Is Routine Cholecystectomy Required During Laparoscopic Gastric Bypass?

Background: Routine cholecystectomy is often performed at the time of gastric bypass for morbid obesity.The aim of this study was to determine the incidence of gallstone formation requiring cholecystectomy following a laparoscopic Roux-en-Y gastric bypass (LRYGBP). Methods: 289 LRYGBP were performed between November 1999 and May 2002. 60 patients (21%) who had prior cholecystectomy were excluded. If gallstones were identified by intra-operative ultrasound (IOUS), simultaneous cholecystectomy was performed. Patients without gallstones were prescribed ursodiol for 6 months and scheduled for follow-up with transabdominal ultrasound. Results: During LRYGBP, gallstones were detected in 40 patients using IOUS (14%) and simultaneous cholecystectomy was performed. Of 189 patients with no stones identified by IOUS, 151 patients (80%) had a postoperative ultrasound after 6 months. 33 patients developed gallstones (22%) and 12 developed sludge (8%) as demonstrated by ultrasound at the time of follow-up. 11 patients had gallstone-related symptoms and subsequently underwent cholecystectomy (7%). 106 patients (70%) were gallstone-free at the time of ultrasound follow-up. Ursodiol compliance was found to be significantly lower for patients who developed stones than for gallstone-free patients (38.9% vs 58.3%, z =-2.00, P = 0.045). Conclusions: There is a low incidence of symptomatic gallstones requiring cholecystectomy after LRYGBP. Prophylactic ursodiol is protective. Routine IOUS and selective cholecystectomy with close patient follow-up is a rational approach in the era of laparoscopy.     

Is Routine Cholecystectomy Required During Laparoscopic Gastric Bypass?

Background: Routine cholecystectomy is often performed at the time of gastric bypass for morbid obesity. The aim of our study was to determine the incidence of gallstone formation requiring cholecystectomy following a laparoscopic Roux-en-Y gastric bypass (LRYGBP). Methods: 289 LRYGBP were performed between November 1999 and May 2002. 60 patients (21%) who had prior cholecystectomy were excluded. If gallstones were identified by intra-operative ultrasound (IOUS), simultaneous cholecystectomy was performed. Patients without gallstones were prescribed ursodiol for 6 months and scheduled for follow-up with transabdominal ultrasound. Results: During LRYGBP, gallstones were detected in 40 patients using IOUS (14%) and simultaneous cholecystectomy was performed. Of 189 patients with no stones identified by IOUS, 151 patients (80%) had a postoperative ultrasound after 6 months. 39 patients developed gallstones (22%) and 12 developed sludge (8%), as demonstrated by ultrasound at the time of follow-up. 11 patients had gallstone-related symptoms and subsequently underwent cholecystectomy (7%). 106 patients (70%) were gallstone-free at the time of ultrasound follow-up. Ursodiol compliance was found to be significantly lower for patients developing stones than for gallstone-free patients (38.9% vs 58.3%, z =-2.00, P = 0.045). Conclusions: There is a low incidence of symptomatic gallstones requiring cholecystectomy after LRYGBP. Prophylactic ursodiol is protective. Routine IOUS and selective cholecystectomy with close patient follow-up is a rational approach in the era of laparoscopy.     

Esophageal Motility after Laparoscopic Roux-en-Y Gastric Bypass: the Manometry Should Be Preoperative Examination Routine?

Background

Our goal was to identify the changes of esophageal motility, lower esophageal sphincter (LES) function, and eating adaptation before and after Roux-en-Y gastric bypass (RYGBP) and whether manometry should be a routine examination in patients who undergo this procedure.

Methods

A total of 81 patients underwent manometry before surgery and 1?year after surgery. The control group consisted of 10 nonobese volunteers. Patients were classified as presenting with vomiting and without vomiting 1?year after surgery. Manometric variables were compared before and after surgery. Statistical analysis was performed using Wilcoxon and Mann?CWhitney test.

Results

The patients (45.6%) had preoperative manometric findings, 29.8% had LES hypertonia, 18.9% LES hypotonia, 43.2% increase in wave amplitude of contraction, and three 8.1% abnormal peristalsis. One year after surgery manometry was abnormal in 62.9% of patients, 11.7% with hypertonia and 15.7% with hypotonia of the LES, 53% with changes in amplitude contraction and 19.6% with abnormal peristalsis. The control group showed no manometric abnormalities. Chronic vomiting was noted in 21% of patients. When comparing all variables between the pre and postoperative periods, there was no significant difference for all of them except for peristalsis. Comparing the results of manometric findings between the vomiting and non-vomiting groups, no significant changes were found in the variables studied.

Conclusions

There was an association between RYGBP and motor abnormalities in the esophagus but no differences in postoperative feeding adaptation. Thus, we conclude that esophageal manometry is not necessary as a routine preoperative examination.     

Is Routine Preoperative Upper GI Endoscopy Needed Prior to Gastric Bypass?

Background

In Finland, upper GI endoscopy (UGI) prior to bariatric surgery is routine in all but one hospital performing bariatric surgery. However, UGI is an unpleasant investigation for the patient and requires resources. Helicobacter pylori (HP) can be tested from blood and cannot be considered as an indication for UGI. We wanted to identify the most common findings in UGI and see if the findings influenced the decision to operate or if they even canceled the operation.

Methods

We evaluated retrospectively the data of 412 patients undergoing preoperative UGI in Vaasa Central Hospital in the years 2006–2010.

Results

UGI was considered normal in 191 (55.8 %) patients. The most common findings were hiatal hernia in 25.4 % (n?=?87); gastritis, 13.7 % (n?=?47); and esophagitis, 13.2 % (n?=?45). Also benign polyps, 6.7 % (n?=?23), and ulcers, 2.9 % (n?=?10), were detected. One 0.5-cm esophageal leiomyoma was found, but no malignant lesions. Histology was found normal in 185 (54.1 %) patients. HP was found in 12.0 % (n?=?41) of patients.

Conclusions

In this study, all the findings were benign and mild. The findings did not influence the operative plan. The most common findings were hiatal hernia and esophagitis which may be considered contraindications for sleeve gastrectomy, but not for gastric bypass. Our results do not support the performance of routine preoperative UGI prior to gastric bypass.     

Elective Cholecystectomy During Laparoscopic Roux-En-Y Gastric Bypass: Is it Worth the Wait?

Background: Combined gastric bypass and cholecystectomy have been advocated for open bariatric procedures. Our goal was to evaluate the safety of this technique in laparoscopic bariatric surgery patients with gallstones diagnosed preoperatively. Methods: 94 out of 556 consecutive morbidly obese patients (16.9%) underwent laparoscopic gastric bypass with simultaneous cholecystectomy (LGBP/LC) for cholelithiasis. Results: 328 patients (59%) had a concomitant secondary procedure, most commonly cholecystectomy (28.7%). Preoperative BMI was 48.6±6.9 kg/m² for LGBP/LC patients and 48.8±7.3 kg/m² (P=0.85) for LGBP alone. 5 patients had preoperative biliary colic; the others were asymptomatic for cholelithiasis. Postoperatively, at a mean follow-up of 7.6±6.7 months, the percent excess weight loss (%EWL) was 46.1±0.25 for the combined procedure vs 50.2±63.0 (P=0.55) for LGBP alone. There were no conversions to open procedures for the LC. Port placement for the LGBP was not altered for LC. None required intraoperative cholangiography. Operative time for the combined procedure was 293.4±79.8 minutes vs 244.8±77.2 minutes for LGBP alone (P<0.0001). Length of stay for the combined procedure was 4.35±10.8 days vs 2.69±1.8 days for LGBP alone (P=0.0069).There were no postoperative bile leaks or bile duct injuries. Conclusion: Concomitant LGBP/LC is safe and feasible without altering port placement. Combining these procedures significantly increases operative time and nearly doubles the hospital stay.     

Laparoscopic Repositioning of Heliogast® Gastric Band after Anterior Slippage

Background: Gastric slippage is a well-described complication of gastric banding. The Heliogast? band is equipped with a locking mechanism that enables its straightforward reopening and repositioning. Our experience with Heliogast? band salvage after anterior slippage is reported. Methods: The study sample comprised 418 consecutive patients who underwent 2-step laparoscopic gastric banding with the Lap-Band? first (n=235) followed with the Heliogast? band (n=183). Gastric slippage was diagnosed by symptoms of dysphagia and vomiting and was confirmed with Gastrografin? swallow. Patients who did not respond to conservative treatment were laparoscopically reoperated. In the Heliogast? group, the band was dissected free, unlocked, and repositioned. In the Lap-Band? group, when reopening proved impossible, the band was removed with or without replacement. Results: 10 patients (2.4%) underwent reoperation for anterior slippage, 5 with a Lap-Band? (2.1%) and 5 with a Heliogast? band (2.7%). Band repositioning was feasible in all 5 patients in the Heliogast? group, but in only one of the patients in the Lap-Band? group; in the others, the band was removed. Band repositioning was confirmed radiologically. No postoperative complications were recorded, and all patients were discharged on the first day after surgery. At a median 10 months' follow-up after Heliogast? repositioning, all patients had satisfactory weight loss. Conclusion: Laparoscopic Heliogast? band salvage after anterior slippage is comparatively simple and safe, with excellent postoperative results and no interference with continued weight loss. This constitutes an important means of management for the bariatric surgeon.     

Are Laparoscopic Gastric Bypass After Gastroplasty and Primary Laparoscopic Gastric Bypass Similar in Terms of Results?

Background  

This retrospective study compares the results of primary gastric bypass (PGB) versus secondary gastric bypass (SGB) performed after gastroplasty.     

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.     

Routine Preoperative Ultrasonography and Selective Cholecystectomy in Laparoscopic Roux-en-Y Gastric Bypass. Why Not?

Background Preoperative evaluation and treatment of biliary lithiasis in morbid obese patients who are candidates to bariatric surgery raise a series of questions which to date has no clear consensus. The aim of this study was to evaluate the results of routine preoperative abdominal ultrasonography and selective cholecystectomy comparing patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP) with and without simultaneous cholecystectomy. Methods The prospective database of all the patients who underwent laparoscopic RYGBP in our institution was reviewed. The demographic characteristics, comorbidities, operative time, hospital stay, and postoperative complications were analyzed. Results From August 2001 to December 2006, 1,311 patients underwent laparoscopic RYGBP, 137 (10.4%) of them were excluded due to previous cholecystectomy. In 128 (10.9%) of the remaining 1,174 patients, a cholecystectomy associated to laparoscopic RYGBP was performed. The mean age was 38.5 ± 10.1 years, and 106 (82.8%) were women. The mean operative time in patients with and without simultaneous cholecystectomy was 129.8 ± 45 and 108.5 ± 43 min, respectively (p < 0.001). The hospital stay was 3.6 ± 0.8 days in patients with simultaneous cholecystectomy and 4 ± 3 days in patients without simultaneous cholecystectomy (p = 0.003). There were no deaths. Postoperative complications were observed in 9 (7%) and 73 (6.9%) patients with and without simultaneous cholecystectomy respectively (p = NS). Postoperative complications were not related to the cholecystectomy. Conclusion Cholecystectomy associated to laparoscopic RYGBP should be considered in all patients with preoperative ultrasound diagnosis of cholelithiasis.     

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.     

Combination of Laparoscopic Adjustable Gastric Banding and Gastric Bypass: Current Situation and Future Prospects – Routine Use Not Advised

Although bariatric surgery has proven to be the most effective treatment for morbid obesity, most surgical techniques do have failures. In an effort to improve the reliability, several surgeons started to use a combination of a laparoscopic gastric bypass with an adjustable gastric band. Because of concerns regarding a possible negative outcome, an expert meeting was organized to evaluate the current situation and future application. In total, 104 operations were reported,with several technical variations. The overall complication rate was acceptable, but the percentage of the band erosions was 6.7%, which is too high. The potential advantages (adjustability, maintained access to the stomach and biliary tree, and reversibility) do not compensate for this complication rate. Based on the results and the opinion of the surgeons experienced in this technique, it is concluded that the combination of gastric bypass with an adjustable gastric band to form the pouch is not recommended.     

Robotic Roux-en-Y Gastric Bypass,is it Safer than Laparoscopic Bypass?

Background

Along with the development of technology, robotic approach is being performed for laparoscopic Roux-en-Y gastric bypass (LRYGB). Some literatures reported same or better peri-operative outcomes with the robotic procedure. The aim of this study is to compare our experience in robot-assisted LRYGB (RA-LRYGB) with LRYGB in terms of peri-operative outcomes.

Methods

From January 1, 2012 to April 30, 2014, a total of 270 patients underwent LRYGB by one surgeon at a single institution. Of these, 64 cases were done robotically. A retrospective review was performed for these patients, noting the outcomes and complications of the procedure.

Results

The 64 RA-LRYGB patients had a mean age of 45.9?±?10.0 years (range, 23–67) and a mean preoperative body mass index (BMI) of 48.4?±?7.9 kg/m² (range, 33.8–76.4). The 207 LRYGB patients had a mean age of 45.0?±?10.7 years (range, 21–67) and a mean preoperative BMI of 48.4?±?8.1 kg/m² (range, 34.0–80.4). These two groups were clinically comparable. Mean length of hospital stay was 3.0?±?4.1 days (range, 1–19) in RA-LRYGB patients, significantly longer than 1.6?±?1.7 days (range, 1–17) in LRYGB patients (p?<?0.01). Thirty-day readmission rate was 9.3 % (n?=?6) in the RA-LRYGB group and 6.8 % (n?=?14) in the LRYGB group. Higher leak rate was noticed in RA-LRYGB patients at 7.8 % (n?=?5), compared to 0.5 % (n?=?1) in LRYGB patients (p?<?0.01). All the leaks occurred at the pouch level in the RA-LRYGB group, while one leak from the LRYGB group occurred at the gastrojejunal anastomosis site.

Conclusions

Robot-assisted Roux-en-Y gastric bypass may result in higher leak rate at the pouch level, when compared to that of laparoscopic procedures.

     

Conversion of Lap-Band® to Gastric Bypass for Dilated Gastric Pouch

An 18-year-old female who had undergone a laparoscopic adjustable gastic banding developed several episodes of gastric pouch dilatation (GPD), treated conservatively. The last GPD (31 months after Lap-Band placement) involved the lesser curvature of the stomach and was refractory to medical treatment. Conversion to an open gastric bypass was performed. Gastric bypass is an option in the case of Lap-Band failure.     

Single Incision Transumbilical Laparoscopic Roux-en-Y Gastric Bypass—Our Technique

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the gold standard procedure in bariatric surgery but requires 4–7 ports. We have reported the first single incision transumbilical Roux-en-Y gastric bypass (SITU-RYGB) in 2009 (Huang et al. Obes Surg 19:1711–1715, 2009). Over the years, we have standardized our procedure and this video highlights the same by showing both inside and outside views. This video was shot from outside as well to give better understanding of the procedure. A 4.5-cm incision was made according to the contour of umbilicus and space was created over the sheath to give more range of movement to the instruments. The procedure was carried out using conventional laparoscopic instruments and replicating all the steps of the procedure under adequate visualization. Picture-in-picture effect has been used at important steps. Findings were recorded. The procedure took 96 min without any intraoperative complication. Blood loss was 20 cc. The incision was hardly noticeable at the end of the procedure. We have previously compared our results of SITU-RYGB with that of our multiport RYGB where operative time was longer for SITU-RYGB versus multiport technique (101.1 vs. 81.1 min, P?=?0.001) (Huang et al. Surg Obes Relat Dis 8:201–207, 2012). No difference in complications was observed. The SITU-LRYGB patients reported greater satisfaction related to scarring than those who had undergone five-port surgery (P?=?0.005). Difference in analgesia requirement was not statistically significant. There was no mortality. Compared with conventional LRYGB, SITU-RYGB resulted in acceptable complications, the same recovery, comparative weight loss, and better patient satisfaction related to scarring.     

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.     

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.

     

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.     

Food Aversions in Women During The 2?Years After Roux-En-Y Gastric Bypass

The anatomical and physiological changes of the gastrointestinal tract after Roux-en-Y gastric bypass lead to changes in dietary patterns and their effects are still little known. Hence, the objective of this work was to characterize the prevalence, the associated factors and the list of food aversions with the effect of surgery on the body weight of women in the first two years after Roux-en-Y gastric bypass. A total of 141 women were studied. Their food aversions were assessed with a short food frequency questionnaire (FFQ-S) containing 26 items before and 6, 12 and 24?months after surgery. The FFQ-S was filled out during individual interviews and referenced in the medical records. The association between total aversion score and body weight variables and general characteristics of the group was analyzed. Variation of food aversions over time was assessed for 26 foods individually and grouped. Of all the studied variables, a weak but significant negative correlation (rs?=?-0.1944; p?=?0.0208) was found between total aversion score and shorter postoperative period and a weak but significant positive correlation was found between total aversion score and percentage of weight regained (rs?=?-0.1759; p?=?0.0369). Food aversions were more common in the first six months after surgery, especially to red meats, rice, chicken, eggs, pasta, milk and others. Food aversions in the early postoperative period are associated with weight variations in the first two years after surgery and subside significantly over time, probably because of a physiological and cognitive adaptation of the individual to the surgical procedure.     

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.