Outpatient Weight Loss Surgery: Initiating a Gastric Bypass and Gastric Banding Ambulatory Weight Loss Surgery Center

Background:

Ambulatory surgery or outpatient surgery is becoming increasingly common. In 2002, 63% of all operations performed in the United States were ambulatory procedures. Bariatric procedures performed in the United States have increased from 16,200 in 1992 to approximately 205,000 in 2007. In 2002, our center began offering laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures on an outpatient basis for select candidates at an ambulatory surgery center (ASC). We subsequently added laparoscopic adjustable gastric band procedures (LAGB) in 2005.

Methods:

Between 2002 and 2008, 248 LRYGB and LAGB patients were carefully selected for ASC surgery by the bariatric surgeon and medical director. Extensive preoperative education was mandatory for all surgical candidates.

Results:

Since 2002, we have performed 248 bariatric cases at the ASC, including 38 LRYGB and 210 LAGB procedures. In this overall experience, 5 patients (2%) required readmission within 30 days of surgery, and 98.6% of LAGB patients were discharged the same day; 62% were discharged after a 4-hour to 6-hour stay in the ASC. All LRYGB patients remained in the ASC overnight and were discharge within 24 hours of their procedure. Weight loss results have been excellent.

Conclusion:

LAGB surgery can be safely performed in an ASC setting in most patients. LRYGB can be performed safely in the ASC setting with careful scrutiny and cautious selection of patient candidates.     

单切口经脐腹腔镜胃旁路术与腹腔镜5孔胃旁路术的比较研究

目的腹腔镜胃旁路手术Roux-en-Y已经成为减重手术的金标准,但常规手术常需要5～7个皮肤切口来放置trocar,因此,切口可能会产生不尽患者满意的结果。我们设计了一个治疗病态肥胖的新技术:单切口经脐胃旁路手术(singleincision transumbilical LRYGB,SITU-LRYGB)。本研究比较腹腔镜5孔胃旁路手术(5-port LRYGB)和SITU-LRYGB手术结果与患者满意度。方法 50例重度肥胖(男14例,女36例)分别接受5-port LRYGB(25例)或SITU-LRYGB(25例)。在肚脐上方以Omega形状切口6 cm,在直接可视下、将3个trocar分置于三角形的三角位置入。术中我们使用新设计的肝脏牵引方法———肝悬吊带。结果术后2组皆未出现接口泄漏或出血并发症。SITU组手术时间较5-port LRYGB组长[(99.8±11.1)min vs(67.6±20.5)min,t=6.906,P=0.000]。对术后切口,SITU组有更高的满意度[(4.5±0.6)分vs(4.0±0.7)分,t=2.712,P=0.009]。结论腹腔镜胃旁路手术可以成功地以单切口经脐方式来施行,除了手术时间短与术后恢复良好之外,几乎无瘢痕是手术最让病人满意的地方。     

30-Day readmission rates at a high volume bariatric surgery center: Laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and vertical banded gastroplasty-Roux-en-Y gastric bypass

Background Recent studies suggest that weight loss operations may actually increase the costs to society due to increased hospital readmission rates. The purpose of this study was to determine the 30-day readmission rates following bariatric operations at a high volume bariatric surgery program. Methods Records for all patients undergoing bariatric operations during a 3-year period were harvested from the hospital electronic medical database. All hospital readmissions within 30 days of surgery were reviewed to determine the cause, demographics, and patient characteristics. Logistic regression analysis assessed the impact of various factors on the risk of readmission. Results 2,823 consecutive patients were identified using the corrected operative log. Of these patients, 165 (5.8%) patients required 184 (6.5%) readmissions within 30 days of their index bariatric operation. Laparoscopic adjustable gastric banding (LAGB) had the lowest patient readmission rate of 3.1%; vertical banded gastroplasty-Roux-en-Y gastric bypass (VBGRYGBP) 6.8% and Laparoscopic Roux-en-Y gastric bypass (LRYGBP) 7.3%. Technical considerations were the most common cause for readmission (41% of readmissions). White race and undergoing LAGB decreased the odds for readmission, while total operating-room time >120 minutes, initial hospital stay of >3 days and deep venous thrombosis increased the odds for readmission. Conclusion This study found an overall 30-day readmission rate of 6.5% following bariatric operations at a high volume bariatric surgery program.This study supports the concept of bariatric surgery Centers of Excellence and accreditation of Bariatric Surgery Programs based on hospital volume of bariatric operations.     

Bariatric Surgery: Low Mortality at a High-Volume Center

BACKGROUND: The American Society of Bariatric Surgery has initiated a Bariatric Surgery Center of Excellence Program and the American College of Surgeons has followed with their Bariatric Surgery Center Network Accreditation Program. These programs postulate that concentration of weight loss operations in high-volume centers will decrease surgical mortality and improve outcomes. METHODS: The purpose of this study was to calculate the in-hospital mortality for bariatric operations accomplished at the highest volume bariatric surgery center in the state of New Jersey. After receiving Institutional Revew Board approval, the revised surgical schedule was used to identify all patients undergoing weight loss surgery (WLS) at Hackensack University Medical Center from 1998 through June, 2006. Data for these patients were then harvested from the hospital's electronic medical record. Step-wise and univariate logistic regression analysis tested the impact of various factors on hospital length of stay and in-hospital mortality. RESULTS: Between 1998 and June, 2006, 5,365 patients underwent WLS surgery: 2,099 open vertical banded gastroplasty-Roux en Y gastric bypass (VBG-RYGB); 2,177 laparoscopic Roux en Y gastric bypass (LRYGB); and 1,089 laparoscopic adjustable gastric banding (LAGB). 75.5% of patients were women. Median age was 41 years old (13-79), median weight 128 kg (81.2-290.3), and median body mass index 46.1 kg/m2 (35.0-92.6). Median total operating room time for VBG-RYGB was 115 min (33-328); LRYGB 155 min (53-493), and LAGB 92 min (33-274). Median length of stay for VBG-RYGB was 3 days (1-39 days), LRYGB 2 days (1-46 days), and LAGB 1 day (1-20). Seven patients died in hospital after the 5,365 WLS operations (0.13%): four after VBG-RYGB (0.19%); three after LRYGB (0.14%); and none after LAGB (0%). The characteristics of the patients who died did not significantly differ from the group as a whole. CONCLUSION: Surgeons at Hackensack University Medical Center, a high volume, accredited 1A American College of Surgeons Bariatric Surgery Center, achieved a 0.13% mortality among 5,365 patients undergoing weight loss operations between 1998 and June, 2006. This study supports the concept that high-volume centers perform bariatric operations with low mortalities.     

Procedural Changes to Decrease Complications in Laparoscopic Gastric Bypass

Methods:A retrospective review of all procedures performed by a fellowship-trained surgeon (MK) from December 1, 2000, to October 31, 2013, identified patients who underwent LRYGB. We evaluated perioperative outcomes in 1117 patients and examined the impact of modification of surgical techniques on complications. The patients were divided into 4 groups: cases 1–100 (group 1), cases 101–400 (group 2), cases 401–700 (group 3), and cases 701-1117 (group 4).Results:Operating time decreased significantly after the initial 100 cases, from 179.1 minutes for group 1 to 122.1 minutes for group 4. With experience, early complication rates improved from 25.0% to 5.0%, but the rates of early reoperation increased from 1.0% to 2.2% over the 4 case groups. Late complication and reoperation rates increased from 4.0% to 10.5%. However, rates of bleeding, early stricture, internal hernia, and wound infection all decreased after the modification of surgical techniques.Conclusions:Operating time and early complication rates decreased with operative experience, but late complication and early and late reoperation rates increased. However, after modifications of surgical technique, common complications of LRYGB decreased to rates lower than those reported in several gastric bypass case series in the literature. The findings in this study will be helpful to fellow bariatric surgeons who are refining their strategies for reducing morbidity related to LRGYB.     

Intestinal Malrotation Discovered at the Time of Laparoscopic Roux-en-Y Gastric Bypass

Four morbidly obese women who met the NIH criteria for bariatric surgery had laparoscopic Roux-en-Y gastric bypass. At operation, each was found to have intestinal malrotation. Two cases were completed laparoscopically, and two were converted to open operation because of difficulty defining the anatomy. All four operations were successful with no immediate complications and patients tolerated the procedures well. We present the four cases and offer recommendations should this unusual congenital defect be discovered at the time of laparoscopic gastric bypass.     

腹腔镜Roux－en－Y胃旁路术

腹腔镜Roux－en－Y胃旁路术(laparoscopic Roux－en－Y gastric bypass, LRYGB)是经典的减重代谢手术术式,属于限制摄入＋减少吸收的混合型减重术式。LRYGB对于2型糖尿病有较高的缓解率,可能与其改变胃肠道激素分泌和旷置十二指肠对胰岛细胞功能的影响有关。LRYGB可以作为合并中重度反流性食管炎或代谢综合征严重的肥胖病人或超级肥胖病人的首选术式。该术式的手术要点包括：①贲门下方建立胃小囊,隔离全部胃底,严格控制胃小囊容积在30 ml以下;②建立食物支和胆胰支,两者长度之和大于200 cm;③严格控制胃肠吻合口直径在1.5 cm以下;④确切关闭系膜缺损预防内疝形成。     

Management of Anastomotic Leaks After Laparoscopic Roux-en-Y Gastric Bypass

Background Anastomotic leaks after bariatric surgery carry high morbidity and mortality. We aimed to describe our experience of the diagnosis and management of gastrointestinal anastomotic leaks in patients undergoing laparoscopic gastric bypass in a single institution. Methods Of 1,200 patients who underwent laparoscopic Roux-en-Y gastric bypass with manual gastrojejunal anastomosis for morbid obesity from January 2002 to January 2007, we retrospectively analyzed 59 patients with anastomotic leak. The location of the leak, day of diagnosis, diagnostic methods, clinical manifestations, treatment modalities, associated complications, and length of hospital stay were analyzed. Results Leaks were located as follows: 67.8% in the gastrojejunostomy, 10.2% in the gastric pouch, 3.4% in the excluded stomach, 5.1% in the jejunojejunal anastomosis, 3.4% in the gastrojejunostomy plus pouch, 3.4% in the pouch plus excluded stomach, and 6.8% in undetermined sites. Routine upper gastrointestinal series revealed contrast extravasation in nine patients (15.3%). Leaks were asymptomatic at diagnosis in 29 patients (49.2%). Surgical reintervention was carried out in 23 patients, and conservative treatment was provided in the remaining 36. Transfer to the intensive care unit was required in 11 patients, with five deaths (0.4%). Conclusion In our experience, most anastomotic leaks can be managed with conservative measures alone. In many patients, abdominal drains are effective in the management of leaks, obviating the need for reintervention. Nasoenteral nutrition was effective in the non-operative management of gastrojejunal leaks in patients without signs of systemic toxicity.     

Internal Hernias and Nonclosure of Mesenteric Defects During Laparoscopic Roux-en-Y Gastric Bypass

Background  Internal hernias have been described after laparoscopic Roux-en-Y gastric bypass (LRYGB) as a major problem. Thus, many routinely close defects during LRYGB. In our technique, we do not close any defects. We hypothesize that not closing the defects would not cause a significant internal hernia rate diagnosed during reoperations. Methods  Patients who were reoperated after LRYGB were included in this study. Only patients who had a laparoscopic or open exploration focused on inspecting for internal hernias are reported here. The LRYGB technique that was utilized included an antecolic, antegastric gastrojejunostomy, minimal division of the small bowel mesentery, a long jejunojejunostomy performed with three staple lines, adequate division of the omentum, and placement of the jejunojejunostomy above the colon in the left upper quadrant. Results  There were a total of 387 patients who had LRYGB from 2002 to 2007 utilizing this particular technique. Fifty-four patients had a reoperation at an average of 24 (Range: 1–60) months postoperatively. The procedures were abdominoplasty, cholecystectomy, diagnostic laparoscopy, and lysis of adhesions. While two patients had a defect present, no patient had an internal hernia despite aggressive attempts to diagnose one. Conclusions  Internals hernias are not common after our particular method of LRYGB. Before adopting and advocating routine closure, surgeons should consider the surgical technique and the true associated incidence of internal hernias. We do not recommend routine closure of these defects with our technique. Presented in part at International Federation for the Surgery of Obesity annual meeting; August 2006; Sydney, Australia.     

Effect of Preoperative Knowledge on Weight Loss After Laparoscopic Gastric Bypass

INTRODUCTION: Gastric bypass surgery has been demonstrated to be an effective treatment for morbid obesity. Unfortunately, not all patients have the same weight loss after surgery. It may be that the more informed patients will have more weight loss than less informed patients. No study has investigated the relationship between initial preoperative knowledge and weight loss after laparoscopic gastric bypass surgery. METHODS: All patients who underwent laparoscopic gastric bypass for a 6-month period were included in this study. Our preoperative education process includes a 21-question true/false test given at the appointment immediately before surgery. Patients repeat the test until all questions are answered correctly. We compared percentage of excess body weight loss (EBWL) between patients who correctly answered all the questions the first time (pass patients) and patients who did not correctly answer all the questions the first time (fail patients). RESULTS: There were 104 patients involved in this study; although complete data were only available on 98 patients. The average preoperative body mass index was 48 kg/m(2). Forty-eight percent of patients answered all the questions correctly the first time. Follow-up ranged from 1 to 2 years on all 98 patients. Pass patients had an average of 73% EBWL, whereas fail patients had an average of 76% EBWL (p = NS). CONCLUSIONS: Preoperative knowledge, assessed by a test, did not predict success after laparoscopic gastric bypass surgery. Patients who do not, at first, have full knowledge of bariatric surgery should not be discriminated against undergoing surgery if they are eventually properly educated.     

The Surgical Treatment of Type II Diabetes Mellitus: Changes in HOMA Insulin Resistance in the First Year Following Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) and Laparoscopic Adjustable Gastric Banding (LAGB)

Background  Bariatric operations significantly improve glucose metabolism, decrease insulin resistance, and lead to clinical resolution of type II diabetes mellitus in many patients. The mechanisms that achieve these clinical outcomes, however, remain ill defined. Moreover, the relative impact of various operations on insulin resistance remains vigorously contested. Consequently, the purpose of this study was to compare directly the impact of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) on hemoglobin A1c (HbA1c) levels and insulin resistance in comparable groups of morbidly obese patients. Methods  Data were entered prospectively into our bariatric surgery database and reviewed retrospectively. Patients selected operations. Principle outcome variables were percent excess weight loss (%EWL), HbA1c, and homeostatic model assessment for insulin resistance (HOMA IR). Results  The number of follow-up visits for 111 LAGB patients was 263 with a median of 162 days (17–1,016) and 291 follow-up visits for 104 LRYGB patients for a median of 150 days (8–1,191). Preoperative height, weight, body mass index, age, sex, race, comorbidities, fasting glucose, insulin, HbA1c, and HOMA IR were similar for both groups. In particular, the number of patients who were diabetics and those receiving insulin and other hypoglycemic agents were similar among the two groups. The LAGB patients lost significantly less weight than the LRYGB patients (24.6% compared to 44.0% EWL). LAGB reduced HbA1c from 5.8% (2–13.8) to 5.6% (0.3–12.3). LRYGB reduced HbA1c from 5.9% (2.0–12.3) to 5.4% (0.1–9.8). LAGB reduced HOMA IR from 3.6 (0.8–39.2) to 2.3 (0–55) and LRYGB reduced HOMA IR from 4.4 (0.6–56.5) to 1.4 (0.3–15.2). Postoperative HOMA IR correlated best with %EWL. Indeed, regression equations were essentially identical for LAGB and LRYGB for drop in %EWL versus postoperative HOMA IR. Conclusion  Percent excess weight loss significantly predicts postoperative insulin resistance (HOMA IR) during the first year following both LRYGB and LAGB.     

Five-Year Follow-up after Laparoscopic Roux-en-Y Gastric and Partial Ileal Bypass for Treatment of Morbid Obesity and Uncontrolled Hyperlipidemia

BACKGROUND: Morbid obesity is associated with significant co-morbid illnesses and mortality. Hyperlipidemia is strongly associated with atherosclerosis and cardiovascular disease. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a proven and effective procedure for the treatment of morbid obesity and its related co-morbid illnesses. In a randomized prospective clinical trial, partial ileal bypass showed sustained control of hyperlipidemia and reduced comorbidities. Given risks of surgery, pharmacologic agents are the current primary therapy for hyperlipidemia. However, a morbidly obese patient with medically refractory hyperlipidemia may benefit from a combined laparoscopic Roux-en-Y gastric bypass and partial ileal bypass. We are describing the first case of a totally laparoscopic approach. METHODS: A 56-year-old female patient with morbid obesity (BMI 45.2 kg/m(2)) and medically refractive hyperlipidemia underwent a combined LRYGB and partial ileal bypass in 2002. She was continuously followed for 5 years for weight profile, hyperlipidemia, post-operative complications, and morbidity. RESULTS: Five-year follow-up of the patient showed sustained excess body weight loss. Her lipid profile has approached normal ranges with less medication. She experienced no comorbidities related to surgery or hyperlipidemia. CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass and partial ileal bypass may be the best option for the patient who has morbid obesity and medically refractory hyperlipidemia and should be considered for select patients.     

Laparoscopic Roux-en-Y Gastric Bypass for Morbidly Obese Chinese Patients: Learning Curve,Advocacy and Complications

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) involves a combination of both restrictive and mal-absorptive mechanisms and has become the procedure of choice for patients with morbid obesity in Western countries. However, its efficacy remains uncertain in Asian populations. We report our pilot experience with LRYGB in a Chinese population. METHODS: Between August 2005 and February 2007, 100 morbidly obese patients received LRYGB. We evaluated the learning curve for the operation, its efficacy in weight reduction, and its postoperative complications. RESULTS: Surgical time reached a plateau after about 50 cases, decreasing from 216 min for the initial 50 patients to 105 min for the final 50. The conversion rate from laparoscopic to open surgery was 2%. The mean percent body mass index loss was 33.9% after 12 months. Twenty-four complications occurred in 18 patients, but most resolved with conservative treatment without mortality. Patients with advanced age (P = 0.04) or hypertension (P = 0.03) were at increased risk for complications leading to prolonged surgical times and hospital stays. The complication rate declined as technical expertise increased. CONCLUSION: In Chinese patients with morbid obesity, LRYGB is promising procedure because of its acceptable learning curve, good efficacy, and low complication rate.     

Clinical Pathway for Laparoscopic Gastric Bypass

Background Patients undergoing bariatric surgery are ideal candidates for a clinical pathway, as it is a standardized, common, and elective procedure and most patients have a predictable clinical course. Objective The aim of developing this clinical pathway is the result of a wide consolidated experience with patients undergoing laparoscopic Roux-en-Y gastric bypass, the purpose of which is to minimize complications without affecting patient care or the outcome of the procedure. Patients and Method The clinical pathway was applied to the 311 patients that received a laparoscopic Roux-en-Y gastric bypass. The clinical pathway includes a temporary matrix, which shows the sequence of events that will occur on each of the days between patient admission and discharge. It also includes medical interventions, nursing care, medication, determinations, physical activity, diet, and information for the patient. Results Complications occurred in 36 patients (11.5%): 14 patients (4.5%) during admission and 22 patients (7%) after discharge. Of the 22 patients presenting with complications after discharge, 12 required readmission to hospital (3.8%), and the other 10 were treated on an ambulatory basis. Conclusions We can say that, because of its frequency and predictability, laparoscopic Roux-en-Y gastric bypass is nowadays a procedure for systematization using a clinical pathway, providing it is controlled by a team with a wide experience in bariatric surgery. This clinical pathway is to offer our patients with morbid obesity a laparoscopic Roux-en-Y gastric bypass with the smallest possible range of complications.     

Band versus bypass: randomization and patients’ choices and perceptions

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are becoming increasingly popular; however, little is understood about patients' motivational factors and reasons for choosing a particular procedure. This investigation explored patient choices and perceptions concerning LRYGB and LAGB. METHODS: A survey was given to 120 consecutive patients who had undergone LRYGB or LAGB 3-24 months earlier. The survey was designed to ascertain why patients chose banding or bypass, and how they rated their surgical outcome. RESULTS: A total of 101 patients responded (84%): 22 had undergone LAGB, 79 LRYGB. The top reason for choosing LRYGB was greater expectation of weight loss, whereas LAGB was chosen for its lower risk. Overall, 21% (18/84) of the patients were willing to be involved in a prospective randomized study of bariatric procedure choice. Six of 19 (32%) patients who underwent LAGB, but only 12 of the 65 (18%) who underwent LRYGB stated that they would be willing to accept randomization between the operations. CONCLUSIONS: Patients expressed varied reasons for choosing their procedure, most related to weight loss or safety profiles. Patients undergoing LAGB would have predicted similar results with either procedure, whereas those undergoing LRYGB showed a trend toward greater overall satisfaction with their operations (p = 0.06) and would have predicted an inferior outcome with the other procedure. Although the overall percentage of patients willing to be randomized is not high, a busy bariatric practice could recruit sufficient numbers of willing patients to undergo a prospective randomized trial of LRYGB and LAGB.     

Factors that predict 30-day readmission after bariatric surgery: experience of a publicly funded Canadian centre

BackgroundHospital readmissions after bariatric surgery can significantly increase health care costs. Rates of readmission after bariatric surgery have ranged from 0.6% to 11.3%, but the rate of complications and the factors that predict readmission have not been well characterized in Canada. The objective of this study was to characterize readmission rates and the factors that predict 30-day readmission in a Canadian centre.MethodsA retrospective study was performed on all patients who underwent bariatric surgery between 2010 and 2015 in a single Canadian centre. Procedures included laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB). Prospectively collected data were extracted from an administrative database. Multivariable logistic regression analysis was performed to determine which factors predict 30-day readmission.ResultsA total of 1468 patients had bariatric surgery (51.0% LRYGB, 40.5% LSG, 8.6% LAGB) during the 6-year study period, with an overall 30-day readmission rate of 7.5%. LRYGB was associated with a higher readmission rate (11.4%) than LSG (3.7%) or LAGB (1.6%). Common reasons for readmission were infection (24.8%), pain (17.4%) and nausea or vomiting (10.1%). Multivariable analysis identified 3 factors that independently predicted readmission: length of stay greater than 4 days (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.03–4.63, p = 0.042), LRYGB (OR 5.21, 95% CI 1.19–22.73, p = 0.028) and acute renal failure (OR 14.10, 95% CI 1.07–186.29, p = 0.045).ConclusionReadmissions after bariatric surgery were most commonly caused by potentially preventable factors, such as pain, nausea or vomiting. Strategies to identify and address factors associated with readmission may reduce readmissions and health care costs after bariatric surgery in a publicly funded health care system.     

Laparoscopic Roux-en-Y Gastric Bypass Surgery on Morbidly Obese Patients with Hypothyroidism

Background It is well known that obesity is accompanied by changes in thyroid function. Hypothyroidism is associated with increased body weight. The aim of this study was to evaluate the operative outcomes, weight loss, and the effect of weight loss on thyroid function in morbidly obese patients with hypothyroidism who undergo laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. Methods A retrospective review of 20 morbidly obese female patients with hypothyroidism and on thyroid replacement therapy who underwent LRYGB between January 2003 and August 2006. Results Mean preoperative body mass index (BMI) was 47.6 kg/m² (range 38–58.5 kg/m²). Average patient age was 44.5 years (range 21–66 years). There was one early complication (pneumonia). Late complications included one death, three anastomotic strictures, and one small bowel obstruction. The patients were followed for a mean of 13.5 months (range 3–24 months). Their mean excess body weight loss was 13 kg (22%), 24.4 kg (39.4%), 33.2 kg (63.3%), 38.4 kg (65%), 41.7 kg (70%), and 43 kg (73%) at 1, 3, 6, 9, 12, and 24 months, respectively. Change in a mean BMI was the same regardless of the patient preoperative and postoperative thyroxine dose. Hypothyroidism resolved in 5(25%) patients, improved in 2(10%) patients, unchanged in 8(40%) patients, and worsened in 5 (25%) patients. Most of the five whose hypothyroidism worsened had thyroid autoimmune disease. Conclusions Hypothyroidism appears to improve in the vast majority of morbidly obese patients who undergo LRYGB, except for those whose thyroid disease is autoimmune in nature.     

Risk Factors for Prolonged Length of Hospital Stay and Readmissions After Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-en-Y Gastric Bypass

Background

Laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (LRYGB) are most commonly performed bariatric procedures. Laparoscopic approach and enhanced recovery after surgery (ERAS) protocols managed to decrease length of hospital and morbidity. However, there are patients in whom, despite adherence to the protocol, the length of stay (LOS) remains longer than targeted. This study aimed to assess potential risk factors for prolonged LOS and readmissions.

Methods

The study was a prospective observation with a post-hoc analysis of bariatric patients in a tertiary referral university teaching hospital. Inclusion criteria were undergoing laparoscopic bariatric surgery. Exclusion criteria were occurrence of perioperative complications, prior bariatric procedures, and lack of necessary data. The primary endpoints were the evaluations of risk factors for prolonged LOS and readmissions.

Results

Median LOS was 3 (2–4) days. LOS > 3 days occurred in 145 (29.47%) patients, 79 after LSG (25.82%) and 66 after LRYGB (35.48%; p = 0.008). Factors significantly prolonging LOS were low oral fluid intake, high intravenous volume of fluids administered on POD0, and every additional 50 km distance from habitual residence to bariatric center. The risk of hospital readmission rises with occurrence of intraoperative adverse events and low oral fluid intake on the day of surgery on.

Conclusions

Risk factors for prolonged LOS are low oral fluid intake, high intravenous volume of fluids administered on POD0, and every additional 50 km distance from habitual residence. Risk factors for hospital readmission are intraoperative adverse events and low oral fluid intake on the day of surgery.

     

Taste change after laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding

BACKGROUND: Many patients have described changes in taste perception after weight loss surgery. Our hypothesis was that patients develop postoperative changes in taste that vary by bariatric procedure. METHODS: Patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic adjustable gastric banding (LAGB) completed a 23-question institutional review board-approved survey postoperatively regarding their degree and type of taste changes and food aversion and how these influenced their eating habits. RESULTS: A total of 127 patients participated. After removing the inadequately completed surveys, 82 LRYGB and 28 LAGB patients were included. Of these, 87% of LRYGB and 69% of LAGB patients believed taste is important to the enjoyment of food. More LRYGB patients (82%) than LAGB patients (46%) reported a change in the taste of food or beverages after surgery (P <.001). In addition, 92% of LAGB versus 59% of LRYGB patients characterized the change as a decrease in the intensity of taste (P <.05). Additionally, 68% of LRYGB and 67% of LAGB patients found certain foods repulsive and had developed aversions. Also, 66% of LRYGB and 70% of LAGB patients believed the taste changes were greater than expected preoperatively. Most patients (83% of LRYGB and 69% of LAGB patients) agreed that the loss of taste led to better weight loss. CONCLUSION: Although most LRYGB and many LAGB patients experienced taste changes and food repulsion postoperatively, procedural differences were found in these taste changes. Taste changes need to be investigated further as a possible mechanism of weight loss after bariatric surgery.     

Predicting Stricture in Morbidly Obese Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass: A Logistic Regression Analysis

Gastrojejunostomy stricture after Roux-en-Y gastric bypass occurs in 3 to 27% of morbidly obese patients in the USA. We questioned whether preoperative patient characteristics, including demographic attributes and comorbid disease, might be significant factors in the etiology of stricture. In this study from November 2001 to February 2006 (51 months), at a high-volume bariatric center, of the 1,351 patients who underwent laparoscopic gastric bypass, 92 developed stricture (6.8%). All but two were treated successfully by endoscopic dilation. All patients stopped nonsteroidal anti-inflammatory medications 2 weeks prior to surgery and did not restart them. The operative procedure included the use of a 21-mm transoral circular stapler to create the gastrojejunostomy; the Roux limb was brought retrogastric, retrocolic. In an effort to reduce our center’s stricture rate, late in the study, U-clips used at the gastrojejunostomy were replaced by absorbable sutures, and postoperative H₂ antagonists were added to the treatment protocol. The change to absorbable polyglactin suture proved to be significant, resulting in a lower stricture rate. The addition of H₂ antagonists showed no significant effect. Following the retrospective review of the prospective database, univariate and multivariate logistic regression analyses identified factors associated with the development of stricture. Gastroesophageal reflux disease and age were each shown to be statistically significant independent predictors of stricture following laparoscopic gastric bypass. Presented at the 2006 Annual Meeting of the Society for Surgery of the Alimentary Tract, May 20–24, Los Angeles, CA (poster presentation).