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.     

A Case-Controlled Matched-Pair Cohort Study of Laparoscopic Roux-en-Y Gastric Bypass and Lap-Band® Patients in a Single US Center with Three-Year Follow-up

Background: Open or laparoscopic Roux-en-Y gastric bypass (RYGBP) is the most common operation for treatment of morbid obesity in USA. The laparoscopic adjustable gastric band (LAGB) has been the most common bariatric operation performed worldwide. The LapBand^? was approved for use in USA in July 2001. Since then, several US surgeons have adopted one procedure preferentially over the other, and several have reported patient outcomes. We added the option of the LAGB to the RYGBP in our practice in July 2001. We hypothesized that both procedures will provide similar weight loss and co-morbidity reduction if followed for a sufficient length of time. To enhance weight loss, we adopted a patient behavioral program that is easy to remember, in an attempt to ensure a reduction in caloric intake and reduce hunger regardless of the operation performed. Methods: A case-controlled matched-pair cohort study was conducted. All patients who presented to the Surgical Weight Control Center of Las Vegas between Aug 2001 and Aug 2004 for LAGB were placed into one group, and a matched-pair RYGBP cohort group was created. Patients in the RYGBP cohort were matched for age, sex, date of surgery, and BMI. All patients were evaluated on an intention to treat basis. Data were collected prospectively and analyzed retrospectively. All patients were subjected to the same preoperative education regarding calorie reduction behaviors and diet change, and received the same postoperative counseling regarding long-term eating behavior and food choices. Results: During this period, 208 patients underwent LAGB and 600 underwent RYGBP. Of the 208 LAGB patients, 181 had suitable open or laparoscopic RYGBP matches. The two groups were similar in terms of age, sex, BMI, and co-morbidities. There were no deaths in either group. Resolution of co-morbidities statistically favored RYGBP as did the weight loss, over the study period. Conclusion: When patients are matched with 3-year follow-up according to time of surgery, age, sex and BMI, LRYGBP provides superior weight and co-morbidity reduction and can be done without severe complications. However, the LAGB is an effective weight loss tool and not every patient wishes to have the LRYGBP.     

Stroke and Seizure following a Recent Laparoscopic Roux-en-Y Gastric Bypass

Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been an available operation for weight loss for the past decade, and bariatric surgery is increasing in the United States. Careful patient screening and follow-up have been the cornerstone for success against the complexities of morbid obesity. Neurologic complications have occurred, such as polyneuropathy and Wernicke-Korsakoff syndrome. We report an 18-year-old female with morbid obesity, steatohepatitis, tobacco, recreational drug, and oral contraceptive use who at 4 months after LRYGBP experienced a generalized seizure and stroke. She was diagnosed with an acute ischemic stroke, possibly venous infarction. Her postoperative course had been complicated by malnutrition and dehydration, apparently related to nausea from chronic cholecystitis. She had a possible protein-S deficiency. Rare neurologic complications emphasize the importance of postoperative surveillance in these patients.     

Randomized clinical trial of laparoscopic Roux-en-Y gastric bypass versus laparoscopic vertical banded gastroplasty for obesity

BACKGROUND: Laparoscopic techniques have been developed for performing Roux-en-Y gastric bypass (LRYGBP) and vertical banded gastroplasty (LVBG) in patients with morbid obesity. It is not certain, however, which is the better technique in non-superobese patients (body mass index less than 50 kg/m(2)). METHODS: Eighty-three patients (LRYGBP 37, LVBG 46) were assessed in a randomized clinical trial. Perioperative complications were recorded together with preoperative and postoperative respiratory function and mobilization rate. Patients were monitored for 2 years after operation with regard to weight change and the need for remedial surgery. RESULTS: There were no conversions to open surgery. The mean operating time was longer for LRYGBP than LVBG (138 versus 105 min). Five early reoperations were performed after LRYGBP (three for haemorrhage, one for ileus and one suspected leak) and one after LVBG (suspected leak). There were no differences in postoperative respiratory function or mobilization. Weight reduction was greater after LRYGBP (excess weight loss 78.3 versus 62.9 per cent 1 year after surgery, P = 0.009; 84.4 versus 59.8 per cent at 2 years, P < 0.001). Remedial surgical intervention was required in eight patients after LVBG (conversion to Roux-en-Ygastric bypass) and none after LRYGBP. CONCLUSION: LRYGBP and LVBG were comparable in terms of operative safety and postoperative recovery, but weight reduction was better after LRYGBP.     

Laparoscopic reoperation for early complications of laparoscopic gastric bypass

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a popular operation for morbid obesity.Early complications can be treated successfully with a laparoscopic approach.We reviewed our experience with laparoscopic re-exploration in the early postoperative period. Methods: The initial 85 patients who underwent LRYGBP by two surgeons at a training hospital were reviewed. All patients who required re-exploration within the first 60 days postoperatively were considered. Results: Nine patients underwent ten laparoscopic explorations. Mean BMI was 50 kg/m². One patient underwent revision for proximal anastomotic obstruction at 58 days postoperatively. Three patients developed obstruction at the level of the transverse mesocolon secondary to cicatrix and required laparoscopic release of the scar tissue.Two patients required revision of the jejuno-jejunostomy. Internal hernia through the mesenteric defect at the level of the transverse mesocolon was the cause of bowel obstruction in two patients. One patient underwent lysis of adhesions between the left colon and the transverse mesocolon at 6 days postoperatively. One out of the ten laparoscopic re-explorations was negative for any findings. Eight patients recovered without further complications and one patient required endoscopic dilatations of the proximal anastomosis. Conclusion: In the course of treating morbid obesity with laparoscopic intervention, complications will arise. Laparoscopic exploration for early complications is a safe and feasible option.     

Complications of the Laparoscopic Roux-en-Y Gastric Bypass: 1,040 Patients - What Have We Learned?

Background:The Roux-en-Y gastric bypass (RYGBP) is one of the most common operations for morbid obesity. Laparoscopic techniques have been reported, but suffer from small numbers of patients, longer operative times and seemingly higher initial complication rates as compared to the traditional "open" procedure. The minimally invasive approach continues to be a challenge even to the most experienced laparoscopic surgeons.The purpose of this study is to describe our experience and complications of the laparoscopic Roux-en-Y gastric bypass with a totally hand-sewn gastrojejunostomy. Methods: 1,040 consecutive laparoscopic procedures were evaluated prospectively. Only patients who had a previous open gastric procedure were excluded initially. Eventually, even patients with failed "open" bariatric procedures and other gastric procedures were revised laparoscopically to the RYGBP. All patients met NIH criteria for consideration for weight reductive surgery. Results:There were no anastomotic leaks from the hand-sewn gastrojejunostomy. Early complications and open conversions were related to sub-optimal exposure and bowel fixation techniques. Several staple failures were attributed to a manufacturer redesign of an instrument. Average hospital stay was 1.9 days for all patients and 1.5 days for patients without complications. Operative times consistently approach 60 minutes. Average excess weight loss was 70% at 12 months.There were 5 deaths: perioperative pulmonary embolism (1), late pulmonary embolism (2), asthma (1), and suicide (1). Conclusions: The laparoscopic Roux-en-Y gastric bypass for morbid obesity with a totally hand-sewn gastrojejunostomy can be safely performed by the bariatric surgeon with advanced laparoscopic skills in the community setting. Fixation and closure of all potential hernia sites with non-absorbable sutures is essential. Stenosis of the hand-sewn gastrojejunal anastomosis is amenable to endoscopic balloon dilation. Meticulous attention must be paid to the operative and perioperative care of the patient.     

Predictors of Prolonged Hospital Stay following Open and Laparoscopic Gastric Bypass for Morbid Obesity: Body Mass Index,Length of Surgery,Sleep Apnea,Asthma and the Metabolic Syndrome

Background: The number of weight reduction operations performed for type II and type III obesity is rapidly escalating. Risk of surgery has been infrequently stratified for patient subgroups. The purpose of this study was to identify patient characteristics that increased the odds of a prolonged hospital length of stay (LOS) following open or laparoscopic Roux-en-Y gastric bypass (RYGBP). Methods: The hospital records of 311 patients who underwent RYGBP in a 6-month period were retrospectively reviewed. Patient characteristics including the presence of significant obesity-related medical conditions were recorded. Analysis was based on intent to treat. Univariate and step-wise logistic regression analysis was used to identify the odds ratio (OR) and adjusted odds ratio (AOR) for predictors of an increased hospital LOS. Results: Datasets for 311 patients were complete. 159 patients underwent open vertical banded gastroplasty-Roux-en-Y gastric bypass (VBG-RYGBP) and 152 laparoscopic RYGBP (LRYGBP). 78% of patients were female. Median age was 40 years (range 18-68). Median BMI was 49 kg/m² (range 35-82). 17% of patients had sleep apnea, 18% asthma, 19% type 2 diabetes, 13% hypercholesterolemia and 44% hypertension. Median length of surgery for open VBG-RYGBP (64 minutes) was significantly faster than for LRYGBP (105 minutes). Median length of stay was significantly shorter for LRYGBP (2 days) than open VBG-RYGBP (3 days). Univariate logistic regression analysis identified 6 predictors of increased LOS: open surgery (0.4 OR); increasing BMI (60 kg/m² 0.38 OR; BMI 70 kg/m² 0.53 OR); increasing length of surgery (120 min 0.33 OR; 180 min 0.48 OR); sleep apnea (2.25 OR); asthma (3.73 OR); and hypercholesterolemia (3.73 OR). Subset analysis identified patients with the greatest odds for a prolonged hospital stay: women with asthma (2.47 AOR) or coronary artery disease (8.65 AOR); men with sleep apnea (5.54 OR) or the metabolic syndrome (6.67 – 10.20 OR); and patients undergoing a laparoscopic operation with sleep apnea (11.53 AOR) or coronary artery disease (12.15 AOR). Conclusions: Open surgery, BMI, length of surgery, sleep apnea, asthma and hypercholesterolemia all increased the odds of a prolonged LOS. Patients with the greatest odds of long LOS were women with asthma or coronary disease, men with sleep apnea or the metabolic syndrome, and patients undergoing laparoscopic surgery with sleep apnea or coronary artery disease. Patients at high-risk for prolonged hospital stay can be identified before undergoing RYGBP. Surgeons may wish to avoid high-risk patients early in their bariatric surgery experience.     

Virtual Gastroduodenoscopy: A New Look at the Bypassed Stomach and Duodenum After Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Background: After open or laparoscopic Roux-en-Y gastric bypass (RYGBP) for morbid obesity, the bypassed stomach and duodenum are not readily available for radiological and endoscopic evaluation. Furthermore, little is known about the long-term physiologic and histologic changes that occur in the bypassed GI segments following these procedures. Many alternative radiological and endoscopic techniques have been described to access the distal gastric pouch and the duodenum after RYGBP. Apart from percutaneous gastrografin? studies, all these techniques require the insertion of a gastrostomy tube in the distal stomach. Methods: a new diagnostic method to access the bypassed segments by virtual CT gastroscopy (VG) was used in 5 morbidly obese patients who underwent laparoscopic RYGBP (LRYGBP). Results: All patients tolerated the procedure well, which appears safe and suitable for an outpatient setting.The virtual images offered an excellent intraluminal view of the stomach and duodenum. Conclusions: VG holds promise as the method of choice in the follow-up of LRYGB patients, having the potential to detect inflammatory changes and cancer in the excluded segments early.     

Is Routine Cholecystectomy Necessary at the Time of Roux-en-Y Gastric Bypass?

Background: Morbid obesity is associated with an increased incidence of gallstones. Rapid weight loss, as occurs after Roux-en-Y gastric bypass (RYGBP) may also increase gallstone development. Standard surgical treatments for gallbladder disease and its complications might be more difficult following RYGBP. Controversy still exists whether prophylactic cholecystectomy is indicated at the time of RYGBP. Methods: Retrospective analysis was performed on a database of 535 patients who underwent RYGBP for morbid obesity during a 5.5-year period. Patients were followed and medical records were reviewed. Ursodeoxycholic acid was not prescribed following surgery. Results: 8% of patients had had cholecystectomy before the RYGBP. 75 of 492 patients (15%) were found to have gallstones at RYGBP, and cholecystectomy was performed at the same time. 3 of these patients had bile leaks but only 1 required further intervention (percutaneous transhepatic drainage for 3 weeks). Following RYGBP, 14 patients (3%) have required cholecystectomy for symptomatic cholelithiasis in the postoperative period. All were performed laparoscopically and without complication. Conclusions: Symptomatic gallbladder disease after RYGBP has not been frequent. Prophylactic cholecystectomy for a normal gallbladder is not necessary at the time of RYGBP. Patients without biliary tract symptoms may not require routine preoperative sonogram. If an abnormal gallbladder or gallstones are found at the time of an RYGBP operation, concomitant cholecystectomy should be considered.     

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.     

Laparoscopic Roux-en-Y gastric bypass--evaluation of three different techniques

Background:The Roux-en-Y gastric bypass (RYGBP) is one of the ideal operations for morbid obesity.The minimal invasive laparoscopic technique has been performed to shorten the operative time and to reduce the complications of the open surgery. Methods: From Jan 1999 through Jan 2001, laparoscopic RYGBP (LRYGBP) was attempted in 90 patients. Median age was 30, with median preoperative BMI 47. The preoperative nutritional habits and comorbidities were recorded. LRYGBP was done by three different techniques in three equal groups. In the first group, the gastrojejunostomy was constructed by passing the EEA anvil transorally, using a pull-wire technique. In the second group, the gastrojejunostomy was fashioned with a totally hand-sewn technique. In the third group, the gastrojejunostomy was performed with an endo-cutter cartridge and the anastomotic incision was closed with an endo TA30 stapler. Results: The results were nearly identical in the three groups. Average excess weight loss at 1 year was 70%. The mean operating time was 120 min in the first group, 100 min in the second group and 75 min in the third group. Esophageal injury was the most common problem in the first group. Incidence of gastrojejunostomy stenosis was higher in the second group (36.6%). Incidence of internal herniation was higher in the second (17%) and first (13.6%) groups than in the third group (3.3%). Conclusion: Whichever technique is used to construct the gastrojejunostomy, LRYGBP is a safe, effective and technically feasible operation for morbidly obese patients. We recommend the technique of constructing the gastrojejunostomy with an endocutter cartridge and closing the anastomotic incision with an endo TA stapler, as it saved time and reduced the incidence of the essential complications in gastric bypass surgery.     

Lower Ghrelin Levels and Exaggerated Postprandial Peptide-YY, Glucagon-Like Peptide-1, and Insulin Responses, After Gastric Fundus Resection, in Patients Undergoing Roux-en-Y Gastric Bypass: A Randomized Clinical Trial

Background

Laparoscopic Roux-en Y-Gastric bypass (LRYGBP) is the commonest available option for the surgical treatment of morbid obesity. Weight loss following bariatric surgery has been linked to changes of gastrointestinal peptides, shown to be implicated also in metabolic effects and appetite control. The purpose of this study was to evaluate whether gastric fundus resection in patients undergoing LRYGBP enhances the efficacy of the procedure in terms of weight loss, glucose levels, and hormonal secretion.

Methods

Twelve patients underwent LRYGBP and 12 patients LRYGBP plus gastric fundus resection (LRYGBP+FR). All patients were evaluated before and at 3, 6, and 12?months postoperatively. Blood samples were collected after an overnight fast and 30, 60, and 120?min after a standard 300-kcal mixed meal.

Results

Body weight and body mass index decreased markedly and comparably after both procedures. Fasting ghrelin decreased 3?months after LRYGBP, but increased at 12?months to levels higher than baseline while after LRYGBP+FR was markedly and persistently decreased. Postprandial GLP-1, PYY, and insulin responses were enhanced more and postprandial glucose levels were lower after LRYGBP+FR compared to LRYGBP. Postoperatively, ghrelin changes correlated negatively with GLP-1 changes.

Conclusions

Resection of the gastric fundus in patients undergoing LRYGBP was associated with persistently lower fasting ghrelin levels; higher postprandial PYY, GLP-1, and insulin responses; and lower postprandial glucose levels compared to LRYGBP. These findings suggest that fundus resection in the setting of LRYGBP may be more effective than RYGBP for the management of morbid obesity and diabetes type 2.     

Internal Hernias after Laparoscopic Roux-en-Y Gastric Bypass: Incidence,Treatment and Prevention

Background: Laparoscopic Roux-en-Y gastric bypass (RYGBP) has been shown to be a safe and effective alternative to traditional "open" RYGBP. Although lack of postoperative adhesions is one advantage of minimally invasive surgery, this is also responsible for a higher incidence of internal hernias. These patients often present with intermittent abdominal pain or small bowel obstruction with completely normal contrast radiographs. Methods: Data was obtained concurrently on 2,000 consecutive patients from February 1998 to October 2001 and analyzed retrospectively. Radiographs, when available, were interpreted by both the operative surgeon and radiologist before intervention. Results: 66 internal hernias occurred in 63 patients, an incidence of 3.1%. 1 patient presented with a traditional adhesive band and small bowel obstruction. 20% of patients had normal preoperative small bowel series and/or CT scans. The site of internal hernias varied: 44 - mesocolon; 14 - jejunal mesentery; 5 - Petersen's space. Although most patients were symptomatic, 5% were incidental findings at the time of another surgical procedure. 5 patients required open repair. 6 patients presented with perforation either at the time of diagnosis or as a result of manipulation of the bowel. There was 1 death associated with complications of the internal hernia. The negative exploration rate was 2%. Conclusion: Internal hernias are more common following laparoscopic RYGBP than "open" RYGBP. Contrast radiographs alone are unreliable in ruling out this diagnosis. Early intervention is crucial; most repairs can be performed laparoscopically. This diagnosis should be entertained in all patients with unexplained abdominal pain following laparoscopic RYGBP. Meticulous closure of all potential internal hernia sites is essential to limit this potentially lethal complication.     

Laparoscopic Gastric Bypass in Patients on Thyroid Replacement Therapy for Subnormal Thyroid Function – Prevalence and Short-Term Outcome

Background: Hypothyroidism is associated with increased body weight. Weight gain may occur despite normal levels of serum thyroid stimulating hormone (TSH) and thyroxine (T4) achieved by replacement therapy. We evaluated the prevalence of patients on thyroid replacement for subnormal thyroid function who were operated on for morbid obesity and monitored their postoperative weight loss pattern. Methods: Data was identified from a prospectively accrued database of patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) or laparoscopic adjustable gastric banding (LAGB) for morbid obesity from February 2000 to November 2001. All patients with subnormal thyroid function, diagnosed by past thyroid function tests and treated by an endocrinologist, who were on thyroid replacement therapy, were identified; 5 of these were matched for age, gender, preoperative body mass index (BMI) and surgical procedure (LRYGBP) to 5 non-hypothyroid patients. Weight loss at 3 and 9 months after surgery was compared between the 2 groups. Results: 192 patients underwent LRYGBP (n=155) or LAGB (n=37). Of the 21 patients (10.9%) on thyroid replacement identified, 14 were primary, 4 were postablative, and 3 were post-surgical; 17 underwent LRYGBP. All patients had normal preoperative serum levels of TSH and T4. Comparison of the 2 matched groups of patients revealed no difference in weight loss at 3 and 9 months after surgery (P=1.0). Conclusions: The prevalence of euthyroid patients on thyroid replacement for subnormal thyroid function who undergo surgical intervention for morbid obesity is high. Short-term weight loss in these patients is comparable to normal thyroid patients. Longer follow-up may be necessary to demonstrate the weight loss pattern in this group.     

Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity: Results of our Learning Curve in 100 Consecutive Patients

Background: Morbid obesity requires life-long treatment, and bariatric surgery provides the best results. Among the bariatric procedures, laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been considered to be superior. However, it requires advanced laparoscopic skills and a learning curve. We analyzed our results in an initial series of 100 patients. Methods: Data of 100 consecutive patients who underwent LRYGBP for morbid obesity in a 2.5-year period were prospectively collected and analyzed with emphasis on results and complications. Results: Mean age was 31±5 years. There were 63 woman and 37 men. Preoperative BMI was 50±9 kg/m². 33 patients were considered super-obese (BMI>50). Mean operative time was 3.8 ± 0.7 hours. Two patients required conversion to open surgery. Mean hospital stay was 6 days. Complications occurred in 10 patients. Mortality rate was 2%. Excess body weight loss was as follows: 33 ± 8% at 3 months (n=92), 47 ± 2% at 6 months (n=82), 62 ± 4% at 1 year (n= 70), 66 ± 5% at 18 months (n= 63) and 67 ± 8% at 2 years (n= 35). There was significant improvement in several co-morbid conditions, such as diabetes and hypertension. Conclusion: LRYGBP is a reproducible technique. It requires the combination of bariatric and laparoscopic expertise.     

Open Versus Laparoscopic Vertical Banded Gastroplasty: A Randomized Controlled Double Blind Trial

Background:Vertical banded gastroplasty (VBG) is a frequently used surgical procedure for the treatment of morbid obesity. It can be done open (OVBG) or laparoscopic (LVBG). The aim of this double-blind randomized clinical trial was to compare the postoperative outcome and 1-year follow-up of 2 cohorts of patients who underwent either OVBG or LVBG. Patients and Methods: 30 patients with morbid obesity were randomized into 2 groups (14 OVBG and 16 LVBG). Pain intensity, analgesic requirements, respiratory function, and physical activity were blindly analyzed during the first 3 postoperative days. Complications, weight loss, and cosmetic results after 1 year follow-up were evaluated. Results: Both groups were highly comparable before surgery. Surgical time was longer in the laparoscopic procedure. Patients in this group required less analgesics during the first postoperative day.There was an earlier recovery in the expiratory and inspiratory forces, as well as faster recovery of physical activities in patients who underwent LVBG. Postoperative complications were more frequent in the open group. Excess body weight loss after 1 year was similar in both groups. Cosmetic results were significantly better in the laparoscopic group. Conclusions: LVBG had advantages over the open procedure in terms of analgesic requirements, respi function, postoperative recovery, and cosmetic results.     

Expectations and Outcomes with Gastric Bypass Surgery

Background: Bariatric surgery is widely accepted as the effective treatment option for morbid obesity. However, the extant literature does not provide mental health clinicians with consistent guidance for evaluating candidates for surgery, nor for preparing patients for postsurgical adjustment. Among both bariatric clinicians and patients, there are commonly endorsed expectations about who will do well postoperatively and what the psychosocial impact of the surgery and weight loss will be. The current study surveyed our patient population regarding the accuracy of these expectations. Methods: Medical charts were reviewed and surveys mailed to all 194 patients who had undergone the Roux-en-Y gastric bypass (RYGBP) at University of New Mexico Hospital prior to April 2003. Surveys explored patients' expectations and actual experiences with RYGBP and the subsequent changes in their physical and psychosocial status. Results: Completed surveys received from 47.9% of the patients reported significant improvements in physical health, emotional status, and binge eating. These improvements were seen across the entire sample, regardless of the presence of preoperative psychological distress, and were unrelated to the degree of weight loss. Professional and non-romantic relationships benefited from the impact of weight loss, but romantic relationships appeared unaffected. There were no significant changes in occupational status. Conclusion: The impact of bariatric surgery appears sufficiently potent to negate whatever preoperative differences might otherwise affect weight management. It may be time for the field to cease its search for surgical outcome predictors and focus instead on improving postoperative support.     

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.     

Outcome of Esophageal Function and 24-hour Esophageal pH Monitoring after Vertical Banded Gastroplasty and Roux-en-Y Gastric Bypass

Background: One of the co-morbidities frequently associated with morbid obesity is gastro-esophageal reflux disease (GERD), present in >50 % of morbidly obese individuals. We compared the anti-reflux effect of vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RYGBP), and their effect on esophageal function. Methods: 10 patients underwent VBG and 40 patients underwent RYGBP. Anthropometric parameters, symptomatology of GERD, esophageal manometry (EM), isotopic esophageal emptying (IEE) and 24hr esophageal pH monitoring were recorded in all patients preoperatively, and at 3 months and 1 year postoperatively. Results: Preoperatively, there was a high prevalence of GERD, symptomatic and pH-metric in both groups (57% and 80% respectively). The preoperative values of EM and IEE parameters were within the normal range in most patients. After surgery, there was an improvement at 3 months postoperatively in both groups. 1 year after surgery, the VBG group presented symptomatic GERD in 30% and pH-metric reflux in 60% of patients while the RYGBP group presented symptomatic GERD and pH-metric reflux in 12.5% and 15% of patients, respectively. There was an increase in postoperative sensation of dysphagia in both groups (70% VBG, 30% RYGBP) one year after operation. After surgery, differences in all EM parameters were minimal, and never reached statistical significance for any group (VBG and RYGBP). The IEE showed a significantly higher percentage of esophageal retention after surgery, but this retention was always within the normal range. Both groups had an improvement in anthropometric parameters, but 1 year after surgery the results were significantly better in RYGBP patients (70% excess weight loss) than in VBG patients (46% excess weight loss). Conclusion: >50% of morbidly obese individuals suffer from GERD. We did not find changes in esophageal function of morbidly obese patients to explain their gastroesophageal reflux preoperatively and postoperatively. EM and IEE studies are not indicated as standard preoperative tests, except in patients with significant symptoms of gastroesophageal reflux. RYGBP is significantly better than VBG as an anti-reflux procedure, and had better weight loss.