morbidly obese patients were included in this prospective study. They were 358 women and 97 men, with a mean age of 41 years and a mean body mass index of 43 kg/m². In all an endoscopic evaluation was performed 1 month after surgery, which was repeated in 315 patients (71.6%) 17 months after surgery, independent of the presence or not of symptoms. Anastomotic diameter was measured and strictures were classified as: (a) mild, with a diameter of 7 to 9 mm, (b) moderate with a diameter of 5 to 6 mm, and (c) difficult or critical with a diameter equal or less to 4 mm. Two methods of dilatation were employed: the endoscope itself or Savary–Gilliard dilators. Patients were submitted to laparotomic resectional gastric bypass in whom a circular stapler 25 was employed for gastrojejunal anastomosis or to laparoscopic gastric bypass, in whom hand-sewn one layer continuous suture was employed. Results  One month after surgery, 23% of patients after open gastric bypass employing circular stapler 25 presented anastomotic stricture, being 22% of them critical. After laparoscopic gastric bypass employing hand-sewn anastomosis, 36% of the patients presented strictures, being critical 10% (p > 0.17). Patients with mild or moderate strictures needed one or two dilatations. Patients with critical strictures needed three to five dilatations. There were no complications associated to dilatation. Moderate and severe strictures were symptomatic; however 29% of patients with mild strictures were asymptomatic. Endoscopy was repeated in 71% of the whole group 17 months after surgery, demonstrating normal anastomosis in all. Conclusions  Stricture at the gastrojejunal anastomosis after gastric bypass is the commonest complication early after surgery. Near 60% present a mild stricture (with a diameter between 7 and 9 mm), being 28% asymptomatic. This complication is easily treated by endoscopic procedure if it is diagnosed early (3 to 4 weeks) after surgery. Routine endoscopy 1 month after surgery is the only objective scientific way to determine the real true incidence of this complication.     

Primary Results of Laparoscopic Mini-Gastric Bypass in a French Obesity-Surgery Specialized University Hospital

BACKGROUND: Since 2002, we have performed 350 laparoscopic Roux-en-Y gastric bypasses (LRYGB). We decided to evaluate the laparoscopic mini-gastric bypass (LMGB), an operation reported as effective, yet simpler than LRYGB. It consisted of a long lesser curvature tube with a terminolateral gastroenterostomy, 200 cm distal to the Treitz ligament. METHODS: From October 2006 to November 2007, 100 patients (23 men and 77 women) underwent LMGB. The mean age was 40.9 +/- 11.5 years (17.5-62.4), the preoperative mean body weight was 131 +/- 23.1 kg (82-203) and the mean BMI was 46.9 +/- 7.4 kg/m(2) (32.8-72.4). Twenty-four patients had prior restrictive procedure: 20 LAGB of which nine were already removed and four VBG (two laparoscopic and two by open surgery). In preoperative gastric endoscopy Helicobacter pylorii was present in 26 patients and eradicated. RESULTS: All procedures were completed laparoscopically by six different surgeons. Mean operative time was 129 +/- 37 min. There was no death. Seven patients (7%) presented major early complications: three reoperations for incarcerated herniation of small bowel in the trocar wound, one peritonitis due to a traumatic injury of the biliary limb, one perianastomotic abscess, one intraabdominal bleeding requiring splenectomy, and one endoscopic haemostasis for anastomotic bleeding. One patient presented anastomotic stenosis that required endoscopic dilatation 2 months postoperatively. Mean BMI at 3 months was 38.7 kg/m(2) (31.2-60.9) and at 6 months 35.1 (23.6-53.0). Nine patients complained of diarrhea that resolved 3 months postoperatively and, significantly, only two patients complained of biliary reflux. CONCLUSION: Pending long-term evaluation, LMBG seems a good alternative to LRYGB, giving the same results with a more simple and reproductible technique.     

Is concomitant cholecystectomy necessary in obese patients undergoing laparoscopic gastric bypass surgery?

Background  Morbid obesity is associated with a high prevalence of cholecystopathy, and there is an increased risk of cholelithiasis during rapid weight loss following gastric bypass. In the era of open gastric bypass prophylactic cholecystectomy was advocated. However, routine cholecystectomy at laparoscopic gastric bypass is controversial. Methods  We performed a retrospective review of a prospectively maintained database of morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) from February 2000 to August 2006. All had routine preoperative biliary ultrasonography. Concomitant cholecystectomy at LRYGB was planned in patients with proven cholelithiasis and/or gallbladder polyp ≥1 cm diameter. Results  1711 LRYGBs were performed. Forty-two patients (2.5%) had a previous cholecystectomy and were excluded from further analysis. Two hundred and five patients (12%) had gallbladder pathology: cholelithiasis in 190 (93%), sludge in 14 (6.8%), and a 2 cm polyp in 1 (0.5%). One hundred and twenty-three patients with cholelithiasis (65%) had a concomitant cholecystectomy at LRYGB, while 68 (35.7%) did not. Of these, 123 (99%) were completed laparoscopically. Concomitant cholecystectomy added a mean operative time of 18 min (range 15–23 min). One patient developed an accessory biliary radicle leak requiring diagnostic laparoscopic transgastric endoscopic retrograde cholangiopancreatography (LTG-ERCP). Of the 68 patients with cholelithiasis who did not undergo cholecystectomy 12 (17.6%) required subsequent cholecystectomy. A further 4 patients with preoperative gallbladder sludge required cholecystectomy. All procedures were completed laparoscopically. One patient required laparoscopic choledochotomy and common bile duct exploration (CBDE) with stone retrieval. Eighty-eight patients (6%) with absence of preoperative gallbladder pathology developed symptomatic cholelithiasis after LRYGB; 69 (78.4%) underwent laparoscopic cholecystectomy; 3 presented with gallstone pancreatitis and 2 with obstructive jaundice, requiring laparoscopic transcystic CBDE in 4 and LTG-ERCP in one. Conclusion  In our experience, concomitant cholecystectomy at LRYGB for ultrasonography-confirmed gallbladder pathology is feasible and safe. It reduces the potential for future gallbladder-related morbidity, and the need for further surgery. Competing Interests Declared: None     

Laparoscopic Roux-en-Y Gastric Bypass Versus Laparoscopic Sleeve Gastrectomy for the Treatment of Morbid Obesity. A Prospective Study of 117 Patients

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most widely used bariatric procedures today, and laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure for the treatment of morbid obesity is becoming increasingly popular. In this study, we prospectively compared both techniques in order to establish whether there is any superiority of one over the other based on morbidity and effectiveness. From January 2008 to December 2008, 117 obese patients with indication for bariatric surgery were assigned by patient choice after informed consent to either a LRYGB procedure (n = 75) or a LSG procedure (n = 42). We determined operative time, length of stay, morbidity, co-morbidity outcomes, and excess weight loss at 1 year postoperative. Both groups were comparable in age, sex, body mass index, and co-morbidities. Mean operative time of LSG was 82 min while LRYGB was 98 min (p < 0.05). Differences in length of stay, major complications, improvement in co-morbidities, and excess weight loss were not significant (p > 0.05). One year after surgery, average excess weight loss was 86% in LRYGB and 78.8% in LSG (p > 0.05). In the short term, both techniques are comparable regarding safety and effectiveness, so not one procedure is clearly superior to the other.     

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     

Establishing Laparoscopic Roux-en-Y Gastric Bypass: Perioperative Outcome and Characteristics of the Learning Curve

Background  Bariatric surgery was established at several Norwegian hospitals in 2004. This study evaluates the perioperative outcome and the learning curves for two surgeons while introducing laparoscopic Roux-en-Y gastric bypass (LRYGB). Methods  Morbidly obese patients undergoing primary LRYGB were included. Lengths of surgery and postoperative hospital stay, and 30-day rates of morbidity, reoperations, and readmissions were set as indicators of the learning curve. Learning effects were evaluated by graphical analyses and comparing the first and last 40 procedures for both surgeons. Results  The 292 included patients had a mean age of 40.0 ± 9.5 years and a mean body mass index (BMI) of 46.7 ± 5.3 kg/m². The mean length of surgery was 101 ± 55 min. Complications occurred in 43 patients (14.7%), with no conversions to open surgery in the primary procedure and no mortality. Reoperations were performed in 14 patients (4.8%), of which five patients required open surgery. The median length of stay was 3 days (range 1–77), and 19 patients (6.5%) were readmitted. High patient age, but not high BMI, was associated with an increased risk of complication. For both surgeons, lengths of surgery and hospital stay were significantly reduced (p < 0.001), leveling out after 100 procedures. Reductions in the rates of morbidity, reoperations and readmissions were not found. Conclusion  LRYGB was introduced with an acceptable morbidity rate and no mortality. Only the length of surgery and postoperative hospital stay were suitable indicators of a learning curve, which comprised about 100 cases.     

Routine Drain Placement in Roux-en-Y Gastric Bypass: An Expanded Retrospective Comparative Study of 755 Patients and Review of the Literature

Routine drain use after laparoscopic Roux-en-y gastric bypass (LRYGB) is still practiced by many bariatric surgeons. After a patient in our program experienced intestinal obstruction secondary to a drain, we reevaluated our practice and hypothesized drains would be of no benefit and potentially harmful after LRYGB. Retrospective record review of all patients undergoing LRYGB from August 2005 to August 2009 was performed. As we changed our practice in December 2006, we have two comparable groups: one with a drain placed at surgery and one without. All operations were otherwise performed in an identical fashion by three fellowship-trained university surgeons. We compared outcomes between the two groups, particularly regarding gastrojejunal (GJ) leaks. Jejunojejunal (JJ) leaks, unlikely to be captured by these drains, were not studied. A total of 755 LRYGBs were performed during the study period, the first 272 patients with routine drains and the subsequent 483 without. Demographics were statistically similar between the two groups. There were four GJ leaks in the drain group (1.47%) and three in the nondrain group (0.62%). Among the drain patients, two required operation and two were treated nonoperatively. Among the nondrain patients, two required operation and one was treated nonoperatively. The leak and reoperation rates between the groups were not statistically different (p = 0.154 and p = 0.514). Routine drains likely have no benefit after LRYGB. Clinical parameters such as tachycardia, fever, oliguria, and increasing abdominal pain should guide further investigation for and treatment of a leak.     

Intraoperative endoscopic pneumatic testing for gastrojejunal anastomotic integrity during laparoscopic Roux-en-Y gastric bypass

Background Gastrojejunal anastomotic leaks remain a major source of morbidity following laparoscopic gastric bypass. Intraoperative pneumatic testing has been offered as a method to reduce the incidence of this complication. This study's purpose was to assess the efficacy of intraoperative pneumatic testing during laparoscopic gastric bypass, to evaluate the types of air leaks detected, and to develop an algorithm for management that takes into account air leak categorization and drainage. Methods A retrospective analysis was performed on the initial 257 consecutive patients undergoing laparoscopic gastric bypass by a single surgeon over a 36-month period. The gastrojejunostomy was constructed using a linear stapler technique. All patients underwent intraoperative endoscopic pneumatic testing with a clamp applied to the Roux limb. All patients underwent water-soluble upper gastrointestinal radiography on the first postoperative day. Results Patients were divided based on the pneumatic testing results into groups for data analysis: persistent air leak (group 1), non-reproducible air leak (group 2), and no air leak (group 3). The overall age (41.7±9.3 years), body mass index (BMI) (47.3±6.4 kg/m²), conversion rate (2%), and length of stay (1.9±2.0 days) were not statistically different among groups (p>0.05). In group 1, the air leak site was repaired, and 11 (92%) were drained. In group 2, the air leak site could not be identified, and all 12 (4.7%) were treated by drainage alone. In group 3, drains were placed in 12 (5.2%) due to difficult construction of the gastrojejunostomy. Overall postoperative gastrointestinal leak rate was 0.78%. No postoperative clinical or radiological gastrointestinal leaks occurred within the region tested pneumatically. Intraoperative complications related to pneumatic testing occurred in 1 (0.39%) patient. Conclusions Intraoperative pneumatic testing of the gastrojejunal anastomosis is a safe and rapid means of evaluating anastomotic integrity. Application of this technique permitted timely repair of flawed anastomoses, thereby averting potential postoperative leaks.