Radiological studies after laparoscopic Roux-en-Y gastric bypass: routine or selective?

Early detection of complications after laparoscopic Roux-en-Y gastric bypass (LRYGB) can be difficult because of the subtle clinical findings in obese patients. Consequently, routine postoperative upper gastrointestinal contrast studies (UGI) have been advocated for detection of leak from the gastrojejunostomy. The medical records of 368 consecutive patients undergoing LRYGB were analyzed to determine the efficacy of selective use of radiological studies after LRYGB. Forty-one patients (11%) developed signs suggestive of complications. Of the 41 symptomatic patients, two were explored urgently, 39 (10%) had radiological studies, and 16 of them (41%) were diagnosed with postoperative complications. Overall morbidity of the series was 4.8 per cent. Four patients (1.1%) developed a leak from the gastrojejunostomy and were correctly diagnosed by computerized tomography (CT). The sensitivity and specificity of CT in determining leak was 100 per cent, with positive and negative predictive value of 100 per cent. The mortality of the series was 0 per cent. No radiologic studies were performed in asymptomatic patients, and no complications developed in these patients. Our results show that selective radiological evaluation in patients with suspected complications after LRYGB is safe. High sensitivity makes CT the test of choice in patients with suspected complication after LRYGB. Routine radiological studies are not warranted.     

Is esophagogastroduodenoscopy before Roux-en-Y gastric bypass or sleeve gastrectomy mandatory?

BackgroundRoux-Y Gastric Bypass is a frequently used technique in bariatric surgery. Postoperative anatomy is altered by exclusion of the stomach, which makes this organ inaccessible for future esophagogastroduodenoscopy (EGD). The value of preoperative assessment of the stomach is unclear. Some institutions choose to investigate the future remnant stomach by EGD, others do not. Aim of the present study is to quantify the yield of preoperative EGD in our institution.MethodsPatients, planned for primary laparoscopic Roux-Y Gastric Bypass (LRYGB) or laparoscopic sleeve gastrectomy from December 2007 until August 2012, were screened by EGD in advance. Results of EGD and patient characteristics were retrospectively analyzed and categorized according to a classification system based on intervention needed.Results523 patients (122 male, 401 female, mean age 44.3 years, average BMI 46.6) underwent preoperative EGD. In 257 patients (48.9%) no abnormality was found (group A), 117 patients (17.2%) had abnormalities without treatment consequences (B1), 84 patients (of the 326 tested [comment #1, reviewer #1, 26.8%] were H. Pylori positive (B2), in 75 (14.3%) treatment with proton pump inhibitors was required (B3), 6 (1.1%) required follow up EGD before surgery (C). For1 patient (0.2%) the operation was canceled because preoperative EGD presented with Barrett’s esophagus with carcinoma (D). When all abnormalities were taken into account, baselines did show a significant difference for age, gender and reflux symptoms.ConclusionStandard preoperative assessment by EGD in patients who are planned for bariatric surgery is not indicated. The number needed to screen to find clinically significant abnormalities is high.     

Sleeve gastrectomy versus Roux-en-Y gastric bypass in patients Aged ≥65 years: a comparison of short-term outcomes

BackgroundBariatric surgery in the elderly population has been reported as feasible and safe. Sleeve gastrectomy (SG) seems to have fewer complications than Roux-en-Y gastric bypass (RYGB) even in the 65 years of age population. We analyzed the difference in weight loss between SG and RYGB in patients age 65 years.ObjectivesTo analyze and compare outcomes between SG and RYGB in patients 65 years of age and older.SettingAcademic hospital, United States.MethodsAfter internal review board approval, we retrospectively reviewed 2486 patients who underwent either SG or RYGB between 2005 and 2018 at our institution. Basic demographics, preoperative body mass index (BMI), and co-morbidities were described. We identified all patients age ≥65 years and subsequently divided them into 2 groups based on type of bariatric procedure performed. Analysis and comparison of outcomes between these groups were completed. Postoperative BMI was reviewed at 6, 12, and 24 months and percent excess BMI loss (%EBMIL, as defined by the ASMBS clinical committee) was calculated accordingly. The t test and χ² analysis were performed for nominal and categorical variables, respectively.ResultsFrom 2486 patients reviewed, 22.7% (n = 565) were aged ≥65 years. From these, 43.1% (n = 244) underwent SG and 56.8% (n = 321) underwent RYGB. White and female patients were predominant in both groups. Mean age was similar for both populations (SG: 71.1 ± 4.0, RYGB: 71.7 ± 4.5; P = .12). Pre-procedure mean BMI for both groups was close in value, but the difference was statistically significant (40.5 ± 5.5 for SG versus 43.7 ± 7.2 for RYGB; P < .0001). Postoperative follow-up rates were similar in both groups at 12 and 24 months (SG: 51.2% and 31.6%; RYGB: 48.3% and 34.3%; P = .49 and P = .5). The %EBMIL at 6, 12, and 24 months was higher for the RYGB group than the SG group (59.3 ± 27.9, 72.1 ± 29.5, 77.4 ± 26.1 versus 50.2 ± 21.9, 55.2 ± 25.6, 43.9 ± 32.2; P < .01, P < .01, and P < .01, respectively). Complication rates were significantly higher in RYGB versus SG (27.7% versus 9.4%; P < .01). We observed significantly higher anastomotic ulcer and stricture rates for RYGB versus SG (7.2% and 5.9 versus 0% and 0%; P < .01 and P < .01, respectively). RYGB had a higher rate for gastrointestinal obstruction requiring intervention (2.2% versus .4%; P = .07). A similar de novo gastroesophageal reflux disease rate was noted in both procedures (3.7% versus 3.7%; P = .98). No leaks were reported in either group.ConclusionsBoth SG and RYGB are effective weight loss procedures for patients aged ≥65 years. RYGB seems to have higher %EBMIL at 1 and 2 years; however, when compared with SG, complication rates appear to be almost 3 times higher.     

Is laparoscopic sleeve gastrectomy a lower risk bariatric procedure compared with laparoscopic Roux-en-Y gastric bypass? A meta-analysis

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the current “gold standard” bariatric procedure in the United States. Laparoscopic sleeve gastrectomy (LSG) has recently become a commonly performed procedure for many reasons, including patients' perception that LSG has less complexity and invasiveness, and lower risk. Our objective was to review the literature and compare the leak rates, morbidity, and mortality for LRYGB versus LSG.

Methods

Publications from 2002 to 2012 with n greater than or equal to 25 and postoperative leak rate reported were included. Statistical analysis included chi-square according to patient number.

Results

Twenty-eight (10,906 patients) LRYGB and 33 (4,816 patients) LSG articles were evaluated. Leak rates after LRYGB versus LSG were 1.9% (n = 206) versus 2.3% (n = 110), respectively (P = .077). Mortality rates were .4% (27/7,117) for LRYGB and .2% (7/3,594) for LSG (P = .110). Timing from surgery to leak ranged from 1 to 12 days for LRYGB versus 1 to 35 days for LSG.

Conclusions

Leak and mortality rates after LRYGB and LSG were comparable. The appropriate procedure should be tailored based on patient factors, comorbidities, patient and surgeon comfort level, surgeon experience, and institutional outcomes.     

Safety of laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass in elderly patients – analysis of the MBSAQIP

Background

An increase in the prevalence of obesity and longer life expectancy has resulted in an increased number of candidates over the age of 60 who are pursuing a bariatric procedure.

Roux-en-Y gastric bypass versus sleeve gastrectomy: what factors influence patient preference?

Background

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the most commonly performed bariatric procedures. RYGB involves altered gastrointestinal anatomy and 2 anastomoses, while SG involves gastric resection. When potential patients view images of the procedures, they may perceive RYGB to involve significant risk compared with SG, in which no significant gastrointestinal alterations are depicted.

Is preoperative gastroscopy necessary before sleeve gastrectomy and Roux-en-Y gastric bypass?

Background

Consensus on the necessity of esophagogastroduodenoscopy (EGD) before bariatric surgery is lacking. Recommendations and practices vary by country and unit. Several reports have expressed concerns on gastroesophageal reflux disease (GERD) and its consequences after sleeve gastrectomy (SG) and the risk of leaving a premalignant lesion in the excluded stomach after Roux-en-Y gastric bypass (RYGB).

Adjustable gastric banding as revisional bariatric procedure after failed gastric bypass—intermediate results

BackgroundAlthough gastric bypass is the most common bariatric procedure in the United States, it is has been associated with a failure rate of 15% (range 5–40%). The addition of an adjustable gastric band to Roux-en-Y gastric bypass has been reported to be a useful revision strategy in a small series of patients with inadequate weight loss after proximal gastric bypass.MethodsWe report on 22 patients who presented with inadequate weight loss or significant weight regain after proximal gastric bypass. All patients underwent revision with the placement of an adjustable silicone gastric band around the proximal gastric pouch. The bands were adjusted at 6 weeks postoperatively and beyond, as needed. Complications and weight loss at the most recent follow-up visit were evaluated.ResultsThe mean age and body mass index at revision was 41.27 years (range 25–58) and 44.8 ± 6.34 kg/m², respectively. Patients had experienced a loss of 19%, 27%, 47.3%, 42.3%, 43%, and 47% of their excess weight at 6, 12, 24, 36, 48, and 60 months after the revisional procedure, respectively. Three major complications occurred requiring reoperation. No band erosions have been documented.ConclusionThe results from this larger series of patients have also indicated that the addition of the adjustable silicone gastric band causes significant weight loss in patients with poor weight loss outcomes after gastric bypass. That no anastomosis or change in absorption is required makes this an attractive revisional strategy. As with all revisional procedures, the complication rates appear to be increased compared with a similar primary operation.     

Robot-assisted versus laparoscopic Roux-en-Y gastric bypass: is there a difference in outcomes?

Background  

Application of the robot for Roux-en-Y gastric bypass has been slow to evolve, despite its rapid acceptance in other fields. This is largely due to associated costs of technology, reports of increased operative time, and inadequate data available to correlate the benefits of robotics to a clinical outcome. The authors present a comparative study between laparoscopic and robot-assisted Roux-en-Y gastric bypass performed at a specialized institution for robotic surgery.     

Laparoscopic adjustable gastric banding: is there a learning curve?

Background: To be certified for laparoscopic placement of adjustable gastric banding, surgeons must have advanced laparoscopic experience. Despite previous exposure to other kinds of laparoscopy, there may a learning curve specific to Lap-Band placement. Methods: Sixty consecutive patients were prospectively separated into two groups: the first 30 patients operated on (group 1) and the second 30 patients operated on (group 2). Results: Both groups were similar statistically in regard to gender, age, and body mass index. Operative time for group 1 was 79 ± 31.1 min. There were 11 (37%) complications in 10 patients. Operative time for group 2 was 59 ± 19.9 min. There were two complications (7%). All operations were completed laparoscopically. Operative time was significantly lower in group 2 (t-test; p = 004). Complications were also significantly lower (chi-square; p = 0.005). The number of reoperations was also reduced and approached statistical significance (chi-square; p = 0.054). Readmissions, although reduced, were not statistically significant. There were no deaths in either group. Conclusions: Despite a surgeons history of advanced laparoscopic experience, there is a definite learning curve associated with the laparoscopically placed adjustable gastric band.     

Does fellow participation in laparoscopic Roux-en-Y gastric bypass affect perioperative outcomes?

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) requires specialized training commonly acquired during a fellowship. We hypothesized that fellows affect patient outcomes and this effect varies during training.

Methods

We included all LRYGB from the 2005 to 2009 American College of Surgeons-National Surgical Quality Improvement Program database. Cases without trainees (attending) were compared to those with trainees of ??6?years (fellow). Outcomes were pulmonary, infectious, and wound complications and deep venous thrombosis (DVT). Multivariable regression controlled for age, BMI, and comorbidities.

Results

Of the 18,333 LRYGB performed, 4,349 (24?%) were fellow cases. Fellow patients had a higher BMI (46.1 vs. 45.7, p?<?0.001) and fewer comorbidities. Mortality was 0.2 and 0.1?% and overall morbidity was 4.8 and 6.0?% for attending and fellow groups, respectively. On adjusted analysis, mortality was similar, but fellow cases had 30?% more morbidity (p?=?0.001). Specifically, fellows increased the odds of superficial surgical site infections (SSSIs) [odds ratio (OR)?=?1.4, p?=?0.01], urinary infections (UTIs) (OR?=?1.7, p?=?0.002), and sepsis (OR?=?1.5, p?=?0.05). During the first 6 months, fellows increased the odds of DVT (OR?=?4.7, p?=?0.01), SSIs (OR?=?1.5, p?=?0.001), UTIs (OR?=?1.8, p?=?0.004), and sepsis (OR?=?1.9, p?=?0.008). By the second half of training, fellow cases demonstrated outcomes equivalent to attending cases.

Conclusions

Involving fellows in LRYGB may increase DVT, SSIs, UTIs, and sepsis, especially early in training. By completion of their training, cases involving fellows exhibited outcomes similar to cases without trainees. This supports both the need for fellowship training in bariatric surgery and the success of training to optimize patient outcomes.     

Does laparoscopic gastric banding create hiatal hernias?

BackgroundWe hypothesized that laparoscopic adjustable gastric band (LAGB) placement might result in the development of a hiatal hernia (HH) over time. The objective of our study was to determine whether HHs develop after LAGB in the setting of a university hospital.MethodsWe retrospectively reviewed all outcomes for consecutive LAGB patients in our institutional, longitudinal prospective bariatric surgical database to identify those patients without evidence of a HH at LAGB placement, who subsequently underwent delayed HH repair.ResultsFrom 2005 to 2009, 695 gastric bands were implanted. Twelve patients (1.72%) were identified who had no radiographic or intraoperative evidence of a HH at LAGB placement and who subsequently underwent HH repair at re-exploration. Patients presented 18 ± 10 months after band placement. Of these patients, 75% presented with gastroesophageal reflux disease or food intolerance (50% with gastroesophageal reflux disease alone). Also, 2 presented with acute pain due to band slippage and 1 with chronic pain and vomiting. In 50% of the patients, revision procedures detected the HH at operation despite negative preoperative studies.ConclusionIn our series, a significant HH developed in 1.7% of LAGB patients who had no clinically identifiable HH at LAGB placement. Persistent dysphagia after band deflation requires careful inspection of the hiatus during surgical revision, even in the absence of radiologic depiction of HH, and might represent an underlying etiology of LAGB dysfunction. This complication, along with esophageal dilation and annular pouch dilation, might represent a constellation of conditions with a common etiology. From the results of our small series, we raise the question of the existence of chronic backpressure created by LAGB restriction and accounting for these complications.     

Location and number of sutures placed for hiatal hernia repair during laparoscopic adjustable gastric banding: does it matter?

Background

It has been demonstrated that hiatal hernia repair (HHR) during laparoscopic adjustable gastric banding (LAGB) decreases the rate of reoperation. However, the technical aspects (location and number of sutures) are not standardized. It is unknown whether such technical details are associated with differing rates of reoperation for band-related problems.

Methods

A retrospective analysis was performed from a single institution, including 2,301 patients undergoing LAGB with HHR from July 1, 2007 to December 31, 2011. Independent variables were number and location of sutures. Data collected included demographics, operating room (OR) time, length of stay (LOS), follow-up time, postoperative BMI/%EWL, and rates of readmission/reoperation. Statistical analyses included ANOVA and Chi squared tests. Kaplan–Meier, log-rank, and Cox regression tests were used for follow-up data and reoperation rates, in order to account for differential length of follow-up and confounding variables.

Results

There was no difference in length of follow-up among all groups. The majority of patients had one suture (range 1–6; 55 %). Patients with fewer sutures had shorter OR time (1 suture 45 min vs. 4+ sutures 56 min, p < 0.0001). LOS, 30-day readmission, band-related reoperation, and postop BMI/%EWL were not statistically significant. Anterior suture placement (vs. posterior vs. both) was most common (61 %). OR time was shorter in those with anterior suture (41 min vs. posterior 56 min vs. both 59 min, p < 0.0001). Patients with posterior suture had a longer LOS (84 % 1 day vs. anterior 74 % 1 day vs. both 74 % 1 day, p < 0.0001). There was no difference in 30-day readmission, band-related reoperation, and postoperative BMI/%EWL.

Conclusions

Patients with fewer or anterior sutures have shorter OR times. However, 30-day readmission, band-related reoperation, and postoperative weight loss were unaffected by number or location of suture. The technical aspects of HHR did not appear to be associated with readmission or reoperation, and therefore a standardized approach may not be necessary.     

Is high BMI associated with specific complications after laparoscopic Roux-en-Y gastric bypass?

Controversy remains whether patients with body mass index (BMI) > or =50 kg/m2 experience more complications after laparoscopic Roux-en-y gastric bypass (LRYGB) than those with a lower BMI. Whether BMI > or =50 kg/m2 is associated with specific complications remains unknown. Charts of 152 patients who underwent LRYGB were reviewed. Logistic regression was used to determine whether high BMI is associated with minor or major complications. Overall, there was a trend that major complications occurred more frequently in patients with BMI > or =50 compared with BMI < 50, (30.4% vs. 19.8%, P = 0.138). Major bleeding complications occurred in 16.1 per cent of high BMI patients as compared with 5.2 per cent with lower BMI (P = 0.025). Multivariate regression found that BMI > or =50 was associated with higher odds of a major technical complication (OR = 2.73, P = 0.04), particularly for bleeding complications (odds ratio [OR] = 5.59, P = 0.01). Male gender was also associated with higher odds of a major technical complication (OR = 3.43, P = 0.04). These results suggest that high BMI patients may be better candidates for other types of weight loss surgery, such as staged procedures, and that surgeons early in their career should operate on patients with lower BMI.