Laparoscopic Gastric Bypass Clinical Outcomes

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Shanu N. Kothari and Eric J. DeMaria Introduction

In 1993, Wittgrove and Clark performed the first laparoscopic gastric bypass. This was soon followed by a published report in 1994 of their initial five cases outlining the technical feasibility of the operation.1 Since that time variations in operative technique have been described, the majority of which differ in the type of gastrojejunal anastomosis created. Regardless of the laparoscopic technique used during the procedure, the questions that must be answered pertain to outcomes in comparison to open gastric bypass. In this chapter, the world's literature will be reviewed pertaining to outcomes following laparoscopic gastric bypass. As of this printing, the following five papers make up the published experience regarding laparoscopic gastric bypass outcomes and are presented in the order they were published.

Literature Review

In 1998, Lonroth and Dalenback published their experience with a variety of laparoscopic bariatric procedures.2 Included in their experiences were 29 patients who underwent laparoscopic gastric bypass. Their initial ten were, in fact, an omega loop gastroanastomosis followed by 19 true Roux-en-Y gastric bypasses. Their pouch size is measured using a ruler from the angle of His to the lesser curve, preferably 4 cm in length. The Roux limb is retrocolic, retrogastric, and the gastrojejunal anastomosis is performed using the linear stapler to create the posterior wall and a running suture to close the anterior wall. Main outcome measures included conversion rates, complications and weight loss at one year.

The weight reduction in the first 15 cases followed for more than one year was 67% of excess body weight. There were three conversions in this series (10.3%). One due to accidental perforation of the stomach and two due to inadequate exposure due to an enlarged left hepatic lobe. One patient developed an internal hernia with obstruction of the transverse mesocolic defect (3.4%). Four patients required postoperative blood transfusions due to postoperative hemorrhage. Two of these patients went on to develop anastomotic leaks requiring reoperation. One patient developed a marginal ulcer with perforation requiring reoperation 2-1/2 years after the initial procedure. There was no operative mortality in this series.

In June of 2000, Wittgrove and Clark published their results of 500 patients undergoing laparoscopic gastric bypass with 3-60 month follow-up.3 Their technique consists of a 15 cc gastric pouch, 75 cm retrocolic, retrogastric Roux limb, and a circular EEA stapled gastrojejunal anastomosis. Their main outcomes measured included pre- and postoperative co morbidities as well as weight loss over time. To date, this is the only publication documenting 60-month follow up following laparoscopic gastric bypass.

Their results showed 60% excess body weight loss six months after surgery and 77% one year after surgery, the best one-year result in the literature. Regarding longer-term weight loss, approximately 80% of patients lost and maintained 50% or more of their excess body weight 36-60 months postoperatively. Their 500 patients had a total of 1,752 comorbidities, which were reduced to 71, a 96% reduction following surgery. Weight loss was less in the diabetic patients compared to nondiabetic patients. However, 64/85 diabetics had elevated HgbAlC prior to surgery compared to only three postoperatively and all 39 type II diabetics on medication were off their medication postoperatively.

The anastomotic leak rate in this series was 2.2% (11/500). Nine of the 11 required reoperation, the majority of which were performed laparoscopically. The stomal stenosis rate was 1.6%. The wound infections were stratified into major, 0.8% and minor, 4.8%, the majority of which occurred at the trocar site used to introduce the circular EEA stapler.

Four out of 500 patients (0.8%) required re-exploration for hemorrhage. Three out of the four were successfully re-explored laparoscopically. Operating times early in the study averaged four hours and at the time of publication approached 90 minutes. The average length of stay was 2.5 days. There was no operative mortality.

In August of 2000, Nguyen et al published their results of 35 patients undergoing laparoscopic gastric bypass.4 This was the first comprehensive study comparing laparoscopic and open gastric bypass patients. The data was collected prospectively in the laparoscopic group and compared to 35 retrospectively matched patients who underwent open gastric bypass. A 15 to 20 cc gastric pouch was created and the gastrojejunal anastomosis was performed using a circular 21mm EEA stapled anastomosis, passing the anvil transorally. The Roux limb was measured 75 cm in length (150 cm for BMI >50). Main outcome measures included operative time, blood loss, hospital stay, complications and weight loss.

Seventeen of 35 patients were available and evaluated for follow-up one year after laparoscopic gastric bypass. The mean percentage excess body weight loss at one year was 69%. Estimated blood loss was 135 cc and mean operating room time was 246 minutes. Mean length of stay was four days.

Two patients developed postoperative hemorrhage requiring transfusion. One patient (2.8%) developed a bowel obstruction secondary to narrowing of the jejuno-jejunostomy, which required laparoscopic revision. One patient developed respiratory failure requiring more than 72 hours of ventilatory support. Seven of 35 patients (20%) developed anastomotic strictures requiring endoscopic balloon dilatation. None of the patients developed venous thrombosis or pulmonary embolism. There were no conversions in this series. There were no anastomotic leaks in this series and no operative mortality.

In September of 2000, Higa et al published their results of 400 patients undergoing laparoscopic gastric bypass.5 Their technique consisted of a 20 cc gastric pouch and a 100 cm retrocolic, antegastric Roux limb (150 cm for BMI >50). The gastrojejunal anastomosis is performed using a standard 2-layer hand sewn anastomosis. Main

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