Learning Curves of Laparoscopic Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in Bariatric Surgery: a Systematic Review and Introduction of a Standardization

BACKGROUND

The most commonly performed bariatric procedures are laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (LSG). Impact of learning curves on operative outcome has been well shown, but the necessary learning curves have not been clearly defined. This study provides a systematic review of the literature and proposes a standardization of phases of learning curves for RYGB and LSG.

METHODS

A systematic literature search was performed using PubMed, Web of Science, and CENTRAL databases. All studies specifying a number or range of approaches to characterize the learning curve for RYGB and LSG were selected.

RESULTS

A total of 28 publications related to learning curves for 27,770 performed bariatric surgeries were included. Parameters used to determine the learning curve were operative time, complications, conversions, length of stay, and blood loss. Learning curve range was 30-500 (RYGB) and 30-200 operations (LSG) according to different definitions and respective phases of learning curves. Learning phases described the number of procedures necessary to achieve predefined skill levels, such as competency, proficiency, and mastery.

CONCLUSIONS

Definitions of learning curves for bariatric surgery are heterogeneous. Introduction of the three skill phases competency, proficiency, and mastery is proposed to provide a standardized definition using multiple outcome variables to enable better comparison in the future. These levels are reached after 30-70, 70-150, and up to 500 RYGB, and after 30-50, 60-100, and 100-200 LSG. Training curricula, previous laparoscopic experience, and high procedure volume are hallmarks for successful outcomes during the learning curve.

Effect of roux-en Y gastric bypass surgery on patients with type 2 diabetes mellitus: A protocol of systematic review and meta-analysis

BACKGROUND

Previous studies have reported that roux-en Y gastric bypass surgery (RYGBS) can benefit patients with type 2 diabetes mellitus (T2DM). However, their conclusions are still inconsistent. Thus, this study will aim to assess the effect of RYGBS for patients with T2DM.

METHODS

In this study, the electronic databases of MEDLINE, EMBASE, CENTRAL, CINAHL, AMED, and CNKI from inceptions to the present without any limitations to language and publication status. All randomized controlled trials on assessing the effect of RYGBS for patients with T2DM will be included in this study. Two independent authors will carry out study search and selection according to the previous designed inclusion and exclusion criteria. At the same time, 2 authors will independently evaluate the risk of bias assessment by Cochrane risk of bias tool. Any disagreements between 2 authors will be solved by a third author through discussion. RevMan 5.3 software will be utilized for statistical analysis.

RESULTS

This study will summarize the most recent studies and will provide a deeper understanding about using the effect of RYGBS for patients with T2DM.

CONCLUSIONS

The findings of this study will present the existing evidence for the effect of RYGBS for patients with T2DM.

SYSTEMATIC REVIEW REGISTRATION

INPLASY202040127.

A Delphi Consensus of the Crucial Steps in Gastric Bypass and Sleeve Gastrectomy Procedures in the Netherlands

PURPOSE

Bariatric procedures are technically complex and skill demanding. In order to standardize the procedures for research and training, a Delphi analysis was performed to reach consensus on the practice of the laparoscopic gastric bypass and sleeve gastrectomy in the Netherlands.

METHODS

After a pre-round identifying all possible steps from literature and expert opinion within our study group, questionnaires were send to 68 registered Dutch bariatric surgeons, with 73 steps for bypass surgery and 51 steps for sleeve gastrectomy. Statistical analysis was performed to identify steps with and without consensus. This process was repeated to reach consensus of all necessary steps.

RESULTS

Thirty-eight participants (56%) responded in the first round and 32 participants (47%) in the second round. After the first Delphi round, 19 steps for gastric bypass (26%) and 14 for sleeve gastrectomy (27%) gained full consensus. After the second round, an additional amount of 10 and 12 sub-steps was confirmed as key steps, respectively. Thirteen steps in the gastric bypass and seven in the gastric sleeve were deemed advisable. Our expert panel showed a high level of consensus expressed in a Cronbach's alpha of 0.82 for the gastric bypass and 0.87 for the sleeve gastrectomy.

CONCLUSIONS

The Delphi consensus defined 29 steps for gastric bypass and 26 for sleeve gastrectomy as being crucial for correct performance of these procedures to the standards of our expert panel. These results offer a clear framework for the technical execution of these procedures.

[Gastric bypass versus sleeve, pros and cons]

Gastric bypass versus sleeve, pros and cons  The most commonly performed bariatric procedure today is gastric bypass, while sleeve gastrectomy has become more common in recent years. Little is known about the long-term effects of sleeve gastrectomy and despite several randomized trials it is still unknown which procedure is the most favourable. Two recently published randomized trials show that the two procedures result in comparable weight loss in the short term while gastric bypass could possibly result in better weight loss in the long term. However, gastric bypass tends to lead to a higher incidence of post-operative complications compared to sleeve gastrectomy.

Development, feasibility, validity, and reliability of a scale for objective assessment of operative performance in laparoscopic gastric bypass surgery

BACKGROUND

There is no objective scale for assessment of operative skill in laparoscopic gastric bypass (LGBP). The objective of this study was to develop and demonstrate feasibility of use, validity, and reliability of a Bariatric Objective Structured Assessment of Technical Skill (BOSATS) scale.

STUDY DESIGN

The BOSATS scale was developed using a hierarchical task analysis (HTA), a Delphi questionnaire, and a panel of international experts in bariatric surgery. The feasibility of use, reliability, and validity of the developed scale were demonstrated by reviewing 52 prospectively collected video recordings of LGBP performed by novice and experienced surgeons.

RESULTS

A total of 214 discrete steps were identified in HTA. A total of 12 and 17 panel members completed the first and second round of the Delphi questionnaire, respectively. Consensus among the panel was achieved after the second round (Cronbach's alpha = 0.85). The BOSATS scale demonstrated high inter-rater (intraclass correlation coefficient [ICC] = 0.954; p < 0.001) and test-retest reliability (ICC = 0.99; p < 0.001). Significant differences between BOSATS scores of experienced and novice surgeon groups were noted for the creation of jejunojejunostomy (JJ), gastric pouch, linear stapled gastrojejunostomy (GJ), circular stapled GJ, and hand-sewn GJ. Moderate to high correlations between BOSATS scale and Objective Structured Assessment of Technical Skills Global Rating Scale (OSATS GRS) were seen for JJ (rho = 0.59; p = 0.001), gastric pouch (rho = 0.48; p = 0.0004), linear stapled GJ (rho = 0.70; p = 0.0001), and hand-sewn GJ (rho = 0.96; p < 0.0001).

CONCLUSIONS

The BOSATS scale is a feasible to use, reliable, and valid instrument for objective assessment of operative performance in LGBP. Implementation of this scale is expected to facilitate deliberate practice and provide a means for future certification in bariatric surgery.

Biochemical correlates of bariatric-responsive diabetes

OBJECTIVE

In a prospective observational cohort study, the biochemical profile of bariatrically managed diabetes was documented, aiming to assess its association with clinical outcome.

METHODS

The population (n = 82; age, 50.7 +/- 10.3 years; 92.7% women; followed up for 93 +/- 34 months) was stratified as responsive diabetes (Group I) (36.6%, 30 of 82) and controls without diabetes (Group II) (57.3%, 47 of 82). A few refractory subjects were identified in this cohort (Group III [refractory diabetes], 6.3%, five of 82). Nonbariatric overweight and obese diabetes subjects with similar follow-up (n = 21) were documented as well. Main outcome measures were diabetes regression, body mass índex (BMI), glucose, glycosylated hemoglobin A1c (HbA1c), serum lipids, and white blood cell count (WBC) count.

RESULTS

Preoperative BMI was somewhat discrepant among operated groups but leveled off from 2 years on. Baseline WBC count, total cholesterol, low-density lipoprotein-cholesterol, blood glucose, and HbA1c were higher in responsive subjects, but a downward shift occurred, without differences regarding controls, in the subsequent period. Conservatively managed diabetes displayed favorable changes of some lipid fractions, but not glucose, HbA1c, total cholesterol, or WBC count.

CONCLUSIONS

Diabetes regression rate was 94.3% at 5 years and 84.7% at around 8 years. In responsive patients, both BMI and biochemical indices normalized in the first 2 years and followed a stable path thereafter. Nonoperative treatment was unable to reduce HbA1c, glucose, or WBC count, and HbA1c was a clear prognostic marker of persistent disease in surgical cases. Further studies emphasizing the metabolic and inflammatory signature of obesity-related diabetes are worthwhile.

Identifying high-quality bariatric surgery centers: hospital volume or risk-adjusted outcomes?

BACKGROUND

Payers and professional organizations are expanding accreditation and "centers of excellence" programs in bariatric surgery. Rather than directly measuring outcomes, most programs rely on procedure volume. We sought to determine whether risk-adjusted outcomes or hospital volume were better at predicting future hospital morbidity with bariatric surgery.

STUDY DESIGN

We identified all patients who underwent gastric bypass in the New York State Inpatient database (n = 32,381 patients, n = 105 hospitals). Morbidity was ascertained using a previously validated combination of diagnostic and procedure codes. We first calculated the risk-adjusted morbidity and volume at each hospital during a 2-year period (2003 to 2004). We then ascertained the proportion of hospital-level variation explained by each measure using hierarchical modeling techniques. Finally, we compared the ability of each measure to predict future performance, as assessed with risk-adjusted morbidity, in the next 2 years (2005 to 2006).

RESULTS

Risk-adjusted morbidity explained 83% of future hospital-level variation in morbidity compared with only 21% for hospital volume. When comparing the "best" with the "worst" hospital quartiles, risk-adjusted morbidity predicted a more than fourfold difference in future performance (1.7% versus 7.2%; odds ratio [OR]: 4.5; 95% CI, 3.5 to 5.9). Hospital volume predicted only a twofold difference (2.5% versus 4.5%; OR: 1.9; 95% CI, 1.5 to 2.4) from the best to worst quartile.

CONCLUSIONS

Risk-adjusted morbidity is much better than hospital volume at predicting future performance with bariatric surgery. Rather than focusing on volume, accreditation and centers of excellence programs should focus more on directly measuring outcomes.

[Resection gastric bypass in morbid obese patients aged less than 18 and over 65 years]

BACKGROUND

The incidence of morbid obesity is increasing and gastric bypass is the most effective surgical treatment.

AIM

To assess the long term results of resection gastric bypass among morbidly obese patients aged less than 18 and over 65 years in terms of weight loss and correction comorbidities.

MATERIAL AND METHODS

From August 1999 to December 2006, 712 patients with morbid obesity were subjected to open resection gastric bypass. A group of 12 patients, aged less than 18 years and a second group of 8 patients aged more 65 years were selected to prospectively assess weight loss, complications and correction of associated comorbidities.

RESULTS

In the first group body mass index (BMI) decreased from 45+/-6.7 kg/m2 to 27.7+/-3.2 kg/m2, in a follow-up period of 22.9+/-8.4 months. All comorbidities disappeared or improved. A single patient (8.3%) had an incisional hernia. Among the second group, BMI decreased from 40.6+/-5.4 kg/m2 to 28.4+/-4.4 kg/m2, in a follow-up period of 26.6+/-15.9 months. All obesity comorbidities disappeared. Three patients (37.5%) presented incisional hernias. No patient died or had postoperative complications.

CONCLUSIONS

In both groups resection gastric bypass was safe, obtained an appropriate weight loss and corrected all associated comorbidities to obesity.

Impact of clinical pathways in surgery

BACKGROUND

One strategy to reduce the consumption of resources associated to specific procedures is to utilize clinical pathways, in which surgical care is standardized and preset by determination of perioperative in-hospital processes. The aim of this prospective study was to establish the impact of clinical pathways on costs, complication rates, and nursing activities.

METHOD

Data was prospectively collected for 171 consecutive patients undergoing laparoscopic cholecystectomy (n = 50), open herniorrhaphy (n = 56), and laparoscopic Roux-en-Y gastric bypass (n = 65).

RESULTS

Clinical pathways reduced the postoperative hospital stay by 28% from a mean of 6.1 to 4.4 days (p < 0.001), while the 30-day readmission rate remained unchanged (0.5% vs. 0.45%). Total mean costs per case were reduced by 25% from euro 6,390 to euro 4,800 (p < 0.001). Costs for diagnostic tests were reduced by 33% (p < 0.001). Nursing hours decreased, reducing nursing costs by 24% from euro 1,810 to euro 1,374 (p < 0.001). A trend was noted for lower postoperative complication rates in the clinical pathway group (7% vs. 14%, p = 0.07).

CONCLUSIONS

This study demonstrates clinically and economically relevant benefits for the utilization of clinical pathways with a reduction in use of all resource types, without any negative impact on the rate of complications or re-hospitalization.

Laparoscopic adjustable gastric band versus laparoscopic Roux-en-Y gastric bypass: ends justify the means?

BACKGROUND

In the United States, the most frequently performed bariatric procedure is the Roux-en-Y gastric bypass (RYGB). Worldwide, the most common operation performed is the laparoscopic adjustable gastric band (LAGB). The expanding use of LAGB is probably driven by the encouraging data on its safety and effectiveness, in contrast to the disappointing morbidity and mortality rates reported for RYGB. The aim of this study was to evaluate the results of LAGB versus RYGB at a single institution.

METHODS

Between November 2000 and July 2004, 590 bariatric procedures were performed. Of these, 120 patients (20%) had laparoscopic RYGB and 470 patients (80%) had LAGB. A retrospective review was performed.

RESULTS

In the LAGB group, 376 patients (80%) were female, and the mean age was 41 years (range, 17-65). In the RYGB group, 110 patients (91%) were female, and the mean age was 41 years (range, 20-61). Preoperative body mass index was 47 +/- 8 and 46 +/- 5, respectively (p = not significant). Operative time and hospitalization were significantly shorter in LAGB patients (p < 0.001). Complications and the need for reoperation were comparable in both groups. Weight loss at 12, 18, 24, and 36 months for LAGB and RYGB was 39 +/- 21 versus 65 +/- 13, 39 +/- 20 versus 62 +/- 17, 45 +/- 25 versus 67 +/- 8, and 55 +/- 20 versus 63 +/- 9, respectively.

CONCLUSIONS

The current study demonstrates that LAGB is a simpler, less invasive, and safer procedure than RYGB. Although mean percentage excess body weight loss (%EBWL) in RYGB patients increased rapidly during the first postoperative year, it remained nearly unchanged at 3 years. In contrast, in LAGB patients weight loss was slower but steady, achieving satisfactory %EBWL at 3 years. Therefore, we believe that LAGB should be considered the initial approach since it is safer than RYGB and is very effective at achieving weight loss.

Optimizing outcomes in bariatric surgery: outpatient laparoscopic gastric bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is an effective treatment of severe obesity and one of the fastest growing surgical procedures in the United States.

METHODS

A single institution prospective database of patients undergoing outpatient laparoscopic (lap) RYGB over a 3-year period was reviewed. Study end points included hospital discharge within 23 hours, 30-day hospital readmission rate, early (<30 day) and late complication rates, and 30-day perioperative mortality. Variables assessed included surgeon experience, patient demographics, comorbidities, operative time, Roux limb pathway, intraoperative steroid bolus, and use of dexmedetomidine.

RESULTS

Two thousand consecutive patients undergoing outpatient lap RYGB were identified, and 84% (n = 1669) were discharged within 23 hours. Of these, 1.7% (n = 34) were readmitted within 30 days. The overall early and late complication rates were 1.9% (n = 38) and 4.3% (n = 86), respectively. The 30-day mortality rate was 0.1% (n = 2), and neither patient was discharged before death. Univariate analysis demonstrated surgeon experience (<50 cases), age (<56 years), body mass index (<60 kg/m), weight (400 lbs), comorbidities (<5), and intraoperative steroid bolus as predictive of successful outpatient discharge. Multivariate analysis revealed surgeon experience, comorbidities, body mass index, and steroid bolus as predictive variables.

CONCLUSIONS

These data suggest that outpatient lap RYGB can be performed with acceptable perioperative complication rates, hospital readmission, and mortality rates. Surgeon experience, careful patient selection, and the use of intraoperative steroid bolus predicted optimal patient outcomes.

Quality Assurance in Bariatric Surgery

Quality assurance is a function that exists in manufacturing,engineering, and the service industry. Bariatric surgery is an undertaking with a special form of consumer product and service. In this day of limited resources and significant value exchanges among stakeholders (ie, patients, surgeons, third-party payers),the goal of the bariatric community is to deliver quality outcomes with safety, efficacy, and efficiency. The American Society for Bariatric Surgery and the Surgical Review Corporation, in conjunction with the bariatric community, will use quality assurance methods to produce quality outcomes that will satisfy the value exchanges of all stakeholders.

Propuesta y fundamentos para una norma de manejo quirúrgico del paciente obeso: Año 2004

Obesity is a chronic disease with an increasing prevalence in all groups of age, and is associated to increased general mortality and cardiovascular risk. The multidisciplinary non surgical approach must be the treatment of choice for obese subjects. However, the results of such approach among subjects with severe or morbid obesity, are unsatisfactory. In this group of patients, bariatric surgery and specifically gastric bypass achieves good long term results, maintaining a low body mass index, reducing complications and improving quality of life. Considering the widespread practice of bariatric surgery in Chile, the Nutrition Unit of the Ministry of Health formed a task force to propose update guidelines for the surgical treatment of obesity. These guidelines were proposed after a thorough literature review and discussion with groups that practice bariatric surgery using defined protocols. This document provides a summarized version of the guidelines. The first section discusses the background for bariatric surgery and the second part give specific recommendations for patient management and the formation of reference centers for surgical management of obesity.

Leveling the learning curve for laparoscopic bariatric surgery

BACKGROUND

The learning curve for laparoscopic bariatric surgery is associated with increased morbidity and mortality.

METHODS

The study included the first 100 patients undergoing laparoscopic Roux-en-Y gastric bypass (LGB) by a designated surgical team. Surgeon A operated as primary surgeon, with surgeon B assisting (Stage 1). Surgeon B learned LGB in stages: exposure and jejunojejunostomy (stage 2), gastric pouch (stage 3), gastrojejunostomy (stage 4), and sequence all steps (stage 5).

RESULTS

Surgeon A achieved confidence with LGB after 20 cases and surgeon B after 25 cases (stage 2), 18 cases (stage 3), 21 cases (stage 4), and 16 cases (stage 5). Complications (8%) included small bowel obstruction (three); pulmonary embolus (two), and leak, stomal stenosis, and gastrogastric fistula (one each). There was a decreasing trend for operative duration, length of stay, and complications across the five stages (p < 0.05).

CONCLUSIONS

By transferring skills in stages, a laparoscopic bariatric program can be established with minimal morbidity and mortality.

The use and modification of clinical pathways to achieve specific outcomes in bariatric surgery

Clinical pathways are promoted for standardizing patient care and decreasing resource use without compromising outcome. Once established, we hypothesized that clinical pathways can then be used to modify patient care to achieve specific goals. Our aim was to evaluate a clinical pathway for the bariatric surgical patient that was initially designed to standardize care and later altered to modify the postoperative course. We retrospectively reviewed 150 consecutive patients undergoing open gastric bypass by a single surgeon. The first 50 patients were managed without a formal pathway, (group I). The next 50 were managed with a pathway that standardized care in order to reduce length of stay (LOS), (group II). For the final 50 patients, the pathway was modified to shorten nasogastric decompression time (group III). Patient information, blood loss (EBL), operative time, length of stay (LOS), nasogastric decompression, 30-day complication rates, and early readmissions were reviewed. The groups were similar with respect to gender, age, body mass index, American Society of Anesthesiologists (ASA) classification, and EBL. Operative time was significantly less in groups II and III compared to group I (82% and 68% vs. 38% <180 minutes, P < 0.05). LOS was shorter in groups II and III compared to group I (62% and 42% vs. 20% with a 4-day LOS, P < 0.05). Duration of nasogastric tube decompression was successfully decreased in group III when compared to groups I and II (76% vs. 14% and 6% 1 day or less, P < 0.05). Complication rates were significantly lower in group III as well (14% vs. 36% and 28%, P < 0.05). Standardizing patient care with a clinical pathway decreases LOS after bariatric surgery. An established clinical pathway can then be used to further modify patient care in order to achieve specific goals, such as shortened time of nasogastric decompression. This goal was accomplished without compromising patient outcome.

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.

Bariatric and Associated Operations in Private and Academic Practices

BACKGROUND

The types of bariatric and the associated operations performed by academic and private surgeons were surveyed.

METHODS

A survey containing 8 questions regarding type of practice, type of surgery, associated procedures during bariatric surgery, years in practice and bariatric training was e-mailed to all members of the American Society for Bariatric Surgery.

RESULTS

46% of the members responded and were divided between those who performed their procedures laparoscopically and those who performed open procedures. Laparoscopic adjustable gastric banding was almost exclusively performed in academic centers and encompassed 20% of their bariatric operations, while the gastric bypass was the most common operation performed (65%), followed by vertical banded gastroplasty and duodenal switch. Operations performed simultaneously indicated that cholecystectomies were performed equally in private practice (92.5%) and the academic sector (95%), with higher incidence in open procedures (95%) compared to laparoscopic (40%). Of the surgeons performing appendectomies, 20% were in private practice and 10% in academic. Liver biopsy was performed with the same incidence in private and academic practices (60%). A minority of responders had formal fellowship training (17%), and many had learned from a partner (40%). The approach was dictated by the surgical training (85%) and background.

CONCLUSION

No significant difference was found between the private and academic surgeons in performing operations. Appendectomy is rarely performed academically, and cholecystectomy is mostly performed in the open procedure.

Bariatric surgery for severely overweight adolescents: concerns and recommendations

As the prevalence of obesity and obesity-related disease among adolescents in the United States continues to increase, physicians are increasingly faced with the dilemma of determining the best treatment strategies for affected patients. This report offers an approach for the evaluation of adolescent patients' candidacy for bariatric surgery. In addition to anthropometric measurements and comorbidity assessments, a number of unique factors must be critically assessed among overweight youths. In an effort to reduce the risk of adverse medical and psychosocial outcomes and increase compliance and follow-up monitoring after bariatric surgery, principles of adolescent growth and development, the decisional capacity of the patient, family structure, and barriers to adherence must be considered. Consideration for bariatric surgery is generally warranted only when adolescents have experienced failure of 6 months of organized weight loss attempts and have met certain anthropometric, medical, and psychologic criteria. Adolescent candidates for bariatric surgery should be very severely obese (defined by the World Health Organization as a body mass index of > or =40), have attained a majority of skeletal maturity (generally > or =13 years of age for girls and > or =15 years of age for boys), and have comorbidities related to obesity that might be remedied with durable weight loss. Potential candidates for bariatric surgery should be referred to centers with multidisciplinary weight management teams that have expertise in meeting the unique needs of overweight adolescents. Surgery should be performed in institutions that are equipped to meet the tertiary care needs of severely obese patients and to collect long-term data on the clinical outcomes of these patients.

Socioeconomic characteristics of the population eligible for obesity surgery

BACKGROUND

Obesity is increasing in the American population in epidemic proportions. Weight reduction surgery results in sustained weight loss for morbidly obese individuals-a group of patients refractory to nonsurgical obesity treatment. Surgical indications were outlined in a National Institutes of Health (NIH) consensus conference published in 1991. Using the NIH criteria, we compared the socioeconomic characteristics of the population eligible for these operations to those receiving them.

METHODS

The 2000 National Health Interview Survey database was examined to identify how many individuals in the American population were eligible for obesity operations. Socioeconomic characteristics for those individuals were then assessed. The Healthcare Cost and Utility Project and National Hospital Discharge Survey databases were queried to determine how many gastric bypass operations were performed and what the patient's socioeconomic characteristics were.

RESULTS

There are 5,324,123 people, or 2.8% of the American population, who are eligible for obesity surgery. Of these, a disproportionate number were black, poorly educated, or impoverished, and 38% rely on Medicare or Medicaid for their health insurance. Of the 28,590 gastric bypass operations performed in 2000, only 13% of patients used Medicare or Medicaid to pay for the operation. Fewer than expected operations were performed on blacks. Regional differences were observed with disproportionately more operations performed in the Northeast and fewer in the Midwest than would be predicted from the surgery-eligible population living in these regions.

CONCLUSIONS

A significant fraction of the American population could potentially benefit from obesity surgery. However, many of those individuals are black, poorly educated, and impoverished. Public assistance programs need to account for these patients. Centers performing bariatric operations need to accommodate the educational and financial constraints these patients have when planning long-term postoperative care.

Effect of the learning curve on the early outcomes of laparoscopic Roux-en-Y gastric bypass

Open gastric bypass has been demonstrated to provide durable weight loss in morbidly obese patients. As laparoscopic techniques have evolved surgeons are offering patients such an approach for performance of gastric bypass. The purpose of this study was to evaluate the relationship between increasing experience and outcome for this technically challenging operation. A retrospective analysis was performed on the initial 160 consecutive patients undergoing laparoscopic gastric bypass by a single surgeon over a 24-month period. Patients were divided into quartiles for data analysis. Duration of surgery decreased significantly between quartiles: 324 +/- 124, 225 +/- 70, 190 +/- 47, and 168 +/- 40 minutes, respectively (P < 0.01). However, the conversion rate (3.1%) and mean hospital length of stay (2.1 +/- 2.4 days) were unaffected by surgeon experience. The early and late postoperative complication rates were 9.4 and 3.1 per cent, respectively. Early complications included: leak (1.3%), bleeding (3.8%), obstruction (1.9%), acute gastric distention (0.6%), subphrenic abscess (0.6%), and wound infection (0.6%). Late complications include: obstruction (1.3%), anastomotic stricture (1.3%), and marginal ulcer (0.6%). The complication rates did not change statistically between quartiles. The excess weight loss at one year was 77.4 +/- 16.7 per cent. These data suggest that throughout the learning curve laparoscopic gastric bypass can be accomplished with acceptable complication rates, conversion rates, and hospital length of stay. Duration of surgery improves with experience. Early weight loss results compare favorably with those of open gastric bypass.

Establishing a laparoscopic gastric bypass program

OBJECTIVE

To evaluate the outcomes for laparoscopic Roux-en-Y gastric bypass in a newly developed bariatric surgery program.

METHODS

A prospective analysis of the initial 100 patients who underwent laparoscopic Roux-en-Y gastric bypass at a community based teaching hospital between December 2000 and October 2001 was performed. Study endpoints included operative time, early (less than 7 days) and late complication rates, hospital length of stay (LOS), time to initiation of oral diet, and percentage of excess body weight loss.

RESULTS

There were 91 women and 9 men with a mean age of 39 years (range 21 to 57). Mean preoperative weight was 126.4 kg (range 92.3 kg to 214 kg), with a mean preoperative body mass index of 47.4 (range 37.3 to 75.7). Ninety (90%) patients had at least one significant medical comorbidity (median = 6 per patient). Mean operative time was 2.4 hours (range 1.0 to 6.5; 3.0 hours for the first 50 patients and 1.8 hours for the last 50 patients). Three patients required conversion to open gastric bypass, all due to equipment failure (two harmonic scalpel failures and one linear stapler malfunction). Seven patients had early complications, 3 with anastomotic hemorrhage requiring transfusion, 3 with intestinal leaks requiring reoperation, and 1 with transected nasogastric tube. Eleven patients had late complications: 5 patients with small bowel obstruction, all due to herniation through the transverse colon mesentery (these occurred early in the series, prompting a change in technique, with no subsequent occurrences), 3 with gastrojejunostomy strictures requiring endoscopic dilation, 2 superficial wound infections, and 1 port-site incisional hernia. No complications occurred in the last 40 patients. No deaths occurred. Median hospital stay was 2 days (range 1 to 37); 3 days in the first 50 cases and 1 day in the last 50 cases. The median number of days to the start of an oral diet was 1 day. Average excess body weight loss was 34% (median follow-up 4 months).

CONCLUSIONS

Laparoscopic Roux-en-Y gastric bypass is a technically challenging procedure that can be safely integrated into a bariatric treatment program with good results. Improved outcomes, shorter operative times, and fewer complications are associated with increased surgical experience.

Current status of laparoscopic gastric bypass

Laparoscopic gastric bypass is emerging as a commonly performed procedure for the treatment of morbid obesity. This article discusses the indications for surgery, patient selection, surgical technique, management of complications, and outcomes of laparoscopic gastric bypass.

Reduced length of stay by implementation of a clinical pathway for bariatric surgery in an academic health care center

Bariatric surgery is being performed in increasing numbers in an era when reimbursements are being reduced. Academic health centers bear the responsibility for training surgeons to perform these operations yet must keep costs to a minimum and retain high quality. The UCLA Bariatric Surgery Program developed a clinical pathway for the pre- and postoperative management for gastric bypass patients to achieve these goals. Medical records for 182 consecutive gastric bypass patients were retrospectively reviewed before implementation of the pathway (Group I) during the fiscal year of 1998/1999. Data on average length of stay, average intensive care unit length of stay, average standard variable cost, percentage readmission rate, and percentage return to the operating room were collected. This information was compared with the data collected prospectively from 182 patients after implementation of the pathway in July of 1999 (Group II) during the fiscal year of 1999/2000. Hospital cost per admission was reduced by 40 per cent in Group II compared with Group I (P < 0.02). The average length of stay was reduced from 4.05 days in Group I to 3.17 days in Group II (P < 0.033). Overall readmission rate was decreased from 4.2 per cent in Group I to 3.2 per cent in Group II (P < 0.05). There were no differences in morbidities between both groups. The pathway reduced costs by reducing the hospital length of stay, intensive care unit utilization, and readmission rates. Quality was maintained as evidenced by a similar pattern of postoperative morbidities yet readmission rates were reduced. Our results indicate that implementation of a clinical pathway for bariatric surgery reduces cost and improves quality of care in an academic institution.

Glucose utilization in morbidly obese subjects before and after weight loss by gastric bypass operation

OBJECTIVE

To investigate the effect of weight reduction induced by gastric bypass operation (GBO), on the peripheral resistance to insulin in extremely obese subjects.

DESIGN

A three-stage euglycemic clamp was applied to assess the metabolic clearance rate of glucose (g-MCR) in lean controls and in obese subjects, prior to and 6-12 months post operation.

SUBJECTS

Six obese subjects (four obese normoglycemics-ON and two obese non-insulin dependent diabetics-OD) before and after GBO and six healthy, lean controls (LC) were compared.

MAIN OUTCOME MEASURES

Body mass index after GBO, metabolic clearance rate of glucose under increasing insulin concentrations.

RESULTS

GBO resulted in a significant change in body mass index from a pre-operation value (mean +/- s.d.) of 45.0 +/- 8.5 to 30.4 +/- 5.9 kg m-2 and remained significantly greater than controls (23.3 +/- 2.3 kg m-2). Glucose MCR increased from a mean baseline value of 3.0 +/- 1.6 to 6.7 +/- 3.9 ml kg-1 min-1 at post GBO (P) (P < 0.02). Similar effects were obtained under the two higher insulin concentration.

CONCLUSIONS

GBO resulted in a massive reduction in BMI, that still remained above normal controls. This could explain the effect of weight reduction to decrease, but not completely reverse, peripheral resistance to insulin associated with obesity.

Regression of hepatic steatosis in morbidly obese persons after gastric bypass

Morbid obesity has been associated with hepatic steatosis and occasional cirrhosis. Despite producing weight loss, intestinal bypass procedures formerly performed to correct morbid obesity, often worsened steatosis and fibrosis, and occasionally resulted in hepatic failure. Current surgical procedures of choice for morbid obesity involve gastric bypass with gastrojejunostomy. Ninety-one liver biopsies taken at the time of gastric bypass for morbid obesity (mean body weight 125.8 kg), and 106 biopsies taken from the same patients from 2 to 61 months later (mean body weight 89.4 kg) were studied. Steatosis and perisinusoidal fibrosis were assessed in histologic sections. Serum albumin, alkaline phosphatase, aspartate aminotransferase (AST), and total bilirubin levels were measured before most biopsies were taken. Both pre- and post-gastric bypass hepatic steatosis varied directly with body weight (r = .5231, P < .001). Steatosis varied inversely with length of time after gastric bypass (r = .4590, P < .001). Of the original biopsies, 37% had lipid vacuoles in at least 26% of hepatocytes. After gastric bypass, 65 patients had reduced steatosis, 18 patients with no steatosis, and 5 patients with minimal steatosis had no change, and 3 patients had increased steatosis. Pre-gastric bypass biopsies from 13 patients had perisinusoidal fibrosis (PSF) that was marked with bridging in three patients, was moderate in one patient, and slight in nine patients. Following gastric bypass, PSF was eliminated in 10 patients, reduced in one patient, and the same in two patients. One patient developed PSF after gastric bypass. Of the three patients who had undergone previous intestinal bypass procedures, two had slight PSF in the biopsies taken at the time of gastric bypass, and one of these had slight PSF in the follow-up biopsy. Serum biochemical abnormalities tended to be slight. Before gastric bypass, serum albumin was low in 11% of cases, alkaline phosphatase was high in 14% of cases, AST was high in 11% of cases, and total bilirubin was high in 1% of cases. After gastric bypass, there was a small reduction in mean serum albumin from 43 g/L before to 41 g/L afterward (P < .05), and a slight rise in mean total bilirubin from 7.0 mumol/L before to 9.6 mu mol/L afterward (P < .01). Most hepatic fatty change and probably some PSF occurring in morbidly obese persons is reduced or eliminated with weight loss following gastric bypass surgery.

Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement

The National Institutes of Health Consensus Development Conference on Gastrointestinal Surgery for Severe Obesity brought together surgeons, gastroenterologists, endocrinologists, psychiatrists, nutritionists, and other health care professionals as well as the public to address: the nonsurgical treatment options for severe obesity, the surgical treatments for severe obesity and the criteria for selection, the efficacy and risks of surgical treatments for severe obesity, and the need for future research on and epidemiological evaluation of these therapies. Following 2 days of presentations by experts and discussion by the audience, a consensus panel weighed the evidence and prepared their consensus statement. Among their findings, the panel recommended that (1) patients seeking therapy for severe obesity for the first time should be considered for treatment in a non-surgical program with integrated components of a dietary regimen, appropriate exercise, and behavioral modification and support, (2) gastric restrictive or bypass procedures could be considered for well-informed and motivated patients with acceptable operative risks, (3) patients who are candidates for surgical procedures should be selected carefully after evaluation by a multidisciplinary team with medical, surgical, psychiatric, and nutritional expertise, (4) the operation be performed by a surgeon substantially experienced with the appropriate procedures and working in a clinical setting with adequate support for all aspects of management and assessment, and (5) lifelong medical surveillance after surgical therapy is a necessity. The full text of the consensus panel's statement follows.

Gastric bypass revision: lessons learned from 920 cases

Roux-en-Y gastric bypass (RGB) is an accepted operation for the control of body weight in morbidly obese patients. Early technical complications and inadequate weight loss, well-known sequelae of this procedure, necessitated reoperation in 42 patients of 920 who underwent RGB in a 10-year period. Indications for reoperation included dilated gastrojejunal anastomosis (16), inadequate weight loss without demonstrable enlargement of the anastomosis (10), staple line breakdown (6), anastomotic obstruction (4), anastomotic leak (4), and enlarged proximal gastric pouch (2). Reoperation consisted of completely redoing the initial RGB in 20 patients, redoing the anastomosis alone in 17 patients, staple line revision in four patients, and intraoperative dilatation of the anastomosis in one patient. After initial RGB, 26 of the 42 patients (61.9%) experienced major complications. After revision of RGB, there were major complications in 21 patients (50%). In conclusion, major postoperative complications may contribute to RGB failure, RGB revision for early technical failure or inadequate weight loss is associated with a high incidence of major complications and, subsequently, negligible weight loss. Therefore repair of RGB for technical failure or complications is not recommended.