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

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

Endoscopy after Roux-en-Y Gastric Bypass: A Community Hospital Experience

Background: Roux-en-Y gastric bypass (RYGBP) is a common surgical intervention for morbid obesity. Postoperative GI symptoms are common. This study reports the endoscopic findings in symptomatic patients. Methods: Patients who developed GI symptoms after RYGBP at a single community hospital were referred for endoscopic evaluation. Standard endoscopic procedures using standard endoscopic equipment were used. Results: From April 2002 to April 2004, 23 out of 200 patients underwent 35 endoscopic procedures. All patients complained of some degree of epigastric pain, nausea and vomiting regardless of endoscopic findings. The most common endoscopic finding was ulcer disease (12 patients - 52%). Other findings included normal postoperative anatomy (7 patients - 30%), anastomotic stricture (1 patient - 4.3%), obstructed biliopancreatic limb (1 patient - 4.3%), acute gastric pouch bleed (1 patient - 4.3%), anastomotic rupture/dehiscence (1 patient - 4.3%). H. pylori was not detected in any patient. Conclusions: In patients who have had RYGBP, symptoms were a poor predictor of endoscopic pathology. Ulcer disease was the most common endoscopic finding. These ulcers were not associated with H. pylori. All ulcers responded well to oral proton pump inhibitors (PPI) and sucralfate therapy. The community gastroenterologist should be acquainted with the typical post-surgical anatomy and possible endoscopic intervention for RYGBP patients.     

A Functional Roux-en-Y Gastric Bypass to Avoid Gastric Exclusion: 1-Year Results

Background: Roux-en-Y gastric bypass (RYGBP) is rarely performed in Italy because it involves gastric exclusion. RYGBP with the stomach partitioned by an adjustable gastric band has been previously described. We have developed a functional RYGBP (FRYGBP) where an adjustable band allows access from a stapled gastric bypass pouch into the distal stomach. Methods: From October 2001 to May 2002, 16 patients underwent FRYGBP. A 30-cc vertical gastric pouch was fashioned by a 25-mm circular and 90-mm four-row stapler as in the Mason VBG. A hand-sewn retrocolic gastroenterostomy with 150-cm Roux and 30-cm afferent limbs completed the operation. The pouch outlet was encircled distal to the gastrojejunostomy by a non-inflated adjustable gastric band. The bands were inflated at 1 month during barium swallow, to demonstrate occlusion of the gastro-gastric outlet and patency of the gastrojejunostomy. Results: There was no operative mortality. After 1 year, mean percent excess BMI loss (%EBMIL) was 71.2 ± 16.2% (SD), and gastroscopy of the bypassed stomach was possible on 81% of the patients. There were three asymptomatic late complications (19%): two band erosions, converted to RYGBP, and one stenosis of the gastro-gastric outlet. Conclusion: FRYGBP thus far has been effective and allows the study of the excluded stomach. This ongoing study will undergo long-term evaluation.     

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

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

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

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

Management of Acute Bleeding after Laparoscopic Roux-en-Y Gastric Bypass

Background: The authors reviewed the incidence of hemorrhage after laparoscopic Roux-en-Y gastric bypass (LRYGBP). The purpose of this study was to determine the incidence of this complication and to evaluate various treatment options. Material and Methods: The records for 450 consecutive patients who had undergone LRYGBP over a 30-month period, were retrospectively reviewed. In all patients, the abdominal cavity had been drained with 2 19-Fr closed suction drains. The charts of patients who had developed an intraluminal or an intraabdominal bleed were chosen for further review. Results: 20 patients (4.4%) developed an acute postoperative hemorrhage. The bleeding was intraluminal in 12 cases (60%), manifested by a drop in hematocrit, tachycardia and melena. The other 8 patients (40%) developed intra-abdominal hemorrhage, confirmed by large bloody output from the drains. 3 patients (15%) with intraluminal bleeding were unstable and required a reoperation. All others were successfully treated with observation, and 15 patients (75%) required blood transfusions. Conclusions: The diagnosis and treatment of acute intraluminal bleeding after LRYGBP represents a surgical dilemma, mainly due to the inaccessibility of the bypassed stomach and the jejuno-jejunostomy, as well as the risks associated with early postoperative endoscopy. The presence of large intra-abdominal drains allows for bleeding site localization (intraluminal vs intraabdominal) and for more accurate monitoring of the bleeding rate. Most cases respond to conservative therapy. Failure of conservative management of intraluminal bleeding, however, is more problematic and may require operative intervention. A treatment algorithm is proposed.     

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

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

Laparoscopic Roux-en-Y Gastric Bypass in Patients with Congenital Malrotation

Bariatric surgery is the only solution for morbidly obese individuals who desire to lose weight and maintain it and have failed to do so by non-surgical means. As the incidence of morbid obesity rises, laparoscopic Roux-en-Y gastric bypass (LRYGBP) is increasingly performed. With the increase in bariatrics, the chances of discovering aberrant anatomy at the operating-table also increase. We present two cases of LRYGBP in patients with intestinal malrotation, which is a congenital anomaly caused by failure of the intestines to rotate and fixate at 270° during embryonic development. It occurs in one out of every 500 births in the United States, accounting for 5% of all intestinal obstructions. To this date, only three reports have been published describing the incidental finding of congenital malrotation during the initial laparoscopic exploration for gastric bypass. We found that the operation can still be performed laparoscopically in such patients, with some modifications to the standard technique.     

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.     

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

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

Lumbar Muscle Rhabdomyolysis as a Cause of Acute Renal Failure after Roux-en-Y Gastric Bypass

Background: Rhabdomyolysis occurs when injury to skeletal muscle disrupts the integrity of the sarcolemmal membrane, allowing release of intracellular proteins into the circulation. Serious complications, such as hyperkalemia, hypocalcemia, hyperphosphatemia, compartment syndrome, cardiac dysrhythmias, disseminated intravascular coagulation, and acute renal failure can develop if diagnosis and treatment are delayed. Methods: A morbidly obese patient is presented who developed this rare complication after Roux-en-Y gastric bypass. Etiology, pathophysiology, complications, diagnosis and treatment are reviewed, to enable prompt treatment. Results: The patient was treated with crystalloid resuscitation, mannitol, and sodium bicarbonate, and underwent 3 courses of hemodialysis. Normal renal function returned by postoperative day 5. Conclusions: Morbidly obese patients are at higher risk for developing postoperative rhabdomyolysis, likely because of increased compressive pressure due to the patient's weight. Surgeons should consider rhabdomyolysis in morbidly obese patients who experience postoperative oliguria. Frequent position changes during operations lasting more than 2 hours can protect muscle tissue from compressive injury.     

Band Erosion after Laparoscopic Gastric Banding: Occurrence and Results after Conversion to Roux-en-Y Gastric Bypass

Background: Laparoscopic adjustable gastric banding is a popular bariatric operation. Unfortunately, long-term complications such as slippage, infection, and intragastric migration (erosion) may occur. With erosion, band removal is mandatory. Options to prevent weight regain are delayed implantation of a new band, or conversion to another bariatric procedure such as Roux-en-Y gastric bypass (RYGBP) or biliopancreatic diversion. We present our experience with band erosion and immediate or delayed conversion to RYGBP. Methods: With a multidisciplinary team approach and prospective data collection, a comparison was made between patients with and without band erosion. The patients who were converted to RYGBP for band erosion were analyzed. Results: Gastric banding was performed on 347 patients between 1995 and 2002. Median follow-up is 52 months. Band erosion developed in 24 patients (6.8 %).The latter were heavier before gastric banding (BMI 45.9 vs 43.3, P <0,01). No band had ever been overinflated. Band erosion was diagnosed after a mean of 22.5 months (3-51). At time of diagnosis, mean BMI of 33.5 kg/m² (22.5-48) and average excess weight loss (EWL) of 52.9% (25-97) did not differ from that of the remaining patients at the respective time interval. The band was removed in all cases. Conversion to RYGBP was performed at the same time in 11, and a few months later in 2 patients. Operative morbidity included 1 leak (reoperation) and 4 wound infections. All but 1 patient lost further weight after reoperation, or at least maintained their weight. At last follow-up, mean EWL in relation to the pre-banding weight was 65.1%, and 69.2% of the patients had an EWL >50%, which compares favorably with the results obtained after primary RYGBP. Conclusions: In our series with a median follow-up >4 years, band erosion was more common than usually reported. Band removal with immediate or delayed conversion to RYGBP is feasible with an acceptable morbidity, and prevents weight regain in most cases. These results support further use of this approach for band erosion.     

Revision of Failed Gastric Restrictive Operations to Roux-en-Y Gastric Bypass: Impact of Multiple Prior Bariatric Operations on Outcome

Background: Morbid obesity is now an epidemic with considerable associated morbidity for which bariatric surgery has been the only effective treatment. Despite its success, occasional patients require revision because of weight regain or mechanical complications. The impact of multiple prior bariatric operations on complications and weight loss after revision to Roux-en-Y gastric bypass (RYGBP) was evaluated. Methods: All patients undergoing revisional surgery to RYGBP by the senior author from 1997 through 2004 were retrospectively reviewed at a multi-center academic institution. Patients who had previously undergone multiple revisional operations (MR) were compared to patients who had undergone primary ("first-time") revision (PR). Demographics, indications for revision, complications, and weight loss were reviewed. Results: 66 patients underwent open revision to RYGBP after failed bariatric operations, with 12 in the MR group and 54 in the PR group. Mean preoperative BMI was 46.1 and 45.2 (P=0.8), respectively. Operative time (227 vs 162 min, P=0.07), blood loss (517 vs 313 ml, P=0.09) and hospital length of stay (11.5 vs 6.7 days, P=0.2) were higher in the MR group. Major perioperative complications occurred in 16.7% of MR patients compared to 9.3% of PR patients (P=0.6). Percent of excess weight loss (%EWL) has been 54.3% in the MR group and 60.6% in the PR group (P=0.6). Average follow-up is 26 and 23 months, respectively. Conclusion: Although operative times, blood loss, and LOS were greater in MR patients, RYGBP can be performed in patients with multiple previous bariatric operations with acceptable weight loss and complication rates.     

Totally Robotic Laparoscopic Roux-en-Y Gastric Bypass: Results from 75 patients

Background: A technique for Totally Robotic Laparoscopic Roux-en-y Gastric Bypass (TRL-RYGBP) has been reported previously. In this paper, we report our experience with our first 75 TRLRYGBP operations, including the training of three laparoscopic fellows. We describe changes in technique that have evolved with more experience, lessons learned, and the results from a larger series. Methods: A retrospective review was conducted of the first 75 TRLRYGBP procedures performed at our institution using the da Vinci surgical robot. We recorded demographics including patient age, gender, preoperative BMI, and numbers of NIH-defined co-morbidities. Data were collected on operative time, length of stay, complications, and postoperative weight loss. Results were compared between the three fellows to examine learning curves. Results: The average patient age was 44 years (23-61), average BMI was 46.1 kg/m² (34.3-65.5), and the median number of NIH defined co-morbidities was 1 (0-3). Median operative time was 140 minutes (80-312) with mean operative time per BMI of 3.1 minutes (1.6-5.7). Excess weight loss was 48% at 3 months, 64% at 6 months, and 82% at 1 year. The overall complication rate was 22.6% (5.3% intraoperative, 8.0% major, and 9.3% minor including a 2.9% stricture rate and 0% leak rate). Each fellow demonstrated a learning curve of 10-15 cases. Conclusion: The authors' continued experience with the TRLRYGBP has confirmed our early results that the use of the da Vinci robot for laparoscopic gastric bypass is a superior alternative to the standard laparoscopic RYGBP, and that the learning curve is significantly faster.     

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

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

Laparoscopic Roux-en-Y Gastric Bypass with Remnant Gastrectomy for Focal Intestinal Metaplasia of the Gastric Antrum

Background: Inaccessibilility of the excluded stomach after isolated gastric bypass prevents postoperative evaluation and treatment of disorders of the gastric remnant. Bleeding complications, peptic ulcer disease, and gastric malignancy in the gastric remnant have all been reported. We report a patient with morbid obesity and focal intestinal metaplasia in the antrum of the stomach that was treated with laparoscopic Roux-en-y gastric bypass (LRYGBP) with remnant gastrectomy. Case Report: A 46-year-old female with a long history of morbid obesity presented with a BMI of 47 kg/m². Preoperative upper endoscopy revealed focal intestinal metaplasia. Since intestinal metaplasia is a risk factor for gastric cancer, a LRYGBP with remnant gastrectomy was performed. Conclusions: LRYGBP with remnant gastrectomy is a safe and cost-effective treatment for morbidly obese patients with focal intestinal metaplasia of the stomach.     

Silastic Ring Vertical Gastric Bypass: Evolution of an Open Surgical Technique,and Review of 1,588 Cases

Background: Silastic ring vertical gastric bypass (SRVGBP) has evolved from a stapled (SSRVGBP) to a transected (TSRVGBP), and finally to a transected pouch with jejunal interposition (TSRVGBP with J-I). The creation of the gastroenterostomy evolved from a hand-sewn to a stapled and finally to a combined stapled and hand-sewn anastomosis. The circumference of the ring was increased from 5.5 to 6.0 cm. We address the effect of these modifications on surgical outcome. Method: The records of 1,588 consecutive patients (mean BMI of 44.5) since 1990 who had a SRVGBP were indentified from a prospective data-base of all patients undergoing bariatric operations. 205 patients with a prior bariatric operation were excluded from the review, leaving 1,383 patients who had a primary SRVGBP. Results: In the 193 SRVGBP patients, there was 1 gastric leak (0.5%) and 64 gastrogastric fistulas (33.2%). In the 165 TSRVGBP patients, there were 4 gastric leaks (2.4%) and 14 gastrogastric fistulas (8.5%). In the 1,025 patients with TSRVGBP with JI, there were 8 gastric leaks (0.8%) and no gastro-gastric fistulas. In the TSRVGBP with J-I, 367 patients had a hand-sewn, 16 a stapled, and 642 a combined stapled and hand-sewn anastomosis. Stricture rate was 3.8%, 31%, and 2.6% respectively. There were 7 ring migrations (0.7%), all in the totally hand-sewn group. Ring removal was necessary in 20 (5%) with a 5.5-cm and 4 (0.74%) with a 6.0-cm ring. Conclusion: TSRVGBP with J-I with a combined stapled and hand-sewn gastrojejunal anastomosis using a 6.0-cm ring decreased the incidence of complications, and is our current technique.     

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

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

Laparoscopic Roux-en-Y Gastric Bypass 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.     

Loss of Insulin Resistance after Roux-en-Y Gastric Bypass Surgery: a Time Course Study

Background: Gastric bypass has repeatedly been shown to improve and even cure type 2 diabetes by substantially improving insulin resistance. The mechanism by which it achieves this is not currently known, but some have hypothesized that there may be important humoral effects brought about by the bypass of the stomach, duodenum or proximal jejunum. A better understanding of the time course of the changes in insulin resistance after surgery might assist our understanding of potential mechanisms. Methods: Intravenous glucose tolerance tests (IVGTT) were performed in 26 severely obese patients on the morning of gastric bypass surgery and again 6 days later. In addition insulin resistance was assessed in 71 patients undergoing gastric bypass surgery by the homeostasis model assessment (HOMA) method before surgery, and again at 6 days, 3, 6, 9, and 12 months. Patients were divided into 3 groups for analysis: diabetics, impaired glucose tolerance and normal glucose tolerance. Results: All 3 groups of patients were noted to have insulin resistance prior to surgery. This was greatest in the diabetic patients, as indicated by HOMA. There was marked loss of/improvement in insulin resistance within 6 days of gastric bypass by both IVGTT and HOMA methods in all groups, which was maintained over the 12-month period. The study included 31 diabetic patients, of whom only 3 required medication following hospital discharge. Conclusion: The changes in insulin resistance seen after gastric bypass, which are responsible for the resolution or improvement of type 2 diabetes occur within 6 days of the surgery, before any appreciable weight loss has occurred. This finding has implications for our understanding of the mechanism of insulin resistance in severely obese patients and is consistent with a humoral mechanism emanating from the GI tract.