Patients’ Experience of Surplus Skin After Laparoscopic Gastric Bypass

Background  

Previous studies have described that many obese patients who undergo bariatric surgery develop surplus skin. However, there is a lack of knowledge about where on the body the problems are located and to what extent surplus skin affects the person. The aim of this study was to examine whether and where patients develop surplus skin after laparoscopic gastric bypass and if there is any relation between surplus skin and the patient’s sex, age, weight loss, or activity level.     

Why Would Laparoscopic Gastric Bypass Patients Choose Open Instead?

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been demonstrated to be comparable to open Roux-en-Y gastric bypass (ORYGBP) surgery in randomized studies. Although a steep learning curve exists, laparoscopic bariatric surgery offers advantages if performed by an experienced bariatric surgeon. Despite these facts, some patients still choose to undergo ORYGBP. This investigation explored the reasons why patients who have had LRYGBP would decide to undergo the laparoscopic operation. Methods: A survey was given to patients who had undergone LRYGBP. The survey was designed to ascertain what factors would influence them to have LRYGBP versus ORYGBP. Incomplete responses were not included in the data analysis. Results: There were 41 patients who filled out the survey. Over 90% of the patients felt LRYGBP is better than open gastric bypass. There were 4 patients who had seen another surgeon who recommended ORYGBP. Approximately 61% (23/38) of the patients would have stayed with their surgeon even if their surgeon did not offer LRYGBP. In addition, 79% of patients (31/39) would have ORYGBP if their insurance did not cover LRYGBP. Most patients (67%) would have ORYGBP if their surgeon thought LRYGBP was experimental. If they were told that LRYGBP was too risky for them, 77% of patients (30/39) would have undergone ORYGBP. Only 15% of patients (6/40) would not have had surgery if LRYGBP did not exist. Conclusions: Patients are willing to undergo ORYGBP even if they believe that LRYGBP is better. Non-medical factors and/or surgeon recommendations instead of scientific data influence patient decision-making when choosing ORYGBP over LRYGBP.     

Results of Laparoscopic Gastric Bypass in Patients ≥55 Years Old

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a commonly performed surgical intervention for morbid obesity. Some authors considered age ≥55 years as a relative contraindication to bariatric surgery. We examined the operative outcomes, weight loss, hospital stay and resolution of co-morbidities in patients ≥55 years old compared with those <55 years old undergoing LRYGBP. Methods: From Jan 2000 to Feb 2005, 350 LRYGBPs were performed. 48 patients ≥55 years old (13.7%) were compared to the remaining patients. Results: Analysis of the 48 patients ≥55 years old compared with 302 patients <55 revealed no difference in complication rate, although the older patients had a significantly greater percentage of serious complications. Younger patients lost more weight than older patients. Both groups demonstrated resolution of comorbidities, although the difference was not significant. Conclusions: LRYGBP is safe and well tolerated in morbidly obese patients ≥55 years. The older patients had more serious complications and lost less weight; however, their weight loss and resolution of co-morbidities improved their quality of life. Age should not be a contraindication to bariatric surgery.     

Laparoscopic Roux-en-Y Gastric Bypass is Safe and Effective in Patients with a BMI ≥60

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been shown to be safe and effective. There is little data on the outcomes in massively super-obese patients, with a body mass index (BMI) &ge60 kg/m²(super-super-obese). The goal of this study was to determine the safety and effectiveness of LRYGBP in these patients, and compare these results to patients with a BMI <60. Methods: 213 consecutive patients undergoing LRYGBP by a single surgeon at a university hospital were included in the study. The patients were divided into 2 groups: BMI <60 kg/m²(n=167) and BMI ≥60 kg/m² (n=46). The 2 groups were compared with regard to perioperative complications, and postoperative weight loss. Results: Both groups had statistically similar complication rates. There were major complications in 8 patients (5%) in the lower BMI group and in 3 patients (7%) in the higher BMI group. There were minor complications in 9 patients (5%) in the lower BMI group and in 4 patients (9%) in the higher BMI group. Mean percent excess weight loss (%EWL) was 64% at 1 year in the BMI <60 group and 53% in the BMI ≥60 group. Conclusion: LRYGBP can be performed safely and effectively in super-super-obese patients (BMI ≥60). Although these patients have less %EWL than lighter patients, they still end up with a good result. Therefore, LRYGBP should be considered a good surgical option even for patients with a BMI ≥60.     

Defining Quality for Distal Pancreatectomy: Does the Laparoscopic Approach Protect Patients from Poor Quality Outcomes?

Introduction

Established systems for grading postoperative complications do not change the assigned grade when multiple interventions or readmissions are required to manage a complication. Studies using these systems may misrepresent outcomes for the surgical procedures being evaluated. We define a quality outcome for distal pancreatectomy (DP) and use this metric to compare laparoscopic distal pancreatectomy (LDP) to open distal pancreatectomy (ODP).

Methods

Records for patients undergoing DP between January 2006 and December 2009 were reviewed. Clavien–Dindo grade IIIb, IV, and V complications were classified as severe adverse—poor quality—postoperative outcomes (SAPOs). II and IIIa complications requiring either significantly prolonged overall lengths of stay including readmissions within 90 days or more than one invasive intervention were also classified as SAPOs.

Results

By Clavien–Dindo system alone, 91 % of DP patients had either no complication or a low/moderate grade (I, II, IIIa) complication. Using our reclassification, however, 25 % had a SAPO. Patients undergoing LDP demonstrated a Clavien–Dindo complication profile identical to that for SDP but demonstrated significantly shorter overall lengths of stay, were less likely to require perioperative transfusion, and less likely to have a SAPO.

Conclusions

Established systems undergrade the severity of some complications following DP. Using a procedure-specific metric for quality, we demonstrate that LDP affords a higher quality postoperative outcome than ODP.     

Prophylactic Cholecystectomy,a Mandatory Step in Morbidly Obese Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass?

Background  

The aim of this study was to determine the incidence of symptomatic gallstone disease requiring cholecystectomy (CCE) after laparoscopic Roux-en-Y gastric bypass (LRYGBP) and to identify the peri-operative risk factors associated with postoperative symptomatic gallstone disease.     

Redo Laparoscopic Gastric Bypass: One-Step or Two-Step Procedure?

Background

The adjustable gastric band (AGB) is a bariatric procedure that used to be widely performed. However, AGB failure—signifying band-related complications or unsatisfactory weight loss, resulting in revision surgery (redo operations)—frequently occurs. Often this entails a conversion to a laparoscopic Roux-en-Y gastric bypass (LRYGB). This can be performed as a one-step or two-step (separate band removal) procedure.

Methods

Data were collected from patients operated from 2012 to 2014 in a single bariatric centre. We compared 107 redo LRYGB after AGB failure with 1020 primary LRYGB. An analysis was performed of the one-step vs. two-step redo procedures. All redo procedures were performed by experienced bariatric surgeons.

Results

No difference in major complication rate was seen (2.8 vs. 2.3 %, p?=?0.73) between redo and primary LRYGB, and overall complication severity for redos was low (mainly Clavien–Dindo 1 or 2). Weight loss results were comparable for primary and redo procedures. The one-step and two-step redos were comparable regarding complication rates and readmissions. The operating time for the one-step redo LRYGB was 136 vs. 107.5 min for the two-step (median, p?<?0.001), excluding the operating time of separate AGB removal (mean 61 min, range 36–110).

Conclusions

Removal of a failed AGB and LRYGB in a one-step procedure is safe when performed by experienced bariatric surgeons. However, when erosion or perforation of the AGB occurs, we advise caution and would perform the redo LRYGB as a two-step procedure. Equal weights can be achieved at 1 year post redo LRYGB as after primary LRYGB procedures.

     

Laparoscopic Roux-en-Y Gastric Bypass in Morbidly Obese Patients ≥55 Years Old

Background Advanced age is considered a relative contraindication to bariatric surgery at some institutions because of concerns about higher morbidity and less than optimal weight loss. The aim of our study was to evaluate the operative outcomes, length of stay, weight loss, and improvement of comorbidities in patients ≥55 years old who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery in our institution. Methods Retrospective data on 33 patients (26 women and 7 men) ≥55 years of age who underwent LRYGB from January 2003 to December 2006 were reviewed. Results Average patient age was 59 years (range 55–68 years), and the mean preoperative body mass index was 47 kg/m² (range 41.1–55.8 kg/m²). The median length of hospital stay was 3 days. There were no intraoperative or postoperative deaths. Early complications were one anastomotic leak, two upper gastrointestinal bleedings, and two readmissions for intractable vomiting. Late complications included four anastomotic strictures and one small bowel obstruction. Patients were followed for a mean 13 months (range 3–24 months). The mean excess body weight (EBW) loss was 13.5 kg (23%), 23.3 kg (39.8%), 33.3 kg (58.1%), 39.8 kg (66.8%), 40.1 kg (69.5%), and 40.8 kg (75.3%) at 1, 3, 6, 9, 12 and 24 months, respectively. Diabetes mellitus improved in 19 (100%) patients and completely resolved in 10 (53%). Hypertension improved in 18 (64%) patients, completely resolved in 9 (32%) and was unchanged in 10 (36%). Conclusions LRYGB is safe and effective in morbidly obese patients ≥55 years of age.     

Complications of the Laparoscopic Roux-en-Y Gastric Bypass: 1,040 Patients - What Have We Learned?

Background:The Roux-en-Y gastric bypass (RYGBP) is one of the most common operations for morbid obesity. Laparoscopic techniques have been reported, but suffer from small numbers of patients, longer operative times and seemingly higher initial complication rates as compared to the traditional "open" procedure. The minimally invasive approach continues to be a challenge even to the most experienced laparoscopic surgeons.The purpose of this study is to describe our experience and complications of the laparoscopic Roux-en-Y gastric bypass with a totally hand-sewn gastrojejunostomy. Methods: 1,040 consecutive laparoscopic procedures were evaluated prospectively. Only patients who had a previous open gastric procedure were excluded initially. Eventually, even patients with failed "open" bariatric procedures and other gastric procedures were revised laparoscopically to the RYGBP. All patients met NIH criteria for consideration for weight reductive surgery. Results:There were no anastomotic leaks from the hand-sewn gastrojejunostomy. Early complications and open conversions were related to sub-optimal exposure and bowel fixation techniques. Several staple failures were attributed to a manufacturer redesign of an instrument. Average hospital stay was 1.9 days for all patients and 1.5 days for patients without complications. Operative times consistently approach 60 minutes. Average excess weight loss was 70% at 12 months.There were 5 deaths: perioperative pulmonary embolism (1), late pulmonary embolism (2), asthma (1), and suicide (1). Conclusions: The laparoscopic Roux-en-Y gastric bypass for morbid obesity with a totally hand-sewn gastrojejunostomy can be safely performed by the bariatric surgeon with advanced laparoscopic skills in the community setting. Fixation and closure of all potential hernia sites with non-absorbable sutures is essential. Stenosis of the hand-sewn gastrojejunal anastomosis is amenable to endoscopic balloon dilation. Meticulous attention must be paid to the operative and perioperative care of the patient.     

Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy as Revisional Procedure after Adjustable Gastric Band—a Systematic Review

The adjustable gastric band (L)AGB gained popularity as a weight loss procedure. However, long-term results are disappointing; many patients need revision to laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG). The purpose of this study was to assess morbidity, mortality, and results of these two revisional procedures. Fifteen LRYGB studies with a total of 588 patients and eight LSG studies with 286 patients were included. The reason for revision was insufficient weight loss or weight regain in 62.2 and 63.9 % in LRYGB and LSG patients. Short-term complications occurred in 8.5 and 15.7 % and long-term complications in 8.9 and 2.5 %. Reoperation was performed in 6.5 and 3.5 %. Revision to LRYGB or LSG after (L)AGB is feasible and relatively safe. Complication rate is higher than in primary procedures.     

Laparoscopic Roux-en-Y Gastric Bypass:Transoral Or Transgastric Anvil Placement?

Background: Laparoscopic techniques have been used to perform the Roux-en-Y gastric bypass (RYGBP). The gastrojejunostomy may be constructed using an end-to-end anastomosis (EEA) stapler. Most reports describe passing the EEA anvil transorally using an esophagogastroscope and a pullwire technique. Method: We describe problems experienced using this technique and present an alternative method. Results: Esophageal injury may occur during laparoscopic RYGBP (LRYGBP) using the transoral anvil placement technique. When the anvil is retrieved into the gastric pouch, the anvil may become lodged at the cricopharngeus muscle. Dislodgment can be problematic and time-consuming. We present a case of mild esophageal injury which occurred during transoral anvil placement. The patient had transient postoperative dysphagia and recovered without sequelae. We present an alternative method in which the anvil is passed through a gastrotomy. Conclusion: Transgastric anvil placement alleviates the need for endoscopy, thereby saving time and resources.This technique eliminates the potential for esophageal injury. The transgastric anvil placement technique has proven reliable. The transgastric method may make the LRYGBP operation safer and easier to perform.     

Trocar Injuries in 17,446 Laparoscopic Gastric Bypass—a Nationwide Survey from the Scandinavian Obesity Surgery Registry

Background

Although, the vast majority of bariatric procedures worldwide are performed laparoscopically, there is no consensus on the best technique to enter the first trocar, a potentially dangerous maneuver. Three principally different techniques exist: initial pneumoperitoneum by Verres needle, open Hasson technique, and direct placement of an optical trocar. In this nationwide survey, we have studied the presently used technique to place the first trocar and identified any intraabdominal injuries in 2012–2014.

Methods

A questionnaire concerning techniques for placing the first trocar and identified intraabdominal injuries was sent to all 41 centers performing laparoscopic Roux en-Y gastric bypass (LRYGB) in Sweden. Total number of procedures were collected from the national quality registry, Scandinavian Obesity Surgery Registry (SOReg), also searched for reports on intraabdominal injuries.

Results

During the present study period, 17,446 LRYGBs were performed. Twelve intraabdominal injuries (0.07 %) were found: bleedings from the omentum, small bowel mesentery and liver (n?=?8), and gastric or small bowel perforation (n?=?4). The injuries were evenly distributed between the Veress technique and direct placement of an optical trocar, while no injuries occurred with the Hasson technique. Concerning placement of the first trocar, initial pneumoperitoneum with Veress needle was most common (59 %), followed by direct placement of an optical trocar (30 %). This indicates a switch from 2009–2010 (Veress 45 % and optical trocar 45 %, p?<?0.001).

Conclusions

Twelve intraabdominal injuries (0.07 %) were found in this nationwide survey. The most common technique for placing the first trocar had switched from directly placing an optical trocar to prior establishment of pneumoperitoneum.

     

Are African–Americans as Successful as Caucasians after Laparoscopic Gastric Bypass?

Background Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been demonstrated to provide weight loss comparable to open gastric bypass. It has been suggested that African–Americans (AA) are not as successful as Caucasians (CA) after bariatric surgery. Our hypothesis was that AAs are just as successful as CA after LRYGBP in terms of weight loss and comorbidity improvement. Methods A retrospective chart review was performed on all AA and CA patients who underwent LRYGBP for a 6-month period. Success after LRYGBP [defined as (1) 25% loss of preoperative weight, (2) 50% excess weight loss (EWL), or (3) weight loss to within 50% ideal weight] was compared by ethnicity. Results 102 patients were included in this study. 97 patients (30 AA patients and 67 CA patients) had at least 1-year follow-up data available. Preoperative data did not differ between both groups. There was a statistically significant difference in %EWL between AA and CA (66% vs 74%; P < 0.05). However, there was no ethnic difference in the percentage of patients with successful weight loss (as defined by any of the above 3 criteria). Furthermore, there was no statistical difference between the percentages of AA and CA patients who had improved or resolved diabetes and hypertension. Conclusions LRYGBP offers good weight loss in all patients. While there may be greater %EWL in CA patients, no ethnic difference in successful weight loss exists. More importantly, co-morbidities improve or resolve equally between AA and CA patients. LRYGBP should be considered successful in AA patients. Presented at the Annual Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, Dallas, TX, USA, April 28, 2006.     

Laparoscopic Single-Anastomosis Duodenal–Jejunal Bypass with Sleeve Gastrectomy (SADJB-SG): Short-term Result and Comparison with Gastric Bypass

Laparoscopic duodeno–jejunal bypass with sleeve gastrectomy (DJB-SG) has been introduced as a novel metabolic surgery from Asia recently. It provides benefits of avoiding the risk of remnant gastric cancer, minimization of malnutrition from duodenal switch. Here, we introduce the technique of single-loop anastomosis duodeno–jejunal bypass with sleeve gastrectomy (SADJB-SG) and compare with other gastric bypass surgeries. Fifty morbid obese patients underwent our novel procedure, laparoscopic SADJB-S from 2011 to 2013. Operative complication, weight loss, and diabetes remission were followed. All procedures were completed laparoscopically. The mean operative time was 181.7?±?38.4 min, and the mean hospital stay was 3.8 days. Three minor early complications (6 %) were encountered but no major complication was noted. There was no significant difference in perioperative parameters between the SADJB-SG and gastric bypass except a longer operation time. The mean BMI decreased from 38.4 to 25.4 at 1 year after surgery with a mean weight loss of 32.7 % which is higher than gastric bypass. Laparoscopic SADJB-SG appears to be an ideal metabolic/bariatric surgery, whereas the efficacy is non-inferior to gastric bypass.     

A Comparative Study of Three-Year Weight Loss and Outcomes After Laparoscopic Gastric Bypass in Patients with “Yellow Light” Psychological Clearance

The relationship between psychological factors and bariatric surgical outcomes is unclear. While some psychological contraindications to bariatric surgery are described, there is no consensus on preoperative psychological evaluation or on factors that can predict bariatric outcomes. Our aim was to determine whether full or reserved psychological clearance predicts early weight loss or compliance with follow-up. We found no clinically significant differences in short-term weight loss outcomes or in attendance at scheduled follow-up visits between patients receiving full or “green light” clearance versus “yellow light” clearance, meaning clearance with recommendations for ongoing therapy. Further research may identify psychological predictors of success following bariatric surgery and help optimize preoperative evaluation practices.     

Do Patients Seeking Laparoscopic Adjustable Gastric Banding Surgery Differ from Those Seeking Gastric Bypass Surgery? A Comparison of Psychological Profiles Across Ethnic Groups

Background  

Understanding presurgical psychological functioning is important in determining whether patients may benefit from psychological support before or after undergoing bariatric surgery. However, few studies have directly explored whether presurgical psychosocial profiles differ for patients presenting for different bariatric surgeries and what, if any, impact ethnic background might have. The present study compared presurgical depressive symptomatology, binge eating symptoms, and psychopathology in Caucasian and African American laparoscopic adjustable gastric banding (LAGB) and gastric bypass (RYGB) patients.     

Is Routine Cholecystectomy Justified in Severely Obese Patients Undergoing a Laparoscopic Roux-en-Y Gastric Bypass Procedure? A Comparative Cohort Study

Background  

The aim of the present study was to evaluate the risks and benefits of concurrent prophylactic cholecystectomy (CPC) during laparoscopic Roux-en-Y gastric bypass (LRYGB).