Duodenal Switch Operative Mortality and Morbidity Are Not Impacted by Body Mass Index

Analysis of the Impact of the Learning Curve on the Safety Outcome of the Totally Robotic-Assisted Biliopancreatic Diversion with Duodenal Switch: a Single-Institution Observational Study

INTRODUCTION

Totally robotic-assisted biliopancreatic diversion with duodenal switch (BPD/DS) learning curve has been described to be longer at approximately 50 cases, at which point operative time and complications rate decrease and tend to stabilize. This study aimed to form an analysis of the impact of the learning curve on the safety outcomes of the totally robotic-assisted BPD/DS.

METHODS

A retrospective review of patients who underwent primary totally robotic-assisted BPD/DS by one of our certified bariatric and metabolic surgeon member of our institution was performed. The patients were classified into two groups, the learning stage group (first 50 cases) and the mastery stage group. Differences in operative time in minutes and postoperative outcomes were analyzed.

RESULTS

Two hundred seventy-six patients were included. The operative time and the postoperative length of stay were significantly higher in the learning stage group (173.8 ± 35.8 min vs. 139.2 ± 30.2 min, p= 0.0001; 3.4 ± 1.4 days vs. 2.6 ± 0.9 days, p= 0.0002). The overall leakage rate was significantly higher in the learning stage group (8% vs. 0.4%, p= 0.0001). The global rate of complications for the learning stage group was 14%, and for the mastery stage group was 6.6% (p= 0.08).

CONCLUSIONS

After the first 50 cases, the operative time, the length of stay, and the overall rate of complications decreased, being especially significant the decrease in the duodeno-ileal anastomosis leakage rate after reaching the learning curve.

Combined laparoscopic pouch and loop resizing as a revisional procedure for weight regain after primary laparoscopic one-anastomosis gastric bypass

Introduction

One-anastomosis gastric bypass (OAGB) presents a satisfactory long-term outcome in terms of weight loss, amelioration of comorbidities and low morbidity. However, some patients may present insufficient weight loss or weight regain. In this study, we tackle a case series evaluating the efficiency of the combined laparoscopic pouch and loop resizing (LPLR) as a revisional procedure for insufficient weight loss or weight regain after primary laparoscopic OAGB.

Materials and Methods

We included eight patients with a body mass index (BMI) ≥30 kg/m2 with a history of weight regain or insufficient weight loss after laparoscopic OAGB, who underwent revisional laparoscopic intervention by LPLR between January 2018 and October 2020 at our institution. We conducted a 2 years' follow-up. Statistics were performed using International Business Machines Corporation® SPSS® software for Windows version 21.

Results

The majority of the eight patients were males (62.5%), with a mean age of 35.25 at the time of the primary OAGB. The average length of the biliopancreatic limb created during the OAGB and LPLR were 168 ± 27 and 267 ± 27 cm, respectively. The mean weight and BMI were 150.25 ± 40.73 kg and 48.68 ± 11.74 kg/m2 at the time of OAGB. After OAGB, patients were able to reach an average lowest weight, BMI and per cent of excess weight loss (%EWL) of 89.5 ± 28.85 kg, 28.78 ± 7.47 kg/m2 and 75.07 ± 21.62%, respectively. At the time of LPLR, patients had a mean weight, BMI and %EWL of 116.12 ± 29.03 kg, 37.63 ± 8.27 kg/m2 and 41.57 ± 12.99%, respectively. Two years after the revisional intervention, the mean weight, BMI and %EWL were 88.25 ± 21.89 kg, 28.44 ± 4.82 kg/m2 and 74.51 ± 16.54%, respectively.

Conclusion

Combined pouch and loop resizing is a valid option for revisional surgery following weight regain after primary OAGB, leading to adequate weight loss through enhancement of the restrictive and malabsorptive effect of OAGB.

Comparison of single- versus double-anastomosis duodenal switch: a single-center experience with 2-year follow-up

BACKGROUND

Single-anastomosis duodenal switch (SADS) has emerged in recent years as an alternative to the standard double-anastomosis duodenal switch (DADS). The objective of this study was to compare short- and medium-term outcomes between SADS and DADS.

METHODS

Data collected in the Ontario Bariatric Registry between 2010 and 2019 were used for this retrospective study to determine outcomes of patients undergoing primary laparoscopic SADS versus DADS at a Canadian tertiary hospital and bariatric center of excellence. The primary outcome was weight loss at 1 and 2 years after surgery. Short-term secondary outcomes included operative times, intra- and early postoperative complications, hospital length of stay (LOS), and 30-day readmissions. Medium-term secondary outcomes included late postoperative complications as well as nutritional deficiencies and persistent diarrhea at 1 and 2 years after surgery. Subgroup analyses were performed to compare patients undergoing one- and two-stage procedures.

RESULTS

Data of 107 patients who underwent SADS (n = 25) or DADS (n = 82) were included in the study. Follow-up data were available for 59/107 (55.1%) patients at 1 year and 47/107 (43.9%) at 2 years after surgery. Patients in the SADS and DADS groups had similar %TBWL at 1 year (23.6 versus 26.2, P = 0.617) and 2 years (24.8 versus 30.2, P = 0.116) after surgery. Short- and medium-term outcomes were similar between groups. There was no difference between patients undergoing one- versus two-stage procedures.

CONCLUSION

This study showed that patients undergoing SADS and DADS had similar weight loss at 1 and 2 years. Early and late postoperative morbidity, operative times, early readmissions, and LOS were also similar between groups. Further studies with longer follow-up are required to confirm these results.

Robotic Duodenal Switch Is Associated with Outcomes Comparable to those of Laparoscopic Approach

Introduction/Purpose

This study evaluates the outcomes of robotic duodenal switch (RDS) when compared to conventional laparoscopy (LDS).

Materials and Methods

Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), patients who underwent RDS were compared to those of LDS (2015–2018) for perioperative characteristics and thirty-day postoperative outcomes. Operative complexity, complications, and resource utilization trends were plotted over the included years for the two approaches. Multivariable analysis was conducted to characterize the impact of each approach on these outcomes.

Results

Of 7235 minimally invasive operations, 5720 (79.1%) were LDS while 1515 (20.9%) were RDS. Intraoperative endoscopy, anastomosis testing, and shorter operative duration were associated with LDS. RDS group had more concomitant procedures with less attending assistance. The odds ratios of organ space infection and sepsis were equivalent. RDS increased the odds ratios for venous thromboembolism [VTE] (odds ratio [OR] = 2.3, 95% confidence interval [CI] = 1.1–4.8, p = 0.02) and early discharge (OR = 7.3, CI = 4.9–10.9, p < 0.01). The difference in wound infection between LDS and RDS has been decreasing (1.5% and 1.5% in 2018 from 2.3% and 4.1% in 2015, respectively) over the years. Similarly, the decreasing trends were noted for systemic infections.

Conclusion

While the development of VTE after RDS was higher, most of the other complications were comparable between LDS and RDS in this study. RDS may reduce the need for advanced intraoperative assistance and minimize hospital stay in select cases, without increasing morbidity. The recent trends suggest a gradual decrease in the variations between LDS and RDS outcomes over time.

Revision of Roux-en-Y Gastric Bypass with Limb Distalization for Inadequate Weight Loss or Weight Regain

BACKGROUND

Of patients undergoing Roux-en-Y gastric bypass (RYGB), 15-35% of patients fail to achieve "adequate" weight loss or regain significant weight. Multiple solutions have been proposed, but not well studied. We report our experience with limb distalization with lengthening the biliopancreatic (BP) limb and shortening the common channel (CC).

METHODS

We retrospectively reviewed data from patients undergoing laparoscopic limb distalization for excess weight loss (EWL) <50% or BMI >35 kg/m² after RYGB from 2012 to 2017. The BP limb was lengthened and CC was shortened to 100-200 cm. Perioperative outcomes such as morbidity, weight loss, nutritional deficiencies, comorbidity remission, and operative details were analyzed.

RESULTS

Twenty-two patients were included. The mean BMI prior to RYGB was 54.1 ± 8.5 kg/m² and 43.0 ± 5.5 kg/m² prior to limb distalization. The mean follow-up was 18.3 ± 12.9 months with a mean BMI change, %EWL, and %TWL (total weight loss) of 11.8 ± 7.4 kg/m², 62.3 ± 32.4%, and 25.4 ± 14.4%, respectively. The total mean BMI change, %EWL, and %TWL from RYGB was 22.2 ± 9.9 kg/m², 77.8 ± 23.6%, and 40.2 ± 13.3%, respectively. Of patients with persistent comorbidities, remission rates of diabetes, hypertension, and gastroesophageal reflux disease were 100%, 17%, and 38%, respectively. The mean operative time was 132.6 ± 54.4 min and mean hospital stay was 2.2 ± 1.3 days. Overall morbidity was 27.3%. Three patients (13.6%) developed nutritional deficiencies requiring reversal surgery.

CONCLUSION

In patients with inadequate weight loss or weight regain after RYGB, limb distalization with lengthening of the BP limb is an effective procedure for additional weight loss and further improvement of comorbidities. Nutritional complications are a risk, but can be minimized with close follow-up and patient compliance.

Perioperative Outcomes of Proximal and Distal Gastric Bypass in Patients with BMI Ranged 50-60 kg/m(2)--A Double-Blind, Randomized Controlled Trial

Background

Proximal Roux-en-Y gastric bypass may not ensure adequate weight loss in superobese patients. Bypassing a longer segment of the small bowel may increase weight loss. The objective of the study was to compare the perioperative outcomes of laparoscopic proximal and distal gastric bypass in a double-blind randomized controlled trial of superobese patients. The study was conducted at two public tertiary care obesity centers in Norway.

Methods

Patients with body mass index (BMI) 50–60 kg/m² were randomly assigned to a proximal (150 cm alimentary limb) or a distal (150 cm common channel) gastric bypass. The biliopancreatic limb was 50 cm in both operations. Patients and follow-up personnel were blinded to the type of procedure. Thirty-day outcomes including complications are reported.

Results

We operated on 115 patients, of whom two were excluded at surgery, leaving 56 and 57 patients in the proximal group and distal group, respectively. The median (range) operating time was 72 (36–151) and 101 (59–227) min, respectively (p < 0.001). Two distal procedures were converted to laparotomy during the primary procedure. Median length of hospital stay was 2 (1–4) days in the proximal group and 2 (1–24) days in the distal group. The number of patients with complications and complications categorized according to the Contracted Accordion classification did not differ significantly. However, all six reoperations were performed in the distal group, of which three were completed by laparoscopy (p = 0.01 between groups). There were no deaths.

Conclusions

In superobese patients with BMI between 50 and 60 kg/m², distal gastric bypass was associated with longer operating time and more severe complications resulting in reoperation than proximal gastric bypass.

Biliopancreatic diversion-duodenal switch: independent contributions of sleeve resection and duodenal exclusion

BACKGROUND

The choice of first-stage operation in bilio-pancreatic diversion with duodenal switch (BPD-DS) is controversial. There are no published long-term comparisons of one- and two-stage BPD-DS outcomes.

METHODS

During 2001-2009, among 1,762 patients scheduled for BPD-DS 48 had duodenal switch (DS) and 53 sleeve gastrectomy (SG) as first-stage procedures. We compared prospectively updated outcomes of 42 DS (100 % open) and 49 SG (88 % laparoscopic), 13 of whom completed their second stage, to a control group of 91 patients with open one-stage BPD-DS.

RESULTS

One-year mean percent excess weight loss (%EWL) was greater after SG than DS (47 ± 19 vs. 39 ± 13 SD; p = 0.01) with earlier nadir (16 ± 10 vs. 45 ± 30 months; p < 0.0001) but more rapid significant weight regain. After 5 years, %EWL was 12 ± 35 for 9 SG, 45 ± 19 for 30 DS (p < 0.0006), and 70 ± 18 for the first-stage BPD-DS (p < 0.0001). Weight loss was less after two- than one-stage procedures (p < 0.02). Comorbidities improved progressively between SG, DS and BPD-DS (p < 0.001 for trend). HbA1C decreased by 10, 19, and 31 %, respectively (p < 0.0001). Dyslipidemia was cured in 41, 82, and 100 %, respectively. Systolic and diastolic blood pressure decreased only after DS (12 %; p < 0.0002). Patient satisfaction was similar for SG and DS but greater after BPD-DS overall (p = 0.04).

CONCLUSIONS

SG and DS independently contribute to beneficial metabolic outcomes after BPD-DS. Long-term weight loss and correction of metabolic abnormalities were better after DS favoring its use as first stage in BPD-DS; one-stage BPD-DS outcomes were superior to two-staged.

Surgical interventions for obesity and metabolic disease

Obesity continues to be a growing problem in both the developed and the developing world. Its strong link with co-morbid conditions such as type 2 diabetes, hypertension, obstructive sleep apnea, and depression presents an increasing strain on health care systems around the world. Diet and exercise alone has been shown to be largely ineffective at managing obesity. Surgery is the only evidence-based method of allowing morbidly obese patients to lose weight and to maintain this weight loss. Weight-reduction in obese individuals from bariatric surgery has also been found to markedly improve obesity-related co-morbid conditions, particularly, type 2-diabetes. Diabetic remission from bariatric surgery has resulted in the inclusion of bariatric surgery, by the International Diabetes Taskforce, as a treatment modality for type-2 diabetes. This consensus statement named four surgical options that have been found to be effective in both weight-loss and in inducing diabetes remission. These four surgical procedures lead to weight-loss through restrictive and malabsorptive mechanisms. Each specific operation has a different level of efficacy in inducing weight-loss and diabetic remission, as well as distinct types and rates of complications. This article reviews the best evidence that exists for the effectiveness and complications of these four operations.

Benefits and complications of the duodenal switch/biliopancreatic diversion compared to the Roux-en-Y gastric bypass

BACKGROUND

Despite providing superb excess weight loss and increased resolution of comorbid diseases, such as type 2 diabetes mellitus, compared to other bariatric procedures, the duodenal switch/ biliopancreatic diversion (DS/BD) has not gained widespread acceptance among patients and physicians. In this study, we investigated outcomes, symptoms and complications among postsurgical DS patients compared to RYGB patients.

METHODS

We used propensity scores to retrospectively match patients who underwent DS/BD between 2005 and 2010 to comparable Roux-en-Y gastric bypass (RYGB) patients. We then reviewed patient charts, and surveyed patients using the University of Minnesota Bariatric Surgery Outcomes Survey tool to track outcomes, comorbid illnesses and complications.

RESULTS

One hundred ninety consecutive patients underwent primary DS/BD between 2005 and 2010 at the University of Minnesota Medical Center. There were 178 patients available for follow-up (93.7%) who were matched to 139 RYGB patients. Type 2 diabetes, hypertension, and hyperlipidemia all significantly improved in each group. Improvements were significantly higher in the DS/BD group. Percent total weight loss was not different between groups. Loose stools and bloating symptoms were more frequently reported among DS/BD patients. With the exception of increased emergency department visits among DS/BD patients (P < .01), overall complication rates were not significantly different between DS/BD and RYGB. There was no difference in mortality rates between the groups.

CONCLUSION

The DS/BD is a robust procedure that engenders both superior weight loss and improvement of major comorbidities. Complication and adverse event rates are similar to those of RYGB.

Robotically-assisted laparoscopic biliopancreatic diversion with duodenal switch: the utility of the robotic system in bariatric surgery

Biliopancreatic diversion with duodenal switch (BPD/DS) is considered the most effective surgical option for morbidly obese patients. Several techniques have been described: open, laparoscopic, and the combination of open and laparoscopic. Only a few centers in the world perform robotically-assisted laparoscopic BPD/DS and the published literature is limited. We describe our experience using this technique as a safe alternative for treatment of morbid obesity. A review of a prospectively maintained database from 2008 to 2011 was conducted. A total of 107 consecutive patients (F:M = 83:24) were included in this series. Average age was 44.76 years (range 20-67), body mass index 49.97 kg/m(2) (range 37-70), and the number of preoperative comorbidities was 6.24 (range 3-11). The mean operative time for a typical BPD/DS with or without an appendectomy was 264 min (range 192-413), which increased to 298 min (range 210-463) when lysis of adhesion or additional procedures were performed. All study cases were completed using a minimally invasive approach. There were no intraoperative or 30-day major postoperative complications. Two patients returned to the operating room: one for endoscopic release of an inadvertently-sutured nasogastric tube during creation of the duodeno-ileal anastomosis and another patient for a port-site infection. Minor postoperative complications included carpal tunnel syndrome exacerbation (n = 1), which did not require surgical intervention. The median length of stay was 3.0 days (range 2-13). Two patients were readmitted within 30 day due to fluid retention and incarcerated umbilical hernia. The percentages of excess body weight loss (EBWL) at 1, 3, 6, 9, 12, and 18 months were 18.9, 36.4, 54.5, 67.4, 73.9, and 82.42 %, respectively. No mortality occurred in this study. Robotically-assisted laparoscopic technique for BPD/DS is a feasible, safe, and effective alternative for weight loss surgery with excellent outcomes.

Weight loss is more sustained after biliopancreatic diversion with duodenal switch than Roux-en-Y gastric bypass in superobese patients

BACKGROUND

Although biliopancreatic diversion with duodenal switch (BPD-DS) is not the most performed procedure, Roux-en-Y gastric bypass (RYGB) is challenged by weight regain and insufficient weight loss, especially in patients with a body mass index >50 kg/m(2). The aim of our retrospective study was to compare the weight loss after 2 types of primary bariatric surgery. A total of 83 BPD-DS and 97 RYGB procedures were performed from March 2002 to October 2009 for an initial mean body mass index of 55 kg/m(2).

METHODS

All RYGB patients underwent surgery at a private practice hospital and BPD-DS patients underwent surgery at a university hospital before February 2007 and at the same private hospital thereafter. The patients were seen in follow-up every 4 months the first year, every 6 months the second, and yearly thereafter. The maximum weight loss was assessed, as well as the weight regain beyond the first postoperative year. Weight loss success was defined as a percentage of excess weight loss (%EWL) of ≥50%.

RESULTS

The patients did not differ by age, gender, or length of follow-up (mean 46 mo, range .5-102 for RYGB and 44.3 mo, range 9-111 for BPD-DS). Of the patients, 17 RYGB and 7 BPD-DS patients were lost to follow-up within 3 years postoperatively. At 3 years of follow-up, the mean %EWL was 63.7% ± 17.0% after RYGB and 84.0% ± 14.5% after BPD-DS (P < .0001). Weight loss success was achieved by 83.5% of the RYGB and 98.7% of the BPD-DS patients (P = .0005).

CONCLUSION

After 12 months postoperatively, the number of patients regaining 10% of the weight lost during the first postoperative year was significantly greater after RYGB than after BPD-DS.

Laparoscopic sleeve gastrectomy followed by duodenal switch in selected patients versus single-stage duodenal switch for superobesity: case-control study

BACKGROUND

The prevalence of superobesity (body mass index [BMI] ≥50 kg/m(2)) has increased steadily during the past decade, and the most suitable surgical strategy for these patients is still controversial. Our objective was to test the hypothesis that in selected superobese patients, laparoscopic sleeve gastrectomy (SG) followed by laparoscopic duodenal switch (DS) might reduce the rate of postoperative complications and the need for the second step duodenal switch. The setting was a university hospital in France.

METHODS

A retrospective analysis was performed of a prospective database of 110 consecutive patients with a BMI of ≥50 kg/m(2) undergoing the staged approach and matched for age, gender, and BMI with 110 consecutive patients undergoing single-stage DS. The excess weight loss (EWL), co-morbidity improvement, and incidence of postoperative complications were compared between the 2 groups.

RESULTS

One patient died in the staged strategy group (mortality rate .9%). The postoperative complication rate was 8.2% in the staged strategy group (110 patients) and 15.5% in the single-stage DS group (110 patients; P = 1). Multivariate analysis showed that single-stage DS surgery is the only variable significantly associated with the occurrence of postoperative complications (odds ratio 2.36; 95% confidence interval 1.001-5.61). In the staged strategy group, at a mean follow-up of 36.4 ± 13 months, 39 patients (35.5%) required the second-stage procedure. The mean %EWL was 50.8% ± 17.5% for SG alone (35% failed to maintain 50% EWL after SG), 61.5% ± 19.3% for the staged strategy, 72.7% ± 14.1% for 2-step DS (3.3% failed to maintain 50% EWL after 2-step DS), and 73.3% ± 17.6% for single-stage DS (7.3% failed to maintain 50% EWL after single-stage DS).

CONCLUSIONS

At 3 years of follow-up, staged DS surgery avoided biliopancreatic diversion in 72.7% of the patients. Single-stage DS increases the risk of postoperative complications but not of anastomotic leak.

Biliopancreatic diversion with duodenal switch

The biliopancreatic diversion with a duodenal switch (BPD-DS) is a less commonly performed but very effective bariatric procedure that has been in existence for more than 20 years. It is particularly effective for the resolution of diabetes and is associated with the highest weight loss among other bariatric operations. Typically, the BPD-DS is not associated with postgastrectomy symptoms, such as dumping and marginal ulceration. Because of its complexity, it has usually been performed by laparotomy in the past; but, more recently, minimally invasive techniques are being used with acceptable risk.

Perioperative complications in a consecutive series of 1000 duodenal switches

BACKGROUND

In the past 10 years, most bariatric surgeries have seen an important reduction in the early complication rate, partly associated with the development of the laparoscopic approach. Our objective was to assess the current early complication rate associated with biliopancreatic diversion with duodenal switch (BPD-DS) since the introduction of a laparoscopic approach in our institution, a university-affiliated tertiary care center.

METHODS

A consecutive series of 1000 patients who had undergone BPD-DS from November 2006 to January 2010 was surveyed. The primary endpoint was the mortality rate. The secondary endpoints were the major 30-day complication rate and hospital stay >10 days. The data are reported as a mean ± SD, comparing the laparoscopic (n = 228) and open (n = 772) groups.

RESULTS

The mean age of the patients was 43 ± 10 years (40 ± 10 years in the laparoscopy group versus 44 ± 10 years in the open group, P < .01). The preoperative body mass index was 51 ± 8 kg/m(2) (47 ± 7 laparoscopy versus 52 ± 8 kg/m(2) open, P < .01). The conversion rate in the laparoscopy group was 2.6%. There was 1 postoperative death (.1%) from a pulmonary embolism in the laparoscopy group. The mean hospital stay was shorter after laparoscopic surgery (6 ± 6 d versus 7 ± 9 d, P = .01), and a hospital stay >10 days was more frequent in the open group (4.4% versus 7%, P = .04). Major complications occurred in 7% of the patients, with no significant differences between the 2 groups (7% versus 7.4%, P = .1). No differences were found in the overall leak or intra-abdominal abscess rate (3.5% versus 4%, P = .1); however, gastric leaks were more frequent after open surgery (0% versus 2%, P = .02). During a mean 2-year follow-up, 1 additional death occurred from myocardial infarction, 2 years after open BPD-DS.

CONCLUSION

The early and late mortality rate of BPD-DS is low and comparable to that of other bariatric surgeries.

[Treating morbid obesity with laparoscopic biliopancreatic diversion with duodenal switch]

BACKGROUND

Biliopancreatic diversion with duodenal switch is used in the treatment of morbid obesity. Few centres perform the procedure laparoscopically. We aimed to evaluate the perioperative outcomes and weight loss after laparoscopic duodenal switch.

MATERIAL AND METHODS

All patients operated with biliopancreatic diversion with duodenal switch at the Centre for Morbid Obesity at Oslo University Hospital (2004-2009) were included. The perioperative period was defined as within 30 days of surgery.

RESULTS

A total of 48 patients were operated, all laparoscopically. Median preoperative BMI was 54 kg/m2 (range 41-88), and 33 patients (69 %) were women. Ten patients (21 %) were operated in two steps: first gastric sleeve and later duodenal switch. Median operation time was 200 minutes (100-658). Twelve patients (25 %) had complications, four (8 %) were reoperated, and one died. Median postoperative hospital stay was three (1-56) days. After two years, median BMI was 32 kg/m2 (24-45), median weight loss 39 % (22-60) and median excess BMI (> 25 kg/m2) loss 73 % (43-106).

INTERPRETATION

Duodenal switch was applied in a minority of patients operated for morbid obesity. The procedure can be performed laparoscopically with a short hospital stay and leads to a substantial weight loss. Perioperative morbidity was high and was comparable to the results from other series.

Superobese and super-superobese patients: 2-step laparoscopic duodenal switch

BACKGROUND

Morbidity and mortality after bariatric surgery in superobese (body mass index [BMI] >50 but <60 kg/m2) and super-superobese (BMI >60 kg/m2) patients can allegedly be reduced by performing surgery in 2 steps. We report a retrospective study gathered from a prospective database for superobese and super-superobese patients who underwent laparoscopic biliopancreatic diversion/duodenal switch (LBPD/DS) after laparoscopic sleeve gastrectomy (LSG) as the first step.

METHODS

From October 2004 to June 2010, 31 patients underwent LBPD/DS after LSG. The mean age was 45.8 ± 10.1 years (range 21-64). The mean interval between the 2 procedures was 13.9 ± 8.4 months (range 6-37). At LSG, the mean weight and BMI was 168.8 ± 35.4 kg (range 127-255) and 58.3 ± 6.7 kg/m2 (range 50-74.5). At LBPD/DS, the mean weight, BMI, and percentage of excess weight loss was 136.3 ± 32.6 kg (range 92-220), 47.1 ± 7.2 kg/m(2) (range 37.8-64.3), and 31.6% ± 12.2% (range -11.7 to +54.6). At LSG, 26 patients had 43 obesity co-morbidities. Three co-morbidities (6.9%) resolved in 3 patients before the second step of LBPD/DS was performed.

RESULTS

The mean operative time was 175.5 ± 60.6 minutes (range 75-285). There were no deaths or conversions to open surgery. Four patients had early complications (1 anastomotic leak, 1 small bowel perforation, 1 case of renal insufficiency, and 1 case of pneumonia). The mean hospital stay was 6.6 ± 8 days (range 3-35). All patients, with the exception of 3, were followed up for a mean of 28.8 ± 21.4 months (range 4-71). At follow-up, the mean weight, BMI, and percentage of excess weight loss (compared with the pre-LSG weight) was 99.4 ± 23.7 kg (range 62-150), 34.5 ± 5.8 kg/m2 (range 24.9-46.3), and 54.8% ± 16% (range 18.9-84.8). A total of 22 obesity co-morbidities (51.1%) resolved in 14 patients. Three patients presented with late complications (1 ventral hernia, 1 case of protein deficiency, 1 anastomotic stenosis).

CONCLUSION

In the treatment of superobese and super-superobese patients with 2-step LBPD/DS, we experienced no deaths and achieved acceptable morbidity, considering the high operative risk in this group. This procedure is effective for both weight loss and resolution of co-morbidities.

Bariatric surgical anatomy and mechanisms of action

Because bariatric surgery is becoming increasingly common, gastroenterologists need to be familiar with the surgical and endoscopic anatomy of the operations in use today. This review focuses on the 4 most commonly performed bariatric operations in the United States: Roux-en-Y gastric bypass, adjustable gastric band, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch. The anatomy and mechanism of action of each procedure is discussed and illustrated. Emphasis is placed on the endoscopic anatomy, with review of the commonly encountered complications. Emerging techniques and devices are reviewed.

Robot-assisted sleeve gastrectomy for super-morbidly obese patients

BACKGROUND

Sleeve gastrectomy represents a valid option for morbidly obese patients, either as a primary or as a staged bariatric procedure. Several variations of the technique have been reported. Herein, we report our initial experience with robot-assisted sleeve gastrectomy (RASG).

MATERIALS AND METHODS

A prospectively held database for patients who underwent RASG was reviewed. Data included patient demographics, operative parameters, morbidity, and follow-up outcomes. The outcomes after RASG were compared to the laparoscopic approach.

RESULTS

From September 2007 to February 2010, 69 morbidly obese patients underwent sleeve gastrectomy. Of these, 30 (43.5%) were robot-assisted and 39 (56.5%) were laparoscopic. There was no statistically significant difference in demographics between the two groups. The RASG group underwent an oversewing of the staple line, and mean operative time was 135 minutes. In the laparoscopic group, where the staple line was not oversewn, mean operative time was 114 minutes (P = .003). Morbidity after RASG was 3.3%, and there were no gastrointestinal leaks or staple line bleeding. Mean postoperative hospital stay after RASG was 2.6 days (range: 1.6-8.3 days). Mean body mass index decrease at 1 year was 16  kg/m(2). There were no differences between the two groups in terms of morbidity, mortality, length of stay, and weight loss.

CONCLUSIONS

RASG can be performed safely, with good outcomes. However, the exact role and the advantages of RASG require further study in larger series.

Five-year follow-up after biliopancreatic diversion with duodenal switch

BACKGROUND

Only limited data are available for assessing the medium and long-term outcomes after bariatric surgery. We report our own long-term results after biliopancreatic diversion with duodenal switch (BPD-DS).

METHODS

The data from 51 patients with a theoretical ≥5-year follow-up were reviewed after BPD-DS performed from February 2002 to October 2004. The patients were assessed every 3 months during their first postoperative year, every 6 months during the second year, and annually thereafter.

RESULTS

The preoperative body mass index (BMI) was 47 ± 6.1 kg/m(2). The first 23 patients had undergone open BPD-DS. The same procedure was used (150-mL sleeve, 150-cm alimentary limb, and 100-cm common channel) for the 28 laparoscopic BPD-DS procedures, although 15 patients underwent conversion to laparotomy at the beginning of our experience. No patients died postoperatively. Of the 51 patients, 7 were not available for follow-up: 2 patients had died 9 months after BPD-DS (1 of myocardial infarction and 1 after ventral hernia repair), 1 underwent reversal, 1 refused follow-up after a complicated postoperative course, and contact was lost with 3 patients (7.8% lost to follow-up). The 5-year BMI was 31 ± 4.5 kg/m(2), with a mean excess weight loss of 71.9% ± 20.6%. Of the 44 patients, 7 (15.9%) had an excess weight loss of <50%; 4 of these unsatisfactory results occurred after revision BPD-DS. After primary BPD-DS, excess weight loss of 75.8% ± 18.0% was observed. Biologic data were obtained for 85% of the patients at 5 years. The main vitamin and micronutrients parameters remained stable over time. However, a trend was seen toward an increase in the parathormone levels and difficulties in maintaining a normal vitamin D level despite updated vitamin supplementation.

CONCLUSION

The results of our study have shown that BPD-DS achieves sustainable significant weight loss with >5 years of follow-up, with unsatisfactory results in <20% of cases. Although not statistically significant, revision surgery more often resulted in lesser weight loss, although this difference had almost vanished when the initial BMI was taken as a reference compared with the BMI before BPD-DS.

Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic biliopancreatic diversion with duodenal switch (LDS) are surgical options for superobesity. A randomized trial was conducted to evaluate perioperative (30-day) safety and 1-year results.

METHODS

Sixty patients with a body mass index (BMI) of 50-60 kg/m(2) were randomized to LRYGB or LDS. BMI, percentage of excess BMI lost, complications and readmissions were compared between groups.

RESULTS

Patient characteristics were similar in the two groups. Mean operating time was 91 min for LRYGB and 206 min for LDS (P < 0.001). One LDS was converted to open surgery. Early complications occurred in four patients undergoing LRYGB and seven having LDS (P = 0.327), with no deaths. Median stay was 2 days after LRYGB and 4 days after LDS (P < 0.001). Four and nine patients respectively had late complications (P = 0.121). Mean BMI at 1 year decreased from 54.8 to 38.5 kg/m(2) after LRYGB and from 55.2 to 32.5 kg/m(2) after LDS; percentage of excess BMI lost was greater after LDS (74.8 versus 54.4 per cent; P < 0.001).

CONCLUSION

LRYGB and LDS can be performed with comparable perioperative safety in superobese patients. LDS provides greater weight loss in the first year.