Mesenteric Defect Closure in Laparoscopic Roux en-Y Gastric Bypass: A Randomized Control Trial

Ulysses Rosas, BA, Shusmita Ahmed, MD, Natalia Leva, BA, Trit Garg, BA, Michael Russo, MD, John M Morton, MD, MPH. Stanford University School of Medicine.

Introduction: Bowel obstruction caused by internal herniation is a potential complication following laparoscopic Roux-en-y Gastric Bypass (LRYGB). Previous studies have shown that closure of mesenteric defects after LRYGB may reduce the incidence of internal herniation and its potential complications. However, controversy remains as to whether mesenteric defect closure is necessary to decrease the incidence of internal hernias and complications after LRYGB.

Objective: To determine if jejeunal mesenteric defect closure reduces incidence of hernias and complications in patients undergoing LRYGB.

Methods: 105 patients undergoing laparoscopic antecolic RYGB were randomized into two groups: Closed mesenteric defect (n=50) or Open mesenteric defect (n=55). Complication rates were obtained from medical record. Patients were contacted up to three years post-operatively to obtain self-reported incidences of complications. Patients also completed the Gastrointestinal Quality of Life Index (GI QoL) pre-operatively and 12 months post-operatively in order to determine symptoms associated with obstruction. Outcome measures included incidence of complications, readmissions and reoperations, GI QoL scores, and percent excess weight loss. Dichotomous variables were analyzed using chi-squared test, and continuous using two-tailed t-test. Analysis was performed using STATA software, release 12 and GraphPad Prism 6.

Results: Preoperatively, there were no significant differences between the two groups. The Closed group had a significantly longer operative time (Open 139 minutes, Closed 157 minutes, p=0.044). There were three internal hernias in both groups. Between the two groups, there was no significant difference at 12 months for decrease in BMI (-16.2 vs. -15.1, p=0.329), change in waist circumference (-11.7 cm vs. -10.0, p=0.357), or the percent excess weight loss (69.0 vs. 75.3, p=0.134). There was no significant difference between the groups in incidence of internal hernias and general complications postoperatively. Multivariate logistic analysis controlling for age, sex, race, insurance, and preoperative BMI also showed no significant effect of closure on incidence of hernias and complications. Both groups showed significantly improved GI QoL index scores from baseline to 12 months post-surgery, but there were no significant differences at 12 months between groups in total GI QoL (Open 111.10, Closed 108.50, p=0.612), physical domain score (Open 17.26, Closed 18.59, p=0.464), and symptoms domain score (open 59.74, closed 60.00, p=0.910).

Conclusions: In this study, closure or non-closure of the jejeunal mesenteric defect following LRYGB appears to result in equivalent internal hernia and complication rates.

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