Impact of Fellowship Training on the Learning Curve for Laparoscopic Gastric Bypass

Background: We have previously shown that the learning curve for laparoscopic Roux-en-Y gastric bypass (LRYGBP) is approximately 75 cases. Patients have worse outcomes during the learning curve. Our aim was to evaluate the impact of fellowship training on outcomes during a surgeon's early experience with LRYGBP. Methods: The study population consisted of the first 75 consecutive LRYGBP operations attempted by two laparoscopic surgeons, one with laparoscopic gastric bypass fellowship training (Group A) and one without laparoscopic bypass fellowship training (Group B). Outcome parameters included mortality, major perioperative complications, operative time, and conversion to an open operation. Results: Age, BMI, and gender distribution were similar in both groups. Operative time was significantly longer in Group B (189 min. vs 122 min., P <0.05). Conversion to an open procedure occurred uncommonly in both groups (3%). Major complications occurred more frequently in Group B (13% vs 8%, P =NS). In addition, the complications in Group B were more severe, resulting in 2 deaths. No deaths occurred in Group A. Conclusion: Laparoscopic gastric bypass fellowship training improves perioperative outcomes during a surgeon's early experience with LRYGBP.     

Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity: Results of our Learning Curve in 100 Consecutive Patients

Background: Morbid obesity requires life-long treatment, and bariatric surgery provides the best results. Among the bariatric procedures, laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been considered to be superior. However, it requires advanced laparoscopic skills and a learning curve. We analyzed our results in an initial series of 100 patients. Methods: Data of 100 consecutive patients who underwent LRYGBP for morbid obesity in a 2.5-year period were prospectively collected and analyzed with emphasis on results and complications. Results: Mean age was 31±5 years. There were 63 woman and 37 men. Preoperative BMI was 50±9 kg/m². 33 patients were considered super-obese (BMI>50). Mean operative time was 3.8 ± 0.7 hours. Two patients required conversion to open surgery. Mean hospital stay was 6 days. Complications occurred in 10 patients. Mortality rate was 2%. Excess body weight loss was as follows: 33 ± 8% at 3 months (n=92), 47 ± 2% at 6 months (n=82), 62 ± 4% at 1 year (n= 70), 66 ± 5% at 18 months (n= 63) and 67 ± 8% at 2 years (n= 35). There was significant improvement in several co-morbid conditions, such as diabetes and hypertension. Conclusion: LRYGBP is a reproducible technique. It requires the combination of bariatric and laparoscopic expertise.     

Open versus Laparoscopic Roux-en-Y Gastric Bypass: A Comparative Study of Over 25,000 Open Cases and the Major Laparoscopic Bariatric Reported Series

Background: Laparoscopic bariatric surgery has experienced a rapid expansion of interest over the past 5 years, with a 470% increase. This rapid expansion has markedly increased overall cost, reducing surgical access. Many surgeons believe that the traditional open approach is a cheaper, safer, equally effective alternative. Methods: 16 highly experienced "open" bariatric surgeons with a combined total of 25,759 cases representing >200 surgeon years of experience, pooled their open Roux-en-Y gastric bypass (ORYGBP) data, and compared their results to the leading laparoscopic (LRYGBP) papers in the literature. Results: In the overall series, the incisional hernia rate was 6.4% using the standard midline incision. Utilizing the left subcostal incision (LSI), it was only 0.3%. Return to surgery in <30 days was 0.7%, deaths 0.25%, and leaks 0.4%. Average length of stay was 3.4 days, and return to usual activity 21 days. Small bowel obstruction was significantly higher with the LRYGBP. Surgical equipment costs averaged ∼$3,000 less for "open" cases. LRYGBP had an added expense for longer operative time. This more than made up for the shorter length of stay with the laparoscopic approach. Conclusions: The higher cost, higher leak rate, higher rate of small bowel obstruction, and similar long-term weight loss results make the "open" RYGBP our preferred operation. If the incision is taken out of the equation (i.e. use of the LSI), the significant advantages of the open technique become even more obvious.     

Virtual Gastroduodenoscopy: A New Look at the Bypassed Stomach and Duodenum After Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Background: After open or laparoscopic Roux-en-Y gastric bypass (RYGBP) for morbid obesity, the bypassed stomach and duodenum are not readily available for radiological and endoscopic evaluation. Furthermore, little is known about the long-term physiologic and histologic changes that occur in the bypassed GI segments following these procedures. Many alternative radiological and endoscopic techniques have been described to access the distal gastric pouch and the duodenum after RYGBP. Apart from percutaneous gastrografin? studies, all these techniques require the insertion of a gastrostomy tube in the distal stomach. Methods: a new diagnostic method to access the bypassed segments by virtual CT gastroscopy (VG) was used in 5 morbidly obese patients who underwent laparoscopic RYGBP (LRYGBP). Results: All patients tolerated the procedure well, which appears safe and suitable for an outpatient setting.The virtual images offered an excellent intraluminal view of the stomach and duodenum. Conclusions: VG holds promise as the method of choice in the follow-up of LRYGB patients, having the potential to detect inflammatory changes and cancer in the excluded segments early.     

Preoperative Carbohydrate "Addiction" Does Not Predict Weight Loss after Laparoscopic Gastric Bypass

Background: Weight loss after laparoscopic Roux-en-Y gastric bypass (LRYGBP) varies. Dietary habits that exist preoperatively may continue after surgery and affect weight loss. This study investigated the hypothesis that preoperative carbohydrate addiction would predict weight loss after laparoscopic gastric bypass. Methods: 104 consecutive patients in our LRYGBP program were included in the study. A preoperative survey was used to determine level of carbohydrate craving. This survey was scored from 0 to 60. A higher score indicated a higher level of carbohydrate addiction. Percentage of excess weight loss (%EWL) was determined after at least 1 year postoperatively in all patients. Results: Data were available in 95 (91%) of the patients. There was no correlation seen between level of carbohydrate addiction and %EWL at 1 year (r=0.02; P=NS). In addition, we looked at patients with successful weight loss (>50% %EWL; n=83) versus those patients who were considered unsuccessful (<50% EWL; n=12). There was no statistical difference in the level of preoperative carbohydrate craving between these 2 groups (36±13 vs 33±15; P=NS). Conclusions: Consistently large carbohydrate intake preoperatively does not predict weight loss after LRYGBP. High level of carbohydrate addiction is not a contraindication to LRYGBP.     

Revision of Failed Laparoscopic Adjustable Gastric Banding to Roux-en-Y Gastric Bypass

Background: The most common bariatric surgical operation in Europe, laparoscopic adjustable gastric banding (LAGB), is reported to have a high incidence of long-term complications. Also, insufficient weight loss is reported. We investigated whether revision to Roux-en-Y gastric bypass (RYGBP) is a safe and effective therapy for failed LAGB and for further weight loss. Methods: From Jan 1999 to May 2004, 613 patients underwent LAGB. Of these, 47 underwent later revisional Roux-en-Y gastric bypass (RYGBP). Using a prospectively collected database, we analyzed these revisions. All procedures were done by two surgeons with extensive experience in bariatric surgery. Results: All patients were treated with laparoscopic (n=26) or open (n=21) RYGBP after failed LAGB. Total follow-up after LAGB was 5.5±2.0 years. For the RYGBP, mean operating time was 161±53 minutes, estimated blood loss was 219±329 ml, and hospital stay was 6.7±4.5 days. There has been no mortality. Early complications occurred in 17%. There was only one late complication (2%) – a ventral hernia. The mean BMI prior to any form of bariatric surgery was 49.2±9.3 kg/m², and decreased to 45.8±8.9 kg/m² after LAGB and was again reduced to 37.7±8.7 kg/m² after RYGBP within our follow-up period. Conclusion: Conversion of LAGB to RYGBP is effective to treat complications of LAGB and to further reduce the weight to healthier levels in morbidly obese patients.     

Rhabdomyolysis Following Laparoscopic Gastric Bypass

Rhabdomyolysis is a rare complication of serious surgical procedures, and constitutes a clinical and biochemical syndrome, caused by injury and destruction of skeletal muscles. It is accompanied by pain in the region of the referred muscle group, increase in creatine phosphokinase levels, myoglobinuria, often with severe renal failure, and finally multi-organ system failure and death, if not treated in time. The main risk factor in the development of postoperative rhabdomyolysis is prolonged intraoperative immobilization of the patient. Morbidly obese patients who undergo laparoscopic bariatric operations should be considered high-risk for rhabdomyolysis, from extended immobilization and pressure phenomena in the lumbar region and gluteal muscles. We report a 20-year-old woman with BMI 51, who underwent a prolonged laparoscopic Roux-en-Y gastric bypass. Postoperatively, she presented severe myalgia in the gluteal muscles and lumbar region, oliguria and creatine phosphokinase levels that reached 38,700 U/L. She was treated with intensive hydration and analgesics, and did not develop acute renal failure because diagnosis and treatment were attained immediately.     

Early Gastrointestinal Hemorrhage after Laparoscopic Gastric Bypass

Background: Early gastrointestinal (GI) hemorrhage after open gastric bypass has been infrequently reported. The aim of this study was to examine the incidence of early GI hemorrhage after laparoscopic Roux-en-Y gastric bypass (LRYGBP), its presentation, and possible treatment options. Methods: A retrospective review of 5 patients who developed early postoperative GI hemorrhage after LRYGBP was performed.The charts were reviewed for demographics, clinical presentation, diagnostic evaluation, and treatment. All patients underwent a transected LRYGBP with creation of the gastrojejunostomy anastomosis with a circular stapler and the jejunojejunostomy anastomosis with a linear stapler. Results: Of the 155 patients in our database who underwent LRYGBP, 5 (3.2%) developed early clinical GI hemorrhage. There were 2 males with an average age of 40 years. Clinical presentations of GI hemorrhage were hematemesis (2 patients), bright red blood per rectum (1 patient), melena (1 patient), and hypotension (1 patient). A diagnostic study (nuclear scintigraphy) was performed in only 1 of 5 patients. 3 of 5 patients were managed nonoperatively; 2 patients required fluid and blood resuscitation, and the other patient was managed without blood transfusion. The onset of hemorrhage in these 3 patients occurred 24 hours postoperatively or later. 2 of 5 patients required operative intervention for control of hemorrhage. The onset of hemorrhage or hypotension in these 2 patients occurred within 12 hours after surgery. The sites of hemorrhage were at the gastric remnant staple-lines in 1 patient and at the gastrojejunostomy and gastric remnant staple-lines in the other patient. Conclusion: Early GI hemorrhage is a potential complication after transected LRYGBP. Early reoperative intervention should be performed for patients with hemodynamic instability and patients with early onset of hemorrhage after surgery.     

The Effects of Roux-en-Y Gastric Bypass Surgery on Body Image

Background: Numerous studies examine the physical effects of Roux-en-Y gastric bypass (RYGBP) surgery on morbid obesity. However, the effects of this surgery on psychosocial issues such as body image have not been extensively studied. Methods: This pilot study used a cross-sectional design to examine the effects of RYGBP surgery on patients' perceived body image. Four groups (n=20) were assessed for perceived change in body image at 4 time intervals.These included pre-surgery,1 to 3 weeks post-surgery, 6-months post-surgery, and 1- year post-surgery,with two measures of body image. One-way ANOVA was applied, with body image measures as the dependent variables, and time since surgery (group) as the independent variable. Planned post-hoc t-tests were applied to assess the differences between specific groups (pre vs. 1 week, pre vs. 6 months post, 6 months post vs. 1 year post). Results: Results of the one-way ANOVAs revealed significant improvement on perceptions of body image over time following surgery. Follow-up t-tests revealed that the most significant improvement occurred between pre-surgery and 6 months postsurgery. Although smaller, the change between 6 months post-surgery and 1 year post-surgery was also significant. Conclusion: While RYGBP results in numerous medical and physical benefits, this study reveals that there are also dramatic improvements in perceived body image, demonstrating the impact of this surgery on a patient's psychosocial health.     

Predictors of Prolonged Hospital Stay following Open and Laparoscopic Gastric Bypass for Morbid Obesity: Body Mass Index,Length of Surgery,Sleep Apnea,Asthma and the Metabolic Syndrome

Background: The number of weight reduction operations performed for type II and type III obesity is rapidly escalating. Risk of surgery has been infrequently stratified for patient subgroups. The purpose of this study was to identify patient characteristics that increased the odds of a prolonged hospital length of stay (LOS) following open or laparoscopic Roux-en-Y gastric bypass (RYGBP). Methods: The hospital records of 311 patients who underwent RYGBP in a 6-month period were retrospectively reviewed. Patient characteristics including the presence of significant obesity-related medical conditions were recorded. Analysis was based on intent to treat. Univariate and step-wise logistic regression analysis was used to identify the odds ratio (OR) and adjusted odds ratio (AOR) for predictors of an increased hospital LOS. Results: Datasets for 311 patients were complete. 159 patients underwent open vertical banded gastroplasty-Roux-en-Y gastric bypass (VBG-RYGBP) and 152 laparoscopic RYGBP (LRYGBP). 78% of patients were female. Median age was 40 years (range 18-68). Median BMI was 49 kg/m² (range 35-82). 17% of patients had sleep apnea, 18% asthma, 19% type 2 diabetes, 13% hypercholesterolemia and 44% hypertension. Median length of surgery for open VBG-RYGBP (64 minutes) was significantly faster than for LRYGBP (105 minutes). Median length of stay was significantly shorter for LRYGBP (2 days) than open VBG-RYGBP (3 days). Univariate logistic regression analysis identified 6 predictors of increased LOS: open surgery (0.4 OR); increasing BMI (60 kg/m² 0.38 OR; BMI 70 kg/m² 0.53 OR); increasing length of surgery (120 min 0.33 OR; 180 min 0.48 OR); sleep apnea (2.25 OR); asthma (3.73 OR); and hypercholesterolemia (3.73 OR). Subset analysis identified patients with the greatest odds for a prolonged hospital stay: women with asthma (2.47 AOR) or coronary artery disease (8.65 AOR); men with sleep apnea (5.54 OR) or the metabolic syndrome (6.67 – 10.20 OR); and patients undergoing a laparoscopic operation with sleep apnea (11.53 AOR) or coronary artery disease (12.15 AOR). Conclusions: Open surgery, BMI, length of surgery, sleep apnea, asthma and hypercholesterolemia all increased the odds of a prolonged LOS. Patients with the greatest odds of long LOS were women with asthma or coronary disease, men with sleep apnea or the metabolic syndrome, and patients undergoing laparoscopic surgery with sleep apnea or coronary artery disease. Patients at high-risk for prolonged hospital stay can be identified before undergoing RYGBP. Surgeons may wish to avoid high-risk patients early in their bariatric surgery experience.     

Psoriasis Remission after Laparoscopic Roux-En-Y Gastric Bypass for Morbid Obesity

Background: Psoriasis is a chronic skin disease characterized by epithelial hyperplasia and an accelerated rate of epithelial turnover affecting approximately 1-3% of the population. Exogenous and endogenous factors including morbid obesity can increase the morbidity of psoriasis. Case Report: A 55-year-old male, who weighed 131 kg with BMI 41 kg/m², underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP). He had a 15-year duration of severe psoriasis and was being medically treated. At 12 months after LRYGBP, he had lost 39 kg (68% EWL), and had complete resolution of the psoriasis and had discontinued all preoperative medications related to the disease. At 2 years after LRYGBP, psoriasis has not recurred. Conclusion: Weight loss after LRYGBP should be considered as a strategy in the treatment of severe psoriasis in morbidly obese patients.     

Extremely High Body Mass Index is not a Contraindication to Laparoscopic Gastric Bypass

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is an effective operation for morbidly obese patients who have failed conservative weight loss treatments. It is currently indicated for patients with BMI >40 kg/m² or >35 with significant co-morbidities. Controversy exists whether there is an upper limit to BMI beyond which this operation should not be performed. Methods: Between April 1999 and February 2001, 82 patients (19 male, 63 female) underwent LRYGBP. Average age was 43.6, and average BMI was 56 kg/m². These patients were divided into those with BMI <60 and those with BMI ≥60 kg/m². Results:There were 61 patients with BMI <60 and 21 patients with BMI ≥60. The groups were similar in age, gender, distribution or incidence of co-morbid conditions (diabetes, coronary artery disease, hypertension, sleep apnea, asthma) between the groups. The BMI ≥60 group had a significantly longer length of stay (6.6 days vs 5.3 days, P <0.05), and only 1 patient (BMI 85) developed an anastomotic leak and died. 2 patients in this group (BMI 62 and 73) developed small bowel obstruction requiring lysis of adhesions. 1 patient in the BMI <60 group developed a gastrojejunal stricture requiring balloon dilatation. Conclusion: While patients with a BMI ≥60 are at higher risk for postoperative complications, they are also at higher risk from continued extreme obesity. In our series, 85% of these patients had an uneventful postoperative course and began shedding excess weight. BMI ≥60 should not be a contraindication for LRYGBP.     

Prospective Randomized Comparison of Linear Staplers during Laparoscopic Roux-en-Y Gastric Bypass

Background: The development of laparoscopic linear staplers has enabled minimally invasive approaches to bariatric surgery, but there have been no comparison studies of the two current 6-row devices. We report our experience with a prospective randomized comparison of 6-row linear staplers during laparoscopic Roux-en-Y gastric bypass (LRYGBP). Methods: From January to March 2003, 100 patients were randomly assigned to undergo LRYGBP with either an Endo-GIA Universal 6-row stapler (USSC) or the ETS-Flex 6-row stapler (Ethicon). Mean preoperative BMI was 49±8 for 50 Endo-GIA patients, and 49±7 for 50 ETS-Flex patients. Parameters measured included quantity of cartridges, handles, hemoclips, estimated blood loss, misfires, OR time, postoperative leaks and bleeds, and cost. Results: Mean follow-up was 135 days (range 90- 180). The ETS-Flex group experienced significantly more misfires (28% vs 2%, P <.001), hemoclips applied (30±9 vs 21±7, P <.001), estimated blood loss (132±56 vs 100±32 ml, P <.001) and OR time (66±19 vs 58±13 mins, P <.02) compared with the Endo-GIA group respectively.There was one postoperative leak associated with the ETS-Flex group and two postoperative bleeds with the Endo-GIA group, which were not a significant differences.The Endo-GIA group averaged $319 more per case for staple cost. Conclusion: While the ETS-Flex stapler was less expensive, it was associated with more technical failures requiring surgeon intervention to reduce potential patient morbidity, compared with the Endo-GIA.     

Laparoscopic Roux-en-Y Gastric Bypass: Preoperative Determinants of Prolonged Operative Times, Conversion to Open Gastric Bypasses, and Postoperative Complications

Background: We examined our database of 600 consecutive laparoscopic Roux-en-Y gastric bypasses (LRYGBP) to determine predictors of prolonged operations, conversion to open operations and postoperative complications. Methods: All were primary bariatric operations. Body habitus, gender, and previous surgery were evaluated. Results: Regression analysis showed the following parameters to correlate positively with increased operative time: 1) Waist, 2) BMI, 3) Weight, and 4) Waist/Hip ratio. Height and hip measurement did not correlate with operative time. No previous operations affected operative time. Conversion to open operation was necessary in 25/600 cases (4.2%). Conversion was necessary with larger waist measurement (P=0.00007) and increased waist/hip ratio (P=0.01) but not BMI. Conversion occurred more frequently in males (6/43, 14.0%) than females (19/557, 3.4%). This trend was statistically significant (P=0.006). An enlarged liver was responsible for 12/25 conversions. 6/12 patients with large livers had type II diabetes and 6/12 patients had biopsy-proven steatohepatitis. 2/12 had huge yellow-brown livers that were not biopsed. Liver function tests were normal in 8/8 patients preoperatively. Complications including leak (5), pulmonary embolus (2), hemorrhage (12), stenosis of the GI tract (24) and infection (7) occurred in 48/600 patients (8.0%). There were no deaths. Complications did not correlate with body habitus, gender, or previous surgery. Conclusion: Larger patients as measured by waist measurement, weight, and BMI but not previous surgery prolonged LRYGBP. Conversion to open surgery was more frequently necessary in patients with larger abdomens, central obesity, and type II diabetes. Complications did not correlate with any preoperative parameter measured.     

Laparoscopic Removal of Gastric Band after Open Banded Gastric Bypass

Open banded gastric bypass has been the choice of some bariatric surgeons. This procedure includes a band (of various materials) around the gastric pouch. While there are advantages to this band, erosion and/or displacement of the band may occur. We describe a case of a symptomatic displaced band which was treated by laparoscopic removal. Laparoscopic removal of the band after open banded gastric bypass is feasible. Revision of previous bariatric surgery may be performed laparoscopically if the technical expertise is available.     

Intraoperative Endoscopic Test Resulting in No Postoperative Leaks from the Gastric Pouch and Gastrojejunal Anastomosis in 366 Laparoscopic Roux-en-Y Gastric Bypasses

Background: Postoperative leak from the gastric pouch and the anastomosis are leading causes of morbidity and mortality after gastric bypass. Many modalities have been emerging to prevent this complication. 326 consecutive laparoscopic Roux-en-Y gastric bypasses (LRYGBP) were analyzed in a two-surgeon practice and found no incidence of leaks from the gastric pouch (GP) and the gastrojejunal anastomosis (GJA) with intraoperative endoscopic testing. Methods: 328 consecutive RYGBP performed in antecolic fashion from March 2003 to January 2004 were analyzed. 326 (99%) were performed laparoscopically. After creating a 15 to 25 cc gastric pouch, integrity of the GP and GJA was tested for leak under saline submersion with endoscopic insufflation and placement of a bowel clamp on the intestinal limb distal to the GJA. Suture repair of apparent leak was performed if needed. Results: Of 326 consecutive LRYGBP utilizing the endoscopic leak test, there was no incidence of leak from the GP or GJA. There was one leak from the jejuno-jejunosotmy which was repaired laparoscopically on postoperative day #1. There was no incidence of leaks in the 2 open RYGBPs. Conclusions: Many "leak prophylaxis" measures have been emerging to prevent this potentially devastating complication. However, checking the GP and GJA with a simple endoscopic test can minimize the incidence of leaks after LRYGBP.     

Laparoscopic vs Open Roux-en-Y Gastric Bypass: A Prospective Randomized Trial

Background: The feasibility of laparoscopic Roux-en-Y gastric bypass (Lap-RYGBP) for morbid obesity is well documented. In a prospective randomized trial, we compared laparoscopic and open surgery. Methods: 51 patients (48 females, mean (± SD) age 36 ± 9 years and BMI 42 ± 4 kg/m²) were randomly allocated to either laparoscopy (n=30) or open surgery (n=21). All patients were followed for a minimum of 1 year. Results: In the laparoscopy group, 7 patients (23%) were converted to open surgery due to various procedural difficulties. In an analysis, with the converted patients excluded, the morphine doses used postoperatively were significantly (p< 0.005) lower in the laparoscopic group compared to the open group. Likewise, postoperative hospital stay was shorter (4 vs 6 days, p<0.025). Six patients in the laparoscopy group had to be re-operated due to Roux-limb obstruction in the mesocolic tunnel within 5 weeks. The weight loss expressed in decrease in mean BMI units after year was 14 and 13 after 1 ± 3 ± 3 laparoscopy and open surgery,respectively (not significant). Conclusions: Both laparoscopic and open RYGBP are effective and well received surgical procedures in morbid obesity. Reduced postoperative pain, shorter hospital stay and shorter sick-leave are obvious benefits of laparoscopy but conversions and/or reoperations in 1/4 of the patients indicate that Lap-RYGBP at present must be considered an investigational procedure.     

Routine Abdominal Drains After Laparoscopic Roux-en-Y Gastric Bypass: A Retrospective Review of 593 Patients

Background: The authors reviewed the benefits of routine placement of closed drains in the peritoneal cavity following laparoscopic Roux-en-Y gastric bypass (LRYGBP). The purpose of the study was to determine whether routine closed abdominal drainage provides diagnostic and therapeutic advantages in the presence of complications such as bleeding and leaks. Materials and Methods: The medical records of 593 consecutive patients who had undergone LRYGBP from July 2001 through May 2003 were retrospectively reviewed. In all cases, antecolic antegastric LRYGBP was performed. Two 19-Fr Blake closed suction drains were left in place, one at the gastrojejunostomy and the other at the jejunojejunostomy. The incidence of bleeding and leaks was reviewed, and the utility of the drains relative to diagnosis and management was evaluated. Results: Bleeding presented in 24 patients (4.4%); in 8, the diagnosis was based on increased sanguinous output from the drain and decreased hematocrit. None of the patients with intraabdominal bleeding required reoperation. Of the 10 patients (1.68%) who presented with leaks, the diagnosis was made within 48 hours postoperatively in 5 patients (50%), based on the characteristics of the drain output. Nonoperative management with drainage and total parenteral nutrition was accomplished in 5 (50%) of the 10 patients with leaks. There was no mortality in the series. Conclusion: The routine use of abdominal drains after LRYGBP appears to be beneficial. Drains allowed early diagnosis of complications and in most cases, the successful treatment of leaks. When bleeding is suspected or documented, appropriate volume replacement therapy is mandatory to maintain adequate hemodynamic parameters. Drain output may orient the surgeon to take preventive measures such as discontinuing anticoagulation and early fluid resuscitation. In this series, in most cases the bleeding spontaneously stopped and no further surgical management was required.     

Reoperative Laparoscopic Roux-en-Y Gastric Bypass: An Experience with 49 Cases

Background: Long-term complications leading to reoperation after primary bariatric surgery are not uncommon. Reoperations are particularly challenging because of tissue scarring and adhesions related to the first operation. Reoperations must address the complication(s) related to the scarring and, at the same time, prevent weight regain that would inevitably occur after simple reversal. Conversion to Roux-en-Y gastric bypass (RYGBP) has repeatedly been demonstrated to be the procedure of choice in most situations. It has traditionally been performed through an open approach. Our aim is to describe our experience with the laparoscopic approach in reoperations to RYGBP over the past 5 years. Methods: All patients undergoing laparoscopic RYGBP as a reoperation were included in this study. Patients with multiple previous operations or patients with band erosion after gastric banding were submitted to laparotomy. Data were collected prospectively. Results: Between June 1999 and August 2004, 49 patients (44 women, 5 men) underwent laparoscopic reoperative RYGBP. The first operation was gastric banding in 32 and vertical banded gastroplasty in 15. The mean duration of the reoperation was 195 minutes. No conversion to open was necessary. Overall morbidity was 20%, with major complications in 2 patients (4%). Weight loss, or weight maintenance, was satisfactory, with a BMI <35 kg/m² up to 4 years in close to 75% of the patients. Conclusions: Laparoscopic RYGBP can be safely performed as a reoperation in selected patients provided that the surgical expertise is available. These procedures are clearly more difficult than primary operations, as reflected by the long operative time. Overall morbidity and mortality, however, are not different. Long-term results regarding weight loss or weight maintenance are highly satisfactory, and comparable to those obtained after laparoscopic RYGBP as a primary operation.     

Laparoscopic Gastric Re-Banding versus Laparoscopic Gastric Bypass as a Rescue Operation for Patients with Pouch dilatation

Background:The authors assessed whether laparoscopic rebanding or laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the best approach for failed gastric banding after pouch dilatation. Methods: Between January 2000 and June 2005, 489 patients underwent laparoscopic gastric banding, and of these, 33 (6.7%) required rescue procedures for pouch dilatation. Each reoperated patient was contacted to obtain information about their postoperative course. Additionally, preoperative weight and BMI, weight loss at 1 year postoperatively, weight at time of pouch dilatation and the time-period between the primary operation and pouch dilatation were analyzed. Results: The most common operation for pouch dilatation was band repositioning or rebanding (16 patients). Band removal without replacement was performed in 7 patients. 8 patients underwent conversion to a LRYGBP. 1 patient underwent laparoscopic gastric sleeve resection and 1 patient received an intragastric balloon. Patients who underwent conversion to LRYGBP are very content and, although weight loss has been nearly the same as after gastric banding, they would prefer the gastric bypass operation to the gastric banding. Conclusion: Conversion to LRYGBP appears to offer significant advantages, and appears to be the rescue therapy of choice after failed laparoscopic gastric banding.