A 13-year review of jejunoileal bypass

One hundred and eighty patients had a jejunoileal bypass performed during the years 1971-1982. By leaving only 14 in. (35 cm) of intestine in continuity a mean weight loss of 34.4 per cent (s.d. = 8.5) was achieved over 2 years and, unless the operation had to be reversed for complications, this weight loss was maintained. The improvement in quality of life for a majority of patients should not be undervalued. Two-thirds of patients required admission for complications and eight patients died (4 per cent). Many of these problems were provoked by an inability to control eating. There have been no hospital deaths since 1976 which we attribute to better management of complications and a policy of early reversal for patients with excessive weight loss and signs of metabolic failure. Despite performing jejunoileal bypass less often in recent years we are still frequently reversing patients with electrolyte disturbances, metabolic failure, urinary calculi or arthritis. Thirty patients (16.7 per cent) have been reversed, half more than 5 years after bypass. Metabolic failure may occur even after many years of stable weight reduction. Because this is not well known the insidious onset of new weight loss and malaise may not be recognized, or not associated with the bypass many years before. Indefinite outpatient surveillance is mandatory. Changes in the operation have not significantly affected results. There has been no serious liver dysfunction in the 7:7:CJ group but this may reflect better management of lesser metabolic disturbances. Jejunoileal bypass remains the most effective operation for gross obesity and, with experience, can be performed safely. However, the complication rate and difficulty maintaining satisfactory follow-up on large numbers of young patients makes it an unacceptable procedure on any major scale.     

Reoperative bariatric surgery. Lessons learned to improve patient selection and results.

OBJECTIVE: The purpose of this study was to determine the spectrum of presentation, safety, and efficacy of operative bariatric surgery. SUMMARY BACKGROUND DATA: The only lasting therapy for medically complicated clinically severe obesity is bariatric surgery. Several operative approaches have resulted in disappointing long-term weight loss or an unacceptable incidence of complications that require revisionary surgery. METHODS: Sixty-one consecutive patients who underwent reoperative bariatric surgery from 1985 to 1990 were observed prospectively. One, two, or three previous bariatric procedures had been performed in 77%, 18%, and 5% of patients, respectively. Reoperation was required for unsatisfactory weight loss after gastroplasty or gastric bypass (61%), metabolic complications of jejunoileal bypass (23%), or other complications (16%), including stomal obstruction, alkaline- or acid-reflux esophagitis, and anastomotic ulcer. Revisionary procedures included conversion to vertical banded gastroplasty (33% of operations) and vertical Roux-en-Y gastric bypass (52% of operations); partial pancreato-biliary bypass was used selectively in four patients with severe, medically complicated obesity. RESULTS: A single patient died postoperatively of a pulmonary embolus; serious morbidity occurred in 11%. Weight loss (mean +/- SEM) after reoperation for unsuccessful weight loss was greater with gastric bypass than with vertical banded gastroplasty (54 +/- 6% versus 24 +/- 6% of excess body weight). Metabolic complications of jejunoileal bypass were corrected, but 67% of the patients were dissatisfied with their postoperative lifestyle because of changes in eating habits or weight gain (64% of patients). Stomal complications and esophageal reflux symptoms were reversed in all patients. CONCLUSIONS: Reoperative bariatric surgery in selected patients is safe and effective for unsatisfactory weight loss or for complications of previous bariatric procedures. Conversion to gastric bypass provides more effective weight loss than vertical banded gastroplasty.     

Mason gastric bypass. Long-term follow-up and comparison with other gastric procedures

The Mason gastric bypass as performed over 8 years on 171 patients for the treatment of massive exogenous obesity. The first 26 patients had a large pouch constructed, and poor long-term weight loss occurred. In the last 6 years, 145 patients had a smaller pouch with a 5.5 percent immediate postoperative complications rate. One early death resulted. Late complications and revisions were few. In the last 145 patients there were only 9 who did not maintain a weight loss of greater than 25 percent of their total weight. This group of 145 patients have lost an average of 42 percent of their total weight (121 pounds) and 72 percent of their excess weight. The stapled Alden gastric bypass and horizontal gastroplasties, when compared with the Mason gastric bypass, have similar complications with the potential for poor weight loss after long-term follow-up due to channel enlargement or staple-line leakage. The Mason gastric bypass is an excellent surgical method of weight loss.     

The Effects of Acute Preoperative Weight Loss on Laparoscopic Roux-en-Y Gastric Bypass

Background: Minimal acute pre-operative weight loss significantly reduces liver size and intra-abdominal adipose tissue. We hypothesize that these changes will reduce intra-operative complications and reduce the difficulty of laparoscopic Roux-en-Y gastric bypass (LRYGBP). Methods: This is a retrospective chart review of consecutive patients who had undergone isolated LRYGBP between July 2003 and March 2005. All patients participated in our institution's medically supervised Weight Management Program before surgery. Results: 48 patients (Weight Loss Group) had an average percent loss of excess weight (%EWL) of 4.6; whereas 47 patients (No Weight Loss Group) gained an average of 4.8% of excess weight over an average period of 2.4 and 3 months (P=0.09), respectively. There were no differences between the two groups in age, gender, ASA class, co-morbidities, or BMI at operation. The Weight Loss Group had less intra-operative blood loss (102 vs 72 ml, P=.03). The surgeon was also less likely to report an enlarged liver in the Weight Loss Group (P=.02). Finally, the operation was less likely to deviate from the standard LRYGBP when patients lost weight (P=.02). No differences were seen in operative time, length of hospital stay, wound infections, or major complications. Conclusion: Acute preoperative weight loss is associated with less intra-operative blood loss and reduces the need for intraoperative deviation from the standard LRYGBP. A larger series with a greater reduction in excess weight is necessary to determine the maximal benefits of acute preoperative weight loss.     

Near-total gastric bypass for morbid obesity

Among 50 morbidly obese patients who underwent gastric bypass, the gastric pouch was made only large enough to permit an anastomosis with the jejunum. Eighteen months after operation, the mean weight loss was 55 kg, and the mean excess weight loss was 70%. One half of the patients had less than 22.7 kg of residual excess weight. The most frequent immediate postoperative complication involved the respiratory tract (ten patients). Staple line failure in three of ten patients who had pouch construction by a single application of staples and iron deficiency anemia in six patients were the most important late complications. Near-total gastric bypass in which the pouch is constructed with two applications of staples is an effective operation for weight control and should virtually eliminate the need for revision caused by staple line failure or for a pouch that is too large.     

Critical analysis of jejunoileal bypass

This study analyzed a group of morbidly obese patients who underwent jejunoileal bypass over a 10 year period. Patients underwent either a Payne or Scott procedure. Weight loss was reported in terms of percent of excessive weight loss. Results showed that patients who had a Payne bypass had an average excess weight loss of 75 percent, whereas those with the Scott bypass had an average excess weight loss of 61 percent. All patients lost weight. Complications in this series were lower than what has been traditionally reported. The problem that occurred most often was kidney stones (8 percent of the patients). There has been only one death to date. The low incidence of complications can be attributed to the fact that the patients were evaluated, operated on, supervised, and followed by one doctor and his associated nurses. Thus, it is proposed that jejunoileal bypass, compounded with good patient care and careful patient selection, can produce positive results with a minimum number of problems.     

Gastroplasty conversion to Roux-en-Y gastric bypass at the lesser curvature due to weight loss failure

From January 1982 to April 1984, 20 patients with lesser curvature gastroplasty had conversion to Roux-en-Y gastric bypass at the lesser curvature for failure to lose more than 50 per cent of excess body weight within 12 months of the original gastroplasty. The average excess weight of these patients before gastroplasty was 103 lb, and the average excess weight before conversion to gastric bypass was 73 lb. The average weight loss after gastric bypass was doubled within 6 to 15 months. Only one patient failed to lose weight after conversion to gastric bypass, and this patient had endocrine problems. Late surgical complications occurred in two patients (10%); one had cholecystectomy and the other had vagotomy and hiatus hernia repair. There were no mortalities in this series.     

Does Bilio-intestinal Bypass Still Have a Role in the Treatment of Super-obesity?

Background: Super-obesity (BMI > 50) is life-threatening. The jejunoileal bypass had potential long-term problems, and weight loss with gastroplasty may be inadequate. Methods: From 1988 to 1995, 19 patients with morbid obesity had jejunoileal bypass with anastomosis of the fundus of the gallbladder to the proximal end of the bypassed jejunum. Of these patients, 11 were super-obese, with ages 19-49 years, weight 125-172 kg, mean excess weight 97 kg (73-119) and BMI 56 (50-67). Results: Mean weight loss at 3 years was 60 kg. There was no mortality and no major complications. Patients had 5-6 stools per day and some flatulence. There have been no hepatic, renal, calcium or electrolyte problems. Diseases secondary to obesity resolved. Conclusion: Bilio-intestinal bypass has been effective and safe thus far.     

Laparoscopic Roux-en-Y gastric bypass: minimally invasive bariatric surgery for the superobese in the community hospital setting

Roux-en-Y gastric bypass (RYGB) operation has become a popular choice for weight-reduction surgery. We report an outcome analysis of our early results with laparoscopic Roux-en-Y gastric bypass for superobese (BMI >50) patients. Between January 2000 and October 2001, we operated on 71 superobese patients. The mean body mass index (BMI) of patients at time of surgery was 57 kg/m2. The prospectively collected data included patient demographics, comorbidities, operative times, postoperative weight loss, and complications. Conversion to open gastric bypass was required in one patient. The overall complication rate was 10 per cent. Preoperative comorbidities were resolved or improved in 93 per cent of patients at 1-year postoperative. Average operative time and length of hospital stay were 196 minutes and 2.3 days, respectively. Mean percentage excess weight loss at 3, 6, 9, and 12 months was 27 per cent, 39 per cent, 49 per cent, and 55 per cent, respectively. Mean BMI decreased to 36 kg/m2 over a 12-month period. Laparoscopic Roux-en-Y gastric bypass surgery for superobese patients as performed in the community hospital setting can be both safe and effective with respect to overall postoperative course, early weight loss, and reduction of comorbidity.     

Liver transplantation in patients with previous portasystemic shunt

Over a 9-year period, 58 patients who had previous portasystemic shunt procedures underwent orthotopic liver transplantation (OLTx) under a cyclosporine-steroid immunosuppressive regimen. The types of shunt used were distal splenorenal (18 patients), mesocaval (17 patients), end-to-side portacaval (11 patients), side-to-side portacaval (5 patients) and proximal splenorenal (7 patients). The mean interval between shunt and transplantation was 6 years. There was no statistical difference in survival between patients with previous shunts and the entire population of patients with primary liver transplantation performed during the same period of time. Age, sex, shunt patency, status of portal vein, and use of vein or artery graft did not affect survival. Child's classification had a significant influence on graft survival, even though no difference was subsequently observed in patient survival. A progressively improved intraoperative strategy and the use of veno-venous bypass and University of Wisconsin preservation solution had a significant impact on blood loss, length of operation, length of stay in intensive care unit, and ultimately, on survival. Distal splenorenal and mesocaval shunts with no or minimal hilum dissection are safer shunts if subsequent transplantation is planned; in fact, their 9-year survival was 87%, whereas all other shunts were associated with a survival no better than 52% (p less than 0.006).     

Long-limb gastric bypass in the superobese. A prospective randomized study.

This study was designed to determine whether greater diversion of bile and pancreatic secretions away from the functional gastrointestinal tract would produce greater weight loss in superobese patients (greater than or equal to 200 pounds overweight) in comparison with conventional Roux-en-Y gastric bypass (RYGB). During the past 7 years, two modifications of RYGB were prospectively compared in 45 superobese patients: RYGB-1, in which the length of defunctionalized jejunum measured 75 cm, and RYGB-2, in which the defunctionalized jejunum measured 150 cm. Respective mean preoperative weight/body mass indexes were 393 pounds/63.4 for 22 RYGB-1 patients and 404 pounds/61.6 for 23 RYGB-2 patients. Two patients (5%) had nonfatal early complications. There were six late incisional hernias. There were no cases of protein deficiency, hepatic dysfunction, or diarrhea after operation. Mean follow-up was 43 +/- 17 months. Postoperative weight loss in pounds and daily calorie intake were compared at 6-month intervals. Weight loss stabilized by 24 months at a mean 50% excess weight lost in RYGB-1 patients and 64% excess weight lost in RYGB-2 patients. Nineteen of 23 RYGB-2 patients achieved at least 50% excess weight lost versus 11 of 22 RYGB-1 patients (p less than or equal to 0.03). Weight loss was significantly greater at 24 through 36 months in RYGB-2 versus RYGB-1 patients (p less than 0.02). There was no significant difference in either calorie intake or incidence of iron and vitamin B-12 deficiency between the two groups. These data show that gastric restriction and biliopancreatic diversion without intestinal exclusion resulted in significantly greater weight loss than conventional RYGB but did not cause additional metabolic sequelae or diarrhea. This long-limb modification of Roux-en-Y gastric bypass is a safe and effective procedure in patients who are 200 pounds or more overweight.     

Wound complications of autogenous subcutaneous infrainguinal arterial bypass surgery: predisposing factors and management

To identify factors predisposing to wound infection and necrosis complicating in situ or other subcutaneous autogenous lower extremity vein bypass procedures, we retrospectively analyzed all such cases performed in our hospital between July 1983 and July 1988. Among 163 subcutaneous autogenous bypass grafts, wound complications developed in 28 (17%). According to progressive depth of involvement as defined in the text, 10 patients had grade I complications, six had grade II, and 12 had grade III complications with threatened or actual graft exposure. Factors significantly associated with wound morbidity were female gender, chronic steroid therapy, in situ bypass grafting, use of continuous incision (all p less than or equal to 0.05, chi square); diabetes mellitus, ipsilateral limb ulcer, limb salvage indication (all p less than 0.01); and bypass grafting to the dorsalis pedis artery (p less than 0.02). A logistic regression analysis identified four factors (in situ bypass grafting, steroid therapy, ipsilateral ulcer, and dorsalis pedis bypass grafting) that predicted a cumulatively increasing risk of wound complications, and in whose absence wound complications were rare. Grade I and II complications responded to standard regimens of wound care and intravenous antibiotics without loss of any graft or limb. In spite of aggressive efforts to provide secondary soft tissue coverage, grade III complications led directly to four major amputations and one death. Measures to prevent these morbid sequelae must include preoperative control of infection in the ischemic foot and meticulous attention to operative technique.     

Prospective randomized trial of banded versus nonbanded gastric bypass for the super obese: early results

BACKGROUND: Banded gastric bypass has been reported to result in superior weight loss compared with standard nonbanded gastric bypass. However, an adequate comparison of these procedures has not yet been reported. METHODS: A total of 90 patients were enrolled in this prospective randomized double-blind trial comparing banded and nonbanded open gastric bypass for the treatment of super obesity. The banding technique involved placement of a 1.5 x 5.5-cm polypropylene band around the proximal gastric pouch of a standard gastric bypass procedure using the technique of Capella. Chi-square testing and analysis of variance were performed to find any differences in patient characteristics (gender, age, and initial body mass index), percentage of excess weight lost at 6, 12, 24, and 36 months postoperatively, improvement or resolution of co-morbidities, and complications in the banded versus nonbanded gastric bypass groups. RESULTS: As expected, no differences were present in the patient characteristics or incidence of co-morbidities between the banded (n = 46) and nonbanded (n = 44) groups. The body mass index, percentage of women, and mean age was 59.5 and 56.5 kg/m2, 64% and 73.8% (P = .09), and 40.6 +/- 7.4 and 42.6 +/- 7.2 years for the banded and nonbanded groups, respectively; all differences were nonsignificant. No significant differences were found in the resolution of co-morbidities. No significant difference was present in the percentage of excess weight loss at 6, 12, and 24 months (43.1% versus 24.7%, 64.0% versus 57.4%, and 64.2% versus 57.2%, respectively) postoperatively; however, the banded patients had achieved a significantly greater percentage of excess weight loss at 36 months (73.4% versus 57.7%; P <.05). The incidence of intolerance to meat and bread was greater in the banded patients. The overall number of complications was 12 (26%) in the banded and 13 (29.5%) in the nonbanded group, a nonsignficant difference. No band erosions had occurred at the last follow-up visit, and no patients in either group died. CONCLUSION: These results suggest that although the initial weight loss was not significantly different between the 2 groups, the banded patients continued to lose weight for < or = 3 years. The polypropylene band appeared to be well tolerated. We plan longer follow-up to confirm the possibility of additional weight loss and the prevention of weight regain in the banded group, as well as to document any long-term band complications.     

Laparoscopic gastric bypass: risks vs. benefits up to two years following surgery in super-super obese patients

BACKGROUND: Super-super obesity (body mass index [BMI] >/= 60 kg/m(2)) is thought to be a risk factor for complications and mortality in laparoscopic Roux-en-Y gastric bypass. Excess weight loss has been demonstrated to be diminished compared with less obese patients following surgery. However, we hypothesize that super-super obese patients who undergo laparoscopic gastric bypass can realize major improvements in their health and a good quality of life without a significantly increased risk of complications when compared with less obese patients. METHODS: From July 2002 to July 2005, University of Wisconsin Health bariatric surgeons performed 288 consecutive laparoscopic Roux-en-Y gastric bypass procedures. Patients were divided into 2 groups: BMI >/= 60 kg/m(2) (n = 28) and BMI < 60 kg/m(2) (n = 260). The groups were compared at defined time intervals during a 2-year period following surgery. Comparison criteria included complications, weight loss, comorbidities, and quality of life. RESULTS: Both groups had similar morbidity and mortality rates. Excess weight loss was shown to be less, but total pounds lost were greater, for the super-super obese patients at all postoperative time intervals specified for postoperative analysis.Despite this fact, overall health improved to a similar degree in each group of patients following surgery; both groups also had similar Moorehead-Ardelt quality of life scores. Using the Bariatric Analysis and Reporting Outcome System (BAROS) to categorize outcomes, the average result for a patient in either group of patients would be considered "very good" at 1 year following surgery. CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass can be accomplished safely even in extremely obese patients. Although excess weight loss in the super-super obese is diminished postoperatively when compared with less obese patients, health is improved and quality of life is good regardless of a patient's preoperative BMI. Therefore, laparoscopic gastric bypass is a good option even in the extremely obese.     

Interval jejunoileal bypass reduces the morbidity and mortality of Roux-en-Y gastric bypass in the super-obese

Among Roux-en-Y gastric bypass (RYGB) patients, large male patients carry the greatest risk for severe, life-threatening complications. The higher complication rate is partly related to large amounts of intra-abdominal fat that increases the technical difficulty of the RYGB. In order to minimize the risk for complications, we established a staged approach for weight loss surgery for high-risk, super-obese patients. Patients with intra-abdominal fat at exploration which precluded the performance of RYGB underwent jejunoileal bypass (JIB). Following an initial period of weight loss (6-24 months), they were converted to a RYGB during a second operation. Twenty-four patients underwent initial JIB that was associated with a major complication rate of 8.3 per cent (2/24) and no mortality. Eight patients lost 53.4 +/- 6.3 kg prior to their conversion to RYGB (mean, 14.1 months). There was one major complication (12%) and no deaths (0%). Following RYGB, an additional period of weight loss resulted in overall excess weight loss (EWL) totaling 62 per cent. A two-step procedure is a safe and effective approach for minimizing complications for high-risk patients undergoing RYGB. The initial JIB was associated with low morbidity and no mortality, and the follow-up RYGB procedure was a technically simple operation that could be performed with few complications.     

Frequency distribution of weight loss percentage after gastric bypass and adjustable gastric banding

BACKGROUND: The results of surgical procedures for weight loss are often described in terms of the percentage of excess weight lost. Expressing outcomes using the mean and standard deviation might not adequately describe the clinical experience. This could in part be because the use of the mean +/- standard deviation assumes a normal or random distribution of outcomes. It has been our perception that the weight loss results after gastric bypass are relatively normally and tightly distributed around the mean, making it relatively predictable. However, we have found that the results after adjustable gastric banding are more highly variable. In fact, there appears to be 2 groups of patients after this restrictive operation. One group, that is able to work well and does not struggle much against the restriction, accepts the limits that it imposes, and another group, that does not easily learn to deal with the restriction and hence mal-adapts. METHODS: To evaluate the validity of our clinical perception, we undertook an analysis of the distribution of weight loss by the percentiles of excess weight lost. All patients with follow-up of > or =1 years after gastric bypass or adjustable banding were evaluated for this analysis. The demographics and percentage of excess weight loss were evaluated. The distribution of the percentage of excess weight loss in 10% increments was evaluated. RESULTS: Both groups were similar with respect to the mean patient age. However, the patients in the gastric bypass group had had a significantly greater mean preoperative body mass index and were more likely to be women. As expected, the weight loss of the gastric bypass patients fell in a normal single-peak distribution for < or =5 years of follow-up. The data from the adjustable gastric band patients at 1 year demonstrated a normal single-peak distribution, with a longer rightward tail. At 2 and 3 years postoperatively, the data from the band patients had a 2-peaked curve. CONCLUSION: The initial weight loss results after gastric banding are less predictable than those after gastric bypass. A similar analysis of long-term outcomes might be enlightening and assist in making clinical decisions.     

Revisional Surgery for Morbid Obesity - Conversion to the Lap-Band® System

Background:The safety and effectiveness of conversion to the Lap-Band? system‚ of patients who had failure of adequate weight loss and/or severe symptoms from prior bariatric procedures has been measured by prospective evaluation of a consecutive group of 50 patients. Methods:The patients were drawn as a subgroup of 713 patients who had placement of the Lap-Band system between July 1994 and May 2000.The preceding procedures were gastroplasty (35 patients), nonadjustable gastric banding (11), gastric bypass (2) and jejuno-ileal bypass (2). All operations were by open laparotomy. Initial reversal of the initial procedure was performed in 28 patients. M:F ratio was 6%/94%. Inadequate weight was the primary problem in 69%, and symptoms of obstruction were present in 31%. Results: Significant perioperative complications occurred more frequently than after primary placement (17% vs 1.1%). However, late complications were less frequent (2% vs 18%). In particular, there have been no occurrences of prolapse (slippage) of the stomach through the band or erosion of the band into the stomach in this group to date. Weight loss of 47% of excess weight had occurred at 3-year followup. This is not significantly different from the 53% EWL in the primary Lap-Band group. All symptoms of obstruction were relieved by the revision, and a number of comorbidities are seen to be markedly improved. Conclusions: We observe that, when compared to primary Lap-Band placement, revision of failed bariatric procedures to Lap-Band is associated with more perioperative adverse events but fewer late complications. Weight loss is equivalent and is associated with marked improvement in comorbidities and quality of life.The outcomes are better than have been achieved by revision to another form of gastric stapling and should be considered in those patients who have had an unsatisfactory outcome from other bariatric procedures.     

Establishing a laparoscopic gastric bypass program

OBJECTIVE: To evaluate the outcomes for laparoscopic Roux-en-Y gastric bypass in a newly developed bariatric surgery program. METHODS: A prospective analysis of the initial 100 patients who underwent laparoscopic Roux-en-Y gastric bypass at a community based teaching hospital between December 2000 and October 2001 was performed. Study endpoints included operative time, early (less than 7 days) and late complication rates, hospital length of stay (LOS), time to initiation of oral diet, and percentage of excess body weight loss. RESULTS: There were 91 women and 9 men with a mean age of 39 years (range 21 to 57). Mean preoperative weight was 126.4 kg (range 92.3 kg to 214 kg), with a mean preoperative body mass index of 47.4 (range 37.3 to 75.7). Ninety (90%) patients had at least one significant medical comorbidity (median = 6 per patient). Mean operative time was 2.4 hours (range 1.0 to 6.5; 3.0 hours for the first 50 patients and 1.8 hours for the last 50 patients). Three patients required conversion to open gastric bypass, all due to equipment failure (two harmonic scalpel failures and one linear stapler malfunction). Seven patients had early complications, 3 with anastomotic hemorrhage requiring transfusion, 3 with intestinal leaks requiring reoperation, and 1 with transected nasogastric tube. Eleven patients had late complications: 5 patients with small bowel obstruction, all due to herniation through the transverse colon mesentery (these occurred early in the series, prompting a change in technique, with no subsequent occurrences), 3 with gastrojejunostomy strictures requiring endoscopic dilation, 2 superficial wound infections, and 1 port-site incisional hernia. No complications occurred in the last 40 patients. No deaths occurred. Median hospital stay was 2 days (range 1 to 37); 3 days in the first 50 cases and 1 day in the last 50 cases. The median number of days to the start of an oral diet was 1 day. Average excess body weight loss was 34% (median follow-up 4 months). CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass is a technically challenging procedure that can be safely integrated into a bariatric treatment program with good results. Improved outcomes, shorter operative times, and fewer complications are associated with increased surgical experience.     

Roux-en-Y gastric bypass as a re-do procedure for failed restricive gastric surgery

Background Gastric restrictive procedures such as laparoscopic gastric banding or vertical banded gastroplasty show, at longer follow up, more and more failures and complications. This study focuses on the results of Roux-en-Y gastric bypass procedure (RYGBP) done as a re-do procedure, both after a technically failed restrictive procedure or when the restrictive procedure failed to obtain substantial weight loss. Methods We reviewed data concerning the postoperative complications and weight loss of 36 patients undergoing re-do surgery for failed restrictive procedures. Results Over a period of two years, 36 patients with a mean age of 40.9 years were converted to a RYGBP. Median time to conversion was 4.9 years, median follow up after conversion was 6.6 months. Early postoperative complications (less than 30 days postoperatively) were noted in 11 patients (30%). A greater number of early complications were noticed in group A (technical complications) compared to group B (insufficient weight loss) (39% vs. 22%). Late postoperative complications were seen in six patients (16%). In this relatively short follow up period we noticed a drop in body mass index (BMI) from a mean of 38.8kg/m² to 30.9 kg/m² with a mean excess body weight loss (EBWL) of 33.1% after the re-do procedure. Body mass index decreased from a mean preoperative value of 37.6kg/m² to 28.9 kg/m² in group A patients with an EBWL 36%, while group B patients had a change in BMI from 40.1kg/m² to 32.9 kg/m² with a mean EBWL of 30%. Conclusion Based on the literature, we can presume that restrictive surgery for morbidly obese patients will require many reoperations in the future. The standard operation of choice is RYGBP. In our study this procedure showed a higher, but not significantly early morbidity rate when the indication for re-do surgery was a technical complication of the initial procedure.     

Intestinal bypass: a modification.

Six hundred sixty-four patients who have had metabolic intestinal surgery for the treatment of morbid obesity are reviewed. Particular attention is directed to difference in weight loss, morbidity and mortality in end-to-side and end-to-end shunts, the former performed in 300 patients and the latter in 262 patients. Unsatisfactory weight loss was observed in 20% of patients with end-to-side shunts, while only 8% of patients with end-to-end shunts failed to lose a sufficient amount of weight. Morbidity and mortality were significantly increased in this latter group. This led to adoption of a modification of the end-to-side operation by developing a plication ?REVENT REFLUX. Our preliminary observation indicates that in 102 patients who have had this operation, similar weight loss is attained to that of end-to-end shunts with no greater morbidity or mortality than the end-to-side type.