The Effect of Stoma Size on Weight Loss After Laparoscopic Gastric Bypass Surgery: Results of a Blinded Randomized Controlled Trial

The tighter the stoma, the greater the loss: A narrower gastrojejunostomy is more beneficial for weight loss following roux-en-Y gastric bypass

The optimal size of Gastrojejunostomy (GJ) in Laparoscopic Roux-EnY Gastric Bypass (LRYGB) for a- preferential weight loss is still unknown. This study aimed to investigate the influence of linear-stapled GJ size in long-term LRYGB weight reduction results. We performed a retrospective analysis of 100 patients who underwent LRYGB surgery between January and July 2021. The patients were divided into two 50-patient groups based on the size of their linear-stapled GJ, either 30 or 45 mm. Their weight loss was observed and compared on day 15, and the following appointments were 1, 3, 6, 9, 12, 18, and 24 months after surgery. After 24 months, the 30-mm group reduced their BMI by an average of 19.23, compared with the 16.43 kg/m2 of the 45-mm group (p < .001). Overall, repeated measures ANOVA showed a beneficial weight loss pattern for the 30-mm group in all four categories (weight, BMI, EWL, and TWL). Upon adjusting for age, biliopancreatic length, alimentary length, sex, history of diabetes, and a history of hypertension in repeated measures ANOVA, this difference remained significantly in favour of the 30-mm GJ. Based on the results of this study, performing a gastrojejunostomy with a 30-mm stapler compared to a 45-mm stapler increases weight loss in LRYGB patients.

Impact of Early Gastrojejunal Stenosis on Weight Loss in Patients Undergoing Roux-en-Y Gastric Bypass

BACKGROUND

Gastrojejunal (GJ) anastomotic stenosis is a well-described complication after Roux-en-Y gastric bypass (RYGB); however, its impact on weight loss outcomes is not well elucidated.

METHODS

We performed a retrospective cohort study of adult patients who underwent RYGB at our institution between 2008 and 2020. Propensity score matching was used to match 30 patients who developed GJ stenosis within the first 30 days post-RYGB with 120 control patients who did not develop this outcome. Short and long-term complications and mean percentage of total body weight loss (TWL) were recorded at 3 months, 6 months, 1 year, 2 years, 3 to 5 years, and 5 to 10 years postoperatively. Hierarchical linear regression modeling was used to analyze the association between early GJ stenosis and the mean percentage of TWL.

RESULTS

Patients who developed early GJ stenosis had a 13.6% increase in the mean percentage of TWL when compared with controls in the hierarchical linear model [ P < 0.001 (95% CI: 5.7; 21.5)]. These patients were also more likely to present to an intravenous infusion center (70% vs 4%; P < 0.01), require readmission within 30 days (16.7% vs 2.5%; P < 0.01), and/or develop an internal hernia (23.3% vs 5.0%) postoperatively.

CONCLUSIONS

Patients who develop early GJ stenosis after RYGB have a greater degree of long-term weight loss compared with patients who do not develop this complication. Although our findings support the key contribution that restrictive mechanisms play in maintaining weight loss after RYGB, GJ stenosis remains a complication associated with significant morbidity.

Gastrojejunostomy Closure Technique and Risk of Leak: an Evaluation in Ex Vivo Porcine Models

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed bariatric operations worldwide. Leaks following RYGB are rare, but the consequences can be devastating. Although most leaks occur at the gastrojejunostomy (GJ) anastomosis, there is a lack of data on modifiable technical factors that can reduce the risk of leaks. Therefore, we evaluated whether the leak pressure of a GJ linear stapled anastomosis is dependent on the closure technique.

METHODS

Two expert surgeons constructed gastric pouches and GJ anastomoses on ex vivo porcine models in a laparoscopic simulator using 30-mm and 45-mm endoscopic staplers. The GJ anastomosis was closed using either a single layer suture, double layer suture or stapler. The endpoints were leak pressure to air insufflation, measured by two independent observers, site of leak and internal circumference of the GJ anastomosis.

RESULTS

In total, 30 GJ anastomoses were constructed (30 mm, n = 15; 45 mm, n = 15). The GJ anastomosis was closed using single layer (n = 9), double layer (n = 9) and stapled techniques (n = 12). Inter-observer agreement was high. Stapled and double layer closures were more resilient than a single layer closure, with 75% (9/12) stapled closures remaining intact at < 70 mmHg. GJ stoma circumference was lower using a 30-mm stapler (64.8 mm vs 80.2 mm; p < 0.05) but independent of closure technique. The most common leak site was the corner of the closure (67%).

CONCLUSION

In summary, the GJ anastomosis closure technique may be a modifiable factor to prevent anastomotic leak.

Resizing a large pouch after laparoscopic Roux-en-Y gastric bypass: comparing the effect of two techniques on weight loss

BACKGROUND

Insufficient weight loss or weight regain has many causes including a large gastric pouch. A large gastric pouch may be due to the surgical technique or can be patient related (dilation). Resizing the gastric pouch may lead to additional weight loss. Currently, there is no gold standard for the revisional surgical technique. Therefore this study was performed to determine which surgical technique for revisional bariatric surgery (BS) has superior outcomes in terms of weight loss: sleeve resection of the gastrojejunostomy and gastric pouch (SGP), or resection of the gastrojejunostomy with resizing of the pouch and creation of a new anastomosis (RGJ).

METHODS

All patients who underwent revisional BS for insufficient weight loss or weight regain as a result of an enlarged pouch after LRYGB from April 2014 to June 2018 in our hospitals were included in this observational cohort study. Outcomes were measured in percentage total weight loss (%TWL).

RESULTS

A total of 37 patients who underwent SGP and 21 patients who underwent RGJ as revisional BS were included in this study. The median body mass index before revisional BS was 37.6 kg/m² versus 35.7 kg/m² (SGP vs RGJ, respectively, P = 0.115). There was no significant difference in %TWL between the two cohorts 1 and 2 years after revisional BS, respectively; SGP 14.5% vs RGJ 11.0%, P = 0.885 and SGP 12.3% vs RGJ 10.8%, P = 0.604. Comparing %TWL based on weight at LRYGB, there was also no significant difference two years after revisional BS (SGP 22.0% vs RGJ 22.2%, P = 0.885). The average use of surgical disposables for the SGP technique were lower compared to the RGJ technique.

CONCLUSIONS

Resizing a large pouch leads to additional weight loss. Both techniques have comparable outcomes in terms of weight loss. However, based on average surgical costs, the SGP technique may be preferable.

Gastrojejunostomy in Roux-En-Y Gastric Bypass for Morbid Obesity: Linear Stapler Length Does Not Affect Mid-term Outcomes

BACKGROUND

The purpose of this study was to compare whether different linear stapler lengths used to form the gastrojejunostomy during laparoscopic Roux-En-Y gastric bypass affects mid-term weight loss outcomes.

MATERIALS AND METHODS

A retrospective single center analysis was performed. Surgical technique was identical other than either a 35 or 45 mm linear stapler being used to form the gastrojejunostomy. Multivariate regression was used to assess the relationship between the different stapler lengths and weight loss outcomes 2 years following surgery.

RESULTS

Of the 97 patients identified, 67 (69.1%) were included in the study. There were 30 patients in the 35 mm group and 37 in the 45 mm group. The groups were comparable in terms of basic demographic data and preoperative weight characteristics. There was no significant difference in weight loss outcomes 2 years following surgery when comparing between the different linear stapler lengths.

CONCLUSION

Thirty-five versus 45 mm linear stapler lengths does not affect mid-term weight loss outcomes.

Calibrated Gastrojejunostomy in Gastric Bypass: It Is a Myth

BACKGROUND

Many surgeons prefer a narrow gastrojejunostomy in gastric bypass believing that this provides greater weight loss. The question is whether the anastomosis remains at its initial diameter, whether it narrows or widens over time. This study tests the hypothesis that the initial diameter of the anastomosis varies over time.

MATERIALS AND METHODS

One hundred obese had undergone surgery. Group A with anastomosis 1.5 cm wide and group B with anastomosis 3 cm wide. One-year follow-up was done for 83 patients. The size of the anastomosis diameter was evaluated using a balloon for cardia dilation.

RESULTS

Comparing the results of surgery with the values presented 1 year after the procedure, (i) BMI decreased from 43.3 ± 6.6 to 28.7 ± 7.0 kg/m² for group A and 44.6 ± 5.9 to 29.1 ± 6.3 kg/m² for group B, (ii) the total weight loss was 30.6 ± 4.7% for group A and 31.9 ± 5.2% for group B, and (iii) the initial 1.5-cm anastomosis in group A measured 2.3 ± 1.0 cm while the initial 3-cm anastomosis in group B measured 2.7 ± 1.0 cm 1 year after surgery. No statistically significant difference was found for any of the variables evaluated before and after the surgical procedure.

CONCLUSION

Calibrated anastomosis has no utility in increasing weight loss in gastric bypass.

A Matched Cohort Analysis of Sleeve Gastrectomy With and Without 300 cm Loop Duodenal Switch With 18-Month Follow-Up

BACKGROUND

In bariatric surgery, a significant question remains unanswered-What proportion of weight loss comes from each component and does this differ with time? Single anastomosis duodenal switch (LDS) combines a vertical sleeve gastrectomy (VSG) with a loop attachment of the duodenal stump. There are two major variables the sleeve, and the intestine that processes ingested food. A comparison of patients that had a VSG with those that have had a LDS approximates the contribution of each component.

METHODS

A retrospective matched cohort analysis of VSG and LDS patients was obtained by matching every LDS patient to a VSG patient of the same sex and BMI. Excess weight lost percentage (%EWL) and the total weight loss percentage (%TWL) was analyzed. The data was compared through descriptive statistics and non-linear regression analysis.

RESULTS

Over 18 months, patients who received the LDS lost more %TWL and %EWL and the difference was statistically significant (p < 0.05). Additionally, with time, the difference became more profound. Weight loss stabilized at approximately 9-12 months and 15 to 18 for VSG and LDS patients', respectively. At 6 months post op, there was approximately 13 % difference in weight loss. This increased to 29 % difference at 18 months.

CONCLUSION

LDS patients lose more weight than VSG. Preserving 3 m of intestinal length adds 30 % greater weight loss at 18 months. Early weight loss is similar between the two operations, while the intestinal component becomes more important with weight loss differentials increasing as time since surgery lengthens.

Gastric pouch emptying of solid food in patients with successful and unsuccessful weight loss after Roux-en-Y gastric bypass surgery

BACKGROUND

After Roux-en-Y gastric bypass (RYGB), approximately 10% of patients have insufficient weight loss (excess body mass index loss<50%). Gastric pouch emptying may have a role in weight loss.

OBJECTIVES

To compare pouch emptying of patients with poor weight loss and patients with successful weight loss after RYGB.

SETTING

A research-intensive nonacademic hospital and center of expertise in bariatric surgery in the Netherlands METHODS: Female patients were included from among patients with the least (poor weight loss group [P-WL]) and the most weight loss (successful weight loss group [S-WL]) in our center 2 years after RYGB. Pouch emptying scintigraphy was performed after ingestion of a radiolabeled solid meal. Emptying curves, intestinal content (IC) at meal completion and after 15, 30, 45, and 60 minutes, half emptying time, and maximal pouch emptying rate were compared.

RESULTS

Five individuals were included in P-WL and 5 in S-WL, on average 2.5 ± .3 years after RYGB. Total weight loss was 18 ± 4.1% in P-WL and 44 ± 5.7% in S-WL (P<.001). In P-WL, a fast initial pouch emptying and exponential emptying curve was observed, compared with a slower initial emptying and more linear curve in S-WL. Faster emptying in P-WL was also shown by a larger IC_meal (42 ± 18% versus 4.0 ± 3.3%,), IC₁₅ (76 ± 15% versus 35 ± 22%), and IC₃₀ (85 ± 12% versus 54 ± 25%), and a greater maximal pouch emptying rate (17 ± 4.7 versus 5.6 ± 3.4%/min) compared with S-WL (P<.05). A linear correlation was found between total weight loss and maximal pouch emptying rate (Pearson R = .82, P = .004).

CONCLUSIONS

Pouch emptying for solid food was faster in patients with the least weight loss compared with patients with the most weight loss after RYGB. If pouch emptying is an important mechanism in weight loss, altering the pouch outlet may improve poor weight loss management.

The Role of Gastrojejunostomy Size on Gastric Bypass Weight Loss

BACKGROUND

The laparoscopic Roux-en-Y gastric bypass (LRYGB) has been considered a reference procedure in the bariatric surgery. The linear-stapled gastrojejunostomy (GJ) has proved to be safe and effective, but its optimal size referred to postoperative weight loss remains poorly understood.

OBJECTIVES

Evaluate the role of the linear-stapled GJ size in the mid-term post-LRYGB weight loss and occurrence of complications.

MATERIALS AND METHODS

From January to April 2014, 128 patients underwent LRYGB with linear-stapled GJ in a 2-year follow-up. The LRYGB were carried out with the same technical steps, except for the length of the GJ. In GJ-15-mm group (n = 64), the GJ was constructed with white 45-mm cartridge in an extension of only 15 mm whereas in GJ-45-mm group (n = 64), the GJ was achieved using full extension of the cartridge. The body mass index (BMI) reduction was recorded for 24 months after procedure.

RESULTS

The mean ages were 38 ± 10.6 and 41.3 ± 12.3 years, and there were 45 (70.3%) and 51 (79.7%) females in the GJ-15-mm and GJ-45-mm groups, respectively. The analysis on raw BMI data showed that both groups had significant reduction of BMI over time (p ≤ 0.05); however, reduction was greater in the GJ-15-mm group from 18 months onwards (p ≤ 0.05). The only complication observed was a case (1.56%) of stenosis in the group GJ-15 mm.

CONCLUSION

The global analysis of BMI reduction indicated that the narrower GJ used (GJ-15-mm group) represented a favoring factor decreasing significantly more the BMI when compared to the wider one (GJ-45-mm group).

A comparison of outcomes of bariatric surgery in patient greater than 70 with 18 month of follow up

BACKGROUND

There is a scarcity of data available to determine the safety and effectiveness of bariatric surgery in the elderly population. Additionally, there are no studies showing the effect of the single anastomosis duodenal switch (SADS) has on the elderly obese, in comparison with other more popular procedures. Here we compare laparoscopic gastric band surgery (LAGB), Laparoscopic Roux-en-Y gastric bypass surgery (LRYGB), and the SADS to analyze the weight loss, perioperative and postoperative morbidity in the patients >70 years of age at a single US center.

METHODS

A retrospective analysis was performed on 53 consecutive patients ≥70 years old who underwent weight loss surgery from 2009 to 2015.Weight loss in terms of the percentage excess body mass index lost (%EBMIL), percentage excess weight lost (%EWL) and body mass index (BMI) points lost, resolution of comorbidities, length of stay, early (30-day) and late complication rates were compared using descriptive statistics and non-linear regression analysis.

RESULTS

Of 53 patients, 24 underwent LAGB, 14 underwent LRYGB and 15 underwent SADS. The average patient age was 72.7 ± 2.5 years (range, 70-81.4) and 66 % were females. There was no statistical difference in the demographic data between three groups except for age and sleep apnea. There were no operative or early deaths. There were differences in complication rates between the surgical arms; however, with our small data set statistical significance was not achieved. There was 1 patient who lost to follow up in SADS group. Follow up time period was 18 months.  % EBMIL and BMI reduction showed a statistically significant difference between the procedures, where the SADS had the highest loss of  %EBMIL and BMI points. Comorbidities prevalence decreased post-operatively with SADS having higher percentage of patients who had resolution of their comorbidities.

CONCLUSION

Each of the three procedures can be performed on patients older than 70 with low morbidity rate. However, when the focus is weight loss alone, the SADS procedure is the most effective of the three procedures in regards to weight loss in the short term for patients older than 70. The SADS is as safe as RYGB but LAGB with all its limitations is still the safest bariatric procedure.

A matched cohort analysis of single anastomosis loop duodenal switch versus Roux-en-Y gastric bypass with 18-month follow-up

BACKGROUND

The Roux-en-Y gastric bypass (GBP) has been considered the gold standard for many years. The loop duodenal switch (LDS) is a relatively new procedure that simplifies the complexity of the duodenal switch (BPDDS) by making it a single anastomosis procedure while at the same time giving it more intestinal absorption to reduce the rates of malnutrition associated with traditional BPDDS. This paper seeks to compare the 18-month weight loss outcomes and complications of the more standard GBP with the newer LDS in a single US center.

METHODS

A retrospective matched cohort was analyzed on 108 patients who had either GBP (54 patients) or LDS (54 patients). Regression analysis was used to compare weight loss outcomes as measured by BMI and weight loss percentages. Complications gathered included bleeds, reoperations, diagnostic or therapeutic endoscopy (EGD), ulcers and chronic nausea.

RESULTS

GBP and LDS have statistically similar weight loss at 18 months (39.6 vs 41 % weight loss, respectively). However, there were significantly more nausea complaints (26 vs 5), diagnostic endoscopies (EGD) (21 vs 3) and ulcers (6 vs 0) with the GBP than the LDS.

CONCLUSION

LDS has comparable weight loss results to GBP. However, LDS has fewer 30-day and 18-month complications and patients suffer from less nausea postoperatively.

Endoscopic management of bariatric surgery complications: what the gastroenterologist should know

Obesity is a serious disorder in almost the entire world. It is an important risk factor for a series of conditions that affect and threaten health. Currently, bariatric surgery is the most effective treatment for morbid obesity, and in addition to the resulting weight loss, it reduces morbidity in this population. There has been a significant increase in the number of obese patients operated on. Despite the success of bariatric surgery, an important group of patients still present with major postoperative complications. In order for endoscopy to effectively contribute to the diagnosis and treatment of complications deriving from obesity surgery, the gastroenterologist must be aware of the particularities involved in bariatric surgery. The present article is a review of the resulting anatomic aspects of the main surgical techniques employed, the most common postoperative symptoms, the potential complications, and the possibilities that endoscopic diagnosis and treatment offer. Endoscopy is a growing and continuously evolving method in the treatment of bariatric surgery complications. The aim of this review is to contribute to the preparation of gastroenterologists so they can offer adequate endoscopic diagnosis and treatment to this high-risk population.

Importance of pouch size in laparoscopic Roux-en-Y gastric bypass: a cohort study of 14,168 patients

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common bariatric procedures worldwide, but the importance of gastric pouch size is still under debate. We have studied how pouch size affects risk of marginal ulcer and excess body mass index loss (EBMIL%) at 6 weeks and 1 year postoperatively.

METHODS

Scandinavian Obesity Surgery Registry included 14,168 LRYGB patients with linear stapled gastrojejunostomies, having complete pre- and postoperative data concerning length of stapler needed to complete the gastric pouch, incidence of marginal ulcers and weight loss. LRYGB technique in Sweden is highly standardized, and total length of stapler was used as a proxy for pouch size.

RESULTS

Mean length of stapler used for the pouch was 145 mm. At 1 year, symptomatic marginal ulcers were noted in 0.9 % of the patients. The relative risk of marginal ulcer increased by 14 % (95 % confidence interval 9-20 %), for each centimeter of stapler used for the pouch. Body mass index (BMI) was reduced from 42.4 ± 5.1 to 36.1 kg/m(2) at 6 weeks and 28.9 kg/m(2) at 1 year. The total length of stapler predicted EBMIL% at 6 weeks but not at 1 year. Female gender, low preoperative BMI, young age and absence of diabetes predicted better EBMIL% at 1 year.

CONCLUSION

A smaller pouch reduces the risk of marginal ulcers, but does not predict better weight loss at 1 year. Additional stapling should be avoided as each extra centimeter increases the relative risk of marginal ulcers by 14 %.

[Dumping syndrome: Diagnostics and therapeutic options]

BACKGROUND

Dumping syndrome is a common complication after surgery of the upper gastrointestinal tract with symptoms ranging from mild gastrointestinal discomfort and moderate vasomotor disturbances, to severe hyperinsulinemic hypoglycemia. Due to the increasing number of bariatric procedures being performed worldwide, bariatric surgery has become the most common cause for this disease entity.

OBJECTIVE

The aim of this review is to highlight the evidence for the physiological mechanisms contributing to dumping syndrome after the two most common bariatric surgery procedures, Roux-en-Y gastric bypass and sleeve gastrectomy, to discuss technical aspects of the procedures underlying the development of the syndrome, patient-related predictive factors and other differential diagnoses, together with diagnostic and therapeutic algorithms.

Outcome reporting in bariatric surgery: an in-depth analysis to inform the development of a core outcome set, the BARIACT Study

Outcome reporting in bariatric surgery needs a core outcome set (COS), an agreed minimum set of outcomes reported in all studies of a particular condition. The aim of this study was to summarize outcome reporting in bariatric surgery to inform the development of a COS. Outcomes reported in randomized controlled trials (RCTs) and large non-randomized studies identified by a systematic review were listed verbatim and categorized into domains, scrutinizing the frequency of outcome reporting and uniformity of definitions. Ninety studies (39 RCTs) identified 1,088 separate outcomes, grouped into nine domains with most (n = 920, 85%) reported only once. The largest outcome domain was 'surgical complications', and overall, 42% of outcomes corresponded to a theme of 'adverse events'. Only a quarter of outcomes were defined, and where provided definitions, which were often contradictory. Percentage of excess weight loss was the main study outcome in 49 studies, but nearly 40% of weight loss outcomes were heterogeneous, thus not comparable. Outcomes of diverse bariatric operations focus largely on adverse events. Reporting is inconsistent and ill-defined, limiting interpretation and comparison of published studies. Thus, we propose and are developing a COS for the surgical treatment of severe and complex obesity.

Surgical stapling device-tissue interactions: what surgeons need to know to improve patient outcomes

The introduction of both new surgical devices and reengineered existing devices leads to modifications in the way traditional tasks are carried out and allows for the development of new surgical techniques. Each new device has benefits and limitations in regards to tissue interactions that, if known, allow for optimal use. However, most surgeons are unaware of these attributes and, therefore, new device introduction creates a “knowledge gap” that is potentially dangerous. The goal of this review is to present a framework for the study of device– tissue interactions and to initiate the process of “filling in” the knowledge gap via the available literature. Surgical staplers, which are continually being developed, are the focus of this piece. The integrity of the staple line, which depends on adequate tissue compression, is the primary factor in creating a stable anastomosis. This review focuses on published studies that evaluated the creation of stable anastomoses in bariatric, thoracic, and colorectal procedures. Understanding how staplers interact with target tissues is key to improving patient outcomes. It is clear from this review that each tissue type presents unique challenges. The thickness of each tissue varies as do the intrinsic biomechanical properties that determine the ideal compressive force and prefiring compression time for each tissue type. The correct staple height will vary depending on these tissue-specific properties and the tissue pathology. These studies reinforce the universal theme that compression, staple height, tissue thickness, tissue compressibility, and tissue type must all be considered by the surgeon prior to choosing a stapler and cartridge. The surgeon’s experience, therefore, is a critical factor. Educational programs need to be established to inform and update surgeons on the characteristics of each stapler. It is hoped that the framework presented in this review will facilitate this process.

Relevance of Roux-en-Y gastric bypass volumetry using 3-dimensional gastric computed tomography with gas to predict weight loss at 1 year

BACKGROUND

Causes of Roux-en-Y gastric bypass (RYGB) failures are still controversial. Literature data suggest that gastric pouch or gastrojejunal anastomosis distentions over time could be a key factor. Making the hypothesis that progressive distention of RYGB volumes is 1 of the main factors of weight loss failure, the aim of our study was to evaluate bypass volumes changes using repeated 3-dimensional gastric computed tomography with gas and the possible negative correlation with weight loss results at 1 year.

METHODS

Thirty-nine patients eligible for RYGB were prospectively included. Gastric bypass volumes were assessed at 3 and 12 months postsurgery performing 3-dimensional gastric computed tomography with gas and weight loss outcomes were recorded during the first postoperative year.

RESULTS

There was no loss to follow up. Mean % excess body mass index lost (%EBMIL) at 1 year was 66.7%. Seven patients (17.9%) did not reach Reinhold criteria and were considered as RYGB failures. We found no linear correlation between the 1 year %EBMIL and mean values of the gastric pouch (r=.01; P=.94), and the neo stomach (r=.09 ; P=.57) at 3 months. Revisional surgery was correlated negatively with %EBMIL at 1 year.

CONCLUSION

Weight loss at 1 year does not seem to be correlated to RYGB volume changes. Behavioral factors probably play a major role in weight loss failure.

Linear-stapled gastrojejunostomy with transverse hand-sewn enterotomy closure significantly reduces strictures for laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Gastrojejunostomy (GJ) stricture is a common complication after Roux-en-Y gastric bypass (RYGB) for morbid obesity, and the optimal anastomotic technique remains uncertain. The objective of this study was to use cumulative summation (CUSUM) analysis to compare rates of gastrojejunostomy strictures after linear stapling with longitudinal versus transverse enterotomy closure in gastric bypass patients.

METHODS

Charts of all consecutive patients with at least 60 days of post-operative follow-up after laparoscopic RYGB (LRYGB) at our tertiary care institution from Nov 2009 to Dec, 2011 were retrospectively reviewed. Gastrojejunostomy stricture was diagnosed by history and upper endoscopy. CUSUM method of quality control analysis was used to determine sequential improvement in stricture rates with the change in technique.

RESULTS

A total of 197 patients were included (97 longitudinal closure, median age 44 (21-67), median BMI 47 (35-80), 85.8 % female). Gastrojejunostomy strictures occurred in 16 % of longitudinal and 0 % of transverse patients (p = <0.0001). CUSUM analysis demonstrated sequential statistically significant improvement in stricture rates after the change in technique was applied. The longitudinal group had a statistically significant increased rate of surgery-related readmissions (15.5 vs 6.0 %, p = 0.038), with 43.7 % of those readmissions related to GJ strictures. There were no other significant outcome differences between groups.

CONCLUSIONS

Linear-stapled anastomosis with a transverse enterotomy closure significantly reduces the rate of gastrojejunostomy stricture for LRYGB, considerably reducing procedural morbidity.

Weight loss and weight regain-5-year follow-up for circular- vs. linear-stapled gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Weight regain (WR) occurs in some patients after laparoscopic Roux-en-Y gastric bypass (LRYGBP). Loss of restriction due to dilation of the gastrojejunostomy (GJS) or the gastric pouch might be the main cause for WR. With different techniques available for the establishment of the GJS, the surgical technique might influence long-term success.

METHODS

We present a 5-year follow-up for weight loss and WR of a matched-pair study comparing circular stapled (CSA) to linear stapled (LSA) GJS in a series of 150 patients who underwent primary antecolic antegastric LRYGBP. Complete 5-year follow-up was obtained for 79 % of the patients.

RESULTS

Excess BMI loss (EBL) at 3 months was better with the CSA (p = 0.02) and comparable thereafter. The 5-year %EBL was 67.3 ± 23.2 vs. 73.3 ± 24.3 % (CSA vs. LSA, p = 0.19) WR of > 10 kg from nadir was found in 24 patients (16 %) with higher incidence in CSA than in LSA patients (20 % vs. 12 %). The %WR was comparable for both groups, 16 ± 13 vs. 15 ± 19 % (CSA vs. LSA, p = 0.345). Eleven patients underwent surgical re-intervention for WR by placement of a non-adjustable band (n = 2), adjustable band (n = 7) and conversion to distal gastric bypass (n = 2).

CONCLUSIONS

CSA and LSA lead to comparable weight loss in this 5-year follow-up. More patients in the CSA group had WR. Weight regain of more than 10 kg was found in one out of seven patients within 5 years postoperatively.

Fast pouch emptying, delayed small intestinal transit, and exaggerated gut hormone responses after Roux-en-Y gastric bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGB) causes extensive changes in gastrointestinal anatomy and leads to reduced appetite and large weight loss, which partly is due to an exaggerated release of anorexigenic gut hormones.

METHODS

To examine whether the altered passage of foods through the gastrointestinal tract after RYGB could be responsible for the changes in gut hormone release, we studied gastrointestinal motility with a scintigraphic technique as well as the secretion of the gut hormones glucagon-like peptide (GLP)-1 and peptide YY3-36 (PYY3-36 ) in 17 patients>1 year after RYGB and in nine healthy control subjects.

KEY RESULTS

At meal completion, a smaller fraction of liquid and solid radiolabeled marker was retained in the pouch of RYGB patients than in the stomach of control subjects (P = 0.002 and P < 0.001, respectively). Accordingly, pouch emptying in patients was faster than gastric emptying in control subjects (P < 0.001 and P = 0.004, respectively liquid and solid markers). For the solid marker, small intestinal transit was slower in patients than control subjects (P = 0.034). Colonic transit rate did not differ between the groups. GLP-1 and PYY3-36 secretion was increased in patients compared to control subjects and fast pouch emptying of the liquid marker was associated with high gut hormone secretion.

CONCLUSIONS & INFERENCES

After RYGB, the bulk of foods pass without hindrance into the small intestine, while the small intestinal transit is prolonged. The rapid exposure of the gut epithelium contributes to the exaggerated release of GLP-1 and PYY3-36 after RYGB.

Endoscopic management of complications after gastrointestinal weight loss surgery

As more patients undergo bariatric surgery, gastroenterologists will increasingly encounter variant postsurgical anatomies and postoperative complications. We discuss the diagnosis and management of bleeding, ulcers, foreign bodies, stenoses, leaks, fistulas, pancreaticobiliary diseases, weight regain, and dilated outlets.

Pouch size after gastric bypass does not correlate with weight loss outcome

A large gastric pouch is a classic explanation for weight loss problems after gastric bypass. However, several reports have emphasized the role of others, essentially behavorial, factors. We reviewed the outcomes of 151 patients who were operated on over a period of nearly 2 years. 132 patients who had not been reoperated on were assessed between June and September 2009. A barium swallow was available to assess the gastric pouch volume which was determined by the radiologist. %EWL was compared to the pouch volume using ANOVA test. Pouch volumes were compared using t test. The gastric pouch was dilated when >50 ml and failure to lose enough weight was defined by a %EWL<50%. 107 patients (81%) had a complete follow up of 35.7 ± 5.8 months. Mean pouch volume was 68 ± 4.5 ml with a %EWL of 68 ± 26.1%. 59 patients had a large pouch with a weight loss similar to those with a normally sized pouch (68 ± 3.6 vs 66 ± 3.6%EWL). 25 patients (23.3%) had weight loss failure with a similar pouch volume. No correlation was found between the %EWL and the pouch volume. Pouch size probably plays a role in the weight loss process of RYGB. However, 3 years later, pouch volume does not appear to be the most important factor. Behavorial factors such as recurrent eating disorders and failure to adapt to the changes induced by the surgery may explain at least in part weight loss failure.

Predictive factors of weight loss 1 year after laparoscopic gastric bypass in obese patients

BACKGROUND

Substantial weight loss is achieved in majority of severely obese subjects undergoing laparoscopic gastric bypass (LGBP) but some fail to obtain expected results. Our aim was to identify preoperative factors that could influence weight loss (WL) 1 year after LGBP.

METHODS

We studied the predictive value of clinical, biological, and dietary preoperative factors on weight loss in obese patients referred for LGBP. WL was assessed according to mean absolute weight loss (AWL) and mean percent excess weight loss (%EWL) 1 year after LGBP.

RESULTS

One hundred twenty-three subjects were included (112 women, age 42 ± 10 years; weight 127 ± 23 kg; BMI 47 ± 8 kg/m(2)). Mean AWL was 39.4 ± 10.5 kg at 1 year, corresponding to a mean %EWL of 70.5 ± 21.2%. AWL was positively correlated with initial weight, BMI, and energy intake and negatively with age, female sex, and treatment for hypertension and diabetes. %EWL was negatively correlated with initial weight, BMI, and positively correlated with triglycerides and ferritinemia. In multivariate analysis, %EWL was negatively correlated only with initial BMI (p < 0.001). AWL was positively correlated with initial BMI and male sex (both p < 0.001), and negatively correlated with protein intake (p = 0.039) and treatment for diabetes (p = 0.021), but not with biomarkers of diabetes and insulin resistance.

CONCLUSION

Initial BMI appears to be a strong determinant of individual WL, but predictive factors differ when WL was expressed as %EWL or AWL. The treatment of diabetes rather than diabetes itself appears to affect WL.

Is the Roux limb a determinant for meal size after gastric bypass surgery?

The Roux-Y gastric bypass (RYGBP) is an effective weight-reducing procedure but the involved mechanisms of action are obscure. The Roux limb is the intestinal segment that following surgery is the primary recipient for food intake. The aims of the study were to explore the mechanosensory and biomechanical properties of the Roux limb and to make correlations with preferred meal size. Ten patients participated and were examined preoperatively, 6 weeks and 1 year after RYGBP. Each subject ingested unrestricted amounts of a standardized meal and the weight of the meal was recorded. On another study day, the Roux limb was subjected to gradual distension by the use of an intraluminal balloon. Luminal volume–pressure relationships and thresholds for induction of sensations were monitored. At 6 weeks and 1 year post surgery, the subjects had reduced their meal sizes by 62% and 41% (medians), respectively, compared to preoperative values. The thresholds for eliciting distension-induced sensations were strongly and negatively correlated to the preferred meal size. Intraluminal pressure during Roux limb distension, both at low and high balloon volumes, correlated negatively to the size of the meal that the patients had chosen to eat. The results suggest that the Roux limb is an important determinant for regulating food intake after Roux-Y bypass bariatric surgery.

Impact of gastrojejunostomy diameter on long-term weight loss following laparoscopic gastric bypass: a follow-up study

BACKGROUND

Stenosis of the gastrojejunostomy after laparoscopic Roux-en-Y gastric bypass is a common occurrence. We have previously presented data demonstrating that the use of a 25-mm circular stapler results in a decreased incidence of stenosis compared to the results of a 21-mm circular stapler (6.2 vs. 15.9%, P=0.03). One potential drawback of the larger-diameter stapler is the possibility for impaired long-term weight loss due to decreased restriction. We sought to determine the impact of circular stapler diameter on excess weight loss up to 5 years after surgery.

METHODS

Our initial technique for creating the gastrojejunostomy after laparoscopic gastric bypass involved the transgastric passage of a 21-mm circular stapler anvil (group 1). After a large initial experience, we switched to a 25-mm circular stapler (group 2). Follow-up data were entered prospectively into a computer database. Weight loss was recorded as percent of excess weight lost. Only patients with follow-up beyond 3 years postoperatively were eligible for inclusion.

RESULTS

Group 1 consisted of 145 consecutive patients and group 2 consisted of 116 consecutive patients. There was no significant difference in weight loss between the groups at 3 (66.1 vs. 65.2%, P=0.76, n=134), 4 (66.4 vs. 58.6%, P=0.1, n=66), and 5 years after gastric bypass (62.7 vs. 57.5%, P=0.24, n=75).

CONCLUSIONS

The use of a 25-mm circular stapler in laparoscopic gastric bypass operations instead of a 21-mm stapler does not result in significantly different long-term weight loss. The 25-mm stapler is preferred with our technique.

Managing medical and surgical disorders after divided Roux-en-Y gastric bypass surgery

The National Longitudinal Study of Adolescent Health and the National Health and Nutrition Examination Survey reported that over 40% of the US population is overweight. The average weight loss attained by medical management programs is neither sufficient nor durable enough to treat medically complicated obesity. An estimated 220,000 bariatric procedures are performed yearly in the USA and Canada. The divided Roux-en-Y gastric bypass (RYGB) is performed most commonly in these countries and is considered the gold standard bariatric surgical procedure. The complexity of RYGB means that serious and potentially preventable perioperative complications can occur. RYGB alters the normal anatomy and physiology of the upper gut, which has predictable adverse effects and potential complications. Patients seek advice and care for symptoms that develop or persist after RYGB; although some symptoms are expected and predictable, others are complications that may or may not require active medical or surgical intervention. Physicians should be able to predict and manage most postoperative medical and nutritional disorders related to RYGB and should be prepared to assess patients for potential referral for surgical intervention or revision.

Management of gallstones and gallbladder disease in patients undergoing gastric bypass

The appropriate management of gallstones and gallbladder disease in patients undergoing gastric bypass remains unknown. Several therapeutic modalities are used and include performing cholecystectomy on all patients at the time of gastric bypass, performing concomitant cholecystectomy only when patients have gallstones and performing cholecystectomy only in the presence of both symptoms and gallstones. Some groups administer ursodeoxycholic acid for gallstone prevention in the postoperative period. All treatment modalities are analyzed and their results and rationality are discussed.

Circular- vs. linear-stapled gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Different surgical techniques have been developed for the gastrojejunostomy (GJS) in laparoscopic Roux-en-Y gastric bypass (LRYGBP) with the anastomosis performed in a circular-stapled, linear-stapled, or totally hand-sewn way. No technique seems superior to the other as no consistent data on weight loss or complication rates were described.

METHODS

A matched-pair study was conducted including a total of 150 patients, who underwent primary antegastric, antecolic LRYGBP between August 2003 and February 2007. Early weight loss and the incidence of GJS strictures or leaks and wound infections were compared between circular-stapled anastomosis (CSA) and linear-stapled anastomosis (LSA). Both groups were matched for age, sex, and body mass index.

RESULTS

Excess weight loss at 3 months was slightly better with the CSA (p = 0.002) and comparable thereafter. Percentage of excess weight loss at 6, 12, and 24 months was 55.9 +/- 17.5% vs. 51.2 +/- 14.5%, 69.5 +/- 20.9% vs. 71.4 +/- 22.6%, and 70.8 +/- 22.4% vs. 73.2 +/- 23.4%, respectively (CSA vs. LSA). Strictures at the GJS were found only in the CSA group (n = 4), and leaks were found in one patient of the CSA group. More wound infections were observed in patients of the CSA group (ten vs. one).

CONCLUSIONS

CSA and LSA lead to comparable early weight loss in LRYGB. Thus, the technique is the surgeon's choice. In CSA, a higher incidence of GJS strictures and wound infections was observed. As weight regain following LRYGBP is commonly observed after at least 3 years, a longer follow-up is needed to compare the incidence of weight regain in circular- vs. linear-stapled GJS.

The impact of laparoscopy on bariatric surgery

The rising popularity of bariatric surgery over the past several years is attributable in part to the development of laparoscopic bariatric surgery. Morbidly obese patients have associated comorbid conditions that may predispose them to postoperative morbidity. The laparoscopic approach to bariatric surgery offers a minimally invasive option that reduces the physiologic stress and provides clinical benefits, as compared with the open approach. This review summarizes the impact of laparoscopic surgery on bariatric surgery, the various risk factors that could potentially predispose morbidly obese patients to postoperative morbidity, the fundamental differences between laparoscopic and open bariatric surgery, and the physiology of reduced tissue injury associated with laparoscopic bariatric surgery.