Prospective comparative evaluation of stapled versus transected silastic ring gastric bypass: 6-year follow-up

Primary banded Roux-en-Y gastric bypass: a systematic review

Primary banding of Roux-en-Y gastric bypass remains controversial. Though there are surgeons who believe it should be the standard practice as it results in superior weight loss and prevents weight regain in the long term, there are others who are concerned about the risk of food intolerance and complications related to band. This review investigates published English language literature systematically to find out the advantages and disadvantages of primary banding of a Roux-en-Y gastric bypass.

All strictures are not alike: laparoscopic removal of nonadjustable Silastic bands after banded Roux-en-Y gastric bypass

BACKGROUND

The concept of a nonadjustable Silastic band (NASB) has been used to promote surgically induced weight loss for >30 years. Vertical banded Roux-en-Y gastric bypass is an example. Some patients develop serious, band-related complications requiring treatment. Narrowing at the NASB will lead to refractory nausea, vomiting, regurgitation, and, even, malnutrition, requiring revision of their bariatric operation. We report on the evaluation, diagnosis, and laparoscopic treatment of proximal obstructive symptoms secondary to a NASB.

METHODS

From February 2005 to January 2009, we retrospectively reviewed the preoperative and perioperative data for 6 patients who had presented with proximal obstructive symptoms after undergoing banded Roux-en-Y gastric bypass.

RESULTS

The mean interval from primary NASB placement to surgery was 58 months (range 25-110). The mean duration of symptoms was 29 months (range 8-70). All patients presented with multiple symptoms, but all had nausea, vomiting, regurgitation, and dysphagia to liquids and solids. The patients had undergone multiple upper endoscopies (mean 4, range 3-6) and dilations (mean 1.3, range 1-2) without relief of their symptoms. All patients underwent successful laparoscopic removal of the NASB. Their mean hospital stay was 1 day (range 0-2). No operative or postoperative complications occurred. The reflux and obstructive symptoms had resolved immediately postoperatively in all patients.

CONCLUSION

Patients with a NASB in place can experience proximal obstructive symptoms. Endoscopy is deceptive in judging the stomal size, because the endoscope can be pushed through the band area. Moreover, endoscopic dilation will offer no benefit in most patients with symptomatic banded Roux-en-Y gastric bypass. Laparoscopic removal of the NASB is safe, relieves the symptoms immediately, and can be applied to patients who have undergone both open and laparoscopic Silastic banded bariatric procedures.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist health-care professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Estudo da gastrinemia pré e pós-operatória em pacientes submetidos à gastroplastia vertical com banda e reconstrução em Y de Roux por obesidade mórbida

OBJETIVO: Avaliar as concentrações pré e pós-operatória da gastrina sérica, hormônio fundamental na produção do ácido clorídrico gástrico, correlacionando-as com as complicações cloridropépticas pós-cirúrgicas, em pacientes submetidos à gastroplastia vertical com banda e reconstrução em Y de Roux (GVBYR). MÉTODO: Foram incluídos neste estudo, 20 pacientes com Índice de Massa Corpórea (IMC) superior a 40 Kg/m² selecionados após rigorosa avaliação psicológica. A dosagem da gastrina foi realizada no pré e no pós-operatório. Neste mesmo período todos os pacientes forma também submetidos a exame endoscópico com biópsia para estudo histopatológico. RESULTADOS: As quantidades de gastrina produzidas antes e após o tratamento cirúrgico não diferiram significativamente (p= 0,4281). Nenhum paciente apresentou alteração endoscópica ou histológica até o 2º mês de pós-operatório. CONCLUSÃO: Após a realização da GVBYR ocorre uma adaptação do tubo digestivo, de modo a manter a sua fisiologia, conduzindo-nos à convicção da segurança dessa técnica no tratamento da obesidade mórbida.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Three-year results of Roux-en-Y gastric bypass-on-vertical banded gastroplasty: an effective and safe procedure which enables endoscopy and X-ray study of the stomach and biliary tract

BACKGROUND

Cancer, perforation and bleeding in the bypassed stomach after RYGBP are rare but serious complications that require early diagnosis. Our goal was to perform a Roux-en-Y gastric bypass (RYGBP) whereby the traditional endoscopic and x-ray study of the bypassed stomach was possible, and at the same time obtain a good weight loss, similar to the standard RYGBP. We developed the RYGBP-on-Vertical banded gastroplasty (RYGBP on VBG), where a Goretex band surrounds the gastro-gastric outlet.

METHODS

From June 2002 to September 2005, 128 patients, 94 female and 34 male, with age 50.5 +/- 14.8 SD years, BMI 51.6 +/- 7.2 SD kg/m2, and %EW 117.9 +/- 33.5 SD underwent RYGBP on VBG via an open approach. Radiological and, if necessary, endoscopic study has been carried out at 6 months, 1 year and then annually postoperatively.

RESULTS

Two cases of anastomotic ulcer were detected, but no case of infection of the prosthetic material was found. Preoperative BMI fell from 51.6 +/- 7.2 to 38.1 +/- 6.6 after 6 months, to 35.0 +/- 7.1 after 1 year, to 34.4 +/- 6.1 after 2 years, and to 33.2 +/- 5.5 after 3 years.

CONCLUSION

RYGBP on VBG was effective; the weight loss curve, compared to standard RYGBP, is similar, while allowing the traditional x-ray and endoscopy of the bypassed stomach and thus the biliary tract.

Cost-effectiveness analysis of laparoscopic gastric bypass, adjustable gastric banding, and nonoperative weight loss interventions

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the two most commonly performed bariatric procedures. Although both procedures likely reduce healthcare expenditures related to the resolution of co-morbid conditions, they have different rates of perioperative risks and different rates of associated weight loss. We designed a model to evaluate the incremental cost-effectiveness of these procedures compared with nonoperative weight loss interventions and with each other.

METHODS

We used a deterministic, payer-perspective model comparing the lifetime expected costs and outcomes of LAGB, LRYGB, and nonoperative treatment. The major endpoints were survival, health-related quality of life, and weight loss. Life expectancy and lifetime medical costs were calculated across age, gender, and body mass index (BMI) strata using previously published data.

RESULTS

For both men and women, LRYGB and LAGB were cost-effective at <$25,000/quality-adjusted life-year (QALY) even when evaluating the full range of baseline BMI and estimates of adverse outcomes, weight loss, and costs. For base-case scenarios in men (age 35 y, BMI 40 kg/m(2)), the incremental cost-effectiveness was $11,604/QALY for LAGB compared with $18,543/QALY for LRYGB. For base-case scenarios in women (age 35 y, BMI 40 kg/m(2)), the incremental cost-effectiveness was $8878/QALY for LAGB compared with $14,680/QALY for LRYGB.

CONCLUSION

The modeled cost-effectiveness analysis showed that both operative interventions for morbid obesity, LAGB and RYGB, were cost-effective at <$25,000 and that LAGB was more cost-effective than RYGB for all base-case scenarios.

Surgical management of gastro-gastric fistula after divided laparoscopic Roux-en-Y gastric bypass for morbid obesity

BACKGROUND

Gastro-gastric fistula (GGF) formation is uncommon after divided laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity. Optimal surgical management remains controversial.

METHODS

A retrospective review was performed of a prospectively maintained database of patients undergoing LRYGB from January 2001 to October 2006.

RESULTS

Of 1,763 primary procedures, 27 patients (1.5%) developed a GGF and 10 (37%) resolved with medical management, whereas 17 (63%) required surgical intervention. An additional seven patients requiring surgical intervention for GGF after RYGB were referred from another institution. Indications for surgery included weight regain, recurrent, or non-healing gastrojejunal anastomotic (GJA) ulceration with persistent abdominal pain and/or hemorrhage, and/or recurrent GJA stricture. Remnant gastrectomy with GGF excision or exclusion was performed in 23 patients (96%) with an average in-hospital stay of 7.5 days (range, 3-27). Morbidity in six patients (25%) was caused by pneumonia, n=2; wound infection, n=2; staple-line bleed, n=1; and subcapsular splenic hematoma, n=1. There were no mortalities. Complete resolution of symptoms and associated ulceration was seen in the majority of patients.

CONCLUSION

Although uncommon, GGF formation can complicate divided LRYGB. Laparoscopic remnant gastrectomy with fistula excision or exclusion can be used to effectively manage symptomatic patients who fail to respond to conservative measures.

Percutaneous gastrostomy of the excluded gastric segment after Roux-en-Y gastric bypass surgery

A new technique for percutaneous gastrostomy of a decompressed excluded gastric segment after Roux-en-Y gastric bypass (RYGBP) surgery is described and the results in a single institution are reviewed. Computed tomography guidance was used to place a 21- or 22-gauge needle into the lumen of the stomach and distend it to allow placement of a feeding catheter. Ten women underwent the procedure, and despite only three patients having clear access windows, gastrostomy placement was ultimately successful in all 10 patients. Percutaneous gastrostomy of the decompressed excluded gastric segment after RYGBP surgery can be challenging, but a high rate of success can be achieved.

Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients

BACKGROUND

Marginal ulceration after Roux-en-Y gastric bypass (RYGB) is diagnosed in 1% to 16% of patients. The factors predisposing patients to marginal ulceration are still unclear.

METHODS

A total of 260 patients who underwent laparoscopic RYGB were retrospectively reviewed. Data regarding demographics, comorbidities, body mass index (BMI), Helicobacter pylori infection, gastrojejunal (GJ) anastomotic leaks, postoperative bleeding, operative time, type of suture material, and marginal ulcer formation were collected. Fisher's exact test was used for statistical analysis of discrete variables, and Student's t-test was used for continuous variables. Statistical significance was set at an alpha of 0.05.

RESULTS

The overall marginal ulceration rate was 7%. Demographic data (age, gender distribution, BMI) did not differ significantly between patients who experienced marginal ulceration and those who did not (p > 0.05). Similarly, technical factors (choice of permanent or absorbable suture for the GJ anastomosis, attending as primary surgeon, robotic GJ, operative time, postoperative hematocrit drop) were not statistically different between the two groups (p > 0.05). Finally, the prevalence of comorbidities (diabetes, hypertension, obstructive sleep apnea, musculoskeletal complaints, dyslipidemia, gastroesophageal reflux disease [GERD] and peptic ulcer disease [PUD]) did not differ significantly between the two groups (p > 0.05). However, preoperative H. pylori infection, although adequately treated, was twice as common among the patients who had marginal ulceration (32%) as among those who did not (12%) (p = 0.02). All the patients who experienced marginal ulcers had complete resolution of symptoms with proton pump inhibitors and sucralfate. No reoperations were required for marginal ulceration.

CONCLUSION

Helicobacter pylori may potentiate marginal ulcer formation. The authors hypothesize that H. pylori damages the mucosal barrier in a way that persists postoperatively, which may precipitate marginal ulceration even when the organism has been medically eradicated.

Laparoscopic Roux-en-Y gastric bypass with linear cutter technique: comparison of four-row versus six-row cartridge in creation of anastomosis

BACKGROUND

Morbid obesity is refractory to medical treatment. The introduction of laparoscopic linear staplers in the early 1990s contributed to the development of the laparoscopic Roux-en-Y gastric bypass technique. Many series have compared different brands of circular and linear staplers. The purpose of this study was to evaluate the 4-row versus 6-row endoscopic staplers in laparoscopic Roux-en-Y gastric bypass for creation of the anastomosis.

METHODS

Between July 2000 and April 2004, 1240 patients underwent laparoscopic Roux-en-Y gastric bypass. The 4-row linear stapler was used in the first 664 cases (group 1) and the 6-row stapler in the latter 576 patients (group 2) to create the anastomosis. The medical records of those patients who developed leaks, gastrogastric fistulas, strictures, or bleeding were reviewed. Strictures were diagnosed using radiologic or endoscopic techniques.

RESULTS

Leaks were more frequent in group 2 than in group 1 (1.56% versus 1.05%, respectively, P = .46). Documented bleeding occurred in 15 and 13 patients in groups 1 and 2, respectively (2.26% for both). Strictures were diagnosed in 7.68% of patients in group 1 (51 gastrojejunostomy and 4 jejunojejunostomy), and in 4.3% of those in group 2 (25 gastrojejunostomy stenosis, P = .017). Gastrogastric fistulas were found in 5 patients (.75%) in group 1 and 6 (1.04%) in group 2.

CONCLUSION

Using a 6-row instead of a 4-row linear cutter technique to create the anastomosis yielded similar results, but the stricture rate at the gastrojejunal anastomosis was significantly lower with the newer, 6-row staplers.

Endoscopic issues in the post-gastric bypass patient

Obesity in the United States poses a tremendous health risk to approximately one third of the population. As this epidemic grows, the number of bariatric surgeries performed will also increase. Although obesity itself is not gender specific, 85% of bariatric surgeries are performed in women. This article reviews some of the commonly performed weight-reduction surgeries and their associated complications. Particular emphasis is placed on the diagnostic and therapeutic implications of endoscopy in this population.

Gastrointestinal complications of bariatric surgery

The current epidemic of obesity and its myriad comorbidities represents one of the true major public health crises in the United States today. Data reflecting durable weight loss achieved through surgical treatment of obesity demonstrate impressive results heretofore unattainable with less aggressive modalities. However, these outcomes are accompanied by expected side effects and complications, which require specific knowledge to diagnose accurately and a specialized skill-set to manage precisely. With the ever-increasing demand for bariatric surgery, the number of ensuing complications will also rise, requiring the expertise of a gastroenterologist for both diagnosis and treatment. Thus, the gastroenterologist must develop a keen understanding of bariatric surgical anatomy and physiology, as well as the expected postoperative side effects and potential complications experienced by the post-bariatric patient.

Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric operation in the United States. Although rare, gastrogastric fistulas are an important complication of this procedure.

METHODS

We report a series of 1,292 consecutive patients who underwent a divided RYGB procedure at our institution between January 2000 and November 2004. Of the 1,292 patients, we identified 15 (1.2%) who presented with gastrogastric fistulas after surgery.

RESULTS

The mean age, weight, and body mass index of these patients was 39.5 years, 377.5 lb, and 54.9 kg/m(2), respectively. The mean postoperative follow-up was 17.6 months. The overall follow-up success rate in this series at 1 and 2 years postoperatively was 85% and 77%, respectively. Of the 15 patients, 12 (80%) presented with symptoms of nausea, vomiting, and epigastric pain. Esophagogastroscopy revealed marginal ulcers in 8 (53%) of these symptomatic patients. The most sensitive test for the diagnosis of gastrogastric fistula was an upper gastrointestinal contrast study. The mean time to fistula diagnosis was 80 days. Four patients (27%) had had a known leak before their diagnosis of gastrogastric fistula. In all cases, the leaks were managed nonoperatively with drainage, parenteral nutrition, and bowel rest. In this subset of patients, the mean time to fistula diagnosis was 25 days. Four patients (27%) presented to the clinic unsatisfied with their weight loss. The mean excess percentage of weight loss was 60.9%. Of the 15 patients with a diagnosed gastrogastric fistula, 8 (53.3%) presented with concomitant marginal ulcers. When present, marginal ulcers were managed with chronic acid suppressive therapy consisting of proton pump inhibitors and sucralfate. Revisional surgery was performed in 5 (33.3%) of 15 patients because of the combination of constant pain and ulceration refractory to optimal medical treatment and in 1 patient (7%) because of refractory pain unresponsive to medical therapy and weight regain. All revisional procedures (100%) were performed laparoscopically.

CONCLUSION

Gastrogastric fistulas are an uncommon, but worrisome, complication after divided RYGB. Most symptoms of gastrogastric fistula are related to epigastric pain and ulcerations around the anastomotic site, but the fistula can occur anywhere along the divided segment of the gastric wall. They can initially be managed with a conservative, nonoperative approach as long as the patient remains asymptomatic and weight regain does not occur. Refractory ulcers and pain are the main indications for revisional surgery. Weight loss failure or weight regain is an uncommon short-term finding with gastrogastric fistulas after divided RYGB that requires surgical revision as the definitive treatment option. Although we present one of the largest series to date, longer follow-up is needed to better define the management of this patient population and provide a more accurate incidence of its occurrence.

Obesity surgery: evidence-based guidelines of the European Association for Endoscopic Surgery (EAES)

BACKGROUND

The increasing prevalence of morbid obesity together with the development of laparoscopic approaches has led to a steep rise in the number of bariatric operations. These guidelines intend to define the comparative effectiveness and surrounding circumstances of the various types of obesity surgery.

METHODS

A consensus panel representing the fields of general/endoscopic surgery, nutrition and epidemiology convened to agree on specific questions in obesity surgery. Databases were systematically searched for clinical trial results in order to produce evidence-based recommendations. Following two days of discussion by the experts and a plenary discussion, the final statements were issued.

RECOMMENDATIONS

After the patient's multidisciplinary evaluation, obesity surgery should be considered in adults with a documented BMI greater than or equal to 35 and related comorbidity, or a BMI of at least 40. In addition to standard laboratory testing, chest radiography, electrocardiography, spirometry, and abdominal ultrasonography, the preoperative evaluation of obesity surgery patients also includes upper gastrointestinal endoscopy or radiologic evaluation with a barium meal. Psychiatric consultation and polysomnography can safely be restricted to patients with clinical symptoms on preoperative screening. Adjustable gastric banding (GB), vertical banded gastroplasty (VBG), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) are all effective in the treatment of morbid obesity, but differ in degree of weight loss and range of complications. The choice of procedure therefore should be tailored to the individual situation. There is evidence that a laparoscopic approach is advantageous for LAGB, VBG, and GB (and probably also for BPD). Antibiotic and antithromboembolic prophylaxis should be used routinely. Patients should be seen 3 to 8 times during the first postoperative year, 1 to 4 times during the second year and once or twice a year thereafter. Outcome assessment after surgery should include weight loss and maintainance, nutritional status, comorbidities and quality-of-life.

Laparoscopic Roux-en-Y gastric bypass: technique and 3-year follow-up

BACKGROUND

The purpose of this study is to evaluate our experience with the laparoscopic gastric bypass. The technique, weight loss data, and complications are described.

METHODS

1,500 consecutive patients were evaluated prospectively. All patients met NIH criteria for bariatric surgery. Although there have been modifications with respect to staplers, suture material, and dissection techniques, the basic anatomical construct has remained the same, including performing a completely hand-sewn gastrojejunostomy.

RESULTS

There were no anastomotic leaks from the hand-sewn gastrojejunostomy. Operative times now are consistently 60 minutes or less, although the learning curve is quite long. Average hospital stay was 1.5 days. Average excessive weight loss was 69% at one and two years and 62% at three years. Overall complication rate was 14.8%. Perioperative death rate was 0.2%.

CONCLUSIONS

The laparoscopic gastric bypass is a viable alternative to traditional open techniques. It is as safe and effective and can be performed with equal or greater efficiency. Adoption of hand-suturing techniques helps to improve the surgeon's skill and ability to cope with the occasional stapler misfire or complication.

Complications of surgery for obesity

Morbidly obese patients are already considered high-risk because of their comorbidities. Surgical procedures for obesity are, for the most part, completely elective. Careful counseling of the patient before and after the surgery is extremely important. This article reviews the general complications of bariatric surgery and specific complications of restrictive procedures.