The Importance of the Length of the Limbs for Gastric Bypass Patients—An Evidence-based Review

The ideal length of the gastric bypass limbs is debated. Recent evidence suggests that standard limb lengths used today have a limited impact on patient weight loss. Our objective was to appraise critically the available evidence on the influence of the length of gastric bypass limbs on weight loss outcomes. We systematically reviewed MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects for articles reporting the effect of gastric bypass length on outcomes published between 1987 and 2009. Four randomized controlled trials and several retrospective studies were identified and reviewed. Longer Roux limb lengths (at least 150 cm) were associated with a very modest weight loss advantage in the short term in superobese patients. No significant impact of alimentary limb length on weight loss for patients with body mass index (BMI) <50 was seen. When the length of the common channel approaches 100 cm, a significant impact on weight loss is observed. The currently available literature supports the notion that a longer Roux limb (at least 150 cm) may be associated with a very modest weight loss advantage in the short term in superobese patients but has no significant impact on patients with BMI ≤50. To achieve weight loss benefit due to malabsorption, bariatric surgeons should focus on the length of the common channel rather than the alimentary or biliopancreatic limbs when constructing a gastric bypass especially in the superobese population where failure rates after conventional gastric bypass are higher.     

Long limb Roux en Y gastric bypass revisited

Roux-en-Y gastric bypass (RYGB) that is performed with at least a 150-cm Roux limb results in significantly greater weight loss than shorter (<100-cm) Roux limb procedures in superobese patients(BMI >50 kg/m2). Conversely, longer Roux limb procedures do not provide greater weight loss in less obese (BMI <50 kg/m2)patients. Modest elongation of the Roux limb-in the range of 150 cm to 200 cm-does not result in more frequent nutritional sequelae compared with shorter Roux limb procedures. This article discusses the current status of long limb Roux-en-Y gastric bypass in the context of weight loss, metabolic sequelae and CPT coding.     

Comparison of nutritional deficiencies after Roux-en-Y gastric bypass and after biliopancreatic diversion with Roux-en-Y gastric bypass

Background: Patients undergoing either Roux-en-Y gastric bypass (RYGBP) or biliopancreatic diversion (BPD) with RYGBP are at risk of developing metabolic sequelae secondary to malabsorption.We compared the differences in nutritional complications between these two bariatric operations. Methods: A retrospective analysis of a prospective database was done. From June 1994 to December 2001, 243 morbidly obese patients underwent various bariatric procedures at our institution. Of these patients, 79 (BMI 45.6 ± SD=4.9) who underwent RYGBP (gastric pouch 15 ± 5ml, biliopancreatic limb 60-80 cm, alimentary limb 80-100 cm and common limb the remainder of the small intestine), and 95 super obese (BMI 57.2 ± 6.1) who underwent a BPD (gastric pouch 15 ± 5ml, biliopancreatic limb 150-200 cm, common limb 100 cm and alimentary limb the remainder of the small intestine), were selected and studied for the incidence of micronutrient deficiencies and level of serum albumin at yearly intervals postoperatively. A variety of nutritional parameters including Hb, Fe, ferritin, folic acid, vitamin B₁₂ and serum albumin were measured preoperatively and compared postoperatively at 1, 3, 6, 12, 18 and 24 months, and yearly thereafter. Results: Nutritional parameters were compared preoperatively and at similar periods postoperatively. No statistically significant (P <0.05) difference in the occurrence of deficiency was observed between the groups for any of the nutritional parameters studied, except for ferritin, which showed a significant difference at the 2-year follow-up (37.7% low ferritin levels after RYGBP vs. 15.2% after BPD, P =0.0294). All of these deficiencies were mild, without clinical symptomatology and were easily corrected with additional supplementation of the deficient micronutrient, with no need for hospitalization. Regarding serum albumin, there was only one patient with a level below 3 g/dl in the RYGBP group and two in the BPD group.These three patients were hospitalized and received total parenteral nutrition for 3 weeks, without further complications. Conclusion:There was no significant difference in the incidence of deficiency of the nutritional parameters studied, except for ferritin, following RYGBP vs. BPD with RYGBP.The most common deficiencies encountered were of iron and vitamin B₁₂. The incidence of hypoalbuminemia was negligible in both groups, with mean values above 4 g/dl.     

Is Weight Loss Better Sustained with Long-Limb Gastric Bypass in the Super-Obese?

Background  

While some studies have shown that long-limb gastric bypass with Roux limb length of 150 to 200 cm can attain better weight loss outcomes in super-obese patients (BMI >50 kg/m²) than the standard limb gastric bypass with Roux limb length of 100 to 150 cm, other studies have not shown similar findings. Additionally, no study has demonstrated the optimal length of the Roux limb that will result in ideal weight loss. The purpose of this study is to compare the long-term weight loss and weight regain of standard limb length (SLL) and long limb length (LLL) gastric bypass in patients with BMI >50 kg/m².     

Routine Upper Gastrointestinal Gastrografin® Swallow after Laparoscopic Roux-En-Y Gastric Bypass

Background: Upper gastrointestinal (UGI) swallow radiographs following laparoscopic Roux-en-Y gastric bypass (LRYGBP) may detect an obstruction or an anastomotic leak. The aim of our study was to determine the efficacy of routine imaging following LRYGBP. Methods: Radiograph reports were reviewed for 201 consecutive LRYGBP operations between April 1999 and June 2001. UGI swallow used Gastrografin?, static films, fluoroscopic video, and a delayed image at 10 minutes. Mean values with one standard deviation were tested for significance (P<0.05) using the Mann-Whitney U test statistic. Results: Of 198 available reports, UGI detected jejunal efferent (Roux) limb narrowing (n=17), partial obstruction (n=12), anastomotic leak (n=3), complete bowel obstruction (n=3), diverticulum (n=1), hiatal hernia (n=1), and proximal Roux limb narrowing (n=1). A normal study was reported in 160 cases (81%). Partial obstruction resolved without intervention. Complete obstruction required re-operation. Compared to 6 patients who developed delayed leaks, early identification of a leak by routine UGI swallow resulted in a shorter hospital stay (mean 7.7±1.5 days vs 40.2±12.3 days, P<0.03). Conclusions: Early intervention after UGI swallow may lessen morbidity. Routine UGI swallow following LRYGBP does not obviate the importance of close clinical follow-up.     

Effect of standard vs extended Roux limb length on weight loss outcomes after laparoscopic Roux-en-Y gastric bypass

Background: Increasing the length of the Roux limb in open Roux-en-Y gastric bypass (RYGB) effectively increases excess weight loss in superobese patients with a body mass index (BMI) >50 kg/m². Extending the RYGB limb length for obese patients with a BMI < 50 could produce similar results. The purpose of this study was to compare the outcomes of superobese patients undergoing laparoscopic RYGB with standard (100-cm) with those undergoing the procedure with an extended (150-cm) Roux limb length over 1-year period of follow-up. Methods: Retrospective data over 2.5 years were reviewed to identify patients with a BMI < 50 who underwent primary laparoscopic RYGB with 1-year follow-up (n = 58). Forty-five patients (sRYGB group) received limb lengths 100 cm, including 45 cm (n = 1), 50 cm (n = 2), 60 cm (n = 6), 65 cm (n = 1), 70 cm (n = 1), 75 cm (n = 3), and 100 cm (n = 31). Thirteen patients (eRYGB group) received 150-cm limbs. Postoperative weight loss was compared at 3 weeks, 3 months, 6 months, and 1 year. Results: Comparing the sRYGB vs the eRYGB group (average ± SD), respectively: There were no significant differences in age (41.5 ± 11.0 vs 38.0 ± 11.9 years), preoperative weight (119.2 ± 11.9 vs 127.8 ± 12.5 kg), BMI (43.7 ± 3.0 vs 45.2 ± 3.5 kg/m²), operative time (167.1 ± 72.7 vs 156.5 ± 62.4 min), estimated blood loss (129.9 ± 101.1 vs 166.8 ± 127.3 cc), or length of stay (median, 3 vs 3 days; range, 2–18 vs 3–19). Body weight decreased over time in both groups, except in the sRYGB group between 3 and 6 months and 6 and 12 months after surgery and in the eRYGB group between 6 and 12 months. BMI also decreased over time, except in the eRYGB group between 6 and 12 months. Absolute weight loss leveled out between 6 and 12 months in both groups, with no increase after 6 months. Percent of excess weight loss did not increase in the eRYGB group after 6 months. An extended Roux limb did not significantly affect body weight, BMI, absolute weight loss, or precent of excess weight loss at any time point when the two groups were compared. A trend toward an increased proportion of patients with >50% excess weight loss (p = 0.07) was observed in the extended Roux limb group. Conclusions: In this series, no difference in weight loss outcome variables were observed up to 1 year after laparoscopic RYGB. Thus, extending Roux limb length from 100 cm to 150 cm did not significantly improve weight loss outcome in patients with a BMI < 50 kg/m².     

Laparoscopic Gastric Bypass versus Laparoscopic Adjustable Gastric Banding in the Super-obese: A Comparative Study of 290 Patients

Background: Controversy exists regarding the best surgical treatment for super-obesity (BMI >50 kg/m 2 ). The two most common bariatric procedures performed worldwide are laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGBP). We undertook a retrospective single-center study to compare the safety and efficacy of these two operations in super-obese patients. Methods: 290 super-obese patients underwent laparoscopic bariatric surgery: 179 LAGB and 111 LRYGBP. Results: There were one death in both groups. The early complication rate was higher in the LAGB group (10% vs 2.8%, P<0.01). Late complication rate was higher in the LAGB group (26% vs 15.3%, P<0.05). Operating time and hospital stay were significantly higher in the LRYGBP group. LRYGBP had significantly better excess weight loss than LAGB (63% vs 41% at 1 year, and 73% vs 46% at 2 years), as well as lower BMI than LAGB (35 vs 41 at 18 months). Conclusion: LRYGBP results in significantly greater weight loss than LAGB in super-obese patients, but is associated with a higher early complication rate.     

A Novel Distal Very Long Roux-en Y Gastric Bypass (DVLRYGB) as a Primary Bariatric Procedure—Complication Rates, Weight Loss, and Nutritional/Metabolic Changes in the First 355 Patients

Proximal Roux-en Y gastric bypass (RYGB) representing the most frequently performed bariatric procedure yields a weight loss failure rate of around 20?%. In order to reduce failure rates, we established a novel distal RYGB variant characterized by a very long alimentary (Roux) limb and a short common channel. Up to 5?years, follow-up data (complication rates, weight loss, nutritional/metabolic changes) of the first 355 patients (mean?±?SD preoperative age, 41.4?±?10.8?years; BMI, 48.5?±?11.5?kg/m(2)) who underwent the novel Distal Very Long Roux-en Y Gastric Bypass (DVLRYGB) were analysed. Overall follow-up rate was 98.9?%, mean follow-up time 1.6?±?1.4?years. Limb lengths were as follows: common channel 76?±?7?cm, biliopancreatic limb 79?±?14?cm, and alimentary (Roux) limb 604?±?99?cm. The operation was performed laparoscopically in 95.2?% of the cases. Thirty-day mortality was zero; major and minor complication rate was 4.5?% and 10.4?%, respectively. Average excess weight loss (EWL) was >74?% 3, 4, and 5?years after the operation and failure rate defined by an EWL?相似文献   

Distal gastric bypass: 2-m biliopancreatic limb construction with varying lengths of common channel

BackgroundLong-term durability after Roux-en-Y gastric bypass is challenging in the super-obese population. Although lengthening of biliopancreatic limb (BPL) is associated with higher rates of weight loss, shortening of common limb (CL) is related to higher risk of malabsorption.ObjectivesIn this study, we aimed at evaluating the importance of the total alimentary limb length by creating a 2-m BPL diversion with varying CL lengths.SettingHigh-volume bariatric center, Norway.MethodsThree groups of patients (N = 187) with different limb lengths were included in this retrospective cohort-analysis as follows: group 1 (n = 69; Roux limb = 150 cm, BPL = 60 cm), group 2 (n = 88; BPL = 200 cm, CL = 150 cm), and group 3 (n = 30; BPL = 200 cm, CL = 200 cm). Weight loss, regain, and failure were analyzed along with malabsorption issues.ResultsPreoperative body mass index (BMI) was higher in group 2 (58.5, P < .001) and 3 (57.4) versus group 1 (54.6, P = .011). No other clinically significant differences between the groups were noted. Follow-up rate was 95% at year 2, 74% at year 5, and 52% at year 10. At 10-year follow-up, excess weight loss and total weight loss was higher in group 2 (70.4%; 40.3%) and 3 (64.0%; 35.9%) compared with group 1 (55.9%; 29.2%). Excess weight loss failure was higher in group 1 versus 2 (30% versus 8.3%, P < .001). No difference in short- or long-term complications was seen except higher occurrence of internal hernia in distal Roux-en-Y gastric bypass groups (11.4%, 6.7%). Vitamin and mineral deficiencies occurred more frequently the shorter the CL was.ConclusionSustainable weight loss in a long-term follow-up is achieved by shortening the total alimentary limb length with a 2-m BPL diversion that should not be attached <200 cm from the ileocecal junction owing to higher rates of internal hernia and vitamin and mineral deficiencies.     

Internal Hernia after Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is associated with a relatively high incidence of internal hernias (IH) when compared to the open operation. Methods: A search in PubMed MEDLINE from January 1994 through January 2006 was performed (keywords: obesity, laparoscopy, gastric bypass and internal hernia). Results: 26 studies with a total of 11,918 patients were considered. 300 cases of IH occurred (rate 2.51%). IH occurred 116 times at the level of the transverse colon mesentery (69%), 30 at the Petersen's space (18%), and 22 at the entero-enterostomy site (13%). 142 re-operations were performed laparoscopically (85.6%), and 24 by laparotomy (14.4%). Bowel resection was done in 5 cases (4.7%). Mortality was 1.17%. Conclusions: IH after LRYGBP has an incidence of 2.51%. Closure of mesenteric defects with non-absorbable running suture and antecolic Roux limb are recommended. Surgical exploration for suspicion of IH after LRYGBP should be first done by laparoscopy.     

Relationship between varying Roux limb lengths and weight loss in gastric bypass

BACKGROUND: The optimal Roux limb length for gastric bypass is unknown. Therefore, the effect of Roux limb length on weight loss and nutritional deficiency after a Roux-en-Y gastric bypass procedure was studied. METHODS: From September 2000 to February 2004, 165 Roux-en-Y gastric bypass surgeries were performed at William Beaumont Army Medical Center. One-year follow-ups were completed on 97 patients. Roux limbs varied from 100 cm to 150 cm, based on the patient's body mass index (BMI). Roux limb lengths were compared with 1-year changes in absolute weight, BMI, and nutritional levels. RESULTS: In the 97 patients, average age at the time of surgery was 44 years (range, 20-63). Average BMI was 46.7 +/- 6.6 kg/m(2) before surgery and 30.9 +/- 5.8 kg/m(2) at 1-year follow-up. Average absolute weight loss at 1 year was 43.7 +/- 12.8 kg. A statistically significant linear relationship existed between Roux limb length and reductions in BMI and absolute weight. No relationship existed between Roux limb length and changes in nutrient levels. CONCLUSION: A linear relationship exists between Roux limb length and 1-year weight loss.     

The effect of Roux limb lengths on outcome after Roux-en-Y gastric bypass: a prospective,randomized clinical trial

Background:The effect of limb-length on weight loss after Roux-en-Y gastric bypass (RYGBP) is controversial; hence, the optimal limb-lengths have not been determined. This study evaluated the effect of different limb-lengths on weight loss after RYGBP. Methods:The study was a prospective randomized clinical trial in which patients undergoing RYGBP (110 F,24 M; mean age 39.7) were randomized as follows: BMI ≤ 50 (N=69): A-75 cm (N=35) vs B-150 cm alimentary limb (N=34) and C-150 cm (N=33) vs D250 cm alimentary limb (N=31). All other aspects of the operation were identical. Patients were followed at 2 weeks, 6 weeks, 6 months, 12 months, 18 months, 24 months and yearly thereafter. Results: There were no significant differences in age, sex, race, initial BMI, or excess weight between patients assigned to groups A vs B and C vs D. Postoperative nutritional intake was also similar between groups. Within each weight category, there were no differences in mean weight loss, change in BMI, and % excess weight lost (EWL) over time. When the number of patients achieving 50% EWL was evaluated, there was no difference between groups with a BMI ≤ 50 kg/m2; however, among patients with a BMI >50 kg/m2, a significantly greater percentage of those having a 250-cm limb achieved >50% EWL at 18 months postoperatively.This difference was lost at 24 and 36 months, possibly due to the small sample size. Conclusions: In patients with a BMI ≤ 50, there appears to be no advantage to longer limb-lengths. In patients with BMI >50, however, these data suggest that longer alimentary limb-lengths may be associated with a higher percent of patients achieving >50% EWL. Longer follow-up studies of the effects of limb-length on success of RYGBP are indicated.     

Five-year outcome with gastric bypass: Roux limb length makes a difference

BackgroundSurgical reports have indicated that longer Roux limbs (150 cm) have greater or no effect on long-term weight loss in super-obese patients (body mass index [BMI] ≥50 kg/m²) and little effect in less obese patients.MethodsThe weight loss outcomes through 5 years were compared in 3 sequential groups of patients, who underwent gastric bypass by 1 surgeon, and in whom the Roux limb lengths were different. Comparisons were made between 2 cohorts: those with a BMI of <50 (morbid obesity [MO]) and those with a BMI ≥50 kg/m² (super obesity [SO]). Three groups of patients stratified by Roux limb lengths were compared: group 1, 41–61-cm Roux limb; group 2, 130–160-cm Roux limb; and group 3, 115–250-cm Roux limb (one third of small bowel). All comparisons were made using 2-way analysis of variance, and the interaction terms were not significant.ResultsA comparable number of patients were in each group, and the average preoperative weights were similar; however, more than twice as many patients in groups 2 and 3 were SO than MO. The BMI loss and weight loss were similar in each group. The greater BMI cohort (SO) lost more weight than did the MO cohort (P <.001). The BMI change and weight change in the shorter Roux limb group were less than those in groups 2 or 3 (longer Roux limbs; P <.01–.05). This difference was established with the BMI by 18 months. The BMI change and weight loss were not different between groups 2 and 3, presumably because their mean Roux limb lengths were not different. A limited amount of weight gain or recidivism occurred in patients with 5 years of follow-up, and it was not different among the 3 groups.ConclusionThe results of this study have shown that longer Roux limbs improve weight loss outcomes both early and late in SO patients but not in MO patients. Clinically used long lengths of Roux limbs are close enough to one third of the total small bowel length such that the weight outcomes were not different, and total length should not need to be measured operatively. The eventual changes attributed to recidivism were not affected by the Roux limb length.     

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

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

Short-term results of laparoscopic gastric bypass in patients with BMI > or = 60

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been shown to be safe and effective. Little information is available about the subgroup of patients with BMI ≥60. The goal of this study was to evaluate the feasibility and safety of LRYGBP for patients with BMI ≥60. Methods: The study consisted of the first 300 attempted LRYGBPs performed by one surgeon (HJS). This population was analyzed as 2 groups of patients: those with BMI <60 and those with BMI ≥60. Outcome variables included mortality, complications, conversion, and operative time. Results: Of the first 300 LRYGBP patients, 261 had BMI <60 and 39 had BMI ≥60. Age, comorbidity rate, and gender distribution were similar in both BMI groups. Conversion rates were <3% in both groups. Mean operative time for the BMI ≥ 60 group was 156 minutes vs 139 minutes in the lighter group (P=0.04). Major complications occurred more commonly in the BMI ≥60 group (10% vs 6%) but this difference was not significant. The types of complications differed between the 2 groups, with infectious complications and gastrointestinal leak occurring more frequently in the heavier group. The mortality rate was higher in the heavier group (5% vs 0.4%, P=0.055). Conclusion: LRYGBP is feasible for patients with BMI ≥60. Our data suggest that these patients are at a higher risk for GI leak, postoperative infection, and death.     

Bowel Obstruction after Laparoscopic Roux-en-Y Gastric Bypass

Background: Bowel obstruction has been frequently reported after laparoscopic Roux-en-Y gastric bypass (LRYGBP). The aim of this study was to review our experience with bowel obstruction following LRYGBP, specifically examining its etiology and management and to strategize maneuvers to minimize this complication. Methods: We retrospectively reviewed the charts of 9 patients who developed postoperative bowel obstruction after LRYGBP. Each chart was reviewed for demographics, timing of bowel obstruction from the primary operation, etiology of obstruction, and management. Results: 9 of our initial 225 patients (4%) who underwent LRYGBP developed postoperative bowel obstruction. The mean age was 46 ± 12 years, with mean BMI 47 ± 9 kg/m². 6 patients developed early bowel obstruction, and 3 patients developed late bowel obstruction. The mean time interval for development of early bowel obstruction was 16 ±16 days. The causes for early bowel obstruction included narrowing of the jejunojenunostomy anastomosis (n=3), angulation of the Roux limb (n=2), and obstruction of the Roux limb at the level of the transverse mesocolon (n=1). The mean time interval for development of late bowel obstruction was 7.4 ± 0.5 months. The causes for late bowel obstruction included internal herniation (n=2) and adhesions (n=1). 6 of 9 bowel obstructions (66%) were considered technically related to the learning curve of the laparoscopic approach. Eight of the 9 patients required operative intervention, and 6 of the 8 reoperations were managed laparoscopically. Management included laparoscopic bypass of the jejunojejunostomy obstruction site (n=5), open reduction of internal hernia (n=2), and laparoscopic lysis of adhesion (n=1). Conclusions: Bowel obstruction is a frequent complication after LRYGBP, particularly during the learn ing curve of the laparoscopic approach. Specific measures should be instituted to minimize bowel obstruction after LRYGBP as most of these complications are considered technically preventable.     

Laparoscopic Roux-en-Y Gastric Bypass with 2-metre Long Biliopancreatic Limb for Morbid Obesity: Technique and Experience with the First 150 Patients

Background: Laparoscopic Roux-en-Y gastric bypass (RYGBP) is being performed widely as a treatment of choice for morbid obesity. We present our method and experience with the first 150 consecutive cases of laparoscopic RYGBP with a 2-m long biliopancreatic limb (BP-limb). Methods: Between November 2001 and November 2003, a prospective analysis of 150 patients was performed identifying technical success and complications. Before surgery, patients underwent a strict multidisciplinary behavioral program. At operation the stomach was transected proximally with a linear stapler (60-mm, Endo-GIA) to create a prolongation of the esophagus (gastric tube) along the lesser curvature, resulting in a 40-50 ml pouch. Two meters of the proximal jejunum were bypassed (BP-limb), creating an antecolic Roux-en-Y gastro-jejunostomy to the posterior wall of the gastric tube using a 45-mm linear Endo-GIA stapler. The entero-anastomosis was created 50 cm below the gastro-jejunostomy, also with a 45-mm linear Endo-GIA. Results: Mean BMI was 50.0, and 78% of patients were females. With 100% follow-up, we found an EWL of 50% 6 months after surgery, gradually rising to 80% after 18 months. The mean operating time was 116 min for the first 50 cases and decreased to 82 min for the last 50 cases. Intestinal leakage occurred in 5 patients (3%) and bleeding in 5 (3%). Most of these complications occurred in the first 50 cases, and all but one were treated successfully with an early laparoscopic re-operation. Marginal ulcers were found in 16.6% of patients. No internal hernias have occurred. Conclusion: The operation demands advanced laparoscopic skills, but technically it is relatively simple and has an acceptable complication rate. Short-term results regarding excess weight loss are at least comparable to the RYGBP with a long alimentary limb.     

Long versus short biliopancreatic limb in Roux-en-Y gastric bypass: short-term results of a randomized clinical trial

BackgroundThe Roux-en-Y gastric bypass continues to be one of the most performed bariatric surgeries because of its adequate balance of outcomes, complications, and durability. Recently, the role of the biliopancreatic limb on weight loss and co-morbidity control has gained attention because it seems to have a positive impact based on limb length.ObjectiveTo compare results at 12 months of a “standard” (group 1) versus a long (group 2) biliopancreatic limb bypass. Biliopancreatic limbs were 50 cm and 200 cm, and alimentary limbs were 150 cm and 50 cm, respectively.SettingAcademic Referal Center; Mexico City; Public Seeting.MethodsRandomized study with patients undergoing both types of surgeries at a single academic center from 2016 to 2018. The analysis included weight loss, co-morbidity control (diabetes and hypertension), biochemical panel, operative outcomes, and complications.ResultsTwo-hundred ten patients were included (105 in each group). Almost all data were homogenous at baseline. Female sex comprised 86.1% of cases, with a mean body mass index of 43.5 kg/m². Excess weight loss (77.6 ± 15.7% versus 83.6 ± 16.7%; P = .011) and total weight loss (33.5 ± 6.4% versus 37.1 ± 7.1%; P < .001) was higher in group 2; better HbA1C levels were also observed. Co-morbidity outcomes, operative data, and complications were similar between groups.ConclusionThe Roux-en-Y gastric bypass with 200 cm of biliopancreatic limb length induces more weight loss at 12 months than a 50 cm limb length. Better HbA1C levels were also observed, but similar effects on co-morbidities and complications were noted.     

Long-or short-limb gastric bypass?

The aim of this study was to determine whether longer limb length improved results of gastric bypass in patients who were morbidly obese (body mass index <50 kg/m²) or superobese (body mass index >50 kg/m²). A total of 242 patients were followed for a mean of 5.5 years. The standard operation was a Roux-en-Y gastric bypass with a 40 cm Roux limb and a 10 cm afferent limb. The long-limb operation had a 100 cm Roux limb and a 100 cm afferent limb. Morbidly obese patients did not benefit from a long-limb bypass. The final body mass index was 28.6 ±4.7 kg/m² in the short-limb group and 28.5 ± 3.8 kg/m² in the long-limb group. The superobese patients did benefit from a long-limb bypass. Final body mass index was 35.8 ±6.7 kg/m² in the short-limb patients and 32.7 ±5.1 in the long-limb patients (P = 0.049). A subgroup of 20 patients, all of whom had a body mass index greater than 60 kg/m², benefited the most from long-limb bypass. No macronutritional side effects unique to the long-limb bypass were encountered.     

Obesity Surgery Results Depending on Technique Performed: Long-Term Outcome

Background  Many techniques have excellent results at 2 years of follow-up but some matters regarding their long-term efficacy have arisen. This is why bariatric surgery results must be analyzed in long-term follow-up. The aim of this study was to extend the analysis over 5 years, evaluating weight loss, morbidity, and mortality of the surgical procedures performed. Methods  This was a retrospective cohort study of the different procedures for morbid obesity practiced in our Department of Surgery for morbid obesity. The results have been analyzed in terms of weight loss, morbidity improvement, and postoperative morbidity (Bariatric Analysis And Reporting Outcome System). Results  One hundred twenty-five patients were operated on open vertical banded gastroplasty (VBG), 150 patients of open biliopancreatic diversion (BPD) of Scopinaro, 100 patients of open modified BPD (common limb 75 cm; alimentary limb 225 cm), and 115 patients of laparoscopic Roux-en-Y gastric bypass (LRYGBP). Mean follow-up was: VBG 12 years, BPD 7 years, and LRYGBP 4 years. An excellent initial weight loss was observed at the end of the second year of follow-up in all techniques, but from this time an important regain of weight was observed in VBG group and a discrete weight regain in LRYGBP group. Only BPD groups kept excellent weight results so far in time. Mortality was: VBG 1.6%, BPD 1.2%, and LRYGBP 0%. Early postoperative complications were: VBG 25%, BPD 20.4%, and LRYGBP 20%. Late postoperative morbidity was: protein malnutrition 11% in Scopinaro BPD, 3% in Modified BPD group, and no cases reported either in VBG group or LRYGBP group; iron deficiency 20% VBG, 62% Scopinaro BPD, 40% modified BPD, and 30.5% LRYGBP. A 14.5% of VBG group required revision surgery to gastric bypass or to BPD due to 100% weight regain or vomiting. A 3.2% of Scopinaro BPD with severe protein malnutrition required revision surgery to lengthen common limb to 100 cm. A 0.8% of LRYGBP required revision surgery to distal LRYGBP (common limb 75 cm) due to 100% weight regain. Conclusions  The most complex bariatric procedures increase the effectiveness but unfortunately they also increase morbidity and mortality. LRYGBP is safe and effective for the treatment of morbid obesity. Modified BPD (75–225 cm) can be considered for the treatment of superobesity (body mass index > 50 kg/m²), and restrictive procedures such as VBG should only be performed in well-selected patients due to high rates of failure in long-term follow-up.