Gastrointestinal Quality of Life after Laparoscopic Roux-en-Y Gastric Bypass

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a commonly performed bariatric surgical procedure for the treatment of morbid obesity (MO). Obesity-related co-morbidities reduce the quality and expectancy of life. We assessed gastrointestinal quality of life in patients following LRYGBP. Methods: The Gastrointestinal Quality of Life Index (GIQLI test) was used in this study. A higher score correlates with better quality of life. The GIQLI test was administered to 3 non-selected groups: 100 morbidly obese patients (MO group), 100 patients who had undergone LRYGBP (LRYGBP group); and a control group of 100 individuals (CO group). The CO group was composed of healthy individuals with a BMI <30 kg/m², consecutively recruited among the companions of patients who came for a surgery consultation for obesity or other pathologies. Overall test and specific dimensions scores were evaluated for each group. Results: Overall test and specific dimensions scores were significantly lower in patients with MO when compared to the CO and LRYGBP groups. There were no differences between the CO and LRYGBP groups in the overall score with regard to disease-specific digestive symptoms and the psychological and social dimensions. Conclusions: The quality of life of morbidly obese patients is worsened not only because of the presence of digestive symptoms but also because of their emotional, physical and social impact. Patients operated on by LRYGBP experience an improvement in their quality of life, with good tolerance of the anatomical changes.     

Perforated Ulcer at the Gastrojejunostomy: Laparoscopic Repair after Roux-en-Y Gastric Bypass

A 44-year-old woman was admitted from the emergency department with severe acute upper abominal pain. The patient had undergone a laparoscopic Roux-en-Y gastric bypass (RYGBP) operation 16 months previously. CT scan showed intraabdominal free air. At emergency laparoscopic reoperation, a perforated ulcer at the gastrojejunostomy was found. This late complication of RYGBP can be a rapidly progressing life-threatening situation, and requires prompt treatment. Closure and omental patch were successful laparoscopically.     

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.     

Gastric Bezoar after Laparoscopic Roux-en-Y Gastric Bypass

Gastric bezoar is an uncommon complication following Roux-en-Y gastric bypass (RYGBP). We report two cases of bezoar formation that occurred following laparoscopic RYGBPs. In both cases, the patients presented with abdominal pain, nausea, and "frothy" vomiting. The patients were successfully treated by endoscopic fragmentation and removal of the bezoar.     

Gastrointestinal Hemorrhage after Laparoscopic Gastric Bypass

Gastrointestinal hemorrhage is a potential perioperative complication after Roux-en-Y gastric bypass. The surgeon performing laparoscopic gastric bypass should understand the need for early recognition and management of this complication, as it can be life-threatening. This paper discusses the incidence and clinical presentation of gastrointestinal hemorrhage, mechanisms for hemorrhage, management options, and possible methods of prevention.     

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.     

Lower Extremity Compartment Syndrome Following a Laparoscopic Roux-en-Y Gastric Bypass.

Background: Bariatric surgery has the potential for serious complications. A case is presented of unilateral lower extremity compartment syndrome after a laparoscopic Roux-en-Y gastric bypass performed in the modified lithotomy position. Case report: A 38-year-old female (weight 134.5 kg, BMI 49.6) underwent a laparoscopic Roux-en-Y gastric bypass (operating time 375 min). Postoperatively, she complained of bilateral lower extremity pain that gradually subsided over the course of the day. However, on the 1st postoperative day she developed numbness on the dorsum of the foot and compartment syndrome was diagnosed (anterior compartment pressure 71 mmHg). She underwent emergency fasciotomy,which resulted in a reduction of the pain and numbness on the dorsum of the foot. The next day she ambulated without difficulty and was discharged home on the 5th postoperative day. 12 days after her operation, delayed primary closure of the fasciotomy wound was done with the assistance of a novel device (Proxiderm) that applies constant tension to the wound edges. Subsequent recovery was uneventful, and at 4- month follow-up the patient had a weight loss of 28 kg without any right leg motor or sensory deficits. Conclusion: Bariatric surgeons should be aware of compartment syndrome as a rare but serious complication. Prevention, early recognition, and prompt fasciotomy are crucial for a favorable outcome.     

Jejunojejunal Anastomotic Obstruction Following Laparoscopic Roux-en-Y Gastric Bypass Due to Non-Absorbable Suture: A Report of Seven Cases

Introduction: Small bowel obstruction (SBO) is a well-known complication of laparoscopic Roux-en-Y gastric bypass (LRYGBP). We describe 7 cases of jejunojejunal anastomotic obstruction related to adhesion formation after closure of the mesenteric "leaves" defect with non-absorbable suture. Methods: All patients undergoing LRYGBP from October 2002 until February 2005 were entered into a prospective, longitudinal database. All patients who subsequently presented with SBO were analyzed. Results: Jejunojejunal anastomotic obstruction occurred in 7 out of 152 patients (4.6%) in whom LRYGBP was performed from October 2002 to February 2004. Since February 2004, the suture used to close the jejunojejunal mesenteric leaves defect was changed from non-absorbable Dacron (Surgidac^™) to absorbable suture material. The mean interval between initial LRYGBP and subsequent SBO was 153 days. Operative findings common to all 7 cases were dilated loops of proximal small bowel, and a single adhesion just distal to the Roux-Y anastomosis. Following adhesiolysis, each patient had prompt return of bowel function without recurrence of obstruction. Of the 156 patients who have since undergone LRYGBP, none have presented with SBO, and this difference is statistically significant (P=0.008). Conclusions: The overall rate of SBO (2.3%) is consistent with the previous literature, although the incidence of adhesions specifically at the jejunojejunal anastomosis is higher than that previously encountered. It appears that the incidence of postoperative SBO at the jejunojejunal anastomosis is directly linked to the choice of suture material intraoperatively. As such, absorbable suture should be used to close the jejunojejunal mesenteric leaves defect.     

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.     

Anastomotic Leaks after Laparoscopic Gastric Bypass

The gastrojejunostomy may be the most technically challenging step when performing laparoscopic Roux-en-Y gastric bypass. Patients who develop anastomotic leaks have increased morbidity and mortality rates. Difficulty in diagnosis is related to nonspecific systemic symptoms and limitations in most radiological studies. Our aim is to evaluate the incidence, etiology, diagnosis, management, and prevention of anastomotic leaks occurring in patients undergoing laparoscopic Roux-en-Y gastric bypass.     

Laparoscopic Roux-en-Y Gastric Bypass in Patients with BMI <50: A Prospective Randomized Trial Comparing Short and Long Limb Lengths

Background: It has been shown that long limb gastric bypass in the super-obese (BMI >50) results in increased weight loss in comparison with conventional gastric bypass. The purpose of this study was to compare the effect of short and long limb lengths in patients with BM I<50. Methods: 48 patients with BMI <50 (46 females / 2 males, mean age 35±9.6 years) were prospectively randomized to either a short limb (biliopancreatic limb = 50 cm, alimentary limb = 100 cm) or long limb (biliopancreatic limb = 100 cm, alimentary limb = 150 cm) laparoscopic Roux-en-Y gastric bypass (LRYGBP). In all patients, a 25-mm EEA was used to fashion the gastrojejunostomy and the Roux limb was positioned in an antecolic, antegastric location. Limb lengths were precisely measured in all cases. Results: There was no difference in demographic data, preoperative BMI, presence of co-morbidities, or duration of surgery. The overall complication rate was not different between the 2 groups; however, the incidence of internal hernias was significantly higher in the long limb group (0 vs 4, P=0.029). The length of hospital stay was longer for the short limb group compared to the long limb group (3.1 vs 2.2 respectively, P=0.004). When comparing the short limb to the long limb patients, the BMI decreased equally in both groups at the following time intervals: preoperative (44.6 vs 44.9), 3 weeks (40.3 vs 40.9), 3 months (35.5 vs 35.2), 6 months (31.2 vs 31.8), and 12 months (27.7 vs 28.3). There were no significant nutritional deficiencies in either group. Conclusions: In patients with BMI <50 undergoing LRYGBP, increasing the length of the Roux limb does not improve weight loss and may lead to a higher incidence of internal hernias.     

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 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 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.     

Laparoscopic Gastric Bypass in a Patient with Malrotation of the Intestine

The increased prevalence of morbid obesity is associated with an increased prevalence of obesity co-morbidities. Bariatric surgery is generally the only effective treatment. Gastric bypasses are the most common bariatric operation in many countries, and more than half are performed laparoscopically. We discuss the challenges encountered in performing laparoscopic gastric bypass and cholecystectomy in a morbidly obese patient who was found to have malrotated small and large bowel when the procedure started. In the absence of past gastrointestinal symptoms and investigations, there is no way of diagnosing this anomaly preoperatively. However, when such a problem is posed at the time of surgery, it is safe to perform the planned operation if the surgeon has experience and skills in advanced laparoscopic techniques.     

Laparoscopic Roux-en-Y Gastric Bypass is Safe and Feasible after Orthotopic Liver Transplantation

Liver transplantation has become a life-saving procedure for patients with end-stage liver disease. Since obesity is rampant in our society, it is not surprising that patients with a liver transplant suffer from obesity as well. In addition, Roux-en-Y gastric bypass (RYGBP) is a life-saving procedure for patients suffering from morbid obesity. However, a liver transplant is an extensive and invasive abdominal procedure. Further operations after orthotopic liver transplantation may be challenging. With increasing surgeon experience and technical advancements in laparoscopic equipment, previous abdominal surgery is no longer a contraindication to utilize the laparoscopic approach for RYGBP. In fact, herein, we describe the first laparoscopic RYGBP after orthotopic liver transplantation in the world literature.     

Small Bowel Obstruction and Internal Hernias after Laparoscopic Roux-en-Y Gastric Bypass

Background: Small bowel obstruction (SBO) is a recognized complication of open bariatric surgery; however, the incidence after laparoscopic procedures is not clearly established. This paper reviews our experience with small bowel obstruction after laparoscopic Roux-en-Y gastric bypass. Methods: Between 1995 and 2001, 711 (246 antecolic, 465 retrocolic) patients underwent a laparoscopic proximal divided Roux-en-Y gastric bypass via the linear endostapler technique. 13 patients (1.8%) developed SBO requiring surgical intervention.There were 11 females and 2 males, ages 29-60 (mean 38), with mean weight 126 kg (range 105-188), and mean BMI 50 (range 41-59). 7 obstructive patients (55%) had undergone previous open abdominal surgery. Median time to obstruction was 21 days (range 5-1095). Mean follow-up of all patients is 43 months (range 3-79). Results: Etiology of obstruction was internal hernia - 6, adhesive bands - 5 (only 2 were related to prior open surgery), mesocolon window scarring - 1, and incarcerated ventral hernia - 1. The incidence of SBO was 4.5% (11/246) in the retrocolic group, and 0.43% (2/465) in the antecolic group, which was highly significant (P=.006). 1 adhesive patient required an open bowel resection for ischemia. There was 1 death. Conclusion: SBO occurred with an overall incidence of 1.8% in a large series of laparoscopic gastric bypass patients, and was associated with a high morbidity. A significant decrease in occurrence was found after adoption of antecolic placement of the Roux limb.     

Psoriasis Remission after Laparoscopic Roux-En-Y Gastric Bypass for Morbid Obesity

Background: Psoriasis is a chronic skin disease characterized by epithelial hyperplasia and an accelerated rate of epithelial turnover affecting approximately 1-3% of the population. Exogenous and endogenous factors including morbid obesity can increase the morbidity of psoriasis. Case Report: A 55-year-old male, who weighed 131 kg with BMI 41 kg/m², underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP). He had a 15-year duration of severe psoriasis and was being medically treated. At 12 months after LRYGBP, he had lost 39 kg (68% EWL), and had complete resolution of the psoriasis and had discontinued all preoperative medications related to the disease. At 2 years after LRYGBP, psoriasis has not recurred. Conclusion: Weight loss after LRYGBP should be considered as a strategy in the treatment of severe psoriasis in morbidly obese patients.     

Gastrointestinal Symptoms are More Intense in Morbidly Obese Patients and are Improved with Laparoscopic Roux-en-Y Gastric Bypass

Background: Currently there are few reports comparing gastrointestinal (GI) symptoms in the morbidly obese versus control subjects or the effect of laparoscopic Roux-en-Y gastric bypass (LRYGBP) on such symptoms. Methods: A previously validated, 19-point GI symptom questionnaire was administered prospectively to each patient undergoing LRYGBP, and the questionnaire was re-administered 6 months postoperatively. Six symptom clusters (abdominal pain, irritable bowel [IBS], reflux, gastroesophageal reflux disease [GERD], sleep disturbances, and dysphagia) were compared in the following manner using Students t-test: 1) Control vs. Preop, 2) Control vs Postop, and 3) Preop vs Postop. Results are expressed as mean ± standard deviation, significance P=0.05. Results: 43 patients (40 female and 3 male, age 37.3 ± 8.6, BMI 47.8 ± 4.9) completed the questionnaire preoperatively, and 36 patients (34 female, 2 male, BMI 31.6 ± 5.3) completed the questionnaire 6 months postoperatively, for a response-rate of 84%. Abdominal pain, IBS, reflux, GERD and sleep disturbance symptoms were significantly worse in preop versus controls. Dysphagia was not different. Postop vs preop scores revealed abdominal pain, IBS, GERD, reflux, and sleep disturbance symptoms to be improved significantly. Dysphagia was not significantly different. Only dysphagia was worse when comparing postoperative to controls. No other symptom cluster was significantly different in controls vs postoperative. Conclusions: Morbidly obese patients experience more intense GI symptoms than control subjects, and many of these symptoms return to control levels 6 months after LRYGBP. Dysphagia is equivalent to control subjects preoperatively but increases significantly after LRYGBP. This data suggests another quality-of-life improvement (relief of GI symptoms) for morbidly obese patients. Further follow-up is needed to document the long-term reduction of GI symptoms.     

Factors Determining Conversion from Laparoscopic to Open Roux-en-Y Gastric Bypass

Background: Conversion from laparoscopic to open Roux-en-Y gastric bypass (RYGBP) is expensive and time-consuming. Methods: Data from our first 1,000 laparoscopic RYGBP was entered into a database (Minnesota Database-Bariatric, Exemplo Medical). All patients met NIH criteria for bariatric surgery. Results: 41 (4.1%) of 1,000 consecutive lapRYGBPs were converted to open. Patients requiring conversion to open surgery, analyzed for predictors, revealed: 1) BMI, waist size, and weight all were significantly greater in patients converted to open bypass; 2) Gender: 9 of 109 males (8.3%) and 32 of 891 females (3.6%) were converted (Fischer's exact test, P=0.035); 3) Average age of patients converted was 44.9 compared to 41.3 in the lap group (P=0.02); 4) Conversion was required for 12 large livers (1 palpable preop, 7 had diabetes, 7 had NASH or steatosis); 5) 10 conversions for mechanical/technical reasons – 6 for inability to distend abdominal wall and/or manipulate instruments due to thickness of wall, and 2 due to loss of instruments in abdomen; 6) 9 required conversion for adhesions (2 from previous cholecystectomies with biliary leaks, and 1 from previous transverse colectomy; 7) 4 visceral injuries required conversion (2 stomach, 1 small bowel, 1 esophagus); 8) 3 hemorrhages from spleen with blood loss over 1300 ml required conversion (1 spleen removed, 6 minor not requiring open conversion); 9) 3 conversions were for anomaly/disease (1 malrotation of colon, 1 ovarian teratoma, and 1 intra-thoracic stomach). Conclusion: Steatohepatitis, diabetes mellitus, adhesions from various causes, previous bile leaks, large waist size, BMI, and weight are predictors for conversion to open surgery.