Effects of pneumoperitoneum on intraoperative pulmonary mechanics and gas exchange during laparoscopic gastric bypass

Background: Hypercarbia and elevated intraabdominal pressure resulting from carbon dioxide (CO₂) pneumoperitoneum can adversely affect respiratory mechanics. This study examined the changes in mechanical ventilation, CO₂ homeostasis, and pulmonary gas exchange in morbidly obese patients undergoing a laparoscopic or open gastric bypass (GBP) procedure. Methods: In this study, 58 patients with a body mass index (BMI) of 40 to 60 kg/m² were randomly allocated to laparoscopic (n = 31) or open (n = 27) GBP. Minute ventilation was adjusted to maintain a low normal arterial partial pressure of CO₂ (PaCO₂), low normal end-tidal partial pressure of CO₂ (ETCO₂), and low airway pressure. Respiratory compliance, ETCO₂, peak inspiratory pressure (PIP), total exhaled CO₂ per minute (VCO₂), and pulse oximetry (SO₂) were measured at 30-min intervals. The acid–base balance was determined by arterial blood gas analysis at 1-h intervals. The pulmonary gas exchange was evaluated by calculation of the alveolar dead space–to–tidal volume ratio (V_Dalv/V_T) and alveolar–arterial oxygen gradient (PAO₂–PaO₂). Results: The two groups were similar in age, gender, and BMI. As compared with open GBP, laparoscopic GBP resulted in higher ETCO₂, PIP, and VCO₂, and a lower respiratory compliance. Arterial blood gas analysis demonstrated higher PaCO₂ and lower pH during laparoscopic GBP than during open GBP (p < 0.05). The V_Dalv/V_T ratio and PAO₂–PaO₂ gradient did not change significantly during laparoscopic GBP. Intraoperative oxygen desaturation (SO₂ < 90%) did not develop in any of the patients in either group. Conclusions: Laparoscopic GBP alters intraoperative pulmonary mechanics and acid–base balance but does not significantly affect pulmonary oxygen exchange. Changes in pulmonary mechanics are well tolerated in morbidly obese patients when proper ventilator adjustments are maintained.     

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.     

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.     

Laparoscopic gastric bypass

Background: The present report describes the technical details of laparoscopic bypass for morbid obesity. Methods: The laparoscopic approach was attempted in eight patients and completed in six. In these latter patients the stomach was divided with an endoscopic linear cutter (ETC 60 Ethicon), and a antecolic jejunal loop was brought to the proximal pouch and anastomosed by use of manual suture technique supported with locking clips for knotting substitutes [Lapra-Ty (Ethicon)]. Distal to the gastrojejunostomy a side-to-side enteroanastomosis was also performed. Results: Five patients in whom the laparoscopic procedure was completed had an unevenful postoperative period and a rapid recovery. However, one patient had a postoperative left-sided pleuropneumonia that required prolonged hospital stay. Of those who were converted, one was because of a large steatotic left liver lobe and another was due to a perforation of the small intestine. Conclusions: These early results indicate that gastric bypass for the treatment of morbid obesity can be safely performed with laparoscopic techniques. Further development in this field should be encouraged.     

Laparoscopic antecolic Roux-En-Y gastric bypass with closure of internal defects leads to fewer internal hernias than the retrocolic approach

Background  Laparoscopic Roux-en-Y gastric bypass surgery reportedly has a higher rate of postoperative internal hernias than open bypass surgery. Even with closure of mesenteric defects, hernias occur in up to 9% of cases. To minimize this complication, an antecolic antegastric approach to anastomosis of the Roux limb and gastric pouch has been used. Whereas the retrocolic retrogastric technique creates three mesenteric defects, the antecolic approach produces only two: Petersen’s defect and the jejunojejunostomy. The rate of internal hernias was compared among patients undergoing laparoscopic Roux-en-Y gastric bypass surgery using the retrocolic and antecolic approaches. Methods  The experience of a single surgeon from August 2001 to September 2005 was reviewed. Only Roux-en-Y gastric bypass procedures were included. Patients were followed for a minimum of 18 months postoperatively. The retrocolic approach was used for 274 patients and the antecolic approach for 205 patients. All defects were closed at the time of surgery. With the antecolic approach, Petersen’s defect was closed from the root of the mesentery of the Roux limb and the transverse colon mesentery up to the transverse colon. Results  Of the 274 patients, 7 (2.6%) experienced a symptomatic internal hernia with the retrocolic retrogastric technique. No internal hernias were reported among the 205 patients treated with the antecolic antegastric method. Chi-square analysis showed that an antecolic approach was associated with a decreased rate of internal hernias (p < 0.025). Of 479 patients, 35 (7%) underwent diagnostic laparoscopy without any internal hernia found. Of these patients, 15 were found to have cholelithiasis and subjected to laparoscopic cholecystectomy. Conclusions  The antecolic antegastric approach to laparoscopic Roux-en-Y gastric bypass is associated with fewer postoperative hernias than the retrocolic retrogastric approach. The frequency of hernias using either technique is low if meticulous attention is paid to closure of all mesenteric defects. Presented at the 2007 Society of American Endoscopic Surgeons (SAGES) meeting in Las Vegas, SS16: Outcomes, Presentation: S097, Sunday 22 April 2007     

Maximal weight loss after banded and unbanded laparoscopic Roux-en-Y gastric bypass: a randomized controlled trial

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) leads to significant weight loss and correction of co-morbidities in most patients. Banded LRYGB was designed to enhance weight loss and avoid weight regain. METHODS: A randomized controlled pilot trial was designed to comparatively analyze the results and complications of banded (6.5 cm) and unbanded LRYGB. The present study was an interim analysis focused on morbidity, mortality, and maximal weight loss. RESULTS: The 60 patients were divided into 2 groups. Group 1 underwent unbanded LRYGB (n = 30) and group 2 underwent banded LRYGB (n = 30). No differences were found between the 2 groups in terms of age, gender, body mass index, or operative time. No significant differences were found in the percentage of excess weight loss and body mass index at 6, 12, and 24 months between the 2 groups. The frequency of complications was similar in both groups; 1 patient required band removal because of stenosis at the level of the mesh. CONCLUSION: The weight loss pattern in both groups was similar at 1 and 2 years postoperatively. Proper assessment of weight maintenance and late weight regain will require longer follow-up.     

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     

Robotic platform for gastric bypass is associated with more resource utilization: an analysis of MBSAQIP dataset

Background

The current literature comparing robot-assisted Roux-en-Y gastric bypass (RA-RYGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) is limited to single center retrospective series.

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.     

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.     

Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases

BACKGROUND: It is common practice to close mesenteric defects in abdominal surgery to prevent postoperative herniation and subsequent closed-loop obstruction. The aim of this study was to review our experience with antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGBP) without division of the small bowel mesentery or closure of potential mesenteric defects. METHODS: Data for 1400 patients who underwent AA-LRYGBP between January 2001 and December 2004 was prospectively collected and retrospectively analyzed for the incidence of internal hernias. In all cases, an antecolic antegastric approach was performed without division of the small bowel mesentery or closure of potential hernia defects. RESULTS: Three patients (0.2%) developed a symptomatic internal hernia. Two of these patients had a 200-cm-long Roux limb, and the other had a 100-cm-long Roux limb. All three patients exhibited mild symptoms of partial small bowel obstruction. In all three cases the internal hernia was clinically manifested more than 10 months after the original AA- LRYGBP. Exploration revealed that the hernia site was between the transverse colon and the mesentery of the alimentary limb at the level of the jejunojejunostomy (Petersen's defect) in all three cases. All three patients underwent successful laparoscopic revision, hernia reduction, and mesenteric defect closure. CONCLUSIONS: AA-LRYGBP without division of the small bowel mesentery or closure of mesenteric defects does not result in an increased incidence of internal hernias. The laparoscopic approach for reexploration appears to be an effective and safe option.     

Impact of major co-morbidities on mortality and complications after gastric bypass

BACKGROUND: We hypothesized that major co-morbidities affect survival and complications after gastric bypass. METHODS: A total of 1465 patients undergoing laparoscopic and open gastric bypass between 1995 and 2002 were studied. Patients with a body mass index >or= 35 kg/m(2) and major co-morbidities (group 1, n = 1045) were compared with patients with a body mass index >or= 40 kg/m(2) with minor/no co-morbidities (group 2, n = 420). RESULTS: Group 1 patients were older (43 versus 36 years, P < 0.001) and had a greater BMI (53 versus 50 kg/m(2), P < 0.001). Early postoperative complications were greater in group 1 than in group 2 and included leaks (4.1% versus 1.2%, P < 0.0032) and wound infections (3.9% versus 1.4%, P < 0.0133). Procedure-related mortality in the series was 1.7%. Mortality was 10-fold greater in group 1 (2.3% versus 0.2%, P < 0.0032). The incidence of small bowel obstruction, incisional hernia, and pulmonary embolism was similar in the two groups. Excess weight loss was significantly greater in group 2 (68% versus 62%, P < 0.001) at 1 year. Resolution of group 1 co-morbidities was great, including hypertension in 62%, diabetes in 75%, venous stasis disease in 96%, and pseudotumor cerebri in 98%. CONCLUSION: Outcomes analysis of obesity surgery requires risk stratification. The very low mortality rates in published studies are likely explained by surgical treatment of low-risk patients with minor co-morbidities, such as those seen in group 2. However, despite the increased perioperative risk, the group 1 patients (with major co-morbidities) demonstrated dramatic resolution of their co-morbid conditions, justifying the decision to go forward with surgery. The data support a radical change in treatment philosophy in which morbidly obese individuals should be offered bariatric surgery before major co-morbid conditions develop as a strategy to decrease the operative risk.     

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.     

腹腔镜胃旁路术的并发症及其防治

腹腔镜Roux-en-Y胃旁路手术（LRYGB）治疗病态肥胖,因其疗效快捷、持久而成为减重外科的“金标准”术式。然而,由于其手术操作复杂和学习曲线较长,故具有潜在风险。LRYGB术后并发症分为早期和晚期两类,并发症如果发现不及时或处理不当,可导致严重的后果,甚至死亡。因此,预防和及早诊断LRYGB术后出现的并发症,并及时有效地进行处理,对LRYGB的健康开展具有重要意义。     

Perforating marginal ulcers after laparoscopic gastric bypass

Background: Laparoscopic Roux-en-Y gastric bypass (LGB) can be performed with minimal morbidity and mortality. This article describes the first presentation of a known disease entity after LGB: perforating marginal ulcers of the jejunum immediately distal to the gastrojejunal anastomosis. Methods: A chart review of 902 LGB procedures performed by a single surgeon between April 2000 and September 2004 identified eight patients with perforating marginal ulcers. Results: The patients presented an average of 157 days (range, 53–374 days) after LGB. All the patients were treated using laparoscopic primary closure followed by medical therapy. Morbidity, in one patient only, consisted of two abdominal fluid collections requiring separate drainage procedures. There was no mortality. The average follow-up period was 13 months (range, 2–18 months). No patient experienced recurrent ulceration. Conclusions: Although the etiology is unclear, marginal ulcers, a known complication of gastrojejunostomy, may present as perforating ulcers after LGB in a characteristic fashion and can be managed laparoscopically.     

Initial outcomes of laparoscopic Roux-en-Y gastric bypass in morbidly obese adolescents

BACKGROUND: Adolescent obesity is an epidemic in the United States, leading to significant morbidity. Because the impact of laparoscopic bariatric surgery in this population is not as well delineated as in adults, we examined the short-term outcome of adolescents undergoing laparoscopic Roux-en-Y gastric bypass at our institution. METHODS: The medical records of patients < or =18 years of age who had undergone laparoscopic Roux-en-Y gastric bypass for morbid obesity from 1999 to June 2005 were reviewed. The outcome variables examined included preoperative body mass index, percent of excess weight lost for those with at least 3 months of follow-up, length of hospital stay, postoperative morbidity and mortality, changes in comorbid conditions, and effects of surgical weight loss on quality of life. Data are presented as the mean +/- standard error of the mean. RESULTS: Eleven patients (seven girls and four boys) had undergone laparoscopic Roux-en-Y gastric bypass. The mean follow-up was 11.5 +/- 2.8 months (range 3-32). The average patient age was 16.5 +/- 0.2 years, and the average body mass index was 50.5 +/- 2.0 kg/m(2). The average number of comorbidities was 5.3, 70% of which improved or resolved postoperatively. No mortalities resulted. Of the 11 patients, 1 had early postoperative bleeding and 2 developed a marginal ulcer. The quality-of-life surveys obtained from 9 patients reflected an overall improvement in self-esteem, social functioning, and productivity in school or the workplace. CONCLUSIONS: The initial data suggest that laparoscopic gastric bypass is an effective weight loss treatment for morbidly obese adolescents.     

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.     

Introducing laparoscopic Roux-en-Y gastric bypass at a Veterans Affairs medical facility

BACKGROUND: Previous studies have shown that advanced age, diabetes, and male gender are associated with higher morbidity and mortality after bariatric surgery. Those risk factors are characteristic of patients in the Veterans Affairs (VA) health care system. Laparoscopic Roux-en-Y gastric bypass (RYGB) has become an established treatment modality for morbid obesity. Our objective was to review the initial experience with laparoscopic (RYGB) for morbid obesity at our VA facility. METHODS: A retrospective review was used. RESULTS: Between May of 2002 and April of 2004, 40 patients underwent laparoscopic RYGB. All patients met National Institutes of Health consensus statement guidelines for bariatric surgery. There were 30 (75%) male and 10 (25%) female patients, with an average age of 49.9 +/- 8.7 years and an average body mass index (BMI) of 48.1 +/- 8.5 kg/m(2). Preoperative comorbidities included diabetes mellitus (DM) in 59%, hypertension in 79%, and obstructive sleep apnea in 74.4%. The procedure was converted to an open procedure in 3 patients (7.5%). There were no mortalities. Immediate (within 30 days) complications developed in 9 (22.5%) patients, necessitating abdominal re-operation in 3 patients (7.5%). The median length of hospital stay was 3 days. Late complications (>30 days) developed in 8 (20%) patients. Percent excess weight loss at 3, 6, and 12 months was 44% (n = 34), 59% (n = 29), and 70.0% (n = 22), respectively. In 23 patients who were followed-up for more than 3 months, DM resolved in 79% and improved in 21% at a mean follow-up evaluation of 13 months. CONCLUSIONS: Laparoscopic RYGB can be performed with acceptable morbidity and with good short-term results in a VA hospital setting. Morbid obesity is prevalent in the VA patient population and access to bariatric surgery should be an available alternative.     

Learning curve for laparoscopic Roux-en-Y gastric bypass with totally hand-sewn anastomosis

Background Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a challenging operation for the treatment of morbid obesity with well-demonstrated effectiveness in weight lost. There are several variations to the technique.Methods From September 2000 to July 2004, 600 consecutive patients underwent surgery for morbid obesity at our institution. The surgical technique employed was LRYGB with totally hand-sewn gastrojejunal anastomosis (GJA). All patients were considered candidates for laparoscopic approach regardless of age, gender, body mass index (BMI), or previous bariatric or digestive surgery.Results Mean BMI was 44.4 ± 7.6 kg/m². Thirty-two patients had undergone previous failed bariatric procedures. Conversion to an open procedure was necessary in three patients. Seventy-two patients (12%) developed early complications, including 23 (3.8%) leaks at the GJA (eight in the first 18 patients). Mortality rate was 1.1% (one death was related to GJA leakage). Early and late reoperation rates were 5.3 and 1.8%, respectively. Rate plateau of morbidity and mortality was reached after the first 18 patients when the surgical technique was fully standardized.Conclusions LRYGB is a technically demanding procedure for the surgical treatment of morbid obesity with significant morbidity during the learning curve. The learning curve can be soon overcome, reaching a rate plateau of complications after adequate training. Morbidly obese patients should be operated on in expert bariatric surgical laparoscopic units to obtain the best results.