Effect of preoperative knowledge on weight loss after laparoscopic gastric bypass

INTRODUCTION

Gastric bypass surgery has been demonstrated to be an effective treatment for morbid obesity. Unfortunately, not all patients have the same weight loss after surgery. It may be that the more informed patients will have more weight loss than less informed patients. No study has investigated the relationship between initial preoperative knowledge and weight loss after laparoscopic gastric bypass surgery.

METHODS

All patients who underwent laparoscopic gastric bypass for a 6-month period were included in this study. Our preoperative education process includes a 21-question true/false test given at the appointment immediately before surgery. Patients repeat the test until all questions are answered correctly. We compared percentage of excess body weight loss (EBWL) between patients who correctly answered all the questions the first time (pass patients) and patients who did not correctly answer all the questions the first time (fail patients).

RESULTS

There were 104 patients involved in this study; although complete data were only available on 98 patients. The average preoperative body mass index was 48 kg/m(2). Forty-eight percent of patients answered all the questions correctly the first time. Follow-up ranged from 1 to 2 years on all 98 patients. Pass patients had an average of 73% EBWL, whereas fail patients had an average of 76% EBWL (p = NS).

CONCLUSIONS

Preoperative knowledge, assessed by a test, did not predict success after laparoscopic gastric bypass surgery. Patients who do not, at first, have full knowledge of bariatric surgery should not be discriminated against undergoing surgery if they are eventually properly educated.

Are African-Americans as successful as Caucasians after laparoscopic gastric bypass?

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been demonstrated to provide weight loss comparable to open gastric bypass. It has been suggested that African-Americans (AA) are not as successful as Caucasians (CA) after bariatric surgery. Our hypothesis was that AAs are just as successful as CA after LRYGBP in terms of weight loss and comorbidity improvement.

METHODS

A retrospective chart review was performed on all AA and CA patients who underwent LRYGBP for a 6-month period. Success after LRYGBP [defined as (1) 25% loss of preoperative weight, (2) 50% excess weight loss (EWL), or (3) weight loss to within 50% ideal weight] was compared by ethnicity.

RESULTS

102 patients were included in this study. 97 patients (30 AA patients and 67 CA patients) had at least 1-year follow-up data available. Preoperative data did not differ between both groups. There was a statistically significant difference in %EWL between AA and CA (66% vs 74%; P<0.05). However, there was no ethnic difference in the percentage of patients with successful weight loss (as defined by any of the above 3 criteria). Furthermore, there was no statistical difference between the percentages of AA and CA patients who had improved or resolved diabetes and hypertension.

CONCLUSIONS

LRYGBP offers good weight loss in all patients. While there may be greater %EWL in CA patients, no ethnic difference in successful weight loss exists. More importantly, co-morbidities improve or resolve equally between AA and CA patients. LRYGBP should be considered successful in AA patients.

Results of Teenaged Bariatric Patients Performed in an Adult Program

BACKGROUND

Morbid obesity is a growing epidemic among adolescents. Bariatric surgery has proven to be the only long-term effective method in treating morbidly obese adults for over a decade. The laparoscopic approach has become a popular option. This study tested the hypothesis that laparoscopic Roux-en-Y gastric bypass is a feasible option in teenaged patients with good results through an adult bariatric program.

METHODS

All patients under the age of 20 at the time of surgery were included in this study. Each patient had undergone a laparoscopic Roux-en-Y gastric bypass. Charts were reviewed for preoperative evaluation, operative time, complications, and length of hospital stay. Percentage of excess body weight lost (%EBWL) was calculated at the follow-up.

RESULTS

Of the 202 patients who underwent a laparoscopic gastric bypass procedure at our institution, 5 (2%) were teenagers. The mean age was 18 years (range, 17-19). The mean height was 69 inches (range, 61-75). Average weight was 323 lbs (range, 227-394). The mean preoperative body mass index was 48 kg/m2 (range, 44-56). All patients had medical and psychological clearance prior to surgery. Mean operative time was 150 minutes (range, 130-172). There were no complications in this subset of patients. All 5 patients were discharged on postoperative day 2. Follow-up ranged from 17.8 to 44.8 months. The mean %EBWL was 77% (range, 58%-88%).

CONCLUSIONS

The laparoscopic gastric bypass procedure is technically feasible in teenaged patients, with excellent results even when performed in an adult bariatric program. Long-term data will be needed to determine its role in the treatment of morbidly obese adolescents.

Laparoscopic Re-operations for Band Removal after Open Banded Gastric Bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGBP) has been demonstrated to be an effective treatment for weight loss in the morbidly obese. Numerous variations of the RYGBP have been performed, including placing a ring proximal to the gastric outlet. This ring in RYGBP is intended to decrease pouch dilation and limit weight regain. We reviewed our experience in laparoscopic re-operation after open banded RYGBP.

METHODS

All charts of patients who underwent laparoscopic revisional bariatric surgery were reviewed. Patients who had laparoscopic removal of the band following the open banded RYGBP were reviewed in this study.

RESULTS

There were 4 patients who had laparoscopic removal of the band. The indication in all patients was dysphagia and emesis. The ring removed was a silicone band (1) and a large braided non-absorbable suture (3). After the laparoscopic reoperation, there was immediate relief. There has been an average of 5.8 kg weight regain at average follow-up of 30 months.

CONCLUSIONS

This complication after open banded RYGBP may require operative intervention. Laparoscopic removal of a band is feasible and safe.

Laparoscopic bariatric patients’ will to help: the foundation of research

BACKGROUND

Bariatric surgery is a fast growing field. Clinical research is essential to its safe delivery. Bariatric patient enthusiasm for research participation has never been objectively measured. Our hypothesis was that most laparoscopic bariatric surgery patients would participate in clinical research.

METHODS

All postoperative patients were surveyed querying their willingness to participate in studies and quantifying the level of time, effort, and commitment they would comply with. Fisher's exact test, the Mann-Whitney U test, and the chi-square test were used to analyzed the responses. A total of 97 patients were the subject of this inquiry.

RESULTS

Of the 97 patients, 92% were willing to participate. Willingness was independent of race or diabetic status. Of those willing to participate, 93% agreed to additional blood tests done during routine blood draws and 75% agreed to additional blood draws. Although 98% agreed to donate fat samples during surgery, only 76% would donate at 1 month postoperatively. Also, 80% would spend 6 hours at 1 month postoperatively in the hospital for preoperative research. This decreased to 56% and 56% for 12 and 24 hours, respectively (P = .004). For postoperative research, 72% committed to 6 hours per month in the hospital. This decreased to 60% and 54% for 12 and 24 hours, respectively (P = .002). No statistical consensus was reached for the financial reimbursement patients desired for their time.

CONCLUSIONS

The results of our study have shown that almost all laparoscopic bariatric surgery patients are willing to participate in obesity-related research, including invasive procedures, when it coincides with their surgery. Enthusiasm decreased with the increasing time commitment in the pre- and postoperative period but remained for most patients.

Laparoscopic revision of the gastrojejunostomy for recurrent bleeding ulcers after past open revision gastric bypass

Late complications of open gastric bypass can include malnutrition, weight gain, stomal stenosis, and recurrent bleeding ulcers. Herein, we describe the case of a woman who had recurrent bleeding ulcers, after an open revision of a stenotic gastric bypass. She now underwent an uneventful laparoscopic revision of her gastrojejunostomy and was discharged within 72 hours. Laparoscopic revision of a gastrojejunostomy, even after an open revision following an open gastric bypass, can be done safely.

What happens to patients who do not follow-up after bariatric surgery?

Loss of follow-up is a concern when tracking long-term clinical outcomes after bariatric surgery. The results of patients who are "lost to follow-up" are not known. After bariatric surgery, the lack of follow-up may result in less weight loss for patients. This study investigated the hypothesis that there are differences between patients who do not automatically return for their annual follow-up and those that do return. Patients who were greater than 14 months postoperative after laparoscopic gastric bypass were contacted if they had not returned for their annual appointment. They were seen in clinic and/or a phone interview was performed for follow-up. These patients (Group A) were compared with patients who returned to see us for their annual appointment (Group B) without us having to notify them. There were 105 consecutive patients, with 48 patients who did not automatically return for their annual appointment. Only six of these patients could not ultimately be contacted. There was no difference in preoperative body mass index between the two groups. Percentage excess body weight loss was greater in Group B (76 vs. 65%; P < 0.003). More patients had successful weight loss (defined as within 50% of ideal body weight) in Group B (50 [88%] vs. 28 [67%]; P < 0.02). We found that a significant number of patients will not comply with regular follow-up care after laparoscopic gastric bypass unless they are prompted to do so by their bariatric clinic. These patients have worse clinical outcome (i.e., less weight loss). Caution should be taken when examining the results of any bariatric study where there is a significant loss to follow-up.

Predictive value of upper gastrointestinal studies versus clinical signs for gastrointestinal leaks after laparoscopic gastric bypass

BACKGROUND

The utility of routine upper gastrointestinal (UGI) studies after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a matter of great debate. Because the morbidity and mortality rates associated with an unrecognized postoperative leak are high after LRYGB, diagnosis of a postoperative leak earlier would be of benefit. Clinical signs, however, may predict the diagnosis of a postoperative leak more often. This study explored the hypothesis that UGI studies are more predictive than clinical signs for the early diagnosis of a postoperative leak after LRYGB.

METHODS

All patients who underwent LRYGB at the authors' institution were included in this study. Charts were reviewed to examine immediate clinical signs (heart rate, temperature, and white blood cell count within the first 24 h), UGI studies, and clinical course. Sensitivity, specificity, positive predictive value, negative predictive value, and efficiency of clinical signs and UGI studies were calculated.

RESULTS

This study included 245 patients with a 3% rate of leak. The positive and negative predictive value of UGI studies were 67% and 99%, respectively. Only an elevated white blood count had a better predictive value (100% for negative predictive value). The efficiency of UGI studies (98%) was better than that of heart rate (83%), white blood count (8%), or temperature (95%).

CONCLUSIONS

According to our data, UGI studies are the most predictive of an early leak diagnosis. Clinical signs alone may not be as useful in predicting leaks early after laparoscopic gastric bypasses. Routine early postoperative UGI studies are a reasonable approach to predicting leaks after LRYGB.

What Happens to Patients who Do Not Follow-Up after Bariatric Surgery?

Loss of follow-up is a concern when tracking long-term clinical outcomes after bariatric surgery. The results of patients who are “lost to follow-up” are not known. After bariatric surgery, the lack of follow-up may result in less weight loss for patients. This study investigated the hypothesis that there are differences between patients who do not automatically return for their annual follow-up and those that do return. Patients who were greater than 14 months postoperative after laparoscopic gastric bypass were contacted if they had not returned for their annual appointment. They were seen in clinic and/or a phone interview was performed for follow-up. These patients (Group A) were compared with patients who returned to see us for their annual appointment (Group B) without us having to notify them. There were 105 consecutive patients, with 48 patients who did not automatically return for their annual appointment. Only six of these patients could not ultimately be contacted. There was no difference in preoperative body mass index between the two groups. Percentage excess body weight loss was greater in Group B (76 vs 65%; P < 0.003). More patients had successful weight loss (defined as within 50% of ideal body weight) in Group B (50 [88%] vs 28 [67%]; P < 0.02). We found that a significant number of patients will not comply with regular follow-up care after laparoscopic gastric bypass unless they are prompted to do so by their bariatric clinic. These patients have worse clinical outcome ( i.e., less weight loss). Caution should be taken when examining the results of any bariatric study where there is a significant loss to follow-up.

Establishing a laparoscopic bariatric program in a safety net hospital

BACKGROUND

Most laparoscopic bariatric programs are situated in a community- or university-based hospital. The authors have recently initiated a program at a safety net hospital. This investigation hypothesizes that a laparoscopic bariatric program can be established at a safety net hospital with good clinical and financial results.

METHODS

A laparoscopic bariatric program was initiated December 2002 at a safety net hospital. The program included a dedicated operative suite, an operative team, a bariatric unit, and a clinical pathway. The data for all the patients who underwent laparoscopic gastric bypasses up to June 2003 were analyzed. The patients were analyzed by type of insurance: government-sponsored insurance (G) or commercial insurance (C).

RESULTS

There were 104 patients during this period. Their mean age was 40 years (range, 18-63 years), and their mean body mass index was 48 (range, 38-62). The median length of hospital stay was 2 days (mean, 3.9 days). Hypertension and diabetes were resolved for more than 80% of the patients. The average percentage of excess body weight loss was 73% after 1 year. There were no significant clinical differences between payor groups. The payor mix was 31% G and 69% C. The mean collection rates for hospital charges were 10% for G versus 53% for C (p < 0.0001).

CONCLUSIONS

A laparoscopic bariatric program can be established in a safety net hospital with good clinical results. Findings showed that 1-year weight loss and comorbidity improvement/resolution compares favorably with those of other programs. Despite the overall poor payor mix of many safety net hospitals, a bariatric program can be established and can attract a high rate of commercially insured patients.

Unexpected pathology during laparoscopic bariatric surgery

BACKGROUND

The popularity of bariatric surgery has increased in recent years with the escalating incidence of morbid obesity in our society. The improvement in minimally invasive technology and the increased number of laparoscopic bariatric procedures being performed have resulted in the discovery of unexpected pathology not suspected preoperatively. The authors hypothesized that the occurrence of unexpected pathology is not associated with immediate adverse outcomes during laparoscopic bariatric procedures.

METHODS

From December 2002 to June 2004, 398 patients underwent laparoscopic bariatric surgery for morbid obesity. A retrospective chart review was performed to determine the incidence of unexpected findings and their effect on patient results.

RESULTS

Nine unexpected pathologic lesions were found in eight patients (2%). The findings included lesions on the small bowel (n = 3), stomach (n = 4), and liver (n = 2). In all cases except one (for which a biopsy was performed), the abnormalities were found and removed laparoscopically. The final pathology showed gastric leiomyomas (n = 2), gastric gastrointestinal stromal cell tumors (n = 2), ectopic pancreatic tissue (n = 2), arteriovenous malformation (n = 1), biliary adenoma (n = 1), and fibrosed hemangioma (n = 1). The planned bariatric procedures were completed for all the patients without incident. No complications occurred postoperatively, and all were discharged in 1 to 3 days (mean, 2 days).

CONCLUSIONS

Unexpected findings occur with relative frequency during laparoscopic bariatric procedures. Biopsy or removal of these lesions usually does not increase complications nor preclude continuation of the planned bariatric procedure.

Vitamin and trace mineral levels after laparoscopic gastric bypass

BACKGROUND

Nutritional deficiencies are a concern after any bariatric surgery procedure. Restriction of oral intake and/or decreased absorption may cause vitamin abnormalities. Prevention of these vitamin deficiencies includes both supplementation and routine measuring of serum values. An investigation was undertaken to examine preoperative and short-term (1-year) postoperative levels of vitamins/trace minerals in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP).

METHODS

Serum preoperative and postoperative vitamin/trace element levels of LRYGBP patients were recorded in a retrospective chart review (n = 100). Unavailable and undrawn levels were not included in the results.

RESULTS

Preoperative and 1-year postoperative percentage of abnormal levels were: vitamin A 11% and 17%, vitamin B(12) 13% and 3%, vitamin D-25 40% and 21%, zinc 30% and 36%, iron 16% and 6%, ferritin 9% and 3%, selenium 58% and 3%, and folate 6% and 11%.

CONCLUSIONS

Abnormal vitamin and trace mineral values are common both preoperatively and postoperatively in a bariatric surgery patient population. Routine evaluation of serum levels should be performed in this specific patient population.

Outcome of a clinical pathway for discharge within 48 hours after laparoscopic gastric bypass

BACKGROUND

The benefits of laparoscopic gastric bypass (LGB) include decreased pain, quicker recovery, and shorter hospital stay. Our hypothesis was that a clinical pathway for 48-hour discharge after LGB can be implemented safely.

METHODS

Charts of patients undergoing LGB were retrospectively reviewed to assess our prospectively placed clinical pathway. Patients were discharged within 48 hours if they met the criteria of the pathway.

RESULTS

There were 104 patients who underwent LGB with no intraoperative conversions. Complications included 5 leaks, 5 reoperations, and no mortality. In our series, 76% (n=79) of patients were discharged within 48 hours. Gender and body mass index (BMI) did not differ between those who were discharged in 48 hours and those who were not (P=not significant). No patient who was discharged in 48 hours required return before their scheduled appointment.

CONCLUSIONS

A majority of patients after LGB can be discharged safely in 48 hours. A formal clinical pathway helps decrease hospital stay without adverse patient outcome.

Metabolic syndrome: yet another co-morbidity gastric bypass helps cure

BACKGROUND

The metabolic syndrome is a group of risk factors predictive of cardiovascular diseases. The rising number of obese Americans has increased the prevalence of metabolic syndrome. This study investigated the hypothesis that the incidence of metabolic syndrome is decreased after laparoscopic gastric bypass surgery.

METHODS

The charts of all patients who had undergone laparoscopic gastric bypass surgery during a 6-month period were reviewed for the presence of the diagnostic criteria for metabolic syndrome, both preoperatively and at least 1 year postoperatively. The National Cholesterol Education Program Adult Treatment Panel III (NCEP ATPIII) criteria were used to define the metabolic syndrome. These criteria included elevated blood pressure, fasting blood glucose, triglycerides, high-density lipoprotein cholesterol, and waist circumference.

RESULTS

Data were available for 53 patients. Before laparoscopic gastric bypass surgery, 32 (60%) of the 53 patients had metabolic syndrome, as defined by the NCEP ATPIII criteria. No difference was found in the preoperative body mass index between patients who had metabolic syndrome (47.4 kg/m(2)) and those who did not (49.8 kg/m(2); P = NS). The percentage of excess body weight lost after at least 1 year was 78% in patients with metabolic syndrome. After surgery, only 1 (2%) of the 53 patients had metabolic syndrome (P <.0001).

CONCLUSION

Metabolic syndrome is quite common in patients undergoing bariatric surgery. The results of our study have shown that laparoscopic gastric bypass surgery resolves metabolic syndrome in most patients. Metabolic syndrome should be considered another co-morbidity that improves and is cured after gastric bypass surgery.

Band versus bypass: randomization and patients' choices and perceptions

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are becoming increasingly popular; however, little is understood about patients' motivational factors and reasons for choosing a particular procedure. This investigation explored patient choices and perceptions concerning LRYGB and LAGB.

METHODS

A survey was given to 120 consecutive patients who had undergone LRYGB or LAGB 3-24 months earlier. The survey was designed to ascertain why patients chose banding or bypass, and how they rated their surgical outcome.

RESULTS

A total of 101 patients responded (84%): 22 had undergone LAGB, 79 LRYGB. The top reason for choosing LRYGB was greater expectation of weight loss, whereas LAGB was chosen for its lower risk. Overall, 21% (18/84) of the patients were willing to be involved in a prospective randomized study of bariatric procedure choice. Six of 19 (32%) patients who underwent LAGB, but only 12 of the 65 (18%) who underwent LRYGB stated that they would be willing to accept randomization between the operations.

CONCLUSIONS

Patients expressed varied reasons for choosing their procedure, most related to weight loss or safety profiles. Patients undergoing LAGB would have predicted similar results with either procedure, whereas those undergoing LRYGB showed a trend toward greater overall satisfaction with their operations (p = 0.06) and would have predicted an inferior outcome with the other procedure. Although the overall percentage of patients willing to be randomized is not high, a busy bariatric practice could recruit sufficient numbers of willing patients to undergo a prospective randomized trial of LRYGB and LAGB.

Does laparoscopic gastric bypass result in a healthier body composition? An affirmative answer

BACKGROUND

Bariatric surgery results in sustained weight loss. While weight loss is the goal of bariatric surgery, fat loss and muscle conservation are germaine goals. This study investigated the hypothesis that body composition would significantly change after laparoscopic Roux-en-Y gastric bypass (LRYGBP).

METHODS

Patients undergoing LRYGBP were studied. Percent fat and percent water were calculated via bioelectrical impedance analysis (BIA). Waist and hip circumference were measured in all patients as well. Measurements were taken preoperatively, and at 1 month, 3 months, 6 months, and 1 year. Non-parametric ANOVA was utilized for statistical analysis.

RESULTS

There were 151 patients included in this study. Fat percentage (48.6 +/- 10.0 vs 34.6 +/- 10.8; P<0.001), total fat mass (141 +/- 37 vs 67 +/- 30; P<0.0001) and total water mass (108 +/- 27 vs 93 +/- 23; P<0.0001) decreased postoperatively at 1 year. Water percentage increased postoperatively at 1 year (37.0 +/- 6.6 vs 52.5 +/- 3.3; P<0.001). Waist:hip ratio improved from preoperatively to 1 year postoperatively (0.895 +/- 0.115 vs 0.811 +/- 0.076; P<0.001).

CONCLUSIONS

Bariatric surgery results not only in fat loss but also in a change in body composition. Improved waist:hip ratio, fat percentage decreases, and water percentage increases all indicate an overall healthy body composition. While weight loss is important, improvement in body composition should be another recognized benefit of bariatric surgery.

Emerging endoluminal therapies for gastroesophageal reflux disease: adverse events

BACKGROUND

Endoluminal therapies are emerging as a new therapeutic option for the treatment of gastroesophageal reflux disease (GERD). Many of these endoluminal therapies are touted as short outpatient procedures with minimal complications. It is thought that these complications are uncommon and minor. This investigation sought to summarize the adverse events of these endoluminal therapies for the treatment of GERD.

METHODS

The Manufacturer and User Facility Device Experience Database for the U.S. Food and Drug Administration's Center for Devices and Radiological Health Web site was searched to examine all voluntary adverse events reported on emerging endoluminal therapies. The adverse events can be divided into 3 categories: (1) radiofrequency ablation based, (2) injection based, and (3) suture based.

RESULTS

There were a total of 50 adverse events reported on 4 specific therapies. Half of the complications were found to result from injection-based therapy and 44% of the complications were found to result from radiofrequency ablation-based therapy. There were 8 deaths reported (5 in the injection-based group and 3 in the radiofrequency ablation-based group). Sixty-four percent of the adverse events resulted in hospitalizations and 10% of these patients required surgery.

CONCLUSIONS

Physicians must be aware that no endoluminal therapy is truly noninvasive. Complications and even deaths are associated with these treatments for GERD. Patients must be informed of all the potential risks and complications of these new technologies.

Preoperative Carbohydrate "Addiction" Does Not Predict Weight Loss after Laparoscopic Gastric Bypass

BACKGROUND

Weight loss after laparoscopic Roux-en-Y gastric bypass (LRYGBP) varies. Dietary habits that exist preoperatively may continue after surgery and affect weight loss. This study investigated the hypothesis that preoperative carbohydrate addiction would predict weight loss after laparoscopic gastric bypass.

METHODS

104 consecutive patients in our LRYGBP program were included in the study. A preoperative survey was used to determine level of carbohydrate craving. This survey was scored from 0 to 60. A higher score indicated a higher level of carbohydrate addiction. Percentage of excess weight loss (%EWL) was determined after at least 1 year postoperatively in all patients.

RESULTS

Data were available in 95 (91%) of the patients. There was no correlation seen between level of carbohydrate addiction and %EWL at 1 year (r=0.02; P=NS). In addition, we looked at patients with successful weight loss (>50% %EWL; n=83) versus those patients who were considered unsuccessful (<50% EWL; n=12). There was no statistical difference in the level of preoperative carbohydrate craving between these 2 groups (36+/-13 vs 33+/-15; P=NS).

CONCLUSIONS

Consistently large carbohydrate intake preoperatively does not predict weight loss after LRYGBP. High level of carbohydrate addiction is not a contraindication to LRYGBP.

Laparoscopic lumbar hernia repair

Lumbar hernias are rare clinical entities that often pose a challenge for repair. Because of the surrounding anatomy, adequate surgical herniorraphy is often difficult. Minimally invasive surgery has become an option for these hernias. Herein, we describe two patients with lumbar hernias (one with a recurrent traumatic hernia and one with an incisional hernia). Both of these hernias were successfully repaired laparoscopically.

Laparoscopic Lumbar Hernia Repair

Lumbar hernias are rare clinical entities that often pose a challenge for repair. Because of the surrounding anatomy, adequate surgical herniorraphy is often difficult. Minimally invasive surgery has become an option for these hernias. Herein, we describe two patients with lumbar hernias (one with a recurrent traumatic hernia and one with an incisional hernia). Both of these hernias were successfully repaired laparoscopically.

Why Would Laparoscopic Gastric Bypass Patients Choose Open Instead?

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been demonstrated to be comparable to open Roux-en-Y gastric bypass (ORYGBP) surgery in randomized studies. Although a steep learning curve exists, laparoscopic bariatric surgery offers advantages if performed by an experienced bariatric surgeon. Despite these facts, some patients still choose to undergo ORYGBP. This investigation explored the reasons why patients who have had LRYGBP would decide to undergo the laparoscopic operation.

METHODS

A survey was given to patients who had undergone LRYGBP. The survey was designed to ascertain what factors would influence them to have LRYGBP versus ORYGBP. Incomplete responses were not included in the data analysis.

RESULTS

There were 41 patients who filled out the survey. Over 90% of the patients felt LRYGBP is better than open gastric bypass. There were 4 patients who had seen another surgeon who recommended ORYGBP. Approximately 61% (23/38) of the patients would have stayed with their surgeon even if their surgeon did not offer LRYGBP. In addition, 79% of patients (31/39) would have ORYGBP if their insurance did not cover LRYGBP. Most patients (67%) would have ORYGBP if their surgeon thought LRYGBP was experimental. If they were told that LRYGBP was too risky for them, 77% of patients (30/39) would have undergone ORYGBP. Only 15% of patients (6/40) would not have had surgery if LRYGBP did not exist.

CONCLUSIONS

Patients are willing to undergo ORYGBP even if they believe that LRYGBP is better. Non-medical factors and/or surgeon recommendations instead of scientific data influence patient decision-making when choosing ORYGBP over LRYGBP.

One-stitch laparoscopic gastric bypass technique for adolescents

Morbid obesity is increasingly recognized in children and adolescents. The National Institute of Health Consensus Conference has concluded that bariatric surgery is the only consistent effective method for achieving long-term weight loss. Advantages of the laparoscopic approach, which include decreased hospital stay and morbidity, have been demonstrated in randomized controlled studies. Herein, we describe our technique of laparoscopic Roux-en-Y gastric bypass.

Laparoscopic Roux-en-Y gastric bypass with subtotal gastrectomy

Laparoscopic gastric bypass is a common procedure for morbid obesity. After gastric bypass, the distal stomach is unavailable for surveillance. When a suspicious distal gastric lesion is present preoperatively, a distal subtotal gastrectomy may be needed. Herein we describe such a case performed laparoscopically. Laparoscopic gastric bypass with subtotal gastrectomy for morbid obesity should be considered for patients with suspicious distal gastric lesions.

Inpatient pain medication requirements after laparoscopic gastric bypass

INTRODUCTION

One of the benefits of laparoscopic Roux-en-Y gastric bypass (RYGBP) includes decreased pain, possibly resulting in decreased narcotic use, quicker recovery of bowel function, and shorter hospital stay. We utilize a pain management strategy for our patients undergoing laparoscopic RYGBP. We investigated this strategy as well as narcotic use and incidence of ileus.

METHODS

Inpatient data for patients who underwent laparoscopic RYGBP were collected. Our pain management strategy included a standing dose of ketorolac, morphine sulphate as needed, and propoxyphene hydrochloride/acetaminophen as needed after liquids were initiated. No PCAs were utilized.

RESULTS

There were 104 patients in this study. 12 patients did not undergo our pain management strategy due to reoperation (5), postoperative hemorrhage (2), and allergies (5). 2 patients required no pain medications other than ketorolac. Only 2 patients had a delay of discharge (postoperative day [POD] 3 and 5) due to lack of bowel function. An average of 11.2 mg of morphine and an average of 170 mg of propoxyphene (1.7 pills) were given by the end of POD 2. In addition, 74% of patients required no morphine on POD 2 and 48% of patients required no propoxyphene on POD 2. Bowel movements were reported in 65% patients on POD 1.

CONCLUSIONS

After laparoscopic RYGBP, only a minimal amount of narcotic use is necessary. Few patients have an ileus when utilizing this pain management strategy after laparoscopic RYGBP.

Mallory-Weiss tear after laparoscopic Roux-en-Y gastric bypass

In the United States, the most common surgical procedure for morbid obesity is the Roux-en-Y gastric bypass. Pulmonary embolism, leak, bowel obstruction, and gastrointestinal bleeding are among the potential early fatal complications. Early postoperative bleeding after laparoscopic gastric bypass, although uncommon, presents a dilemma because of the danger of perforation from postoperative endoscopy and the inability to access the gastric remnant easily. We describe a case of a Mallory-Weiss tear causing massive upper gastrointestinal hemorrhage 1 week after laparoscopic Roux-en-Y gastric bypass. Bariatric surgeons should consider this diagnosis, especially when encountering a patient with a history of significant retching postoperatively.

Laparoscopic Removal of Gastric Band after Open Banded Gastric Bypass

Open banded gastric bypass has been the choice of some bariatric surgeons. This procedure includes a band (of various materials) around the gastric pouch. While there are advantages to this band, erosion and/or displacement of the band may occur. We describe a case of a symptomatic displaced band which was treated by laparoscopic removal. Laparoscopic removal of the band after open banded gastric bypass is feasible. Revision of previous bariatric surgery may be performed laparoscopically if the technical expertise is available.